Category: Traumatic Stress

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Forewarned is forearmed: First Responders and Traumatic stress

The ancient Latin saying, ” Praemonitus, praemunitus,” later in 16th century England became “Forewarned is forearmed” can apply to a wide variety of situations. For this post I’ll be discussing the importance for first responders to learn about the potential dangers of their work to their mental health.

Before I begin it is important to note that each individual will process their experiences differently. Not everyone who is exposed to a traumatic event will end up with a traumatic stress related injury. Advance knowledge of Post Traumatic Stress Disorder (PTSD) and related disorders can help first responders help themselves and their co-workers.

Post Traumatic Stress Disorder (PTSD) is fully explained on the website of the National Institutes of Mental Health. I encourage all first responders to read the information on their site.

For the purpose of this entry I share the criteria the NIMH list on their site for a diagnosis of PTSD below. In the last paragraph the BOLD type was added by me for emphasis:

“To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:

  • At least one re-experiencing symptom
  • At least one avoidance symptom
  • At least two arousal and reactivity symptoms
  • At least two cognition and mood symptoms

Re-experiencing symptoms include:

  • Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
  • Bad dreams
  • Frightening thoughts

Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms.

Avoidance symptoms include:

  • Staying away from places, events, or objects that are reminders of the traumatic experience
  • Avoiding thoughts or feelings related to the traumatic event

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

Arousal and reactivity symptoms include:

  • Being easily startled
  • Feeling tense or “on edge”
  • Having difficulty sleeping
  • Having angry outbursts

Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

Cognition and mood symptoms include:

  • Trouble remembering key features of the traumatic event
  • Negative thoughts about oneself or the world
  • Distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Cognition and mood symptoms can begin or worsen after the traumatic event, but are not due to injury or substance use. These symptoms can make the person feel alienated or detached from friends or family members.”

It is natural to have some of these symptoms for a few weeks after a dangerous event. When the symptoms last more than a month, seriously affect one’s ability to function, and are not due to substance use, medical illness, or anything except the event itself, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.“

I added the bold type above to emphasize the fact that feeling off or experiencing any of the reactions listed above immediately after a traumatic event is normal. The phrase often used is, “It is normal to feel abnormal .” If the reactions do not lessen after a month or so, that is a sign to seek additional support from a therapist or doctor.

First responders, like service members, often hesitate asking for help. No one wants to be taken off of active duty, or to say they are struggling. Fortunately in the military great strides are being made in de-stigmatizing asking for and seeking help. Due to increased awareness of suicide rates among first responders, steps are now being taken by public safety administrators to increase peer support programs and enhance employee assistance programs. More work need to be done in this area.

Administrators of public safety departments need to lead in the realm of education on mental healthcare for their department.

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Dealing with the Stress of COVID-19

The old dock behind the old boathouse on the campus of The Citadel, in Charleston, SC. My favorite spot on campus. I have a copy of this tranquil place by my desk.

We seem to be stuck in some strange combination of the movies Pandemic and Ground Hog Day. If you are like me, days of the week don’t mean anything any more. While I like my quiet time, I am really ready to get out and be social again.

I know quite a few people who are feeling very unsettled with what has become our new normal in the time of COVID-19 self-isolation. There are very good reasons to feel anxious and stressed right now. My friends and family in New Jersey have many friends who are very ill or who have died. Our news and social media feeds are filled with updates on confirmed cases and death tolls.

There was a time in my life where I experienced a lot of loss and change in a very short period of time. I began to show signs of heart trouble. My left arm would go numb and I had chest pains. After being thoroughly checked out by a cardiologist, the determination was I was experiencing a stress reaction to the events in my life. I began my quest to learn all I could about stress, anxiety and the affect on our bodies. If you find it hard to get out of a loop of worry and anxiety I am going to share a few coping strategies I learned that you may find helpful.

Our minds are amazing things. Our thoughts are very powerful. Have you ever had someone describe the taste of a lemon? The thought of the very sour taste of a lemon can lead you to pucker your lips. Have you noticed that after watching a commercial about a certain food or beverage you suddenly have a craving for that food or drink? You end up with a physical craving for something that started with your thoughts.

When we hold a concern or a worry in our mind we often experience a physical reaction. Unfortunately most of us do this and aren’t aware of where we are holding stress in our body. We go from one activity to another holding a worry in our mind and having a physical reaction in our body that we just ignore. For me I held a lot of stress in my gut, but also in my shoulders. To combat this stress I had to become more aware of when I felt it. Like many people, I would worry or get upset about things I had absolutely no control over. I had to slowly learn to control what I could and let go of what I couldn’t. I called this state of being stressed my “What if” side of my brain. My self dialogue would go something like this:

“What if my husband gets that job in Texas he is looking at? We would have to move. The kids would have to change schools. Will I fit in there? What if I can’t find a job?”

I would get worked up over something that may or may not happen. As it turned out my husband didn’t apply for the position. That was a lot of emotional energy spent on something that never happened. Most of our worries are that way. We get worked up over something that we have little control over.

So how to you live with ambiguity? Learn to live more in the moment and not in the “What if” side of your brain. Using a grounding exercise can help you learn how to live in the present. The following exercises help you get from the abstract “what if” the present situation using your senses to bring you into the present moment. So much of our anxiety and stress comes from how we think of something. Slowing down those abstract thoughts with concrete tactile exercises helps us realize we are actually OK.

A popular grounding exercise is the 54321 grounding exercise. You can find several methods online. The exercise involves using your 5 senses. The Mayo Clinic Health System website suggests the following method. Visit their website for additional tips:

Everyone feels anxious now and then. But there are things you can do to minimize those feelings. Mayo Clinic Health System staff suggest trying the exercise below the next time your mind is stuck on the worry setting.

Sit quietly. Look around you and notice:

  • 5 things you can see: Your hands, the sky, a plant on your colleague’s desk.
  • 4 things you can physically feel: Your feet on the ground, a ball, your friend’s hand.
  • 3 things you can hear: The wind blowing, children’s laughter, your breath.
  • 2 things you can smell: Fresh-cut grass, coffee, soap.
  • 1 thing you can taste: A mint, gum, the fresh air.

This exercise helps you shift your focus to your surroundings in the present moment and away from what is causing you to feel anxious. It can help interrupt unhealthy thought patterns.

See the blog post, “Stress Relief: The four A’s” by Alan Conway, MD for another helpful list of ideas to help you ease and reduce stress.

Most stress relief and anxiety relief methods involve being present in the moment. In moments of stress really helps me to take a quick safety inventory. I ask these questions, Am I physically safe? Am I getting the nutrition I need? Am I getting the sleep I need?If the answer is no to any of these questions, that is what needs to be addressed in the moment.

Some simple things you can do in your work space whether it is at home or at an office:

  • Keep a pretty landscape photo in your work area
  • Have a simple rhyming verse or poem nearby to read. See this link for a few options
  • If possible listen to calming music. My current favorite is Bach for the Brain!
  • Listening to the sound of water, like a fountain, river, ocean are shown to have a calming affect. If you don’t have natural water running near you, taking a shower can be helpful. To see this calming affect in action watch small children by an outdoor fountain. They are naturally drawn to them while their parents would walk right by.
  • Unless you are required to wear one, take off your watch. We often stress ourselves over the passage of time. If you want to know the time our phones, computers, and office space usually have clock functions. Glancing at your wrist every few minutes is not helpful. (I stopped wearing a watch in my early thirties.)

If sleep is hard for you, try keeping a journal. Each night before you go to bed, take out your notebook and write down everything you are thinking about. If you find you are caught in the same thought “loop” and can’t move on, write down what you are thinking about in detail. There is great relief in writing down your worries then tearing up the paper and throwing it away. If you have a safe way to do it going outside and burning the paper offers another great release. In the past I’ve had to do that a few times before my thoughts would no longer linger on a negative topic.

Physical exercise is a great release of tension. It can be as simple as talking a walk, outside if possible. Being outside in the sun is also very therapeutic. There is a very helpful organization called Yoga for First Responders. Yoga can help you physically and mentally. Practicing yoga can also help you sleep better.

Social nutrition is a term I learned from Dr. Jonathan Shay, a renown scholar and mental health practitioner. We were attending a conference and I heard him explain how one heals from a traumatic event is determined by the social nutrition a person has around them. He went on to say if a soldier has a mortar wound a big factor in healing that would is the nutrition that person takes into their body. He continued by saying when a person has a psychological wound a big factor in their healing is the social nutrition they have around them. Do they have a supportive family? A group of friend they can talk to? When we talk about our stressors it actually helps us heal the wounds, like intrusive thoughts, that we carry.

I hope you find this information helpful. If I may be of service to you or your organization by leading a workshop/didactic on stress relief, compassion fatigue, or self-care, please send an email to dorie (at) dorielgriggs (dot) com

For further study:

Basics of Compassion Fatigue – A helpful guide to teaching/learning about Compassion Fatigue. Available on the website for the Figley Institute

Gift From Within webcasts and resources on a variety of related issues.

Disclaimer: This website is for information purposes only. By providing the information contained herein we are not diagnosing, treating, curing, mitigating, or preventing any type of disease or medical condition. Before beginning any type of natural, integrative or conventional treatment regimen, it is advisable to seek the advice of a licensed healthcare professional.

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What is Traumatic Stress

Thanks to the public information campaigns of a number of organizations supporting veterans the term PTSD, or Post Traumatic Stress Disorder is now widely known. After almost 20 years of learning and lecturing about PTSD I have learned that while the name is well known there is still very little general understanding of the criteria a person has to meet to be given the diagnosis of PTSD.

Several years ago a chaplain friend of mine asked me to speak to the oncology department at his hospital. The topic was traumatic stress and self care. The nurses attended the didactic thinking they were there to learn how to care for their patients who may be traumatized. What my friend guessed and what I learned after this experience is that some of the nurses experience and struggle with the traumatic events they deal with in the course of their work.

What I wrongly assumed is that medical professionals would know and understand the toll their work takes on them personally, they did not. That lecture led to an invitation to another conference of medical professionals. In the three years I’ve served as a chaplain for the Roswell Fire Department I’ve had conversations about traumatic stress with our public safety employees in the fire, police and 911 dispatch areas. Many know their jobs expose them to trauma, but few know what it takes to meet the criteria for a PTSD diagnosis.

For a comprehensive explanation of PTSD you should read through the National Institute of Mental Health web page on Post Traumatic Stress Disorder. In summary there is a list of conditions that must be present to meet the criteria for a diagnosis. After experiencing or witnessing a traumatic event it is normal to feel unsettled, upset and have trouble processing the experience. If after a month or two after an event, or after responding to a number of disturbing events in the case of public safety personnel, you are struggling with symptoms that interrupt your normal ability to function, you should seek help from a professional trained to diagnose and help people who experience traumatic events.

Much has been done in this field the past 20 years. Therapies have shown to greatly reduce the symptoms of traumatic stress and allow the person with the diagnosis to function at a very high level. There is such a high success rate that professional in the field are working to change the name from Post Traumatic Stress Disorder to Post Traumatic Stress Injury. The word disorder has a connotation that it is a pre-existing condition where as the word injury more correctly fits the symptoms since we now know people can recover and heal from their experiences. In a letter to the American Psychiatric Association, Drs. Frank Ochberg and Jonathan Shay outline their reasoning for the change from disorder to injury. I encourage you to go to the website, Post Traumatic Stress Injury, and read through the various links.

I do need to mention that I look to Dr. Ochberg and Dr. Shay as mentors in the field of traumatic stress. I had the opportunity to meet both in 2003 at the International Society of Traumatic Stress Studies. Both are very generous with their time and knowledge and helped me learn early after I graduated from seminary about traumatic stress and related diagnosis. I have had the opportunity to attend a few other meetings over the years with both doctors, and others like Dr. Charles Figley who wrote the book on Compassion Fatique. You will note several resources on the Resources for First Responders entry are related to these three doctors.

For an easy to understand, and listen to, webcasts about PTSD and related topics, see this webpage from Gift From Within .

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Relieving stress: Push ups or coloring books

A recent article in the Free Beacon caused an uproar among cadets and graduates of senior military colleges. The author of the article wrote about the practice at VMI of offering exam time stress relief activities. One of the activities open to the students is the use of coloring books. The idea that future military officers would be encouraged to use a typical childhood activity was offensive to many who read the article. Social media lit up the day the article was published and days later it si still being discussed.

As a former chaplain resident at the Atlanta VA Medical Center I found the negative comments around this activity offensive. Art therapy is a recognized modality to help veterans who have a diagnosis of Post Traumatic stress disorder and related anxiety issues. Coloring sheets were readily available and used by the veterans on the psychiatric floor.

In July 2016 Jeremy Ramirez, BS, MPH-C wrote, A review of Art Therapy Among Military Service Members and Veterans with Post-Traumatic Stress Disorder for the Journal of Military and Veterans’ Health Volume 24 No. 2 His conclusion after reviewing the various modalities to help veterans including Cognitive Behavior Therapy (CBT) is:

Challenges of military service should be met with a supportive culture that is open to implementing art therapy as a treatment modality in addition to current evidence-based practices. This review suggests that if current service members and veterans were placed into art therapy programs as early as possible after being diagnosed with PTSD, they would be at less risk for developing greater PTSD symptom severity. The preferred method of treatment for patients with PTSD receiving care in the VA healthcare system is CBT, however, since CBT is effective in treating only two of the three symptom clusters, it is an incomplete care package. Given the effectiveness art therapy has in treating the third symptom cluster, it is not meant to replace CBT, but rather it is meant to be offered in addition to CBT in order to produce a more comprehensive care package for past and present service members with PTSD.

I have to wonder why anyone would object to future military officers learning proven techniques to help deal with stress which could eventually help lower the astronomical suicide rate of our veterans. Physical activities like push ups (#22PushUpChallenge) are acceptable but other methods to raise the awareness and/or to teach stress relief are put down. To help prevent suicides early lessons in stress relief a destigmatizing getting help are key.

Putting down efforts to help with stress only adds to the negative stigma already prevalent for mental health issues.

I think I’ll go color now. . .

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Advice from Dr. Frank Ochberg to Military Moms

I recently joined the Facebook group Army Moms. It has been helpful to read the posts of the members and learn what life is like when your child is deployed. The posts about returning soldiers are usually very upbeat, but one recent post hinted at the struggles the returning soldier is having with the things he saw and experienced while deployed.

For the past 10+ I’ve studied traumatic stress, but as my own son approaches his deployment to Afghanistan, I read these posts with a different eye than I did when I began to study trauma.

Some days I fight the lump in my throat and the tears that are sure to follow. On an intellectual level I understand that feeling abnormal after a traumatic event is normal. I know there are many wonderful therapists and doctors in the field to help our returning soldiers. I also know the terribly high suicides rates of our veterans. I know these brave warriors hesitate to ask for help when they return and struggle with thoughts that haunt them, and nightmares that live within them.

And I know that I am a mom of a soldier that needs to use all the strength I can muster to support my son.

Dr. Frank Ochberg, a psychiatrist and one of the founding fathers of modern psychotraumatology, is one of my mentors in the field of traumatic stress studies. I wrote to him after reading the heart wrenching post from the Army mom asking for help with how to support her veteran son.

Dr. Frank Ochberg addresses a session at the annual meeting of the Society of Professional Journalists.

I had already posted links to the National Center for PTSD and the nonprofit Gift From Within and wanted to know if he had any other helpful resources to recommend.

As always Frank wrote back with a very thoughtful response. His letter is one that all military families need to read BEFORE their soldier returns home. Military families need to do research before their soldier returns. The family should know the local resources available and the online resources so that when their soldier returns home the process of adjusting is understood.

Dear Mom of a young Service Member,

 We’re all in this together and it is good to realize that we have a large family of parents, friends, advocates, therapists, clergy, and others who care.  When your son says to you, “You don’t want to know,” I assume he is looking out for you.  He wants to spare you the images and the sounds and the smell of the place.  I’d thank him for that.  It is considerate of him.  And it doesn’t mean he thinks you are fragile.  Many of my patients, including those who know that I have heard hundreds and hundreds of trauma stories, try to spare my feelings.  They don’t want me to hurt for  them, and they don’t want to spread the horror that they have witnessed. When it feels appropriate, I might explain that I have learned how to listen without becoming damaged.  But it’s a fine line.  I can’t say I’m unaffected. I don’t want to suggest that these experiences are less profound and terrible than they really are.  So step one, I’d suggest, is to express gratitude for his kindness and caring.

 It is good for your son to have a person who can hear him out, a buddy or an older person who understands.  Odds are he already has such a person in his life.  You’ll feel reassured if you know that this relationship exists, and is being used appropriately.  He may be willing to let you know.  I’m very interested in the natural friendship network of my patients, and I do try to nurture good, supportive connections.  Not too long ago, I had two Marines come for sessions together. One was married, the other wasn’t.  There was a strong bond between the two.  They let it all out in front of each other and in front of me.  They kept most of this away from their closest family members –certainly their Moms. One had a military Dad and there was some sharing with him, but not all the detail.

 We have good evidence to suggest that Service Members who have “seen some really bad stuff,” as your son reports, do best when they use normal networks to sort out their feelings.  There is no need to think about mental heath professionals until and unless serious signs emerge.

These serious signs include nightmares and flashbacks persisting at least a month.  They include serious drinking and drugging.  They include shutting down and walling off from others so that family life and school or work are imperiled.  They include shifts in character to an alarming extent, including dangerous outbursts of anger.  Usually, this state of affairs can be avoided through peer support and healthy activity.  But exposure to deadly conflict can produce PTSD, depression and substance abuse.  So learning about those conditions is useful, for you, Mom.

Here is a page I have helped create. There are many, many more. Just go to Google, put PTSD Info in the subject line and have look.  Sharing insights and concerns with others in the military support network is useful, too.

 If your son does change his mind and chooses to tell you about his “bad stuff,” listen actively.  Don’t interrupt and don’t rush to reassure and comfort too quickly.  Here’s a good link on “active listening.” It isn’t easy to picture your son in harm’s way, or to realize that he may have been involved in lethal activity that causes him feelings of guilt and grief. I try not to say, “You have no reason to feel guilty,” or words to that effect.  I might say, “Feeling guilty is the burden of having a good character, a conscience.”

After some painful memories are shared, it helps to move to other topics.  But never too abruptly, giving the impression that you have heard enough and want to close him down.  It’s best for him to set the pace and the duration.  It’s best not to interrupt.  In a therapy session, I have to establish a time limit. So I do change the subject well before the end of the hour.  I ask about exercise or friends or family.  I lighten the subject, but keep it relevant.  You could do that, too, if the time together must end soon.

 Everyone is different, so there are few hard and fast recommendations.  You do want your son to feel comfortable being with you, knowing you love him, and trusting that you will honor his private experience of profound reality. You’ll know you are on target when he tells you, little by little, what he wants you to know.  You’ll know you are on the right track when the two of you have fun together.  You’ll know all is well as you see him move through those stages of transformation into adult life, with an occupation, a family, and friends who care.

Frank M Ochberg, MD

Frank

Most people do the equivalent of closing their eyes and hoping they never have to deal with the scarier parts of post deployment life. As hard as it may be to read some of the materials, being knowledgeable of the signs to look for, and how to best support your returning soldier , you can make the transition to civilian life easier for the soldier.

Additional resource links follow:

PTSD 101

Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury

Military Family Network

Betty Clooney Center

About Face – “Learn about post traumatic stress disorder (PTSD from Veterans who live with it every day. Hear their stories. FInd out how treatment turned their lives around.”

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Welcome to my new blog

Welcome

For the past 9 months I’ve contributed to the blog, Off the Base, a project of Bobbie O’Brien of WUSF.  Bobbie and I met at the Carter Center in 2010 at a series of meetings focusing on our returning veterans and Mental health issues. Bobbie is a Fellow with the Rosalyn Carter Mental Health Journalism Program. I attend the meetings as an observer.

Since graduating from Columbia Theological Seminary in 2002 I’ve research traumatic stress. When I met Bobbie my oldest son was a junior at The Citadel, the Military College of South Carolina, and an Army ROTC cadet. She asked me to contribute to Off the Base as the mom of a cadet at a military college and the mom of a future officer in the U.S. Army.

I turned her down at first because as I told Bobbie at the time, “I’m not a writer.” I majored in public speaking at the University of Richmond and would rather speak to a thousand people than write an article. I thought about her offer overnight and agreed to do it the next day. To grow you really have to push yourself into uncomfortable positions.

While I will still contribute to Off the Base, there are topics that are of particular interest to me that won’t fit into their mission. I’m glad you visited the site and hope to hear form you.