Stress Management

Clinicians Course/ Version 1

07 Apr 2009

SECTION I. ADMINISTRATIVE DATA

All Courses Course Number Version Course Title
Including
This Lesson 1 Emergency Preparedness & Response Course

Task(s) Task Number Task Title

Taught(*) or Stress Management
Supported

Reinforced Task Number Task Title

Task(s)

Academic The academic hours required to teach this lesson are as follows:
Hours Resident
Hours/Methods
20 min. mins / Conference / Discussion
mins / Conference/Demonstration
mins / Conference/Demonstration
hrs / Practical Exercise (Performance)
Test 0 hrs
Test Review 0 hrs
Total Hours: 0 hrs
Test Lesson Hours Lesson No.
Number Testing
(to include test review) N/A

Prerequisite Lesson Number Lesson Title

Lesson(s) Stress Management

Clearance Security Level: Unclassified

Access Requirements: There are no clearance or access requirements for the lesson.

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References Additional
Number Title Date Information

FM 3-11.3 MULTISERVICE TACTICS FEBRUARY

TECHNIQUES, AND PROCEDURES 2006
FOR CHEMICAL,BIOLOGICAL
RADIOLOGICAL, AND NUCLEAR
CONTAMINATION AVOIDANCE

FM 3-11.3 MCWP 3-37.2A NTTP 3-

11.25 AFTTP(I) 3-2.56

FM 3-11- MULTISERVICE TACTICS, DECEMBER

14 TECHNIQUES, AND PROCEDURES 2004
FOR NUCLEAR, BIOLOGICAL, AND
CHEMICAL VULNERABILITY
ASSESSMENT

FM 3-11.14 MCRP 3-37.1A NTTP 3-

11.28 AFTTP(I) 3-2.54 DECEMBER
2004

FM 3-11- MULTISERVICE TACTICS, NOVEMBER

34 TECHNIQUES, AND PROCEDURES 2007
FOR INSTALLATION CBRN
DEFENSE

FM 3-11.34 MCWP 3-37.5 NTTP 3-

11.23 AFTTP(I) 3-2.33

NOVEMBER 2007

FM 3-11- MULTISERVICE TACTICS , OCTOBER

86 TECHNIQUES, AND PROCEDURES 2004
FOR BIOLOGICAL SURVEILLANCE

FM 3-11.86 MCWP 3.37.1C

NTTP 3-11.31

AFTTP (I) 3-2.52

2
References Number Additional
Date
Title Information

FM 3-11.4 I.A.W. MULTISERVICE TACTICS, June 2003.

(FM 3-4) TECHNIQUES, AND

PROCEDURES FOR NUCLEAR,

BIOLOGICAL, AND CHEMICAL
(NBC) PROTECTION MCWP 3-37.2

NTTP 3-11.27 AFTTP (I) 3-2.46.

FM 3-11.21 MULTISERVICE TACTICS, APRIL 2008

TECHNIQUES, AND PROCEDURES
FOR CHEMICAL, BIOLOGICAL,
RADIOLOGICAL, AND NUCLEAR
CONSEQUENCE MANAGEMENT
OPERATIONS

MCRP 3-37.2C NTTP 3-11.24

AFTTP(I) 3-2.37

Student Study None

Assignments

Instructor One instructor, 1301 or 1712 Civ (CBRNE/NBC), 74D2/30, 74A- ITC
Requirements qualified
Name St
Additional Ratio Qty Man Hours
Support
Personnel None
Requirements

Equipment Id Stu Instr Spt Qty Exp

Required Name Ratio Ratio

COMPUTER-INSTRUCTOR No 1 No

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 COMPUTER (CPU) WITH
KEYBOARD, INSTRUCTOR USE
ONLY
MONITOR-INSTRUCTOR No 1 No
COMPUTER MONITOR
PROJECTOR-INSTRUCTOR No 1 No
OVERHEAD PROJECTOR WITH
COMPUTER INTERFACE
SCREEN-INSTRUCTOR No 1 No
SCREEN PROJECTOR, INSTRUCTOR
USE
* Before Id indicates a TADSS
Materials Instructor Materials:
Required Power-point presentation and lesson plan.

Student Materials:
ACUs, student handouts, pen/pencil, paper

Classroom, DEMSET, CAMP BULLIS

Training FIELD TRAINING SITE, CAMP BULLIS
Area, and LEVEL ONE, GENERAL PURPOSE CLASSROOM, 20 PN
Range
Requirements
Stu Instr Spt
Ammunition Id Name Exp Ratio Ratio Qty
Requirements
None

Instructional NOTE: Before presenting this lesson, instructors must thoroughly prepare by
Guidance studying this lesson and identified reference material.
Ensure the classroom is open, computer, power-point presentation, and
projector work at least 15 minutes prior to the class.

Proponent Name Rank Position Date

Lesson Plan CBRNE SCI BR, PN
Approvals

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 SECTION II. INTRODUCTION

Method of Instruction: Conference/Demonstration

Instructor to Student Ratio is:
Time of Instruction: 2 mins
Media: Large Group Instruction

Motivator
This country is the biggest target in the world for directing CBRNE activities. The
possibility that an adversary will use CBRN weapons against the United States and its
allies continues to increase daily. If these weapons are used, our forces must be ready to
implement the principles of CBRN defense.

Terminal
Learning NOTE: Inform the students of the following Terminal Learning Objective requirements.
Objective At the completion of this lesson, you [the student] will

Classify the psychological impact of an all-hazards incident on rescuers

Action:
and victims so that appropriate actions can be implemented to reduce or
eliminate long-term psychological effects.
Conditions: Given information about a possible catastrophic CBRNE event in which a
known chemical plant has blown up and many employees and local
residents have been affected.
Describe the psychological impact of an all-hazards incident on rescuers
Standards:
and victims so that appropriate actions can be implemented to reduce or
eliminate long-term psychological effects, I.A.W. MULTISERVICE
TACTICS, TECHNIQUES, AND PROCEDURES FOR NUCLEAR,
BIOLOGICAL, AND CHEMICAL (NBC) PROTECTION FM 3-11.4
(FM 3-4) MCWP 3-37.2 NTTP 3-11.27 AFTTP (I) 3-2.46, June 2003.
MULTISERVICE TACTICS, TECHNIQUES, AND PROCEDURES
FOR CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND
NUCLEAR CONSEQUENCE MANAGEMENT OPERATIONS FM 3-
11.21 MCRP 3-37.2C NTTP 3-11.24 AFTTP(I) 3-2.37 APRIL 2008

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Safety none
Requirements

Risk
Assessment Low
Level

Environmental
Considerations NOTE: It is the responsibility of all Soldiers and DA civilians to protect the environment
from damage.

none

Students will be evaluated using a written test. Students must score at least 70% on the
Evaluation
written test.

Instructional
Lead-In Virtually every conscious patient presenting for medical care in the wake of an all-
hazards incident will be experiencing psychological stress. Many patients with physical
symptoms from exposure to a CBRNE agent will present with co-morbid stress
symptoms which must be teased apart. Others will present with significant symptoms
which will eventually be attributed to stress alone.

This lesson will outline the stress response in terms of what happened and in terms of
patients' presenting symptoms.

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NOTE: Show – S2-S3

SECTION III. PRESENTATION

A. ENABLING LEARNING OBJECTIVE A

Action: Describe how all-hazards incidents can cause stress and impact the
community's ability to recover from the incident
Conditions: Given a scenario in which many CBRNE casualties have been
identified and available resources have been stretched to the limit.
Standards: Describe the stress of the all-hazards incident IAW FM 3-11.4 and
FM 3-11.21

1. Learning Step / Activity 1. Identify basic forms of detection.

Method of Instruction: Conference / Discussion
Instructor to Student Ratio:
Time of Instruction:3 min.
Media: Large Group Instruction

The Stress Response: Natural vs. Pathological

● In the wake of an attack, many individuals mount a normal stress

response and effectively "demobilize" when the danger has passed.

● Others mount an excessive initial

response but later return to near-
normal equilibrium.

● Still others mount a severe initial

stress response which eases only
slightly thereafter, yielding a
pattern of chronic arousal and
hyper-vigilance.

NOTE: Figure: S-3

Figure: At the 2007 'Cars for Kids' charity event, a driver lost control of his drag car
and went into the crowd killing 6 people and injuring at least 20 others. This photo
was taken of one of the responders after the incident. Based on his posture and
expression, he appears to be essentially 'demobilizing' after his initial response to
the tragedy.

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 When confronted with a life-threatening situation, human beings mount a natural,
protective stress response which mobilizes them for "fight or flight". While
functional in the short term, this system is poorly tailored to an overwhelming
and/or sustained stressor.

NOTE: Conduct a check on learning and summarize the learning activity.

Question: What is the difference between Natural vs. pathological stress response?
Answer: Return to normal once threat has subsided. Vs. chronic response.

NOTE: Show – S4

Biopsychosocial Energy in Disaster Response Phases

Disaster experts have identified four relatively distinct phases of post-disaster stress
reactions.
Heroic Phase: During this phase, individuals and the community mobilize increased energy
that they direct toward helping victims and repairing the damage done.
Honeymoon Phase: The honeymoon phase, generally characterized by optimism, is due to an
infusion of resources, national or worldwide media attention, and visiting VIPs. This phase
may be brief (or absent entirely) if the disaster is extreme and/or sustained.
Disillusionment Phase: As honeymoon phase resources disappear, the complexity of
rebuilding and restoration becomes apparent. Energy begins to diminish and fatigue sets in.
Obstacles to progress may become more apparent. They may seem impossible to surmount.
This disillusionment may intensify stress.
Restabilization Phase: The groundwork laid during previous phases begins to produce
observable results, and energy levels increase. A majority of individuals are again
functioning at their pre-disaster level. However, significant individual differences occur in
this phase.

NOTE: Show – S5

Contributing Factors to Stress Reactions

● Inability to strike back (indirect fire, IEDs)

● First time in combat, disaster, horrors
● Preexisting medical/psychological condition
● Surprise attacks
● Domestic worries
● Information vacuum

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● CBRNE agent threat
● Sleep loss
● Physical exhaustion
● Dehydration, hunger
● Lack of preparation and training
● Casualties
● Lack of mobility

NOTE: Show – S6

Most short-term reactions reflect the normal "fight or flight" reaction and subside once the
individual is out of harm's way. These stress symptoms may manifest themselves in one or
more of these categories.
Emotional: Emotional reactions are subjectively experienced feelings and involve physical
changes preparing the body for action. These reactions include anger, grief, and shame.
Cognitive: These reactions relate to conscious intellectual activities such as confusion,
difficulty in concentration, disorientation, indecisiveness, intrusive thoughts, self-blame, and
shortened attention.
Interpersonal: These reactions may manifest themselves as feelings of rejection, increased
conflict, increased distrust, increased use of controlling behaviors, or withdrawal from social
support and social activity.
Physical: Examples of these reactions include body aches, changes in appetite, changes in
libido, diarrhea, sleep disorders, fatigue, hyperventilation, nausea, elevated heart rate, or
tremors.

NOTE: Show – S7

Severe Short-Term Stress Reactions

• Loss of contact with reality

• Flashbacks
• Social withdrawal
• Startle reactions
• Debilitating anxiety
• Depression
• Substance abuse
• Delusions
• Hallucinations

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NOTE: Show S-7

Less commonly, individuals develop severe stress symptoms that are intense
enough to cause significant impairment. A significant number of individuals will go
on to develop debilitating stress.
Individuals with this clinical picture should be targeted for focused intervention.

NOTE: Show S-8

Potential Long-Term Stress Disorders

• Post Traumatic Stress Disorder (PTSD)

• Anxiety disorders
• Substance abuse
• Depression

NOTE: Show S-8

People exposed to a disaster, especially those who experience extreme stress
reactions or are repeatedly exposed, have an increased risk of developing long-term
disorders.

PTSD is a chronic, difficult-to-treat condition characterized by exposure to a

traumatic event; subsequent psychological re-experiencing of the event through
dreams, flashbacks, etc.; persistent avoidance of stimuli associated with the event;
and persistent symptoms of increased arousal.

NOTE: Conduct a check on learning and summarize the learning activity.

Question: What are the four relatively distinct phases of post-disaster stress
reactions.
Answer: Return to normal once threat has subsided. Vs. chronic response

B. ENABLING LEARNING OBJECTIVE B

Action: Identify components of psychological first aid

Conditions: Given a scenario in which many CBRNE casualties have been
identified and available resources have been stretched to the limit,
with individuals demonstrating physical and mental frustrations.
Standards: Identify components of psychological first aid IAW FM 3-11.4 and
FM 3-11.21

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 2. Learning Step / Activity 1. Recognize field detection instruments
Method of Instruction: Conference / Discussion
Instructor to Student Ratio:
Time of Instruction: 3 mins
Media: Large Group Instruction

NOTE: Show – S9

Psychological First Aid

Protect
Support
Connect

The initial response to these stress reactions entails the fulfillment of basic needs appropriately
dubbed psychological first aid.
Psychological first aid first involves:
protecting victims from further traumatization,
supporting them emotionally, and
connecting them with their personal support network.
These common-sense actions have a remarkably strong impact on easing victims' stress, and can
be provided in tandem with treatment of physical injuries.

Protect - The less traumatic stimuli people see, hear, smell, taste, and feel, the better off they will
be. Find ways to shield survivors from further exposure to these stimuli. If feasible, segregate
ambulatory patients from those severely ill or dying. Render the area off limits to onlookers and
the media.

Support - An important component of a disaster (especially a manmade one) is its ability to

return the victims' sense of hope and their ability to trust those around them. Supportive
interpersonal engagement helps reverse these feelings and helps victims begin to put their lives
back together.

Connect - Social disruption is common in the wake of a disaster, compounding the stress of
injury or illness. Try to give them access to accurate, up-to-date information as events unfold.
Make telephones and other forms of communication available. No intervention is likely to be as
helpful as the social support of families, friends, or coworkers.

NOTE: Conduct a check on learning and summarize the learning activity.

Question: What are the components of psychological first aid

Answer: Protecting, Supporting, and Connecting

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 NOTE: Show – S10

C. ENABLING LEARNING OBJECTIVE C

ACTION: Recognize the role of pastoral care as a component of stress
management
CONDITIONS: Given a scenario in which many CBRNE casualties have
been identified and available resources have been stretched to
the limit, with individuals demonstrating suicidal tendencies.
STANDARDS: Describe the role of pastoral care as a component of stress
Management IAW FM 3-11.4 and FM 3-11.21

3. Learning Step / Activity 1. Recognize unusual trends for CBRNE

Method of Instruction: Conference / Discussion
Instructor to Student Ratio:
Time of Instruction: 3 min.
Media:Large Group Instruction

The Role of Pastoral Care in Stress Management

• Perform:
- Formal rituals
- Informal rituals
- Commemorations

• Provide spiritual guidance

Clergy provide an adapted form of stress management support to disaster survivors
Commemorations, such as last rites

NOTE: Conduct a check on learning and summarize the learning activity.

Question: What role does pastoral care perform?

Answer: Formal rituals, Informal rituals, and Commemorations

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 NOTE: Show – S11

D. ENABLING LEARNING OBJECTIVE D

ACTION: Identify categories of stressors encountered by disaster

responders
CONDITIONS: Given a scenario in which many CBRNE casualties have
been identified and available resources have been stretched to
the limit, with many levels of stress being encountered.
STANDARDS: Name the categories of stressors encountered by disaster
responders
IAW FM 3-11.4 and FM 3-11.21

4. Learning Step / Activity 1. Recognize unusual trends for CBRNE

Method of Instruction:Conference / Discussion
Instructor to Student Ratio:
Time of Instruction: 3 min.
Media:Large Group Instruction

Stressors Associated with Disaster Work

Traumatic disaster stimuli affect both victim and responder. While victims' exposure is often
more intense, responders face unique personal situations and occupational burdens.

Disaster Stimuli: These are the sights, sounds, smells, and emotional turmoil of the disaster
scene that lead to stress reactions among disaster victims.
Personal Situations:
● Self-expectations
● Prior disaster experience
● Low level of social support
● Previous traumatization (e.g., history of abuse, disaster exposure)
● Low level of personal and professional preparedness
● Pre-existing medical or psychological conditions
Occupational Burdens:
● Long hours, erratic work schedules, extreme fatigue, time pressures, and human errors
● Authority struggles and role ambiguity
● Equipment failure
● Difficult choices
● Over-identification with victims
● Perceived mission failure
● Communication

Both medical and military cultures champion discipline, rigor, and a

willingness to forgo self-care, i.e. rest cycles. If a disaster response is lengthy,
this "victim comes first" selflessness can backfire in the form of widespread
staff burnout.

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NOTE: Conduct a check on learning and summarize the learning activity.
Question: What are the categories of stressors associated with Disaster Work?
Answer: Disaster Stimuli, Personal Situations, Occupational Burdens:

NOTE: Show – S12

E. ENABLING LEARNING OBJECTIVE E

ACTION: Describe stress management interventions for disaster
responders
CONDITIONS: Given a scenario in which many CBRNE casualties have
been identified and available resources have been stretched to
the limit, and stress management intervention is deemed
necessary.
STANDARDS: Describe stress management techniques used for interventions
for disaster responders IAW FM 3-11.4 and FM 3-11.21

5. Learning Step / Activity 1. Recognize unusual trends for CBRNE

Method of Instruction:Conference / Discussion
Instructor to Student Ratio:
Time of Instruction: 3 min.
Media: Large Group Instruction

The Role of the Disaster Response Team (DRT)

As the disaster response unfolds, the DRT will be called upon to assist primary victims and must
then shift their focus to disaster responders (including themselves). Three essential steps
facilitate this process.
Rapport with Disaster Responders: Rapport established from the preceding steps facilitates the
design and implementation of effective stress management interventions.
Non-traditional Role: When mobilized to respond to a disaster, the DRT must shift gears from
traditional patient care patterns toward a nonclinical, collaborative role.
Response Team Member Role: The DRT must engage as bona fide members of the response
team. While taking pains to avoid interfering with medical interventions, they must be accessible
and in tune with the ongoing efforts of their colleagues.

NOTE: Show – S13

Early Interventions

During the disaster response itself, several types of interventions are likely to be helpful.
Fulfillment of Basic Needs: The cultural selflessness of disaster responders must be actively
counteracted to prevent self-neglect. Responders must be prompted to eat, drink, and take
occasional breaks.

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Support: Dovetailed with the provision of basic needs should be the provision of social support.
Breaks should be scheduled that allow stress management personnel to engage disaster
responders. This offers an opportunity for them to express their thoughts or take their minds
briefly off the disaster through some friendly conversation.
Stress Management Education: Education about stress symptoms helps demystify them and
helps personnel manage them effectively. Pre-disaster stress management training can greatly
reduce responder's stress reactions.
Event Management: For sustained disaster responses requiring shift rotations, consider
employing demobilizations. For shorter, more intense, or more extensive disasters, stress
management briefings can be scheduled.
- Shift rotations are an important means of providing an ongoing supply of rested and effective
personnel.
- Demobilization facilitates the transition between disaster work and off-duty time. Individuals
going off-shift gather away from disaster response activities for a short briefing on possible
stress symptoms, effective means of addressing them, and a question or comment period.
Afterward, personnel are offered refreshments at an adjacent area, and then depart for the off-
duty period.
- This technique is a lecture covering common stress symptoms, and how to identify and
effectively manage them. Given at a set time and place, it is open to all who wish to attend. It
provides an opportunity to advertise other, more in-depth interventions and to identify those
needing one-to-one support.

NOTE: Show – S14

Later Interventions: Organizational Events

There are many means by which leaders can catalyze the process of
post-disaster healing:
● Public addresses acknowledging the
accomplishments of the organization
and its individual responders

● Ceremonies, particularly those which

draw from long established
organizational traditions

● Organizational events which

encourage socialization and esprit de
corps among members of the organization
Medical personnel are members of the disaster community likely to be psychologically affected
by their work. Once an end point has been reached, medical organizations can help their people
manage this stress through the use of organizational and/or group interventions. The key method
is organizational events.
Organizational Events - Confident, engaged leadership is a very effective source of stress
management for organizations touched by disaster.

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 NOTE: Show – S15

Intervention Techniques
• Must take into account:
- Anticipated audience
- Location
- Timing
• Must be tailored to their audience, i.e.:- Age,- Role,- Context
Intervention Techniques
Helping interventions are most effective when their design takes into account their anticipated
audience, their location, and the timing. Different combinations of variables call for different
types of interventions. Interventions must be tailored to their audience, which may vary along
several parameters including age (children, adults, older adults), role (survivors, nearby members
of the community, helpers), and context (individual, group, organization, community).

NOTE: Conduct a check on learning and summarize the learning activity.

Question: Which component of intervention is the following? Responders must be prompted

to eat, drink, and take occasional breaks.
Answer: Fulfillment of Basic Needs

SECTION IV. SUMMARY

Method of Instruction: Conference/Demonstration

Instructor to Student Ratio is:
Time of Instruction: 1 min.
Media: Large Group Instruction

A. Review of Main Points

A. Describe how all-hazards incidents can cause stress and impact the community's ability to
recover from the incident I.A.W. FM 3-11.4, FM 3-11.14, FM 3-11.34

B. Identify components of psychological first aid I.A.W. FM 3-11.4 and FM 3-11.21

C. Describe the role of pastoral care as a component of stress management I.A.W.

FM 3- 11.4 and FM 3-11.21

D. Name the categories of stressors encountered by disaster responders I.A.W. FM 3-11.4

and FM 3-11.21

E. Describe stress management techniques used for interventions for disaster responders
I.A.W. FM 3-11.4 and FM 3-11.21

16
 Summary

A. Survivors of a disaster may be grouped by community. Of these groups, primary victims

experience the elements of the disaster directly. A community's response in the wake of a
disaster falls into four phases: the heroic, honeymoon, disillusionment, and re-stabilization
phases.

B. Disaster responders need to shift gears to a flexible stance in order to provide effective stress
management in the wake of a CBRNE event.

C. Stress management may take many forms, depending on context. In the immediate aftermath
of a CBRNE event, responders should offer psychological first aid in conjunction with the
treatment of their physical problems. It is important to remember that simple interventions are
effective.

D. Pastoral care is an adapted form of stress management for survivors. Ceremonies and
rituals can be very helpful in survivor recovery processes.

E. Effective interventions can temper this stress and prevent staff burnout from interfering with
a sustained disaster response. The establishment of rapport helps overcome cultural barriers to
self-care among medical providers. Early interventions for responders include fulfillment of
basic needs, support, event management, and stress management education. Later
interventions may include organizational events.

NOTE: Show – S16

QUESTIONS??

B. Closing Statement:
Chapter V provides insights into the degradation to be expected from enemy
employment of NBC weapons. The basic goals remain to avoid or minimize the impact of
the contamination and to enhance endurance and task performance. When individuals are
encapsulated in stressful situations they are subjected to both physiological and psychological
stresses; however, given an understanding of the CBRNE environment, its impact, can be
negated by interventions through Disaster responders, Stress management, Pastoral care,
Effective interventions can temper this stress and prevent staff burnout from interfering with a
sustained disaster response.

17
SECTION V. Student Evaluation

Testing Requirements, Student will be required to take a 30 Question multiple choice test. The student
must score a 70% to receive a Go.

Feedback Requirements NOTE: Feedback is essential to effective learning. Schedule and provide
feedback on the evaluation and any information to help answer student’s questions about the test. Provide
remedial training as needed.
 

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