sometimes it is about dealing with potentially traumatic ...€¦ · landroverhad a tyre blowout....
TRANSCRIPT
Sometimes it is about dealing with potentially traumatic events
Looking after yourself and your colleagues
Plan for today• Understand more about traumatic stress:
– the kinds of experiences that may be traumatic – the different ways that people can be affected – the factors which influence our ability to cope and recover
• Feel more confident in taking care of yourself and supporting colleagues following trauma exposure
Getting started• Have a chat with your neighbour (in here or outside on a 10 minute walk)
• Find out how long they’ve been with SMR and why they’re interested in this session
• Listen carefully because you’re going to introduce them to the group
What do we know about risk?Mind Blue Light research found higher risk of mental healthproblems in search & rescue personnel
• 54% of search & rescue respondents had experienced stress, low mood or poor mental health at work
• Compared with26% of general workforce
• Even less likely to take time off• 43% ES personnel take time off• 57% of general workforce• only 12% or SAR folk had taken time off for their reactions
• More likely to link it to trauma exposure– Search & rescue personnel identified trauma as a trigger for poor
mental health (50% more than any other factor)
• Research by Mind (n = 3500
Beyond Blue’s National MH & WB survey, Australia, 2018 (n. 21,014)
• Volunteers found to be more resilient that employees with 2/3 reporting high levels of resilience
• Volunteers showed lower levels of psychological distress & probably PTSD & higher levels pfpositive wellbeing than employees
• However, 33% reported having been diagnosed with a MH condition (cfd w 20% population)
Stuff of life• Upsetting, shocking, frightening events are as much part of the human experience as joy, love, contentment
• Traumatic stress reactions aren’t inevitable• Idea of potentially traumatic experiences• Important to understand interaction between risk and protective factors
• SMR volunteers are exposed to potentially stressful or traumatic situations • Involvement in hazardous situations• Risk of injury or death for you and your colleagues• Exposure to serious injury and death of others• Exposure to other people’s distress
• ..++ stressors (traumatic or not) in rest of your lives
Critical incidents and/or attrition...
• Freak wave or crack in the sea wall
• Impact of repeated exposure
• Idea of burn‐out
Making sense of trauma• Both the event and it’s aftermath
– Individual and collective experiences– Interpersonal / communal / political– Medical and social construct– Potential to cause harm /possibility of recovery
• Helpful to understand the mechanism and the context
Idea of resilience• Being resilient doesn’t mean that people are not affected by the stress or trauma they experience but it refers to the capacity to recover and/or to endure
• Resilience is about the interplay between challenges people face and the resources they have to deal with them; the balance between protective and vulnerability factors
The importance of context
Protectivefactors
Risk / vulnerabilityfactors
Potentially traumatic events happen to people, families, communities , in all of their complexity.
Understanding trauma
BIO PSYCHO SOCIAL
Hyper & hypo arousal
Role of perception Social capital
Impact on mood
Importance of perception
Importance of social support
The biology of our stress response
Survival responses• Hyper and hypo arousal – fight, flight or fright • ‐> physiological changes (triggered by surge of adrenalin, cortisol ++)
• Hyper‐sensitivity to sensory information• Instinctive &/or rehearsed responses• Strong emotions or numbness• Fright (tonic immobility)
Survival responses
• Narrowing of focus onto the perceived threat– less flexible thinking– little or no “processing” at the time
Once threat has passed..
• Alarm system switches off • Physical equilibrium restored
• N.B. Levels of distress at this point are key.....
Once threat has passed..• The PSYCHOLOGICAL PART....
– Memory making
– Trauma memories are vivid, sensory
Once threat has passed..• The PSYCHOLOGICAL PART....
– Attempt to find meaning– Learning from experience– Adjustment of assumptions of self, others & world
We dream about it, think about it, maybe talk about it
The SOCIAL part
• Most significant predictor of recovery following trauma = quality and availability of social support
What if the threat or stress is ongoing or repeated?
Physical effects of getting stuck in “alarm mode”
• Heart beats faster ‐> palpitations• Muscles tense ‐> muscular aches & pains, headaches• Breathing increases ‐> breathlessness / hyperventilation• Void impulse / digestion switching off ‐> diarrhoea,
indigestion, reflux• Pupils dilating ‐> headaches• Blood away from skin –> pins & needles• Sweating
• Heightened awareness ‐> hyper‐vigilance, sleep problems
• Focus on threat ‐> poor problem‐solving• Instinct brain ‐> poor concentration, memory difficulties, impaired decision‐making
• Numbing or analgesia responses ‐> things feel unreal, you feel detached ‐> dissociation
• Exhaustion
Emotional & psychological impact• Feelings of anxiety, panic, dread• Increased irritability/anger• Feelings of guilt or shame• Feeling overwhelmed • Feeling numb• Helplessness• Low mood / hopelessness/Pessimism• Avoiding things (places / people) & emotions• Intrusive memories
Reactions not disorders• Wide range of distress responses are common (normal..) in the aftermath of exposure to a traumatic stressor– Emotional– Physical– Psychological – Behavioural
• What’s important is how we understand and deal with them
Post traumatic stress reactions– Re‐experiencing: intrusive recollections of experience (triggered & random, sensory, day‐time or night‐time)
– Avoidance and emotional numbing of people and places that are reminders of the event, or of thoughts and emotions
– Hyper‐arousal: stuck on red alert, persistent sense of current threat with physiological arousal & hyper‐vigilance (anxiety, irritability, poor concentration, sleep disturbance, physical symptoms such as stomach cramps or sweating)
Chronic hyper‐arousal
+ over-reactingPeople who have been exposed to traumatic events often suffer from a generalised hyper-arousal. Physically and emotionally, trauma survivors with post traumatic stress are alert to anything that might threaten their physical and emotional safety. They overreact to any perceived danger.
+ under-reactingWhen people are permanently
hyperaroused it can be difficult to work out when they’re really in danger. In order to function, people learn to ignore their alarm bells and to carry on anyway. When everyone and everything feels threatening people sometimes don’t recognise situations where they’re in real danger. And then get hurt again.
What makes a difference?
• What do you think are the factors that will influence how the characters are affected by their trauma experiences?
JohnJohn has volunteered with MR for 8 years and still gets a huge buzz from the training and call outs. A month ago he was out looking for a father and his 14 year old son who had got into difficulty on a high mountain. The weather conditions were terrible and John was exhausted when they finally located them. The man had sustained head injuries in a fall and was unconscious. His son was very distressed and kept asking if his dad was dead. The blizzard conditions made it impossible for the helicopter to lift them out and the teams had to carry them out.
AliceAlice’s been with MR for 4 years and loves it. Last week she was involved in a call out to find an elderly man who had gone missing. They found him after a couple of hours. He was still alive but very weak and went into cardiac arrest as they tried to wrap him in blankets. Alice and a colleague tried to resuscitate him but weren’t successful. They had a long wait with his body for the police and ambulance to arrive. This was the 1st fatality for a couple of team members Since then she has been feeling awful. She can’t sleep because it plays like a video in her head, especially the sound of the man’s ribs cracking as she did CPR.
MickMick has volunteered with MR for 20 years. He was out overnight looking for a missing hill walker. They were found by another MR team and Mick was driving his friend and team mate Davey back to base in the team landrover when the landrover had a tyre blowout. Mick lost control and they crashed into a tree. Mick sustained injuries to his chest and legs. He had to be cut out by the emergency services and spent 4 weeks in hospital. Davey died in the collision.
Feedback ‐ what would tip the scales?
What might prevent resilience?
• Threat recurs or doesn’t stop• Other stressors or losses• Mismatch between emotional and psychological capacity and demand so person is overwhelmed by distress or fear
• So body and mind stay in fight or flight mode..• ..or stay detached
Biological mediators• Dose• Duration• Consciousness• Injury / loss• Bereavement / grief• Developmental stage• Pre‐existing health• Safety (has the threat passed?)
• Stuck in F,F or F• over & under‐reacting• ACEs & epigenetics
• Coping responses & distress tolerance• Ability to self‐soothe / regulate emotions
• Use of substances• Risk of further harm
The PSYCHOLOGICAL part
• Trauma memories are fragmented / vivid• Dreams / thoughts / sensory intrusions are brain’s attempts to process raw data
• Memory making• Meaning making• Learning from experience
Psychological mediators• How we think about it during & after exposure• Self‐blame / criticism• Comprehensibility• View of ourselves
• How we feel about it during & after exposure• Helplessness• Guilt / shame• disgust • sadness
• Can we process it?• Fixed ideas or cognitive flexibility
• Ability to (& belief we can) regulate our emotions ...
• ... or avoidance (emotional, psychological, behavioural)
• People to help us and our willingness to use their support
The SOCIAL part
• Community safety • Shared narrative • Supportive responses• Sense of belonging• Social capital
Social mediators
• Basic needs met?• Availability & ability to
use social support• Loss / distrust• Connectedness
• Blame vs. heroism• Hierarchies of need /
entitlement• Cohesion or “othering”
• How does the family / community tolerate distress? Make meaning?
• Victims / martyrs / survivors
• Silence or bearing witness / remembering
• Creative / cultural responses
DiscussionWhat sorts of things would the characters need to cope with their experiences / situation?
Restoring wellbeing
• SAFETY• SOCIAL SUPPORT• HELPFUL COPING STRATEGIES • TOLERANCE OF INTENSE EMOTIONS• ABILITY TO THINK ABOUT THE EXPERIENCE • REGAINING CONTROL / CHOICE
Supporting others
Talk to each otherCan you think of a time when you offered support to a trauma‐exposed colleague
• What was helpful?• What was a challenge?
Why are we encouraging people to talk?
• To increase self‐awareness• So that they have a sense of being understood and accepted
• To develop more helpful relationships• To develop communication skills• To reduce shame and guilt, to increase self‐acceptance
• To resolve problems and conflict
Exercise• Work in pairs• Discuss a personal experience of feeling overwhelmed by the job and incapable of meeting the demands which faced you. Try to describe the experience in as much detail as possible, reflecting on the range of emotions you experienced and the ways in which your inability was evident.
• Feedback to the group
Disclosure exercise• How did that feel?• What thoughts went through your mind?• How many planned to lie or limit what they said?• What did you think the other person would think?• What other strategies did you use to cope with the request?
• What does this tell us about the process of peer support?
• What would have helped you to be able to talk about something like this?
Exercise
Work in pairs– Take it in turns to each talk for 5 minutes about a recent neutral experience e.g. what you had for dinner last night, what you did at the weekend.
Feedback
Clip
https://vimeo.com/66753575
Listening skillsWhy is Listening Important?
• COMPREHENSION– Without listening we have at best a limited understanding of the
other person, biased by our idea of how they should be/typically are.
• RESPONSE– The response you get when speaking to someone has an impact
on how you feel about yourself, the person you are speaking to, the chances of you speaking to them again, the chances of you trying to speak to someone else.
• Because listening is an intervention in itself
• Pay attention• Concentrate• Be aware of your own body language• Ask questions based on them – not you!• Check you have understood what they’ve said
– Reflect back what you’ve heard– Summarise– Establish context– Clarify, don’t pretend you know what they mean if you don’t
• Avoid guess work or filling in the gaps• Respect their subjective reality (it’s their experience not yours!)
Listening/attending to more than the words– body language– facial expression– tone of voice– what is left unsaid– what the feeling is
Be flexible – Adapt how you listen and respond according to the speaker's style
Silence– allow and tolerate it– conversation is not a race
– may be building up courage
– companionship rather than problem solving
Prompts– reassurance you are listening
– verbal and non verbal encouragement
– helps to overcome negative expectations
• Open Questions– cannot be answered with yes or no– encourages the speaker to say more and leads to conversation
• Closed Questions– require minimal information in response– close down the flow– harder work for the listener
Levels of listening
Level 1 – Internal Listening
Here as the listener your focus is on yourself and your own thoughts rather than the speaker. As the listener you interpret what you hear in terms of what it means to you. This is normal everyday conversation where it is natural, as the listener, to seek to gather information to help you form opinions and make decisions
Levels of listening
Level 2 – Listening to understand
Here you are focussing totally on the speaker, listening to their words, tone of voice and body language and are not distracted by your own thoughts and feelings
Levels of listeningLevel 3 – “Global” listening
This involves the listener focusing on the speaker, and picking up more than is being said. You will be listening to everything available using intuition, picking up emotion, and sensing signals from the person’s body language. You can gauge the energy or the person and their emotions as well as picking up what they’re not saying. You will understand what they are thinking and feeling; trusting your own senses. You can be extremely responsive to the needs of the individual, knowing what questions to ask at any given time
Examples of questions / prompts• What do you think is the
main problem / the hardest part?
• Have you been through anything like this before ( if yes, what did you do?)
• What would help / make at difference to you right now?
• Is there anyone who might be able to help? ( If yes, who?)
• Sounds like you’re saying is..... (what I’m hearing is....)Is that right?
• Can I check what you mean when you say...
• Sounds like things have been tough
• I really appreciate you talking to me about this
• I’d like to try and help if I can• Can I check in with you again
to see how you’re doing?
Extraverts and introverts• Be prepared for
brainstorming and thinking out loud
• Extraverts are action oriented and get energy from outside world
• Prefer people and larger groups
• Avoid long, detailed messages or emails
• Don’t mind meeting in busy environments
• Be patient with need to get to know you over time
• Take time to think of responses • Avoid questions that are too
invasive• Consider meeting in a quiet
space• Let introverts finish speaking –
count to 3 (to self!) before responding
• Be comfortable with silences
Types of non‐listeners• Reassurer
– “It really isn’t that bad”, “It could be worse”“It will all work out”
• Problem Solver– “What you should do is..” “ I think you need to...”
• Speaker– “When that happened to me…”
• Mind Reader– “You don’t need to tell me I know what you are going to say” “What you mean is….”
Types of listeners• Hope holder
“Things won’t always feel as bad as this” “You’ve been coping on your own, let’s see if we can get you some help”
• Problem‐sharer“Is there something I can do that will help?” “I’d really like to help you get through this”
• Companion“You’re not alone…” “I / others have been through difficult times too” “I’m here for you”
• Information‐sharer“Stress affects us physically”“How are you sleeping?” “Have you looked at these resources?”
Good social supportEmotional Expressing care and concerns “Are you OK?2
Esteem Fosters someone’s autonomy, “I know you can do this... You did something similar when...”
Tangible Being of practical help, e.g. Driving someone to a doctors appointment
Network Reminds people of their natural support
Information Providing useful information specific to the person’s needs
Protective factors
• Identity as responders ‐ having an active and positive role in the face of potentially traumatic incidents
• Being able to distance yourself – having a professional rather than personal response to the incident
• Expectation and readiness ‐ preparation and training• Sense of competence / expertise ‐ knowing what your role is
and feeling able to do it effectively• Social support ‐ being part of a team
Protective factors• Feeling able to talk about it afterwards and having the opportunity to do so
• Knowing yourself well enough to spot if things aren’t OK
• Willingness to seek help
Resilient teams• Looking out for each other – professionally and personally• Shared sense of purpose• Mutual respect and trust• Knowing what your roles are• Being confident in the knowledge and skills of other team
members• Adequate resourcing and training• Knowing each other• Acceptance and tolerance of different personalities and coping
styles• Open communication• Humour
Threats to resilience (a.k.a. absence of protective factors)
• When things go wrong or you don’t perform well ‐individual or team error
• When you’re unhappy with decision‐making of partner agencies of senior colleagues
• When normal coping (banter etc) is not possible• When physical resilience is overwhelmed• When you can’t detach – identify with those involved • Known victims• Incidents involving colleagues• Incidents involving children
Organisational threats to resilience
Stressful team environment• Low morale• Poor management• Bullying• Scepticism about value of support systems and/or culture that prevents help‐seeking
• Culture of silent coping • Macho culture (competitive, risk seeking)
After trauma exposure – what helps?• Being able to express your feelings if you want to• Feeling understood / heard• Regaining a sense of competence and agency• Monitoring and reducing avoidance• Making a memory • Getting your head round what it meansNot:• Being forced to talk about it
Psychological first aid
What might this look like in practice?• Check in with your colleagues• Protect ‐ address immediate safety and practical needs• Stabilise• Educate about common responses• Tips on helpful coping • Information about where to get support• Check in again
Check in & protect• Ensure immediate safety
• Minimise exposure beyond what is required to fulfil role (physically and online)
• How safe do they feel now?
• What can they do to increase their own safety physical/psychological?
Stabilise
PURPOSE• To ensure the colleague gets
the support they need
• To reduce psychological distress
TASKS• Provide comfort and reassurance• Checkout how they are coping– You’re not alone–I’m here to support you
• Talk through relaxation or grounding techniques (if necessary)
Stabilise ‐ groundingRecognising current safety
• Stomping feet/slap thighs• Check room for red objects• Think about what you will be doing on the weekend• Drink ice cold water• Ask questions about mundane things
Brief muscle relaxation
Brief muscle relaxation
Where do they feel tension (most commonly shoulders, neck, stomach muscles)
Breathe in and tense that muscle are problematic
Hold tension and breath for 5 seconds. Exhale and relax muscles
Repeat
Calming breathing
Tips on helpful coping ‐ exercise
• Compensating for the effects of staying in alarm mode
• Importance of regular exercise to use up excess adrenalin– N.B. Be careful with high adrenalin exercise
• Can also help to interrupt rumination
Tips on helpful coping ‐ relaxation
• Relaxation techniques interrupt the production of adrenalin– Calm / belly breathing– Brief muscular relaxation
• Hobbies / activities that involve focus and absorption
General tips
• Spend time with people who care• Give yourself time to recover• Find out about impact of trauma and what to expect• Try to keep a routine going – work, study• Return to normal activities asap• Talk about how you feel or what happened when ready• Do things that help you relax• Do things that you enjoy
Getting a good sleep
• Limiting caffeine intake• Keeping a regular sleep routine• Making sure your bedroom is not too light/too hot/too cold
• Avoiding over‐arousal in the 2 or 3 hours before sleep
• Keeping sleeping area free from distractions• Try not to “catch up” with naps during the day.• Take some exercise, but not too close to bedtime
Educate about common responses
• Can you explain why they might:– Have nightmares or intrusions– Feel on edge– Not be able to sleep– Think about the incident a great deal– Feel numb
Ability to think about the experience• Trusting brain (information‐processing machine)
• Memory making (through talking, writing, thinking about what has happened)
• Accessing information (own & others’ experience)
• Allows adjustment of unhelpful beliefs (about present safety, beliefs about self or others)
• Make choices
Tips for dealing with post traumatic stress• Avoiding avoidance
– What we resist persists > tolerating and allowing natural processing
– Recognising unhelpful avoidance (including self‐medication) > doing something positive about it
• Managing intrusions– Understand as brain’s attempt to digest memory– Orient in present & recognise current safety– Tolerate and allow natural processing
Things they shouldn’t do• Use alcohol or drugs to cope• Work too much• Engage in stressful family or work situations• Stop doing things that they enjoy• Avoid talking about what happened• Take risks• Withdraw from family and friends
Importance of social support• Explain why social support will help• Who’s around? • Can they talk to family or friends? • Can we help family & friends to understand what’s going on?
• If no‐one is available at home then make a plan on how the team can support them
JohnJohn has volunteered with MR for 8 years and still gets a huge buzz from the training and call outs. A month ago he was out looking for a father and his 14 year old son who had got into difficulty on a high mountain. The weather conditions were terrible and John was exhausted when they finally located them. The man had sustained head injuries in a fall and was unconscious. His son was very distressed and kept asking if his dad was dead. The blizzard conditions made it impossible for the helicopter to lift them out and the teams had to carry them out.
John’s worrying that he didn’t do enough to reassure the son. He can’t stop thinking about him
AliceAlice’s been with MR for 4 years and loves it. Last week she was involved in a call out to find an elderly man who had gone missing. They found him after a couple of hours. He was still alive but very weak and went into cardiac arrest as they tried to wrap him in blankets. Alice and a colleague tried to resuscitate him but weren’t successful. They had a long wait with his body for the police and ambulance to arrive. This was the 1st fatality for a couple of team members Since then she has been feeling awful. She can’t sleep because it plays like a video in her head, especially the sound of the man’s ribs cracking as she did CPR.
MickMick has volunteered with MR for 20 years. He was out overnight looking for a missing hill walker. They were found by another MR team and Mick was driving his friend and team mate Davey back to base in the team landrover when the landrover had a tyre blowout. Mick lost control and they crashed into a tree. Mick sustained injuries to his chest and legs. He had to be cut out by the emergency services and spent 4 weeks in hospital. Davey died in the collision.
Check in againIn pairs have a go at talking to our characters about:
• John – his worry that he didn’t do enough to help the 14 year old lad
• Alice – why she’s dreaming so much about the elderly man who died
• Mick – feeling that he can’t come back to SMR
PTSD – what helps?We have effective treatments for PTSD which involve:
• Understanding our reactions• Tolerating and managing them• Processing the trauma memory• Coming to terms with what it means
Trauma‐focussed cognitive behavioural therapy (TF CBT)Eye Movement Desensitisation & Reprocessing (EMDR)
Why volunteers might not always take care of themselves...
Talking to each other
• What are the challenges of discussing things which may be outside your own experience? e.g. depression, panic attacks, drinking too much
• What are the challenges of discussing things which may be very close to your own personal experiences?
• What are the challenges of holding personal information about colleagues?
Confidentiality
• You may be privy to personal and incident specific information which needs to be kept confidential.
• Others may ask about you what happened, how the person is coping. Be prepared for this and think about how you can respond.
• What are the limits of confidentiality?
Talking to each other
• What if they say they’re OK but you don’t agree?
• What if a friend or family member approaches you with concerns about them, or asks if they’ve spoken to you?
If someone doesn’t want help..You can:• Acknowledge their concern• Reassure about distress being a normal reaction
• Let them know that talking can be helpful when the time is right for them
• Be patient• Inform them how to get help when they’re ready
• Look after yourself
You can’t:• Force someone to talk to you
• Force someone to get help
• See a health care professional for someone else
Assessing harm to self or others
Do you have
concerns about harm to self or others?
Ask the Question –
How?
Be direct
Don’t leave them alone
Refer immediately
Risk to self• Don’t leave them alone• Ask if they have a plan• Ask if there is a friend, family member or someone they trust
who you can contact• Encourage them to ring the Samaritans 116 123, open 24 hours
a day (you can make that call with their permission• Contact their GP for an emergency appointment or the out of
hours service• Call NHS111 for urgent medical advice (111 + free of charge)• Contact Breathing Space, 0800 83 85 87 or other local support
service• Ring 999 if there is an immediate threat
Risk to others
• Don’t leave them alone• Ask if they have a plan• Ask if there is a friend, family member or someone they trust
who you can contact
• If people are telling you they want to hurt someone, they probably want you to stop them
• Ring 999 if there is an immediate threat
Combining peer support + responsibility
• What are the additional challenges?• How does being a team of volunteers affect things?
• What are your responsibilities?• How much discretion can you have?
Combining peer support + responsibility
• Can you agree a plan together and check in with them?
• Do they need to take a break?• Do they want you and the team to stay in touch?
• Do you need to tell anyone? (If yes, make sure you tell them this)
Your psychological first aid kit
How’s yours looking?Does anything need replenished?Is there anything missing?
Discussion
In pairs, have a chat about what you currently do to take care of yourself (when you need to relax or cheer yourself up)
Signposting
• What do you know about local services/what do you need to find out?
• It may be helpful to keep a folder of information with useful contact etc.
• How will you know when to suggest a referral?• What will your role be then?
Signposting• GP
– Access to support/counselling– Access to NHS Mental Health services– Medication
• Financial/debt advice• Couple Counselling/Family Mediation• Social Work• Alcohol and Drug Services• Local voluntary sector organisations and help‐lines
• PFA online module• Lifelines website
Post traumatic growth
• Greater appreciation of life• Warmer closer relationships• Greater sense of personal strength• Recognition of new possibilities in life• Spiritual development
Warning signs
• Physical/Behavioural– Poor sleep– Feeling on edge– Avoiding people/places– Distancing yourself from family/friends
– Increased use of alcohol/drugs
• Emotional/psychological– Increased irritability/anger– Increased distress– Guilt/shame– Feelings of dread– Numbness– Avoiding thinking/feeling– Intrusive memories– Concentration problem
Mountain Rescue Stress ContinuumREADY REACTING INJURED ILLPsyched for pager to gooff. No “bullshit” calls
Eager to help with extra work / clear up
Happy in whatever role on scene of trail head
Open to new ideas, change is exciting / not threatening
Sleeping well, getting exercise, healthy social interactions
Too many “bullshit” calls
Cutting corners, losing situational awareness
Something hurts, I’m responding anyway
Others aren’t pulling their weight. Stupid ideas
Sleep problemsCranky, increased substance use
Oh no, the pager is going off
Barely meeting expectations
No recreation time in the mountains
Easily frustrated & not interested in trainings
Family & friends detect change
Drinking to forget or feel numb
I hate the pager
I don’t want to respond to missions, meetings or trainings
Insomnia &/orrecurrent nightmares
Going through the motions without emotion. Depressed, anxious, suicidal
Alcohol or substance misuse