5 things to know about critical stress

Unfortunately, the skills we need to deal with difficult situations are not typically taught in our training

By Marc Colbeck

Being a paramedic is a difficult and stressful occupation. Regardless of your level of training, experience, or the number of hours you spend working each week, you are bound to be affected by the experiences you have.

Dealing with those experiences requires understanding, patience, acceptance, and compassion. Unfortunately, these are not skills we typically learn about in our training — at least not in relation to dealing with stress.

I worked full time as a critical care paramedic until I experienced post traumatic stress disorder. After that I left clinical practice and pursued an MA in Counseling Psychology.

A part of my work now is presenting emergency services personnel with information about the skills we need in order to deal with what we experience in our work. Below I've summarized five important, but not commonly known points that will help you to process the stressful experiences that might have negatively affected you.

1. It's not your fault.
One of the issues that people sometimes bring to the table when they are suffering with critical stress is the belief that somehow they are weak or inadequate — otherwise, they would not have been so negatively affected by the stress they experienced.

This is a painful belief, and it can get in the way of healing. The reality is that as emergency service workers, we are normal people in very un-normal situations.

Watching people suffer is a painful experience for well adjusted people. In fact, if you do not feel affected by what you experience on the job, then you are likely avoiding a great deal of thought and emotion that needs processing.

Just as no one is surprised when a paramedic has a back injury from lifting a heavy patient in difficult conditions, no one should be surprised when we have an emotional injury from witnessing a patient suffering.

An important aspect of recovery is realizing that being affected, or 'injured' by the psycho-emotional demands of the job is entirely normal and, in fact, something that you should expect to experience as a paramedic repeatedly (although hopefully not too often) through your career. It's normal.

It's also important to be aware that each of us has inherited an ability to deal with stress. Research shows that our ability to handle stress is partially inherited from our parents (1), and because of that, is beyond our control. It is also strongly affected by our experiences as children.

Adults who suffered abuse or other difficulties as children have a harder time dealing with stress when they are adults (2, 3) Since most issues that harm children psychologically are beyond their coping abilities, it isn't fair to blame them for being harmed by them. That's an attitude that is easy to adopt towards others, but is often more difficult for us to accept in relation to ourselves. Yet it is no less valid when we apply that reasoning to our own lives and experiences.

So there are two important points to keep in mind. The first is that being affected by the stressors of the job is normal. The second is that much of what determines how strongly we will be affected is out of our control, and therefore not fair to blame ourselves for.

2. The problem doesn't come from "stressors."
If you read any standard book on stress you will read that there are objective experiences in life that are universally considered to be 'stressors.'

Losing a loved one is considered a stressor; so is speaking in public, or changing jobs. In fact, there are ranked lists of these universal stressors and you can find many examples of these lists online.

Theoretically, you could take such a list, tick off each stressor that you are experiencing, and add up your score to determine the objective 'stress load' that you are currently experiencing. Unfortunately, this sort of practice is naive; reality is more complicated than that.

The reason it's naive is easy to see if you take a moment to question the belief that each of us experiences the same effects from the same stressors.

For example, I love public speaking. I don't find it stressful at all. A divorce might be stressful for some, but it could come as a welcome resolution for others. Similarly, changing jobs could just as well be a wonderful new adventure, as it could actually be a dreaded, stressful experience.

What's the difference? The difference comes from the attitude of the person experiencing the stressor. So it isn't reasonable to assume that any one specific situation will universally result in a specific response (or group of responses) in everyone that experiences it. I'm sure you've had calls that affected you deeply, but not your partner (or visa versa). We all know that medics with kids are often hit harder by paediatric calls than those without.

So, although we know that being a paramedic is a stressful occupation, we can't say that any specific experience will invariably result in a specific response. It is how we process the stressful events that we experience that makes the difference in how we are affected by stressors, not the stressors themselves.

3. The solution doesn't come from outside.
If the negative reactions we are having to stressful situations do not come from the external stressors, then our solution to dealing with our reactions can't be primarily focused on external events either. Dealing with our stress has to happen primarily through internal processes.

Of course, it is very important to realize that we need to be safe first. An abused spouse needs to be safe before they can deal with their emotional reaction to the abuse. A traumatized medic needs to be taken off the road in order to have the necessary safety to start dealing with their internal issues. However, once that essential safety has been secured, it is time to focus on the internal work that needs to be done.

This work is deeply personal. As medics we are immersed in the western medical model which is very mechanical.

If the bone is broken, an external expert diagnoses and repairs it. Similarly, if we have chest pain, it is an external expert that diagnosis and repairs it. A patient having a myocardial infarction can, if they wish, be a passive observer of the medical system that fixes them.

This isn't the way inner healing works though. The constellation of beliefs, habits and processes that make up our internal world is deeply personal and vividly unique. My coronary arteries are remarkably similar to yours, but my hopes, strengths, fears, injuries, habits and beliefs are not, and there is no radiographic or chemical test that anyone can perform to map out our internal world for anyone else to interpret.

The best that someone outside of us can do is to help us to focus on our own exploration and to give support and feedback from an external perspective. Even if someone else could have a detailed understanding of all of our issues (which is so unlikely that it is all but impossible), we are still the ones that have to process those issues and find our own understanding and resolution. At the end of the day, only we can do our internal work.

4. The solution probably isn't what you expect.
As medical professionals we depend very much on our ability to logically and rationally discover and interpret the signs and symptoms our patients present us with, and then to devise and implement a treatment plan. This is what Ann Weiser Cornell, author of The Radical Acceptance of Everything, calls the 'doing/fixing' mode of activity.

This mode is the basis of our technical, scientific way of interacting with our world and it is wildly successful for dealing with our external realities. It repairs broken bones, builds bridges and splits atoms. In fact much of our success as a weak and poorly defended species is due to our mastery of this way of solving problems.

However, the doing/fixing approach doesn't work well with internal problems. It is a truism that people don't mind changing, they just don't like being changed.

There is something within us all that resists being told how we should change. If you tell me I should clean up my room, I'm likely to resist doing that, just to prove that I don't have to listen to you. This is true whether it is someone else telling us to change, or us telling ourselves to change. None of us like a drill sergeant, even if that drill sergeant is internal.

The solution lies instead in adopting a 'being/allowing' attitude towards our internal experiences. Our bodies and minds have a wisdom of their own, and the process of healing our psycho-emotional injuries consists primarily of recognizing those injuries exist — bringing them to the attention of our conscious minds — accepting their existence, and taking a gentle 'hands-off' approach; stepping back and allowing resolution to arise and occur spontaneously, and without our intentional intervention(s).

This is a very different relationship with our 'problems' than we are used to having, and it is more of an attitude than it is an intentional process.
Like most attitudes, it is more easily caught than taught, and getting the groove of this approach is one area in which a trained therapist can help.

5. Things will never be perfect.
Our last point comes full circle around back to our first. Stress is normal. And in extreme situations, extreme stress is normal.

Many of us hold back in the expectation that we will jump into our lives once conditions are 'perfect'. We'll be able to be great medics (or spouses, or parents, or whatever) once the world isn't bugging us so much.

Unfortunately, it will never happen. If you're waiting for the rain to stop before going out for your walk, you're going to be trapped forever, because when it comes to life, there are no long, uninterrupted, sunny seasons.

The trick is in accepting that conditions will never be perfect, and getting on with what we need to do despite that unfortunate fact.

We learn to accept conditions as they are, and commit to what we need to do regardless. However, this isn't an aggressive or forceful way of relating to ourselves. I'm not suggesting that you need to whip yourself into unsafe conditions. Instead, it is a mature acceptance of the reality of what is, and a gentle resolution to engage, despite less than optimal conditions.

Stress affects us all, and sometimes it can be overwhelming. Knowing these basic points about dealing with stress might help you to better cope when those difficult calls affect you.

1. Acute stress modulates genotype effects on amygdala processing in humans.
Cousijn H, Rijpkema M, Qin S, van Marle HJ, Franke B, Hermans EJ, van Wingen G, Fernández G.
Proc Natl Acad Sci U S A. 2010 May 25;107(21):9867-72. Epub 2010 May 10.

2. Previous Exposure to Trauma and PTSD Effects of Subsequent Trauma: Results From the Detroit Area Survey of Trauma. Naomi Breslau, Ph.D., Howard D. Chilcoat, Sc.D., Ronald C. Kessler, Ph.D., and Glenn C. Davis, M.D. Am J Psychiatry 156:902-907, June 1999
© 1999 American Psychiatric Association

3. A Second Look at Prior Trauma and the Posttraumatic Stress Disorder Effects of Subsequent Trauma. A Prospective Epidemiological Study.Naomi Breslau, PhD; Edward L. Peterson, PhD; Lonni R. Schultz, PhD. Arch Gen Psychiatry. 2008;65(4):431-437.< p> 



About the author

Marc Colbeck is a paramedic instructor who currently offers free online counseling for emergency services personnel dealing with critical stress as a part of his practicum to complete an MA in Counseling Psychology. His website is www.criticalstress.com, and he can be reached via marc.colbeck@safe-mail.net

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