Stress First Aid �for �Public Safety Personnel�

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Course Objectives

After taking this course, participants will be able to:

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• Identify the core set of principles that guide SFA

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• Understand and describe the causes of Stress Injury

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• Understand the Stress Continuum Model

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• Describe and apply the Seven Core Actions of Stress First Aid

Stress First Aid Introduction

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Critical Ingredient:

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The ability to focus under high demand

What is Stress First Aid ?� (SFA)

• A framework for self-care, peer support and leadership
• For those in high-risk occupations like military, fire-rescue and law enforcement
• Includes seven actions to help identify and address early signs of stress reactions in yourself/others in an ongoing way (not just after potentially traumatic events)

Reasons for Stress First Aid ��

• Many public safety personnel experience incident related stress
• Stressful experiences may cause lingering or unresolved issues
• Many have trouble sleeping
• Many are haunted by memories of bad calls, recurring unwanted memories, family and relationship problems
• Elevated substance use
• Suicide risk
• Fear of being seen as weak or unfit for duty
• Stigma surrounding asking for help

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Stress First Aid Supports:

Stress First Aid is NOT:

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SFA�is designed �to:

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How is

Stress First Aid Different?

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Rather than prescriptively telling people how they should support each other, SFA highlights the importance of coworker support, which can often only arise via the unspoken understandings that result from working together.

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It is frequently only in moment-to-moment encounters that the right support can happen. Be aware of its importance and open to being creative in accessing and giving that support.

Features of Stress First Aid

Stress Injuries

Two Faces of Stress

Four Causes of Stress Injury

Everyone who lives a life of service has battle scars

INNER CONFLICT

LOSS

WEAR & TEAR

LIFE THREAT/

TRAUMA

�Stress Continuum

Yellow Zone Reactions Vs. �Orange Zone Injuries

Hard work

Physical injuries

Minor illnesses

Peer conflicts

Conflicts with boss

Boredom

Relationship

problems

Money problems

Loss of privacy

Harsh weather

Family separation

Loss of possessions

Legal problems

Lack of sleep

Yellow Zone

Stress

Wear-and-tear

Moral injury

Loss

Life threat

Orange Zone

Stress

Stress Reactions

• Bending from stress
• Very common
• Normal
• Always go away

Stress Injuries

• Damage from stress
• Less common
• Risk for role failure
• Risk for stress illness

Essential SFA Skills

Orange Zone Indicators

Look for:

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• Recent Stressor Events
• Distress
• Changes in Functioning

Signs and Symptoms of Stress Injuries

Indicators of Severe Stress Reactions

�Why is Peer Support Important?

• Public Safety personnel are often focused on other’s welfare before their own
• Most people experiencing significant stress will cope, but some will become ill
• Those that do become ill often do not seek formal help
• Peers and co-workers can give informal support to prevent more significant problems
• Can also be a bridge to more formal treatment
• There is evidence that early treatment for significant stress is effective

Most public safety personnel who need assistance will depend on other public safety personnel to recognize the need and point them toward help

Stress First Aid Actions

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Factors in Recovery From Adversity and Stress�Hobfoll, et al 2007

Stress First Aid Framework

How Can You Use SFA?

Check

Approach

Decide what is most needed:

Anxiety

Guilt/Shame

Isolation

Calm

Competence

Grief

Severe Inability

to Function

Connect

Coordinate

Sleep

Problems

Cover

Confidence

Check

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Check Actions

Check: Why is it Needed?

Ask these five questions:

1. What was our mission?
2. What went well?
3. What could have gone better?
4. What might we have done differently?
5. Who needs to know?

Check Skill: OSCAR

Suicide: Signs That Tell You to Check In

• Relationship problems
• Increased drinking
• Depression
• Chronic stress
• Taking unnecessary risks
• Noticeable change in functioning
• Poor sleep or appetite
• Neglecting appearance, hygiene, uniform
• Poor job performance

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Suicide: Signs That Tell You to Take Action

• Direct comments about suicide
• Comments/jokes/wishes about being dead
• Vague comments:
• “What’s the point of living?”
• “My life is falling apart. I don’t know what to do”
• Isolation at work or at home
• Inexplicably “rebounding” from deep depression
• Self-harm
• Hopelessness
• Giving away belongings/saying goodbye

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Questions to Ask

Ask the person directly whether he or she is suicidal:

• “Are you having thoughts of suicide?”
• “Are you thinking about killing yourself?”

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Ask the person whether he or she has a plan:

• “Have you decided how you are going to kill yourself?”
• “Have you decided when you would do it?”
• “Have you collected the things you need to carry out your plan?”

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Talking with a Person�Who Is Suicidal

• Let the person know you are concerned/willing to help
• Discuss your observations with the person
• Ask the question without dread
• Do not express a negative judgment
• Appear confident, as this can be reassuring

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Check For Two Other Risks

• Has the person been using alcohol or other drugs?
• Has he or she made a suicide attempt in the past?

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Keeping the Person Safe

• Ensure that the person gets immediate, appropriate professional help
• Help the person identify past supports
• Involve them in decision making
• Call law enforcement if the person has a weapon/is behaving aggressively

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Do Not

• Leave an actively suicidal person alone
• Use guilt and threats to try to prevent suicide
• You will go to hell
• You will ruin other people’s lives if you die by suicide
• Agree to keep their plan a secret

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Ask

Care

Take

Check: Fire/EMS Example

“I try to get to know each of my people individually, so I know their baselines and what could potentially be a red flag. Instead of sitting on the couch and watching television, I go out and catch a football and talk. That helped when one of my crew members had a pregnant wife, and we responded to a stillborn birth. After that call I took a little extra time to sit and talk with him, to make sure that he was okay.”

Check: LE

“After an officer on my squad responded to a call for a suicide in progress, I asked him if he would like to grab a quick cup of coffee. I wanted to check in with him because I knew that he had a close family member who had recently taken his own life. I just wanted to make sure that he knew that someone noticed and wasn’t afraid to mention it to him.”

Check: Communications

“One of our telecommunicators had just returned to work after the death of her son who had been killed in a car accident caused by a driver who was under the influence. After she managed a call involving an accident with serious injuries due to a driver who was reported to be intoxicated, I told her what a great job she did with the call and asked her if she wanted to take a quick break with me to grab a snack .”

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Check: Corrections

“One of the key points of check is taking the time to get to know your co-workers on a daily basis, investing the time to learn who they are as individuals. Then you can recognize those subtle changes, signs that someone may be in the orange zone.”

���How do you create opportunities to check in with your co-workers?

Coordinate

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Coordinate Actions

Coordinate: Reasons for Referral

Coordinate: Fire/EMS

“We had an irritable, difficult firefighter who wouldn’t open up to anyone, but we knew a good friend of his on another shift and let this friend know that we had some concerns. He took the crew member out fishing and made more time to do things with him. After that, we stayed in touch with his friend to make sure the crew member was doing okay.”

Coordinate: LE

“I noticed that an officer was carrying around a picture of the damage done to her squad car during a recent shooting event. I asked her about the picture and she said that it reminds her how lucky she is to be alive. As we talked further, it became clear that she was still rattled by the event. I offered to connect her with an officer on our peer team who had been involved in a similar event and we made the call together so I could introduce them to one another.”

Coordinate: LE

“One of our deputies reported to work and was unusually quiet and distracted. I asked her if everything was ok. She explained that her 2-year-old child was just diagnosed with autism and she just did not know where to begin to get the needed services. I told her that I knew someone on another shift who had a child with autism and she and her husband had become resource “experts” and had offered to help others. I offered to make an email introduction to her. At her next shift, she told me how helpful the other deputy had been. ”

Coordinate: Communications

“One of the dispatchers came to me and told me that she had been dealing with elevated feelings of anxiety since last week when she felt that she had misguided a LE officer during a precarious situation. I suggested that she may want to reach out to the peer team to speak with someone who very likely has dealt with a similar situation.”

Group Discussion

Cover

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Cover Actions

When is Cover Needed?

When stress reactions create a threat (to self/ others):

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• External danger to a stress-injured person

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• Danger to others due to the stress-injured person’s impairment

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• Internal danger to a stress-injured person caused by extreme levels of distress (Thoughts/plans for suicide/homicide, reckless behavior)

Cover: Fire/EMS

“After a line-of-duty death, my crew members were telling me that they couldn’t go home to their families and say, ‘my job is safe.’ They felt more vulnerable and were being pressured to quit by family members. So we had a family meeting where we brought in firefighters from a department which had previously had a LODD. They talked with our families about how they had gotten through the situation. It helped our families to feel like they could get through it, and our crew members felt less pressure.”

Cover: Fire/EMS

“I was going through a very difficult divorce during a time when I was assigned as a paramedic.  On a day when I was particularly upset, my Captain told me that the paramedic engine would be responding on every call with the medic unit so I would have backup if I needed it. He wanted to make sure that I did not make a mistake that could harm someone or ruin my career.  He talked with me and then brought the crew together and explained that we are a team.  We are there for each other through good times and bad.”

Cover: LE

Officers at roll call following a line of duty death

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Sgt: (holding up the stress continuum)

“How’s everyone doing this evening?

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Squad in unison:

“Orange zone, sir.”

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Sgt:

“Let’s talk about what we need to do to help ourselves feel safe and get our job done tonight. If at any time, any of you feel unsafe or need a break, all you need to do is let me know. I have your back.”

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Cover: Communications

“One way Cover is achieved is by showing vulnerability yourself and by getting to know others on your squad. SFA needs to start well in advance of anything going on. You slowly implement it into your organization so it’s normal. We talk, drop our guards, and show our vulnerability. It has to begin well in advance of anything happening.”

Group Discussion

Calm

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Calm Actions

Calm: Fire/EMS

“After we had a couple of particularly tough calls, I brought pistachio nuts in for the crew. Shelling pistachios takes time and makes people slow down, so it gave us a chance to unwind and talk about what happened. Doing something supportive doesn’t have to look like a mental health intervention. In fact, the best interventions are often the least noticeable ones.”

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“After a line-of-duty death, we made sure that attendance at the department review of the investigation report was voluntary, and that crew members knew what to do if what they say/heard was distressing (i.e. that it was okay to bring an iPod in to listen to if video or audio recordings were triggering). We also decided to make the memorial a scholarship fund rather than a statue or plaque that would be a constant visual reminder of the death.”� 

Calm: LE

“One of my co-workers became extremely upset when he learned, at the end of our shift, that he had not been chosen for a special assignment. He was cursing and becoming increasingly agitated. I convinced him to go grab a bite to eat. While we ate, I listened to his concerns and problem-solved with him about how he could approach the supervisor in a constructive manner to ask for some feedback about why he wasn’t chosen. He called the next day to let me know that the supervisor had offered to mentor him so he would be in a better position next time.”

Calm: LE

“I train my squad to protect, serve and be alert but not hypervigilant. There is a delicate line where adrenaline is where it needs to be without being too much or too little. I try to train people to become more aware of ways to remain calm, to channel their energy into focused behavior, to stay in their sweet spot. Then, just as importantly, train them to let go of the adrenaline sweet spot and come down, because it can be addictive. It’s a great place to be in mind and reflexes but is not the place to be with your spouse and children at home. Life is not like a light switch – you don’t just turn off and on. You need to be ready to take action when it’s needed and when you go off duty, you need a way to decompress.”

Calm: Communications

“ I noticed that one of my co-workers was withdrawn, avoided contact with other members of the shift and was short (and often abrasive) with others, including callers. When we took a break, I asked her if everything was OK and she confided in me that she recently discovered that her 17 y/o son has an addiction to opiates and she is not sure what to do. She was very upset and afraid that her co-workers would think badly about her if they found out. I listened and assured her that she was not alone. I provided her with some resources for she and her son and shared an app I use for relaxation.”

Group Discussion

Connect

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Connect Actions

�Different Types of Support

• Instrumental support: material aid (such as assistance with daily tasks)
• Informational support: relevant information (such as advice or guidance)
• Emotional support: empathy, caring, reassurance and giving opportunities for venting
• Inclusion: Make efforts to pull the person in

Connect: Fire/EMS

“A firefighter was drinking all the time. He had been on the crew with the two guys who died, but it was hard to get him to talk to us. He had a kitchen remodeling project underway, so I went over and hung out in his home and helped him. While we worked on it, he opened up and I was able to get him some help.” 

Connect: LE

“Our department was involved in an incident that resulted in an officer involved shooting. Without discussing the details of the event, the sergeant was able to discuss with those involved how the incident had impacted their sense of safety, their sense of calm, their relationships, and their sense of competence and confidence. In the meantime, internal affairs made the rapid completion of the investigation a high priority. Stress first aid doesn’t teach us how to talk, but rather, what to talk about. Sometimes it’s necessary to “break the code of silence” in order to communicate that you care. You need to find out what their most urgent needs are and fill them, if possible.“

Connect: LE

“A deputy felt overly responsible for not being able to prevent the death by suicide of another deputy. We rallied around her as much as she would let us. She was a solitary person before the incident, so it would be natural for her reaction to be one of retreat. A year ago, I would have let her retreat, but because I was introduced to Stress First Aid, I rallied an effort to help. Post incident, I included her in discussions and projects in order to create collaborative opportunities with peers that allowed us to informally check with her.”

Connect: Fire-EMS

“When there is a lot of stress, leaders should keep people moving and facilitate talking while they do things. I had one leader who, instead of sitting down and having lunch, would make people walk around. He got people engaged and laughing. It’s helped them lower their stress levels. Or have each person report out on successes, loose ends, and their plan for the next 24 hours. It is time well invested.”

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Group Discussion

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Competence Actions Foster

When is the Competence Action Needed?

• Lack of experience

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• Loss of skill or ability

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• Stressor(s) presents a challenge to coping skills

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Lack of Experience

Contributes to difficulty meeting job demands when:

• Operational challenges are new
• An individual is unprepared to handle emotional aspects of the job
• There is a lack of sufficient training in certain aspects of the job
• An overwhelming event leaves an entire unit feeling unprepared to handle all aspects of the challenge

�Loss of Skill or Ability

Stress reactions cause loss of:

• Mental focus or clarity, cognitive functioning
• Emotional or behavioral, physiological self-control
• Enthusiasm and motivation
• Social ability
• Ability to see the “big picture”

Coping Challenge

Stress reactions cause new challenges to coping:

• Trauma or loss reminders
• Disturbing memories
• Difficulty relaxing, slowing down or getting to sleep
• Difficulty maintaining an emotional “even keel”
• Dread and desire to avoid re-exposure
• Stress-induced physical symptoms

Competence Procedures

Competence: Fire/EMS

“Our fire department had training on conflict resolution because we saw that when our young firefighters were under stress, they didn’t really know how to manage their irritability and anger. They also did not know how to communicate directly, effectively and assertively with others—they were more used to texting than talking. The training helped all of us improve the ways we handle conflict individually, and as an organization.”

Competence

“We were preparing to execute an eviction when the very distraught mother ran into the house and doused herself in gasoline and set herself on fire. I just keep hearing her scream. She made her way outside and we were confronted with a severely burned woman who calmly asked me several times to shoot her, saying “There is no help for me”. I have never felt so helpless. I had no idea what to do for a person with such horrible burns. I can see her face when I close my eyes and I keep wondering if I did the right thing. It took quite a while and several conversations before I could see that the actions I took (keeping her calm, telling her that help would be there quickly and that she was not alone) made a difference.”

Competence: LE

“There was a bus crash on the highway with ten passengers killed. I noticed that a new crash investigator seemed nervous when he arrived on the scene, so I approached him and told him that this is no different than a single fatality crash. The job is exactly the same, with a focus on mapping physical evidence. I gave him a pep talk right before getting to work. If we can anticipate the factors involved in an incident, we can say something constructive.”

Competence: Communications

“I was training a new call taker. He became increasingly frustrated one evening after a challenging call and stood up, threw down all of his training notes, and walked away, saying “I guess I’m just a failure all the way around”. I knew that he had had 2 deaths in his immediate family in the past 2 months and he and his wife were expecting their first child. I suggested that he take a break and I was able to join him. We talked about how stress can interfere with your ability to learn new skills and discussed some actions that he may take to better manage his stress so that he could have his head fully in the game at work.”

Competence

“After the shooting, I dreamed about being killed by friendly fire every night. I would wake up in a cold sweat. Because I was working undercover when I was shot and was in plain clothes, I would dream that the arriving officers would mistake me for the suspect, and I would die by friendly fire. The dream continued until I talked with someone and she told me “it’s your dream; have you ever thought of writing a new ending”. I thought that was ridiculous and I don’t like writing, but I like to draw. So I drew a new ending. After that, my nightmares diminished and when I would wake up, I would think about my new ending.”

Competence

“While responding, I was involved in an accident in which I struck a woman and she died as a result of her injuries. After I was cleared by Internal Affairs, I realized that I was feeling anxious about driving. My Sgt. met with me to create a transition back to duty plan. Together, we created a plan for my slow return to full duty. First, I did an EVOC refresher. Then I rode with another officer, then another officer rode with me while I drove, and finally I transitioned to driving alone again.”

Group Discussion

Confidence

Confidence Actions Rebuild

Confidence: When is it Needed?

Double-Edged Sword of Public Safety Ideals

Confidence: LE

“While responding, I was involved in an accident in which I struck a woman and she died as a result of her injuries. Although I was cleared by Internal Affairs, no matter how many times they told me that it was not my fault, I could not shake the guilt I felt. I kept beating my self up for “killing” her. The Lt. in Internal Affairs could see the beginnings of a moral stress injury and asked me if I would be willing to talk with a counselor. Through the conversation, I was able to see that there is a difference between “killing” (which implies intent) and being a part of unfolding circumstances that result in a death. There’s a big difference! That conversation helped me see the event in a different light. I also realized that this experience would make me a better officer. “

Confidence: LE

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“It’s about reframing. A traumatic event is like a tattoo. It hurts and it may stay with you forever, but you learn to live with it and after a period of time it won’t hurt as much. I try to use what I’ve learned from these events to help others.”

Confidence: Fire/EMS

“I give my crew members the message that you don’t take ownership of injuries or deaths unless you clearly stepped over the line. Did we do everything that could be done? If so, we did our job. We don’t control who lives or dies; our job is to provide the best service possible. If not, let’s do a hotwash and improve what we do the next time. We can learn something from every incident.”

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Confidence

“We have some important SFA procedures on our squad for building confidence, such as listening, being person-centered and being aware of how a person responds and when they are ready to respond. You have to start with assessment, give them time, get a sense of where they are and what is going on. It may not be a direct approach, but if you restore depleted resources, help them with what they need, rebuild a sense of purpose and hope and realize that each person will do it their own way, they can usually regain their footing and confidence.”

Group Discussion

Stress First Aid Group Format

SFA Group Format: Introductions

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Group Format Wrap Up

Stress First Aid �Wrap-Up�

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Key Point Emphasis

How Can You Use SFA?

Check

Approach

Decide what is most needed:

Anxiety

Guilt/Shame

Isolation

Calm

Competence

Grief

Severe Inability

to Function

Connect

Coordinate

Sleep

Problems

Cover

Confidence

Take Home Messages

• Stress as a continuum
• Four sources of stress injury
• Good leaders are the best medicine
• One size does not fit all
• If you see something, say something!
• Take care of yourself and one another!

SFA / Suicide Prevention Resource

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Pocketpeer.org

Online Trainings

fireherolearningnetwork.com

Resources

NCPTSD Police Officer Toolkit�https://www.ptsd.va.gov/professional/toolkits/police/index.asp

9/6/2022

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Vickie Taylor, LCSW�vtaylor@pwcgov.org

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Teach-back�Assignments

• Group 1: Intro/Stress Injuries
• Group 2: Stress Continuum/Check
• Group 3: Coordinate/Cover
• Group 4: Calm/Connect
• Group 5: Competence/Confidence

• 30 minutes each team
• Decide who goes when
• Keep it relatively equal

Stress First Aid �Trainer Tips

Stress First Aid Trainer Tips

• Pair up
• Plan more time for your first trainings
• Tell people your background and experience
• Use “I” and “we” versus “you” and “they”
• Explain:
• Why each action is important
• It's not important to implement all actions
• There is no particular order to implementing actions

Stress First Aid Trainer Tips

• Incorporate stories to illustrate points

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• Use humor

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• Find some research or statistics about the material

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• Keep examples and presentation material balanced  

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• Highlight points on slides rather than saying “you can read through that”

Stress First Aid Trainer Tips: �Big Picture

• Give a “topic sentence” for each slide

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• Change sides more frequently if audience looks distracted/un-engaged

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• Review key points at the end of each core action

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• Refer back to the big picture of the entire intervention frequently

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• Connect the dots between core actions regularly

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Stress First Aid Trainer Tips: Questions

• Use questions versus statements

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• Ask questions that are easy for the audience to answer

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• Give enough time for people to answer

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• After one person answers, check to see if others want to answer

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• Use cases/videos as a fallback or as a stimulus to discussion

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Stress First Aid Trainer Tips: Input

• Ask for audience input:
• If you run out of time
• If you are nervous
• If you are stumped by a question or forget what you want to say

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• Regularly ask trainees about obstacles to implementing the core actions/brainstorm solutions as a group

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• Elicit examples from the audience

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Stress First Aid Trainer Tips: Examples

• Give a big picture overview before you give personal examples

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• Pick personal examples that:
• Show how you got through a difficult times
• Highlight how SFA like actions have helped you

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• Set up your own personal story at the beginning/build on it as you go through the SFA actions

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• Highlight that there are:
• A lot of different SFA scenarios
• A lot of different ways to provide SFA

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Team Work

Team Work