Stress First Aid for Wildland Firefighters Stress First Aid for Wildland firefighters is a peer support and self-care intervention that was developed originally from military service members in the Navy and Marine Corps, has been adapted for structural fire fighters, and now has a version for Wildland firefighter's. 1 1

Stress First Aid Improve self awareness and self-care Use Stress First Aid (SFA) to: Improve self awareness and self-care Recognize those who are reacting to stressful events and may need support to promote healing Apply a range of basic actions to assist those individuals Help to create bridges to higher levels of care, when needed Stress First Aid Uses The goals of SFA Call are to improve people’s sense of self-awareness and self care, and also to recognize others who are reacting to stressful events both at work and at home and may need to have support from fellow firefighters to feel better. It also offers some basic actions that can assist people who are stressed, and help create bridges to higher levels of care when they're needed. 2

Stress Continuum Model READY (Green) REACTING (Yellow) INJURED (Orange) ILL (Red) DEFINITION Optimal functioning Adaptive growth Wellness FEATURES At one’s best Well-trained and prepared In control Physically, mentally and spiritually fit Mission-focused Motivated Calm and steady Having fun Behaving ethically Mild and transient distress or impairment Always goes away Low risk CAUSES Any stressor Feeling irritable, anxious or down Loss of motivation Loss of focus Difficulty sleeping Muscle tension or other physical changes Not having fun More severe and persistent distress or impairment Leaves a scar Higher risk Life threat Loss Moral injury Wear and tear Loss of control Panic, rage or depression No longer feeling like normal self Excessive guilt, shame or blame Clinical mental disorder Unhealed stress injury causing life impairment TYPES PTSD Depression Anxiety Substance abuse Symptoms persist and worsen over time Severe distress or social or occupational impairment Stress Continuum Model Stress First Aid was adapted from the Navy/Marine Corps Combat Operational Stress First Aid (COSFA). The Stress Continuum Model was developed as a visual tool for assessing an individual's stress responses, and forms the foundation for both COSFA and SFA.   What the stress continuum model hoped to accomplish was to reduce stigma in service members by increasing their knowledge that people go in and out of ranges of stress reactions all the time. The Stress Continuum Model acknowledges that within this range of reactions to stress, a person can go from being in optimal functioning, feeling good, mentally and physically fit, mission focused, calm, and motivated into what's called a yellow zone where they’re having more stress reactions, but the stress reactions are mild and or transient, and always go away. In the yellow zone a person can feel more irritable anxious or down, have a loss of motivation, loss of focus, have trouble sleeping, or have muscle tension or other physical changes, but these are transient reactions. Once a person gets into the orange zone it's usually caused by an accumulation of different types of stressors or a pretty severe stressor. In the orange zone you start to see more severe and persistent distress or impairment, the person doesn't feel like themselves, or they have a loss of control of their stress reactions. They might feel strong panic on depression, rage, guilt, or blame. In this zone it starts to feel like the stress "leaves a scar,” and the person is at high-risk for having trouble functioning and or strong or persistent distress. The red zone is usually reserved for diagnoses like PTSD, depression, anxiety, or substance-abuse. What signifies a person being Red zone is that their symptoms are very persistent or worsen over time, or the person experiences severe distress, or has significant difficulty functioning at work or in their home life. The stress first aid model was designed to help people move themselves or their peers in the red and orange zone back to the yellow or green zones. For many years, the ethos in fire and rescue culture has been that after a difficult event, firefighters should be able to tough it out. This is still the case in many departments, When a person recognizes that they or a fellow firefighter is in trouble, it is important to break the code of silence. Getting this individual connected with the next level of help as soon as possible may help prevent his or her reaction from progressing into the Red Zone. And once an individual has moved into the red zone, the goal is to help get them into treatment as soon as possible. 3

Stress First Aid Model 9/3/2019 4 4 4 The Stress First Aid Model   Stress First Aid is based on research literature that says that people tend to do better when they feel safe are able to calm them selves, feel connected to others, feel like they can get through what they're having to deal with, or have a sense of hope. Stress First Aid maps onto these five elements, and adds two more, because it is a long long term model involving better supporting ourselves and our peers. The Stress First Aid model is initiated when a person has a stressor, which can occur at work or in the person’s personal life, and they show distress and loss of functioning due to that stress. This is different from other models, like critical incident stress management, because it's not initiated unless the person is showing stress reactions. It’s also different from critical incident stress management because the stressors could occur at home, and only be recognized by fellow firefighters because of the changes in a persons demeanor or functioning. Check should be continuous, even before stressors or reactions and it involves observing, paying attention, and checking in on peers on a regular basis, so that you know both their baseline functioning and behavior as well as any changes in behavior or functioning. Coordinate should also be continuous, and it involves always being aware of additional resources that you may need to refer to, if your SFA actions aren’t sufficient to make a difference in alleviating stress reactions. Once the stressor and reaction combination are shown, there are a number of different actions that can be taken. Cover maps onto helping a person feel more safe. Calm involves calming the person down, or staying calm through an extended difficult experience. Connect involves helping a person feel a greater sense of connection to others, which may be peers, mentors, or family members. This is important because when people go into the orange zone, they often isolate themselves from others, and remove the possibility of social support, which of been shown to be very helpful in recovery from many types of stress. Competence involves helping a person feel more capable in a number of different ways, including feeling more capable to perform their duties at work, feeling more capable to handle their own stress reactions, or feeling better able to function and recover from stressful situations. The last element is Confidence, which maps onto helping people have more Confidence in themselves, life, their work mission, or leadership. It can also sometimes involve helping reduce their sense of guilt, or philosophical questions that arise as a result of the stressors in their life. This diagram makes it seem like these actions are sequential, but in actuality, Check and Coordinate are continuous, and the others are only used as needed. The goal of SFA is to move people towards wellness. 4 4 4

SFA Cover: Interventions Ask about concerns Reassure that it is safe here and now Reduce triggers, reminders, or circumstances that make the person feel unsafe Educate the person about how to feel more safe Provide an accurate voice to help limit sense of threat Educate family members Focus on what to do rather than what not to do SFA Cover: Interventions Keeping in mind that Stress First Aid occurs only as needed, and should be mapped onto the context and personalities of those involved, here are a few examples of how to provide Stress First Aid, gathered from consultation with fire and ems professionals. The first core action of stress first aid involves Cover, which simply involves doing things to help somebody having a stress reaction feel more safe. Depending on the situation, you could: Ask about what's bothering him or her Reassure them that they're safe in the moment Try to reduce reminders are triggers that make them feel unsafe Educate them about how to feel more safe, like when they're having flashbacks or having trouble sleeping You might just provide an authoritative or accurate voice to help limit the level of threat they're feeling Sometimes if their family members are feeling unsafe, as a result of the line of duty death for instance, you might educate their family members, to help the whole family feel more safe, if possible Sometimes it's helpful to focus on what to do rather than what not to do for persons in a very stressed moment on the job.

SFA Calming: Interventions Maintain a calm presence Respect the person’s needs Reassure by authority and presence Show understanding Validate concerns Ask questions in calming or distracting way Provide information about reactions Provide brief instruction in grounding/breathing Provide information about resources and services SFA Calm: Interventions Calm actions are also pretty simple, and depending on the situation, they could involve things like: Just remaining calm yourself Respecting what a person needs in a moment when they're showing strong stress reactions Reassuring them just buy your authority and your presence Showing understanding when they're having a stress reaction Validating the things that they might feel concerned about Asking questions of them in a calming or distracting way to get them focused on something else then what is bothering them Providing information about the fact that it's natural to have reactions in situations like this Providing some brief instructions on how to ground themselves or breath in situations where there are overly activated Providing information about resources that might be available to help them get through ongoing stress situations.

SFA Connect: Interventions Ask about social support Help individuals to link with supportive others (peer support, family, friends, colleagues, professional support) Provide support yourself Address potential negative social influences SFA Connect: Interventions We know that when people are under significant stress, they often isolate themselves. We also know that the right kind of social support is one of the best things to help a person who is responding to stress. Connect actions could involve things like: Asking the person what social support they have Helping them link with supportive others both at home and on the job Providing support yourself, or finding a mentor who's gone through similar situations Also addressing potentially negative social influences on the job, like rumors, or people who might be judging that person because of their stress reactions.

SFA Competence: Interventions Give extra training / mentoring in tasks that are causing stress Ask what the person usually does to calm down, and/or remind him/her of the strategies and skills that have worked before Encourage active coping “Recalibrate” expectations/goals Help problem-solve and set achievable goals Connect to community resources SFA Competence: Interventions Competence involves helping a person either be more competent at their job so they are less stressed by their requirements, or be more competent at handling their own stress reactions so they can focus on what is important to them. There are many actions that could help in both of these situations, including things like: Giving the person extra training or mentoring in tasks that are causing them to feel stressed Asking the person to tell you what they usually do to calm down Reminding them about strategies and skills that worked before for them Encouraging them to problem solve or figure out ways to deal with the things that are causing stress in their life Helping them re-calibrate what their goals or their expectations are for themselves, which might be making them feel like they can't handle the stress Helping them problem solve simple steps toward solutions to the things that are bothering them the most Connecting them to community resources like chaplains, EAP, and other mentors who might help them feel like they can better handle what's going on.

SFA Confidence: Interventions Identify, amplify, concentrate on strengths Normalize responses Honor and make meaning Reframe self-defeating statements Encourage positive coping behaviors Avoid judgment Reduce guilt about actions Clarify rumors, misunderstandings, distortions SFA Confidence: Interventions Confidence involves helping a person feel more hope or confidence in themselves, work, leadership, or life. It often requires more of a connection with a person, and can have a big impact if done well. Again, there are a lot of potential ways to help a person with this, depending on the context, your relationship, and your personalities, including: Helping a person feel more confident in themselves by pointing out what they're good at Telling them that what's going on is expectable and understandable given what they've experienced Honoring and making meaning when there's been a loss on the job or at home Helping them see the way that they're viewing the world or themselves differently Encouraging them to go out and find better ways to cope with what's going on Avoiding judgment yourself and helping them reduce their guilt about their own actions if they feel responsible for something that is happened, or Clarifying rumors, misunderstandings, and distortions in others around that person, or ones that the person holds that are reducing their ability to connect and move forward.

Essential SFA Skills Recognize when a peer has a stress injury Law Enforcement SFA Essential SFA Skills Recognize when a peer has a stress injury Act: If you see something, say something To the distressed person To a trusted support of the distressed person Know at least 2 trusted resources you would offer to a peer in distress Essential SFA Skills So that describes the core actions of stress first, but the essential SFA skills involve: Trying to pay more attention to others Recognizing if they're in there in the orange or red zone of the stress continuum Acting, so if you see something, say something, either to the person themselves or to somebody who they trust. And lastly, knowing at least two resources that you could offer to a person in stress. This is where you need to know your organization and community resources. It’s also important to remember that SFA is a self-care model as well, and while the examples in this overview were mainly geared towards peer support, it can and should be used to increase your own self-awareness and improve your early re-calibration in response to stressors in your life. 2013

How Can You Use SFA? Check Approach Decide what is most needed: Guilt/Shame Anxiety Sleep Problems Isolation Grief Severe Inability to Function Competence How Can You Use SFA? So the model is very creative in a sense, and should look different with every exchange that you have with another person. It's not a one-size-fits-all model. That can be challenging for some people, but we hope that what it does, is allow people to feel the confidence to use the model in a way that makes the most sense to their own personality and the personalities of people around them, as well as situation at hand.   Stress First Aid was designed to be very flexible. Ideally, what you would do ahead of any action is to pay attention and be aware of what's happening in a person’s life, or what has changed in the way that the person is functioning. Then you would approach the person, and together decide what he or she most needs at that time. It is important to keep an open, flexible stance towards Stress First Aid and use it as a framework for remembering the factors that should be considered when someone is exhibiting moderate to severe stress reactions. This is usually based on what type of stress reactions they are having. And each one of the stress reactions could be handled differently, depending on your personality, what's going on in the person’s life, what they're able to tolerate, or what makes the most sense. Calm Connect Coordinate Cover Confidence

Key Point Emphasis SFA is collaborative and non-judgmental Timing and context are important Mentoring and problem solving are highlighted Flexibility and small steps are emphasized SFA is not meant to address all ranges of issues Bridge to higher care when indicated

Next Steps Training Support SFA Next Steps Engage in a discussion of where to go next with SFA, whether that be training others, support of others using the SFA model, implementing SFA in peer support teams, or rolling it out in smaller groups.