(introduction...)

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Introduction

1. Stress is a feature of life which can be both protective and harmful. Unfortunately "stress" is too often viewed in a negative context when, in fact, it enables us to cope with change. Protective stress is part of a natural process - when threatened, the body always reacts with the same general adaptive mechanisms. The physical symptoms that occur when we are under stress enables us to "flee" or "fight" the threat. This response is a basic life protecting mechanism, enhancing physical and mental defences and preparedness - it focuses attention, and mobilizes the energy and resources necessary to be able to take appropriate action. Stress therefore allows us to remain productive even in the face of changing and challenging situations. Stress reactions are dependent on our personality, our professional experience and our physical and emotional well-being.

In an emergency, reactions to stress are normal.

2. However, when the circumstances inducing the stress are excessive, very intense or continuing over a period of time, stress may begin to negatively affect an individual's personality, health and ability to perform.

3. Stress takes up an enormous amount of energy. Being in a stressful situation is physically and mentally exhausting. However, once out of the crisis environment and given time to rest, people usually recover their normal equilibrium.

4.

Understanding normal reactions to stressful situations, knowing how to handle these and early attention to symptoms can speed recovery and prevent long-term problems,

Identifying Stress Symptoms

5. Emergency personnel are exposed to many types of stress and what is needed is to have the "ideal" level. Too little causes boredom, lack of stimulation and fatigue, too much and we become overwhelmed physically and mentally. The names given to the harmful types of stress are cumulative stress and traumatic stress.

Cumulative stress

6. Cumulative (or chronic) stress builds up slowly as a result of the magnitude and multi plicity of demands, lengthy working hours and daily frustrations and difficulties of living and working in emergencies. Because stress reactions develop so slowly and imperceptibly it is quite often difficult to notice them in oneself, they are, however, usually noticeable to close colleagues.

Once removed from a stressful situation and with the possibility for rest and relaxation, a person generally recovers quickly and may become aware of the difference in how one responds to situations when one is not experiencing stress.

Individuals in emergency work, who are experiencing high stress levels, are not the best judges of their own ability to cope.

Team leaders need to be particularly observant of individual reactions during an emergency.

7. Symptoms of stress can be physical and psychological. There could be changes in ordinary behaviour patterns, such as changes in eating habits, decreased personal hygiene, withdrawal from others and prolonged silences. Symptoms of cumulative stress can be seen in every facet of our lives. The following non-exhaustive list gives an indication of some of the most observed symptoms:

Physical symptoms:

i. Gastro-intestinal

Dry mouth, impression of having ones heart in ones mouth, nausea, vomiting, sensation of bloating, heartburn, abdominal pain, appetite changes diarrhoea, constipation;

ii. Cardiovascular

Elevated blood pressure, rapid heart beat, hot flushes, cold hands and feet, sweating;

iii. Respiratory problems

Breathlessness, panting, sensation of not being able to breathe;

iv. Musculoskeletal

Cramps, back pain, trembling, nervous ticks, grimacing;

v. Neurological

Headache.

Psychological symptoms:

i. Emotional Anxiety, anguish;

ii. Behavioural

Sleep problems, abuse of cigarettes alcohol or drugs, modification in ones libido;

iii. Intellectual

Concentration difficulties, memory difficulties, problems with reasoning and verbal expression.

8. The presence of several of these symptoms may mean that a person's coping ability is diminishing and work performance is being affected. However, the signs and the degree of stress presented by a person in any given situation will vary, depending on the level of stress experienced, previous emotional experiences and the personality of the individual.

9.

If the cyclic causes and resultant symptoms of cumulative stress are not promptly addressed, exhaustion sets in, leading eventually to "burnout". Should this happen one needs rest and counselling.

Traumatic Stress

10. Traumatic stress is brought on by unexpected and emotionally powerful events ("critical incidents") that overwhelm the individual's usual coping abilities. Critical incidents may arise in the context of a major disaster or emergency, and could be, for example, injury or death of a colleague, hostage taking, deaths of children, undergoing great personal risk, being a powerless witness of violence, or seeing or being associated with a tragic event accompanied by intense media coverage (especially if this is inaccurate).

11.

Staff might experience acute reactions during a critical incident or a delayed stress reaction minutes, hours or days after the event. In rarer cases reactions may come after a few months or years.

12. The reactions after a critical incident can resemble those of cumulative stress but they can be much more pronounced. Vomiting instead of nausea as an example. The following are mental survival mechanisms that allow us to deal with the event:

Emotional numbing, changes in the perception of time, along with a sense of ones live flashing before ones eyes, highly focused attention or tunnel vision, hyperarousal with sharpened senses.

These initial responses can be replaced in the period of time immediately after the incident by:

Hyperactivity, exaggerated humour, argumentativeness, social withdrawal, fear, anxiety, sadness, grief, memory problems, poor concentration, slow thinking and loss of perception in addition to the physical symptoms mentioned above.

13.

It should be emphasized that these symptoms are normal reactions to abnormal events and in most cases will disappear.

14. However, occasionally a serious condition termed Post Traumatic Stress Disorder (PTSD) can result from critical incidents. The risk of PTSD can be considerably reduced by preparation, on-site care, and post incident defusing or debriefing.

15. The diagnosis of PTSD is made by a psychiatrist or psychologist based on the presence of various elements which include:

i. Invasive memories (flashback);

ii. Nightmares and sleep disturbance;

iii. Repeated reliving of the event;

iv. Detachment;

v. Avoidance of trigger persons or situations;

vi. Hyperarousal;

vii. Anxiety, depression, grief, anger;

viii. Suicidal thoughts;

ix. Reactions intensifying over time;

x. Clear alteration of personality;

xi. Withdrawal from others;

xii. Continued rumination about event;

xiii. Constant expectations of a new disaster;

xiv. Persistent sleep difficulties;

xv. Total absence of reactions;

xvi. Phobia formation;

xvii. Reactions continuing for 3 to 4 weeks.

Techniques for dealing with Stress

Preventing and Minimizing Harmful Stress

16.

It is important to recognize that it is impossible to take care of others if you do not take care of yourself.

17. Being well prepared, both physically and psychologically, is an important way to reduce the chances of harmful stress. This preparation not only includes understanding stress and how to handle it, but also educating oneself in advance on the living conditions, job, likely problems, local language and culture. It is important to be both physically and psychologically fit to work in a particular situation.

18. To prevent stress overload during an emergency, firstly, know your limitations. In addition, there are several practical steps to take:

i. Get enough sleep;

ii. Eat regularly;

iii. Control intake of alcohol, tobacco and medicines;

iv. Take time for rest and relaxation;

v. Take physical exercise. Physical exercise releases tension and helps maintain stamina and good health (any sort of exercise for at least 20 minutes per day). Beneficial exercise for stress reduction also includes deep breathing and muscle relaxation exercises;

vi. Give expression to the stress: Put words to the emotions you feel - find a colleague whom you trust to talk with;

vii. Keep a diary, it may not be as effective as talking, but it can help.

The expression of emotion has proved to be an effective technique in reducing stress.

19. Other ways of reducing stress are:

i. Inward coping: When a person performs difficult work in physically and emotionally threatening conditions, internal dialogue can add to the stress if it is highly negative and self-critical. To remain focused on the task, avoid unhelpful internal dialogue such as, "I'm no good at this. Everything I am doing is making things worse". Instead make positive helpful statements to talk oneself through difficult moments. For example, "I don't feel like dealing with this angry person right now, but I have done it before, so I can do it again";

ii. Peer support: Use the "buddy system": staff members may agree in advance to monitor each other's reactions to identify signs of excessive stress and fatigue levels;

iii. Setting an example: Supervisors in particular have an important role to play as they can provide an example in the way they handle their own personal stress, e.g. by eating properly, resting and taking appropriate time off duty. The team leader who tells a colleague, "Remind me to eat, and get me out of here the moment you notice any sign of fatigue. I'm no good when I'm tired", is setting a positive example for the staff;

iv. Permission to go off duty: In a crisis many staff members need to be given permission to take care of themselves. People do better in difficult situations when they feel that other people care about them. Team leaders are responsible for giving such specific permission to themselves and to their staff, for example, by giving permission to take the afternoon off, etc. The correct use by staff members of Mars and Vari can serve to alleviate stress.

Dealing with Critical Incidents (Traumatic Stress)

20. Stress defusings and debriefings are ways of protecting the health of staff after crises. The person or people who experienced the critical incident talk about the incident, focusing on the facts and their reactions to it. They should take place in a neutral environment, and never at the scene of the incident. They should be led by a trained professional. The information given below is intended to illustrate these processes and does not give sufficient detail to enable an unqualified person to perform either a debriefing or a defusing.

Defusing

21. Defusing is a process which allows those involved in a critical incident to describe what happened and to talk about their reactions directly after the event. A defusing should take place within a few hours of the event, its format is shorter than that of a debriefing. It consists of three steps:

i. Introduction

Introduction of everyone present, a description of the purpose of the defusing, and stimulation of motivation and participation;

ii. Exploration

Discussion of what happened during the incident;

iii. Information

Advice to the participants about potential reactions to the incident, guidance on stress management, practical information, questions and answers.

Confidentiality is important. It should be possible to express strong emotions, secure in the knowledge that this will stay within the group.

22. Angry feelings can be a normal reaction to an upsetting event and staff should be able to "let off steam". This is not the time for criticism of professional performance - this should be dealt with at a separate meeting.

Critical Incident Stress Debriefing (CISD)

23. In cases where staff have to deal with intense distress, defusings may be insufficient and need to be followed by a formal debriefing from a mental health professional. Debriefing is a process designed to lessen the impact of a critical incident. It occurs in an organized group meeting and is intended to allow those involved in a critical incident to discuss their thoughts and reactions in a safe, non-threatening environment. The team leader or a responsible member of the emergency team should request the Division of Resource Management at Headquarters to provide or help identify a mental health professional to conduct a debriefing. Sessions are normally held for groups of staff having undergone intense stress. They aim to integrate the experience, provide information on traumatic stress reactions, and prevent long-term consequences including Post Traumatic Stress Disorder, and help staff manage their own personal reactions to the incident.

24. If a debriefing or defusing is not offered spontaneously after a trauma is suffered, request one. Information on individual consultations for UNHCR staff members and workshops on stress related issues can be obtained from the Staff Welfare Unit, HQ Geneva.

Telephone: 00 41 22 7397858

Confidential Fax: 00 41 22 7397370

Key References

An Operations Manual for the Prevention of Traumatic Stress among Emergency Services and Disaster Workers, Jeffrey T. Mitchell and George Everly, Elliot City Maryland, 1995.

Coping with Stress in Crisis Situations, UNHCR, Geneva, 1992.

Humanitarian Action in Conflict Zones - Coping with Stress, ICRC, Geneva, 1994.

International Handbook of Traumatic Stress Symptoms Edited by John P. Wilson & Berverley Raphael, 1993.

Managing Stress, Terry Looker, Olga Gregson, London,1997.