First Response Resiliency

First Response

Resiliency

Philip Callahan, Ph.D., EMTP

Michael Wm. Marks, Ph.D., ABPP

Mike Grill, MS, NREMTP

2nd Edition

Copyright 2013© MMarksPCallahan

All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval system, without the prior written consent of the authors.

Smashwords Edition

Dedication

Stress is inherent and expected in a profession where life-and-death circumstances coupled with unpredictable and non-specific threats are customary. Mental health emerges as decisive to performance, retention, and quality of life.

First Response Resiliency originated from the Supportive Education Programs for Returning Veterans (SERV) resiliency-based curriculum developed for military combat veterans. The SERV curriculum comprises credit-bearing college-level courses addressing resiliency, learning-teaching, and leadership that were jointly developed through efforts originating from the Southern Arizona VA Health Care System and the University of Arizona. The SERV program has increased the retention and graduation rates of student veterans by improving their resiliency skills. Offering these same skills to police, firefighters, EMS workers, and other service personnel who confront traumatic life events will allow these individuals to better adapt and cope. Compassion fatigue is a part of working with trauma, whether it is on scene or the aftermath. By practicing the skills in this text, responders can have more satisfying, healthy and productive professional and personal lives.

Throughout our efforts we have been blessed with those who have supported and encouraged us: Jim Knight, PhD, Tony Lo Guidice, ABD NREMTP, Alice Packard, LCSW, Terri Riffe, PhD, Dean Gene Sander, PhD, and Robert Torres, PhD. A special thank you to Neil Atkinson, PE, for his extensive technical and editing support in the development of this text. You have been the caring community that has sustained us.

We also want to thank all of our scholars, whatever their background, whether they be veterans, firefighters, police or EMS workers. You have been our inspiration and as in any good mentoring relationship, we have learned far more from you. It has been an honor to serve those who serve us.

Finally, thank you to our partners, who have endured countless dinners as we talked about our work. Who have loved and supported us when we had to travel across the country, or spent numerous sleepless nights refining our work. Your belief in us has been our pillar. To say thank you can never be enough.

MM

Table of Contents

Introduction

1. Goal Setting

2. Eat Right

3. Exercise Might

4. Relaxation Chill Out

5. Sleep Tight

6. Perspective Views

7. Self-Defeating Thoughts

8. ABCs Point Out

9. Empathy

10. Wins and Losses

11. Reaching Out

12. Social Support

13. Make-It-Yourself Resiliency

Introduction

The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet.

--Rachel Naomi Remen, M.D.

What do we know about the first response community? The literature suggests that comparative measures such as the standardized mortality rate, accident injuries, and early retirement based on medical issues are higher than for the general population.1, 2, 3 Prolonged work related stress has been associated with mental health concerns. Indeed, a study found the five core areas where most officers fail are addictive issues, behavioral health, physical health, personality issues and family-relationships.4

The prevalence of Post-Traumatic Stress Disorder (PTSD) appears to be much higher for first responders than for the general population. PTSD is a mental/emotional disorder that potentially follows an event where an individual experienced a potential or actual loss of life or traumatic event that resulted in a sense of helplessness or horror. The regularity of these events, as evidenced in the work of EMS, police, firefighters, military, may be cumulative and add to the risk of PTSD. Finally, such risk factors as stress, mental health concerns, alcohol abuse, divorce or separation, and the presence of a firearm in the home all contribute to the potential of intentional self-harm and suicide.

Beyond the personal needs of responders is that of the community, particularly so in post-disaster psychosocial intervention. Although there are gaps in evidence-based practice, the literature currently emphasizes stress-resistant and resilient outcomes relative to promoting a sense of safety, calming, a sense of self and community, self- efficacy, connectedness, and hope.5 Responders, through their own practice of resiliency skills, have an opportunity to mentor not only each other, but their families and their communities as well.

At the community level, many institutions of higher education and advanced training provide supportive and even remedial academic preparatory classes to better equip students for the specific learning experiences that they will encounter. Yet, students are entering colleges with consistently high levels of stress.6,7 Stress has been conclusively shown to have detrimental effects on both academic outcomes and quality of life.8

Mission of this Text

Teamwork is foundational to responders. What affects one individual will likely have some impact on others and ultimately influence team performance. We believe those who agree to be in service to others need not suffer in isolation. Identification of risk factors and promoting individual well-being through education becomes critical to the success and evolution of you and your profession.

The goal of this resiliency program is to understand, assess, plan, and apply resiliency practices that manage stress in a manner that fosters professional excellence through personal development. Specific focus is on research-based resiliency methods and assessment, and the physical, psychological, and social systems of resiliency. Consistent with the research-based approach, inline superscripts and corresponding end-notes are used as references to source literature and research.

You will get out of this program what you put into it. Read the materials and implement and practice the skills, particularly that of social support.

Those who practice resiliency skills are better able to cope with the stressors that confront everyone. To become more resilient this program asks that you make a commitment to honestly explore your attitudes and behaviors that promote or hinder your ability to grow and learn. You may challenge long held beliefs about how you view yourself, other people and the world. There may be times where learning to become more resilient could indeed be both a very challenging and rewarding task. The hope is that you will log or journal your interaction with this material. Journaling is an effective tool in processing stressful life events and can assist in reducing the long-term negative effects of those events, both psychologically and physically. As an aid to your journaling, there are prompts throughout this entire text asking you to Reflect. Ultimately, resilient people come to enjoy challenges and opportunities to both learn and improve.

Presentation of Materials

There is a substantial body of research supporting resiliency. The skills presented here are representative of the research and we have attempted to recognize and cite the authors and studies supportive of these skills. We have also organized and presented these skills in a manner that is consistent with research and good practice. Because social support is so fundamental to resiliency, we encourage the learning of these materials in a setting where social interaction can occur and can be fostered into a social support system.

The following example is intended to provide a template for the delivery of the twelve resiliency skills. The template considers a setting where only a limited time can be provided to work with the skills. Each skill is therefore modularized so that it can be presented by itself or in conjunction with other skills as time permits. Each module can be introduced and explored in well under one hour and is therefore adaptable to limited time settings such as regularly scheduled meetings. The instructional design encourages extensive interaction and reflection in a learner-centered education format.9 The idea of reflection and problem solving is further encouraged through the use of Think-Aloud Pair Problem Solving (TAPPS).10,11 In the formal sense, two individuals perform TAPPS whereby one individual orally presents an idea and the other listens and offers feedback regarding the clarity and thoroughness of the idea. TAPPS aids in the development of analytical reasoning skills and encourages social interaction by allowing for the rehearsal of an idea thereby producing deeper understanding. Groups of three or even four can be effective in larger group settings or as a matter of convenience especially when a group intends to stay together as a long-term study-support group. Further, a whole-task approach is used to explore the skill in differing contexts to foster a more holistic look at the entire learning concept in an authentic manner.12

1. Review Prior Skills (0-5 minutes)

The attending group, as a whole, names the previously discussed skills and provides a very brief definition of each skill. The process of verbalizing key points of the prior skills improves retention, identifies functionally useful information, and situates a skill within the overall context of the skill-set.13,14

2. Introduction of the Skill (10-15 minutes)

The content component of the skill is presented as relevancy or Why the skill is important to personal resilience. The skill is then processed as a procedure or algorithm describing How the skill can be implemented. A case study is used to situate the skill and provide an example of how the case is translated into the skill algorithm. This is to promote relevant experiential learning.15 Using the Goal Setting skill, as in this example, is thus largely a process of establishing a case and applying the procedure. The Introduction of the Skill content component can be presented as trainer-driven or as a video.

Goal Setting Example.

Why: We set goals for ourselves each day, but we seldom think about the process we are going through as we establish goals. Purposefully setting goals allows us to mark progress and make adjustments.

How: Write the goal in a manner that you can measure the progress and fulfillment. The goal needs to be realistically attainable and measurable.

Identify the steps necessary to meet the goal. When all of the steps are completed the goal is satisfied. Develop as many steps as you need to identify key processes in attaining the goal. These steps or objectives can be refined to include details regarding the condition and degree necessary to satisfy the step. Consider checking-off each step as you complete it towards satisfying the goal.

Case Study: Consider the following example as to how to construct a goal statement and the steps necessary to meet the goal. A 22 year-old first responder intends to complete the resiliency program with two other first responders. As a group discussion and to familiarize ourselves with the Goal Setting worksheet, how might we develop a goal and the steps to meet the goal?

Identify the goal.

Goal: Complete resilience training within two weeks.

Identify the steps or objectives to meet the goal.

1st step/objective: Identify a study group.

2nd step/objective: Determine what needs to be completed.

3rd step/objective: Identify group study times and material to be covered.

4th step/objective: Make any adjustments to study times after meeting.

5th step/objective: Submit completed work for credit.

3. Internalize the Skill (5-10 minutes)

When knowledge is too tightly bound to context, transfer to different contexts is reduced.16,17,18 Therefore, to make the skills more useful, they are explored in multiple contexts. These might include reflecting, or internalizing, upon a past personal experience where the skill was used, or a current personal experience. The skill is then externalized by its application to another individual or community of individuals. Focusing on a past success using the skill, as well as the vicarious experience of seeing others’ successes with the skill, enhances the possibilities of improving upon one’s self-efficacy.19,20 Self-efficacy is most simply defined as the belief in one's capabilities to achieve a goal or an outcome.

Writing information related to the skill is encouraged. Expressive writing is one such technique that has been successfully used as the research suggests that addressing psychological concerns in writing produces psychological and physical health benefits.21

Goal Setting Example.

Use members in your group to assist you in the following exercise. Recall, in as much detail as possible, a past personal experience where you used Goal Setting to successfully address a situation. Complete the entries in the Goal Setting worksheet. The intent is to reflect upon a past experience in sufficient detail so as to complete all or as many of the entries as needed.

Identify the goal.

Goal:

Identify the steps or objectives to meet the goal.

1st step/objective:

2nd step/objective

3rd step/objective:

4th step/objective:

5th step/objective:

Reflect: What are the intrinsic motivators for achieving your goal? What are the extrinsic motivators for achieving your goal? What can you do to improve the likelihood of achieving your goal?

4. Externalize the Skill (5-10 minutes)

Recent literature suggests that expressive writing, which involves thoughts and feelings about a stressful life event, has greater perceived benefits and results in fewer days of activity restriction due to illness, especially when written in the third person.22 Writing is encouraged in this activity to aid in the clarification of thinking and to become familiar with the skill methods. Exploring the skill in a problem-based learning setting is desired as support can be provided by others in the group.23

Goal Setting Example.

Your immediate goal is to develop a team that can provide resiliency and academic support to its team members to assure completion of all resiliency skills. This team also needs to assure that you complete the resiliency skills not covered in the workshop. Identify key steps to developing a successful team that can provide resiliency and academic support to its team members. Use Think-Aloud Pair Problem Solving (TAPPS) collaborative groups of two or three individuals to develop a goal statement and the steps needed to complete the goal.

Identify the goal.

Goal:

Identify the steps or objectives to meet the goal.

1st step/objective:

2nd step/objective:

3rd step/objective:

4th step/objective:

5th step/objective:

Reflect: What are some key elements to developing a successful team? How can this team assure that you are resilient? How can this team assure it is maintaining its own resiliency?

5. Review the Skill (5 minutes)

Review of the skill certainly allows for clarification, but also addresses self-efficacy. Thus, one needs to be mindful to provide credible communication and feedback in both the class and within your group to diminish stressful situations.24,25

Goal Setting Example.

Upon reflection and discussion, what consensus did you arrive at when applying the skill? Internalized or externalized, is there need for clarification or further discussion?

6. How to Effectively Remember this Skill (5 minutes)

Whereas internalizing the skill is intended to be backward-looking or reflective of a past successful experience, the homework explores the skill in the context of a current personal situation. Ideally, exploring the skill in a problem-based learning setting allows one to recall past learning. Support is provided by others in the study group so as to assure some degree of success in completing the skill.26

Goal Setting Example.

As homework, consider how you would best incorporate the concept of Goal Setting into the lifestyle you are currently pursuing. Specifically, develop a Goal Setting worksheet for a current issue you are facing.

7. Additional: Externalize to a Community (Variable)

The intent of this exercise is to begin to consider the application of the skill to others in the sense of a community. While there is little expectation that this can be fully developed in the class setting, it is intended to provoke further thought on the usefulness of the skill to others. The freeform nature of this exercise presents an intended contrast to the more algorithmic approach of some of the other exercises so as to foster self-efficacy and problem-based learning. 27,28

Goal Setting Example.

A goal is often defined as a projected state of affairs that a person or a team plans or intends to achieve. What are the implications of expanding this skill to a community? Community is defined as any group of people living and/or working together in one place. For example, a community could be a team, department, family, neighborhood, town, etc. Consider the following discussion points as we define the community where:

1.You are intending to apply the skill,

2.Why this skill is appropriate, and

3.How the skill will be administered.

Reflect: What are some key elements to developing a successful community or team? How can this team assure that you complete all of the resiliency skills? How can this team assure that you are resilient? How can this team assure it is maintaining resiliency?

8. Summarize the Skill (5 minutes)

This summarization is intended to provide a further review of the skill in the event questions arise following earlier exercises. Additionally, some emphasis is placed on the idea of mentoring and demonstrating the skill to others. The intent is to build one’s sense of self-efficacy.

Goal Setting Example.

What is important to you about Goal Setting?

9. Skill Poster

Create a screen saver or post a Goal Setting Skill Graphic in an area that permits individuals to review the contents and memorable quotes. The process of review permits one to better rehearse and remember the skill.

Recognizing that the goal of this resiliency program is to understand, assess, plan, and apply resiliency practices that manage stress, the skills presented are representative of evidence-based educational and resiliency practices recognizing, where possible, both seminal and current research.29,30

Notes

1. Richard