Download Can`t Take It Anymore? (Keeping Firefighters

Can’t Take It Anymore?
Keeping Firefighters Happy:
An Inside Job
Mike McEvoy, PhD, NRP, RN
EMS Coordinator – Saratoga County
EMS Section Board Member – IAFC
www.mikemcevoy.com
www.nysfirechiefs.com/eap.com
Mike McEvoy, PhD, NRP, RN, CCRN
www.mikemcevoy.com
Objectives
1. Promote Behavioral Health Awareness
2. Improve resiliency in firefighters
3. Discuss behavioral health resources
for individuals and departments
NYS Department of Labor Grant
• NYS DOL Hazard
Abatement Board
– Training and
Education Grant
• Training program
• Resource kit
– Awareness flyer,
poster, web page…
www.nysfirechiefs.com/eap.php
Outline:
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Why behavioral health?
CISD isn’t enough. Why?
Stress and the firefighter personality
Promoting resiliency in the fire service
Protecting our own: an inside job
Tools and resources
August 21, 2012
• Call from Duty Chief
• 7:30 am response to suicide by hanging
• Patient is a fellow
medic, 31 yo joined
department 5 months
ago, well liked,
full time employee
Suicide Among Firefighters/EMTs
• No comprehensive data available
• Some believe rate is high
• FF/EMS represent the highest risk population:
– 72% suicides: white males
– 90% suicides: white males + females
– Age 18 – 29 most common for suicides
– FF 96% male, 85% white,
young
– Medics 69% male,
93% white, young
Facebook Page Post
First Responder Risk Factors
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Divorce
Trauma
Stress
Sudden fame
Trauma/Sudden Fame?
• New York: Three firefighters who helped
rescue 9-11 victims killed themselves within
a year
• Oklahoma City: A police sergeant who
rescued four victims at the bombed Federal
building completed suicide
• Texas: A paramedic who helped rescue baby
Jessica McClure from a well later took his life
Life Events as Triggers
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Suicide/Death of loved one
Serious family illness
Loss of health
Loss of employment
Retirement
Financial problems
Legal problems
Suicide Motivation
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Loss/change in important relationship
Avoid or end perceived pain
Escape intolerable situation
Gain attention
Punish others/self
Become a martyr
Depression
Suicide Warning Signs
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Lack of support system
Rejected by peers
Separation from family or friends
Loner or newcomer
Feels like no one cares
Indirect Suicide Indicators
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Buying a weapon
Giving away possessions
Making a will
Talking about a long trip
Taking unusual risks
Sudden religious interest/disinterest
Substance abuse relapse
Indirect Verbal Clues
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I can’t go on any longer
I’m tired of life
Life has lost its meaning
I can’t take the pain
You’d be better of without me
You’re going to regret how you treated
me
Direct Verbal Cues
• I might as well be dead
• I wish I were dead
• If ------- doesn’t happen, I’m going to
end it
• I’m going to kill myself
Direct Clues
Important Questions
• Have you thought about killing yourself?
– When did you last think of suicide?
– Have you ever attempted suicide?
– Has any family member
attempted/committed suicide?
• Do you have a plan?
• Do you have the means?
• How specific is your plan?
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Risk Factors
Sex (male)
Race (white)
Age (15 to 34) and (65+)
Hx Depression
Previous suicide exposure (self or family)
Loss of hope/rational thinking
Means and plan
No spouse or significant other
Illness
Principles of Suicide Prevention
• Encourage help-seeking behavior
• High risk population = more intensive
effort (like bringing a brother in)
• Age-specific
Can We Prevent Every Suicide?
• Absolutely not!
Andreas Lubitz, Co-Pilot Germanwings 4U9525
Fire Service Suicides Happen
• We do fantastic
funerals!
• We should never
glamorize suicide
Resilience: psych & behavioral lingo
• Resilience = ability to withstand negative
pressure
• Resilient people experience negative
circumstances associated with poor
psychological and social outcomes yet
despite odds, they end up healthy &
productive:
• Mentally ill or abusive parents
• Deprived social or economic conditions
• Major stressful events
What makes some people resilient
and others vulnerable to life
stressors?
Personal Resilience related to:
1. Biology
– temperament, emotions, intelligence, creativity,
immune resistance, genetics and physical
condition
2. Attachment
– capacity for bonding (forming significant
relationships with others), capacity for empathy
3. Control
– mastery over one’s environment, social
competence, self-esteem, personal autonomy
and sense of purpose
“Am I different?”
One Word: Adrenaline
• 90% of population lack traits needed
to perform well as an emergency
responder
• Emergency responders are
“Adrenaline Junkies”
• Average citizens are not
The “Adrenaline Junkie”
• Control oriented
The “Adrenaline Junkie”
• Attentive to detail
The “Adrenaline Junkie”
• Traditional
The “Adrenaline Junkie”
• Strong role identity
The “Adrenaline Junkie”
• Action oriented
The “Adrenaline Junkie”
• Risk takers
The “Adrenaline Junkie”
• Highly dedicated
The “Adrenaline Junkie”
• Family oriented
The “Adrenaline Junkie”
• High expectations
The “Adrenaline Junkie”
• Strongly rescue
oriented
“Adrenaline Junkie” Issues
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Control oriented
Attentive to detail
Traditional
Strong role identity
Action oriented
Risk takers
Highly dedicated
Family oriented
High expectations
Strongly rescue oriented
“Adrenaline Junkie” Issues
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Control oriented
Attentive to detail
Traditional
Strong role identity
Action oriented
Risk takers
Highly dedicated
Family oriented
High expectations
Strongly rescue oriented
Emergency Services
Stressful?
Most Stressful Jobs in US:
1. Firefighter (71.59)
2. Enlisted military personnel (70.78)
3. Military General (63.11)
4. Commercial Airline Pilot (60.46)
5. Police Officer (50.82)
6. Actor (50.33)
7. Broadcaster (50.30)
8. Event Coordinator (49.93)
9. Photojournalist (49.22)
10.Newspaper Reporter (48.76)
Careercast.com 2015/Forbes magazine 2015
Most Stressful Jobs in US:
Fire Service
• Stressful
occupation
• Expect to see
others in trouble
• Routinely manage
crises
“John Wayne Syndrome”
“John Wayne Syndrome”
“You ain’t
hurt unless
there’s a
bone stickin’
out”
Pathological Stress
• Acute Stress Disorder (ASD):
– Symptoms experienced during or
immediately after the trauma, last for at
least 2 days, and resolve within 4 weeks.
• Post-Traumatic Stress Disorder (PTSD):
– Symptoms begin within 1 – 3 months after
the event, may last months to years.
– Lifetime incidence: 7.8%
– Population prevalence 0.8 – 4%
– Lower incidence in emergency responders
Javidi H, Yadollahie M. Post-traumatic stress disorder. Int J Occup Envir
Med. 2012;3:2-9.
Impact of Major Stressors
Have you ever had any education on this?
ASD and PTSD
1. Reliving the
event
2. Emotional
DSM-5
anesthesia
3. Persistent
anxiety
ASD and PTSD Revised 2014
1. Reliving the
event
2. Active avoidance
DSM-5
3. Emotional
anesthesia
4. Persistent
anxiety
Pathological Stress
• Acute Stress Disorder (ASD):
– Symptoms experienced during or
immediately after the trauma, last for at
least 2 days, and resolve within 4 weeks.
• Post-Traumatic Stress Disorder (PTSD):
– Symptoms begin within the 1 – 3 months
after the event, may last months to years.
– Lifetime incidence: 7.8%
– Population prevalence 0.8 – 4%
– Lower incidence in emergency responders
Javidi H, Yadollahie M. Post-traumatic stress disorder. Int J Occup Envir
Med. 2012;3:2-9.
Firefighter Stress
• Is our stress
different than
in other
professions?
Firefighter Stress
• FEMA funded 3-year, 5state study of CISD,
firefighters’ disposition,
and stress reactions.
• Included personnel
from Murrah building
bombing in OKC.
Fire Service Stress
• Social support
structure of fire
service is protective
• Firefighters are quite
resilient
• Firefighter social
support comes first
from family, then from
friends and coworkers
Fire Service Stress
• The majority of firefighters would seek
support from clergy (40.9%) over
professional counselors (7.4%)
• Firefighters tend to have positive views
about the world despite continued
exposure to traumatic
events
Stress in EMS Providers
• 1,600 EMTs and Medics surveyed
• 100% reported exposure to traumatic
events
• PTSD incidence lower than general
population
• Significant relationship between ETOH
use and PTSS
Donnelly E. Work-related stress and post traumatic
stress in emergency medical services. Prehosp
Emerg Care 2012;16:76-85.
Immune to Stress? NOT…
• Firefighters are human
• They are highly effective
on the job
• They also have families, bills to pay, cars
to keep running, homes to maintain and
lives to live outside of the firehouse
Stress at Home
Relationship Stressors
• Work schedules
Relationship Stressors
• Loyalty
Relationship Stressors
• Danger
Relationship Stressors
• Negativity
Relationship Stressors
• Public opinion
Compare FF to John Q Public:
• Substance use/abuse
– Alcohol, drugs, tobacco
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Sleep disorders
Depression
PTSD
Suicide
Anger management, violent behavior
Marital, family, relationship problems
Tobacco
• FF substantially lower smoking rates than
military and civilian populations
• Very high rates of smokeless tobacco use
Product
FF
Military Civilian MD
Cigarettes 13.6% 30.5% 23.4% 2%
SLT
21.2% 15.6%
6.5%
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RN
7%
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LPN
25%
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Poston WS, Haddock CK, Jitnarin N, Janhke SA. A national qualitative study of
tobacco use among career firefighters and department health personnel.
Nicotine & Tobacco Research. 2012;14:734-741.
Haddock CK, Jitnarin N, Poston WS, Turley B, Johnke SA. Tobacco use among
firefighters in the Central United States. Am J Indust Med. 2011;54:697-706.
Sarna L, Bialous SA, Nandy K, Antonio AL, Yang Q. Changes in smoking
prevalences among health care professionals from 2003 to 2010. JAMA. 2014;
311:197-199.
Alcohol Use Among Firefighters
• Binge drinking common (56% monthly)
– Chiefs lowest, ff/paramedics highest
– Little difference between career/volunteer
– 10% reported driving after drinking
Haddock CK, Jahnke SA,
Poston WS, Jitnarin N, Kaipust
CM, Tuley B, Hyder ML.
Alcohol use among firefighters
in the Central United States.
Occupational Medicine. 2012;
62:661-664.
PTSD and Firefighters
• Low rates of PTSD among FF (4.2%)
– Wide variations in other studies (6-32%)
– These data comparable or < civilian PTSD
• FF are very resilient
• Alcohol use among FF > civilians
• PTSD risks = lack of support & higher
level of life stressors
Meyer EC, Daly E, Zimering R, Knight J, Kamholz BW.
Predictors of postraumatic stress disorder and other
psychological symptoms in trauma-exposed firefighters.
Psychological Services. 2012;9:1-15.
Divorce
• Calculating population rate
is elusive
• Attorney data suggest firefighters have
higher incidence of divorce
• Family, home and relationship issues
likely related to work…
16 Firefighter Life
Safety Initiatives
Initiative # 13
Firefighters and their
families must have access
to counseling and
psychological support
What Initiative #13 Means
Firefighting is a high-risk occupation which, from time
to time, can put the employee and his or her family
under extreme stress. They deserve access to mental
health care.
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If you are feeling stress (depression / anxiety or
physical symptoms) seek help from physicians, EAP
counselors, and religious or other sources.
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Don’t “tough it out”; this could lead to bad results for
you and your family.
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Stress-awareness should be part of firefighter
training at all levels.
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Help a buddy you see struggling with stress-related
problems.
NFPA 1500
• Standard on Fire Department Occupational
Safety and Health Program, 2013 edition
• Chapter 11: Behavioral Health and Wellness
Program
– The FD shall provide access to a behavioral
health program for its members and their
immediate families
Employee Assistance Program
• EAP
• NFF: Behavioral Health Assistance
Program (BHAP)
• Regardless of what you call it, they must
be familiar with and prepared to treat
firefighters!
EAP
• Began in 1800’s to deal with alcohol use
– Earliest programs were in fire departments
• Expanded in 1950’s to mental health
– Employers began contracting for EAP services
• More recently, unprecedented growth
– Competition has dramatically lowered costs
– Technology leading to phone and on-line EAP
– EAP vendors are reaching saturation in U.S.
EAP
• No state recognition/licensure
• Accreditation varies
• Requirements:
– Counselors are licensed
– Program has fire service expertise
• NFF Life Safety Initiatives template “From
EAP to BHAP” aids in soliciting vendors
Behavioral Health
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AKA “Mental Health”
Stigmatized by firefighters, medics, cops
As important as physical health & safety
Left untreated, leads to illness & death
Covers a wide range of issues:
– Stress, anxiety, sleep problems, anger
management, depression, PTSD, substance
abuse & addiction, marriage & family issues…
What About CISD?
• Created by Jeff Mitchell at UMB 1980’s
• Became defacto response to “Critical
Incidents”
• Premised on preventing
emergency responder
attrition from stress
• Paucity of research on
effectiveness
CISD – Summary of Scientific
Literature (Peer Reviewed)
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Mitchell model
CISD (not CISM)
Emergency Services
vs. general population
Cochrane Library Database (last
CISD revision 14 Nov 2005, last
substantiative update Dec 2011)
CISD - Conclusions
1. Value neutral to negative
2. Not effective compared to all forms
of debriefing vs. no debriefing at all
3. While perceived as helpful, rescuer
satisfaction ≠ effectiveness
4. Some evidence of harm to certain
individuals, often iatrogenic
CISD – General Population
Unsafe!
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Adds to trauma
Complicates recovery
Should not be used
Now banned in most countries
US Institute of Mental Health and
World Health Organization both
recommend AGAINST it
CISD – Emergency Services
• Not appropriate for 60% of police, fire,
EMS personnel
• 85% talk about critical incidents
afterwards (colleagues and peers
preferred)
• 15% prefer not to talk at all
When Helping Harms
(Worsening anxiety, depression, PTSD)
• Mandatory attendance
• Discussion of event (relive emotional
trauma) – MH error
• “Mixing” groups
– Peripheral personnel with those directly
involved in the incident
– People lost loved one with
people whose loved one
survived
Who Is At Risk for CISD Harm?
• Repeated or accumulated severe unresolved
stressors
• Lack of social supports
• Injury
• Preexisting psychological problems
• Traumatic bereavement
• Strong negative beliefs about meaning of
normal stress reactions
• People who most seek CISD show poorer long
term outcomes
CISD: Neutral Value?
• May interfere with natural psychological processing
(avoidance and intrusion)
• May cause members to bypass usual support
systems
• Members may feel they were “healed” by CISD
• May interfere with natural dept. environment
• May lead people to expect they will suffer posttraumatic stress, triggering psychological problems
• Reliving the event might add to the trauma for some
CISD – What Now?
OK - you made
your point. What
else should we
be doing?
Today’s Recommendations:
1. Immediate assistance
• Starts on scene, informal, “upward contacts”
2. Early, reliable, focused assessment
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FF are resilient – watch for outliers
3. Stepped care matched to needs
4. Evidence based treatment by
competent providers
PFA – Psychological First Aid
Three basics of psychic resilience are
hardwired into our biological makeup:
1. Sense of safety Protect
2. Meaningful social connections Direct
3. Sense of efficacy Connect
Recreate sense of safety
• Immediate physical needs (self-care)
– Bathroom, food, fluids, breaks,
clothing changes, sleep, time off…
• Protect from onlookers & media
• Walk-Around – supportive presence
& monitor well being
(chaplain, peer, etc)
Protect
Meaningful social connection
• Help connect with family, friends, children,
significant others
– Talking in homogenous groups (ie: firefighters vs.
heterogeneous strangers)
• Provide information on normal signs and
symptoms including suggestions for what
to do
• Educate significant others on s/s and how
they can help
Direct
Reestablish sense of efficacy
• Recognition for job well done
• Encourage normal routines & roles
• Discuss self care strategies to reduce anxiety
– Exercise, rest, relaxation
• Encourage people to support and assist others
• Identify resources that promote effective
coping (printed materials)
• Accurate, simple information about plans,
schedules, events
• MH follow-up assessment @ 3 months
Connect
PFA
• Protect
• Direct
• Connect
You have a situation…
Recommended protocol for Occ Stress:
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2.
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Determine if traumatic event
Time out/hot wash
Trauma Screening Questionnaire
Complete assessment
Treatment by qualified clinician
1. Is this a traumatic event?
• Every firefighter is different
• How to ask:
– Not, “how ya doing?”
– But, “What can I/we do to help you?”
• Expressing support may be enough
2. Time Out/Hot Wash
Based on military after action review (AAR):
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5.
What happened?
What was successful?
What could have gone better?
How might we improve?
Who should we tell about what we have
learned?
Halpren J, Gurevich M, Brazeau P, Bishop S, Schwartz B.
Rethinking critical incident stress: Coping strategies in emergency
medical services personnel (NAEMSP Abstract). Prehospital
Emergency Care. 2006;10:107-149
3. Trauma Screening Questionnaire
• If PTE, used 3 – 4 weeks afterwards
• Identifies who is doing well and who
might need additional help
• 10 questions about recent symptoms
• > 6 positive responses suggests need for
screening by a behavioral health
professional
4. Complete Assessment
• Referral to Behavioral Health Assistance
Program (BHAP, EAP…)
• Manage symptoms
• Deal with non-event stressors that may
be complicating recovery (marriage,
financial, etc)
5. Specialty Clinical Treatment
• When intensive treatment needed
(PTSD, anxiety disorders, depression),
must be provided by specialist with
advanced training appropriate to needs
What makes some people resilient
and others vulnerable to life
stressors?
Resilience: The Bottom Line
• Problem-focused coping increases
resiliency while emotion-focused coping
impairs resiliency
• When faced with a setback or challenge
focus outward on the things that must be
handled, not inward on emotions
• Emotions cannot become the focus of
attention.
People who focus
on solving their problems
are the most resilient.
Problem Focused Coping:
1. Examine the situation to see what
solutions may be possible
2. Consider various actions
3. Select the best
4. Take action
5. Observe effects of action
6. Modify for best results
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Resilient People Are:
Sociable (form healthy relationships)
Optimistic (positive about the future)
Flexible (change easily)
Self-confident
Competent (good at something and proud of it)
Insightful (understand people and situations, able to see
other sides)
– Persevering (don’t give up)
– Objective (view crises as challenges, not insurmountable
obstacles)
– Self controlling (manage strong feelings and impulses)
Vulnerable people exhibit:
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Substance abuse
Poor anger management
Lack of community integration/social isolation
Multiple chronic illnesses (or symptoms with
minimal, vague or inadequate organic basis)
• Chronic dysthymia and/or anxiety
• Dysfunctional relationships
• Inadequate school/work/community performance
“You play the
hand you’re
dealt. I think
the game’s
worthwhile.”
Promoting Resiliency
1. Leadership
2. Social support
Do you know a
“Happy Person”?
Happy People Choose to
be Happy
Miserable People Choose
to be Miserable
Most of us are somewhere in
between
Many of us would like to be
happier
How Can I Be Happier?
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Less stress
Improved outlook
Better Health
More success…
Stress?
Stress Prevention
• Stress can not be treated after exposure
• Firefighters must have good stress
management skills
• Most stress in emergency services is not
from major events, but day-to-day job
hassles:
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Pay (or recognition)
Equipment breakdowns
Dealing with the public
Administrative hassles
Work hours/scheduling issues
Stress Prevention
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Well run incidents
Well managed organizations
Well prepared providers
Well conditioned personnel
Well grounded lives
Ranking Causes of Burnout
Top causes of emergency services burnout:
1.
2.
3.
4.
5.
6.
Abuse of 911 system
Extensive shift lengths
Extended length of service
High call volumes
Sleep deprivation
Lack of administrative support
Lloyd BH. Leading community risk reduction.
Memphis Fire Dept., Memphis TN, July 2004.
Define Stress
A response to a demand
for change
BOTH:
• Physical
• Psychological
A response to a demand
for change
• Different for different people
Arousal Score
Study of Arousal Level for Sky Divers
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7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14
Jump Sequence
Experienced
Novice
A response to a demand
for change
• Stress is not
the event but
our reaction to
it
Life Events
Death of spouse
Jail term
20% pay cut
Fired from job
Death of friend
Traffic ticket
Car accident
Life Events
Divorce
Marriage
New home
Retirement
New baby
Vacation
Christmas
Life Events
Divorce
Marriage
New home
Retirement
New baby
Vacation
Christmas
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=
=
=
=
Death of spouse
Jail term
20% pay cut
Fired from job
Death of friend
Traffic ticket
Car accident
Holmes TH, Rahe RH. The social readjustment rating scale.
Journal of Psychosomatic Research. 1967;11: 213-218.
How Can I Be Happier?
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Less stress
Improved outlook
Better Health
More success…
Stress Management
Tips for Firefighters
1. Condition your body and mind
Stress Management
Tips for Firefighters
2. Listen to your inner
voice
Stress Management
Tips for Firefighters
3. Never stop growing and learning
Stress Management
Tips for Firefighters
4. Be positive
Have a sense of humor
Stress Management
Tips for Firefighters
5. Have a life outside the fire
department
Stress Management
• Firefighters are very
resilient
• Use techniques that
promote resilience
• People cope
differently
• Maintain as much
control as possible
What You Need
1.
2.
3.
4.
5.
Protocol for events
BHAP (or EAP)
Chaplain
Forms: TSQ, Information for families
Educational resources
Resources
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www.nysfirechiefs.com/eap.php
NFF
NVFC
EAP
Forms
Etc…
Summary
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People are resilient
Friends are important
Conversation helps
Time is a great healer
Look out for others
while you look out for
yourself
- Gist, et al., The origins and natural history of debriefing, 1998.