April 14, 2021

How to apply stress first aid during crisis

In part 1 of this series, we learned about four types of stress we can face during times of crisis. If left unchecked, these stressors can eat away at our physical, mental, and emotional reserves and eventually put us at risk for stress-related illnesses like PTSD, substance abuse, clinical anxiety, and clinical depression.  

The world is still reeling from one crisis: COVID-19. McKinsey & Company has reported on the pandemic’s economic impact across multiple industries, including restaurants, banks, education centers, auto makers, insurers, and healthcare systems.

Caring for Workers in Crisis: How to apply Stress First Aid

Illustration by Pamela Coburn-Litvak

Since I specialize in coaching healthcare leaders, I’m paying close attention to crisis guidance provided by the American Medical Association. In this article, we are ready to move on to intervention step #2: applying Stress First Aid (SFA).

How do we know what SFA to apply during a crisis? Research teams headed by Dartmouth psychiatrist Patricia Watson have worked out the answer: figure out what has worked for those in high-stress and high-risk jobs like the military, fire and rescue, and law enforcement, and then apply those principles to other workers in crisis. In 2020, Dr. Watson worked with her colleagues William Nash of the United States Marine Corps and Richard Gist from the Kansas City Fire Department to publish a new version of the SFA model for healthcare workers dealing with the COVID-19 crisis (available here).

The Stress Continuum Model

Watson, Gist, and Nash’s SFA model is based on a key fact about stress: we experience stress on a continuum.

The Stress Continuum Model by Patricia Watson, William Nash, and Richard Gist

Illustration by Pamela Coburn-Litvak

It doesn’t matter what kind of job you have – you’ve probably already noticed this. In the green or “ready” zone, you and I have just the right amount of stress to keep us engaged and challenged, but not so much that we feel overwhelmed and burned out. We feel calm, confident, and in control. This level of stress doesn’t pose any risk – in fact, it probably means you and I are humming along happily in our personal and professional lives. 

But then a more severe stressor hits, which move us into the yellow or “reacting” zone. This level of stress is enough to knock us off our game just a bit. You and I may feel tense and frustrated, but usually we can resolve the stress in a short time and move back into the green zone.

Even more severe stress can push us into the orange or “injured” zone. These are crisis conditions that involve one or more of the types of stress we described in part 1. And it’s not so easy to bounce back from this kind of stress. You and I may feel upset and angry, panicked, or depressed. We will almost certainly feel like things are beginning to spiral out of control.

Our ability to move back into the green zone will depend on several things: the severity of the stress, your or my past history with stress and trauma, our biological and psychological risk factors to stress-related mental illness like anxiety and depression, and our respective levels of resilience.

If we can’t resolve our stress, you and I may ultimately end up in the red “ill” zone where we are at high risk for developing stress-related illnesses like PTSD, substance abuse, and clinical anxiety and/or depression.

The whole point of stress first aid is to help us move navigate the orange/red zones of stress successfully and bring us safely back into the green/yellow zones.

The Seven Cs of Stress First Aid

Research shows that we recover best from crisis when our stress first aid kit includes five essential elements:

  • Cover. Providing safety is of paramount concern during crisis. This includes not only physical safety, but psychological safety as well – making sure that workers are able to express their concerns and fears without judgement or retribution. After workers’ basic needs are met, company leaders should make sure that they feel mentally and emotionally safe as well.
  • Calm. Some anxiety during crisis is normal – healthy, even. Anxiety is nature’s way of keeping us on our toes, helping us stay alert and focused on the crisis at hand. But problems will arise if we stay in a state of anxiety for too long. Not only does this produce bad physiological effects like high blood pressure, ulcers, tension headaches, etc., but it also creates mental and emotional strain in the forms of interrupted sleep, poor focus and decision-making, flared tempers and nail-biting worry.  
  • Connectedness. Research shows that social connections are powerfully protective against stress and are linked to emotional well-being and recovery after trauma.
  • Competence. Workers who believe they have the skills and capacity to endure and overcome threat generally come out of crisis conditions better than those who don’t.
  • Confidence. We could also call this hope or optimism. Workers who believe that things will work out, or that some good can come from bad situations, generally come out of crisis conditions better than those who don’t.

Depending on workers’ needs, company leaders may focus on any one or all five tools in the SFA kit. It’s quite possible that different workers will have different needs, and their needs may also change over the course of the crisis. So, company leaders must be able to monitor and adjust their first aid strategy with changing circumstances. To do this, we add two more elements to the toolkit:

  • Check. Company leaders must assess, observe, and listen for signs of stress reactions in themselves and others during times of crisis.
  • Coordinate. This means getting the information and support needed at every stage of a crisis. A solid crisis management plan is a good start here, but since no one can anticipate the unique challenges of every crisis (hello, COVID-19), leaders must be ready to gather additional information and resources as needed.

Together, these create the seven Cs of Stress First Aid:

7 Cs of Stress First Aid

Illustration by Pamela Coburn-Litvak

Click on the tabs below to learn how to implement each step of the Stress First Aid (SFA) model:

Check

How to Check on Your Workers During a Crisis

The first C in the SFA model is “Check.” This means creating a systematic screening process that, in the wake of stressful events, looks and listens for verbal/nonverbal signs that workers are experiencing severe (orange to red) stress reactions.

It's worth noting an important implication here: leaders must already know the baseline functions of their staff so that they can tell the difference.

As they track the presence of new stressors and resulting changes in their workers' stress reactivity, leaders then decide how to:

  • meet workers’ needs according to the company’s crisis management plan;
  • meet unique needs and challenges posed by a unique crisis or stressor; and
  • recruit supplemental staff who can provide help or support.

Why is “Check” is needed?

Well, it turns out that humans aren’t great at monitoring their own stress levels. You and I may not even be aware when we are moving into higher risk zones of stress reactivity. In fact, in the middle of a crisis, this may be the last thing on our minds. You and I can become so focused on the crisis that we forget to think about how it's affecting us.

And there’s another problem. In certain industries, workers may also feel a stigma against acknowledging their own distress during a crisis – healthcare is one notable example in stress research. Such stigma can prove to be a powerful barrier to workers getting the help and resources they need.

Watson, Gist, and Nash cite three key indicators that a person is moving into orange stress or beyond:  

First, the person has been involved in recent stressor events. These can include:

  • accidents
  • mass casualty events
  • recent loss of someone or something important (death, divorce, move, retirement, change at work)
  • loss of a cherished belief or a violation of one’s moral code

Second, the person exhibits signs of emotional distress including persistent feelings of sadness, anguish, anxiety, anger, guilt, and shame. 

Third, they exhibit changes in function at work or home that seem to be beyond the worker’s ability to control.

Here are some specific signs to watch for:

Physical Signs:

Mental & Emotional Signs:

  • Change in eating habits and weight
  • Fatigue, needing more breaks
  • Inability to fall or stay asleep, frequent nightmares
  • Change in hygiene or appearance
  • Drinking more
  • Things piling up
  • Inability to remember things or focus on tasks
  • Loss of interest and pleasure in tasks
  • Feeling out of control, anxious
  • Irritability, relationship conflict, isolation
  • Guilt, shame
  • Depression

Using OSCAR to check workers in crisis

How do we approach someone who we feel may be in the stress danger zone? Watson, Gist, and Nash suggest using the OSCAR communication method, which stands for:

  • Observe: Watch for behavioral or emotional patterns that are out of the ordinary. For example, you may notice a coworker becoming more socially withdrawn over a period of days or weeks.
  • State observations: Express your observations to the coworker, with no judgment or interpretation of those facts. For example: “Hey Joe, I’ve noticed that you don’t meet us for coffee anymore. And your office door is closed more often.”
  • Clarify your role: Explain why you are concerned. “I only bring this up because I care about you and I would like to know if you’re okay.”
  • Ask why: Seek clarification on your observations and how the person is perceiving the change. For example: “I’m wondering if something has changed. Am I right?”
  • Respond: State again your concern and offer suggestions for solutions in behavioral terms. For example, if Joe says yes, “I thought something was up. I’m concerned about you, Joe. Would it be okay if we went for coffee and chat about what’s going on?”

Coordinate

The second C, Coordinate, means that company leaders provide the resources and support needed to bring stress levels back into a manageable range.

Leaders can take several actions here:

  • In the crisis management plan, include several resources such as coworker support teams, support groups, hotlines, mentors, chaplains, and coaches.
  • Normalize the act of seeking help by making regular announcements about it and talking about it in one-on-one conversations.
  • Partner with affected workers to get them the level of support needed. Be able to discern when that support requires outside expertise, e.g. EAP specialists, licensed counselors, etc.

The five remaining Cs can help workers move from the orange and red danger zones back to the green zone.

Cover

The third C stands for Cover, because the first thing leaders must do for their workers in crisis is ensure their safety. As we discussed in part 2, cover begins with the crisis prevention plan, which should anticipate workers’ needs in terms of basic self-care as well as psychosocial safety. As the plan is put into action, leaders must also monitor and protect workers from any additional threats that crop up.

Watson, Gist, and Nash define three categories of situations where cover may be needed:

  • The stressed person is in danger. This means they are unable to think or act clearly in a dangerous situation, or others are endangering them through harassment or assault, or they are endangering themselves with thoughts of self-harm.
  • The stressed person is putting others in danger. This means they are unable to think or act clearly in a dangerous situation, or they are endangering others with threats or actual violence.
  • The stressed person and their loved ones perceive that they are in danger. This means they feel unsupported or threatened by conditions at work and feel unable to set protective boundaries around themselves and/or their families.
While ensuring worker’s safety, it’s important for leaders to try to protect each worker’s sense autonomy and control. For this reason, cover methods should start with those that are least intrusive, such as simply asking “Are you okay? Do you need help?” and escalate to more intrusive only when needed, such as physically moving the person to safety.

Calm

Calming workers will defuse their stress not only physically, but also mentally and emotionally. The SFA model lists four components to calming someone down:

  • Quiet the body by allowing the heart and breathing rate to fall to normal levels, reducing tension and activity of large muscle groups, and decreasing level of alertness,
  • Compose the mind by directing it away from internal feelings of stress and anxiety,
  • Soothe the emotions through empathy and active listening, and
  • Fostering rest for recovery and healing.

Again, it's better to start with the least intrusive and escalate to more intrusive methods only as necessary. Minimally intrusive methods include making eye contact with the stressed person and making reassuring statements such as “It’s okay,” and “I’m right here with you.” More intrusive methods include touching the person in a reassuring way and distracting them by asking them questions about something else or asking them to brief you on what is going on.

Over the long term, leaders can calm their workers by:

  • caring, supportive communication,
  • providing clear instructions for emergency situations,
  • learn from past crises and include workers in plans for future ones,
  • establishing support and mentor groups, and
  • create a culture that accepts and promotes safety and self-care.

Connect

Stressed individuals often isolate themselves from others. Unfortunately, this may work against their ability to pull out of orange/red stress zones and move back into the green zone. Leaders can help by improving Connections in three ways:

  • Reducing isolation. This includes physical isolation, but also emotional isolation in terms of misconceptions, mistrust, and misunderstandings in the workplace. Leaders may need to extend intentional invitations to those who feel marginalized and isolated.
  • Promoting connections between workers. This includes fostering support and mentorship and financing initiatives related to these efforts.
  • Being present. Leaders themselves must be present in the workplace to listen and empathize with concerns raised by workers.

Competence

Leaders may see the need to improve Competence in the following situations:

  • Workers have a lack of experience or training that is feeding their feelings of stress and anxiety,
  • Workers are unable to remember their skills and training due to extreme stress, or
  • Extreme stress is affecting the workers’ physical/mental/emotional coping skills.

We all cope better with stress if we feel competent. This includes not only occupational skills, but also competence in the emotional and social aspects of our work. The SFA model encourages leaders to follow a 3-step process to promote worker competence:

  • Stop. Take time to consider what is going wrong in any or all three areas of competence (occupational, emotional, social). Figure out how to fix it.
  • Back up. Take more time to refresh old skills or learn new ones in the areas where improved competence is needed.
  • Move forward again. Practice the new or refreshed skills. Set specific and achievable goals. Assess success and trouble-shoot challenges along the way. Find ways to positive reinforce success and increase workers’ motivation for future success.

Confidence

Boosting workers’ confidence will boost their self-esteem, hope, and belief they can overcome their stress. It thus improves resilience and makes them more capable to deal with future stress more successfully.

The SFA model includes four components:

  • Trust in oneself but also peers, leaders, and the workplace,
  • Hope that things will be different, forgiveness of self and others,
  • healthy and realistic Self-worth, and
  • a sense of Meaning and purpose.

Leaders can instill confidence in their workers by helping them reframe the stressor in terms that make sense and allow them to find forgiveness, healing, and trust in themselves and others. The SFA model outlines a three-step process:

  • Assess the workers’ current thoughts about their self-image, the meaning of the stressful event, and their level of trust. This can be done with active listening techniques and empathy. Ask the workers questions to clarify and deepen their understanding and promote self-discovery of solutions.
  • Provide resources to help replenish the workers’ needs (physical, mental, emotional, social, or spiritual). Help the worker identify obstacles to their learning and growth and brainstorm ways to overcome them.
  • Encourage growth. This may start with affirming statements, but leaders should also provide opportunities to demonstrate their personal strengths and skills at work.

Conclusion

For more information on the Stress First Aid model, please see the original document developed for healthcare workers here, which also includes a SFA group exercise and suggested questions to ask for each step in the model.   

About the author 

Pamela Coburn-Litvak

Pam is a neuroscientist, author, speaker, and certified executive coach. Her research articles have been published in scientific journals including Neuroscience and Neurobiology of Learning and Behavior.

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