Peer Listener Training Program

1. Peer Listener Training Program This program was developed by the Prince William Sound Regional Citizens’ Advisory Council and Steve Picou, PhD. University of South Alabama www.stevenpicou.com/ picou@centurytel.net Disasters and Mental Health Shawn Hicks Tania Bayne

2. What’s goin on? • Oil? Spill’s long-term effects unknown • Oil Spill takes toll on mental health-30% • Scientists: Coast Guard, NOAA tried to hush oil research • A World in Distress-floods in Asia, ship collision in Arabian Sea, Wildfires in Moscow • Katrina (5 yrs)-Recovery, Rebuilding, Rebirth

3. PEER LISTENERTRAINING I. Disasters and Mental Health II. Communication Skills III. Dealing with Anger IV. Common Concerns V. Support Seeking

4. PEER LISTENERTRAINING SESSION I DISASTERS AND MENTAL HEALTH

5. Hurricane Katrina, 2005

6. The BP Catastrophe

7. AClassification of Disasters2 2Erikson, K. 1994. A New Species of Trouble: Exploration in Disasters, Trauma and Community. New York: W.W. Norton.

8. 9-11

9. Natural Disasters vs Technological Disasters On left, hurricane as seen from space. On right, effects of the Exxon Valdez oil spill.

10. DISASTERS AND MENTAL HEALTH I. History of Disaster Research A. Original studies B. Types of Disasters II. Stages of Response III. Psychological Effects A. Short-term effects B. Long Term effects 1. PTSD 2. Research C. Factors Affecting recovery D. Phases of Psychological Recovery E. Children & Elderly IV. Denial and Resistance V. Exxon Valdez Oil Spill A. 1989 Data B. 1992 Data C. 1995 Data

11. DISASTER: an event with a relatively sudden and identifiable onset that is caused by external or environmental factors and is associated with adverse effects on a group of individuals

12. DISASTER RESEARCH Original Studies Coconut Grove nightclub fire in Boston (1944) • Lindeman describes emotional reactions and a "disaster syndrome" consisting of flashbacks, survivor guilt, anger & hostility, a compulsive need to talk about the trauma, and obsessive thoughts and compulsive behaviors Buffalo Creek Flood (1972) • 4000 of the communities’ 5000 houses were destroyed • people relocated to trailers, lost support systems • 90% had lasting psychological symptoms two years after the flood Mount St. Helens (1980) • tenfold increase in depression, anxiety, and PTSD symptoms long-term Three Mile Island (1979) • even though no actual harm to individuals, significant, long-term increase in rates of depression, anxiety, hostility, and somatization No Long Term Effects? • a number of researchers have suggested that disasters typically produce only transitory effects and few will develop ongoing psychological problems as a result of a single disaster, however, as the above studies demonstrate, long-term effects are found

13. Types of Disasters Natural Disasters • floods, earthquakes, hurricanes • may involve some warning time • "low point" during worst part of disaster • loss of life and property • blame extends from God to man; often most anger associated with recovery and agencies involved • research demonstrates usual positive community response in the aftermath with community bonding in efforts to rebuild • primarily short-term psychological effects "Human-caused" Disasters Examples: Chernobyl, Exxon Valdez Oil Spill • rarely a "low point" • degree of victimization and harm hard to perceive • suffering often not acknowledged • long-term effects more common

14. Stages of Response Predisaster Preparation • reduce vulnerability to disaster through building codes, regulations, etc. • public education on disaster preparedness • drills with public safety/health workers • warnings of imminent disasters (people tend to underestimate likelihood of disaster, even when given warning) Disaster Response • immediate response to disaster • evacuation, search & rescue, care of injured persons, restoration of public order • development of "therapeutic community" - heightened sense of altruism, goodwill towards others, working together • majority of people cope well during the actual crisis, helping one another, minimal severe psychological reactions

15. Postdisaster Recovery • media coverage influences relief • community agencies provide existing services and expand services to deal with disaster • new agencies develop to deal with new issues • stress levels increase due to increased demands, change in routines • individuals become frustrated with relief agencies; decentralization causes agencies to not know where to direct aid • relief and aid often don't match the greatest need • despite aid and relief, most individual have increased debt • individuals resist being in victim role, avoid dependency • "hidden" stressors: temporary housing, loss of leisure time, children out of school and underfoot, need to talk about disaster, lack of good information, resistance to seeking treatment

16. Psychological Effects Short-term Psychological Effects • little systematic research on immediate short-term effects due to their assumed transient nature • "acute stress disorder" with dissociation, numbing, reduced awareness, re-experiencing, anxiety, avoidance, and arousal • sleep difficulties, irritability, and difficulty concentrating are common short-term effects

17. Long-term Psychological Effects Post-Traumatic Stress Disorder Re-experiencing: • recurrent, intrusive memories • nightmares • flashbacks • intense distress when reminded of the event • physiological reactions to reminders Avoidance: • avoid thoughts, feelings, etc. about trauma • avoid reminders of the trauma • loss of memory for events related to the trauma • decreased interest in activities • feelings of detachment from others • restricted feelings • sense of foreshortened future, pessimistic outlook Arousal: • sleep difficulties • irritability, anger • difficulty concentrating • hyper vigilance • easily startled

18. Research on Long-term effects • (Mount St. Helens) 11% of highly exposed men and 21% of highly exposed women were diagnosed with depression, anxiety disorders, or PTSD during the two years following the eruption • (Puerto Rico floods) increased diagnoses of depression, generalized anxiety disorders, and PTSD, greater use of health care services • (Buffalo Creek) 44% with probable PTSD 2 years after the dam collapse; 28% current PTSD 14 years after collapse • decrease in all types of symptoms over the first several years post-disaster; symptom persistence beyond two-years primarily associated with mad-made disasters • relationship problems, somatic complaints, and increased visits to medical and mental health facilities also found as long-term effects • decreased trust, suspiciousness and anger; sense of loss of control

19. Factors Affecting Recovery • individual's personal experiences in the disaster (contact with dead bodies, personal loss) • resource loss (shelter, food, money, sense of control, trust in others, role identifications) • individual's prior level of mental functioning • disasters not associated with a single community (plane crash, train wreck) • degree to which one has to rebuild life • type of disaster • demographics (lower incomes & larger families associated with more emotional problems; women found to have more symptoms than men; age; marital status) • speed of onset of disaster

20. Phases of Psychological Recovery 1) Heroic Phase – emotions strong, altruistic reactions 2) Honeymoon Phase (3 – 6 months) – victims show energy and optimism in reconstructing lives based on promises and help from different agencies 3) Disillusionment Phase (1 month to 1-2 years) – victims deal with frustration of failed help 4) Reconstruction Phase – individuals rebuild their own lives and community

21. Special Populations Children • the majority of disaster research on children demonstrates that children’s' reactions are influenced by their parents' reactions.…if parents are severely distressed, children can be expected to have similar symptoms • children also have direct effects from the disaster • parents and teachers often underestimate the degree of stress experienced by children • typical problems include regressive behavior, fears, sleep problems, repetitive play, nightmares, intrusive symptoms during "quiet" times • girls tend to show more psychopathology than boys • symptoms related to degree of morbidity and/or perceived threat

22. Age differences Preschool age - repetitive play & drawings; crying, thumb sucking, fears, irritability Elementary age - headaches, physical complaints; depression, fears, confusions, poor concentration, decreased school performance; fighting and/or withdrawal from peers Adolescent - headaches, physical complaints; depression, confusion; poor performance; withdrawal and isolation; aggressive and/or rebellious behaviors

23. Elderly Vulnerabilities • poor physical health • isolation • fixed income • higher rates of preexisting mental disorders Strengths • prior experience with disasters • "lifetime" perspective Research findings • elderly often more resilient, less anxious post-disaster • more concerned with loss of exterior items and house\damage, whereas younger individuals more concerned with loss of personal belongings • less use of insurance, and more positive ratings of emotional and physical health than younger individuals

24. Denial and Resistance • not all individuals will have psychological problems following disasters • denial can be a sign of avoidance or an accurate self-perception • denial more likely to be associated with avoidance and some evidence of intrusion or increased arousal • others less likely to see psychological distress as legitimate if little personal damage • others less likely to see psychological treatment as needed if little personal damage • many individuals avoiding treatment may do so because it serves as a reminder of the tragedy • many people will participate in initial mental health services following a disaster, but over time, decreased rate of participation in interventions is typical • persons avoiding mental health services may seek out informal contacts with mental health providers • nonparticipants in post-disaster mental health had higher initial rates of PTSD, with avoidance symptoms

25. PEER LISTENER TRAINING SESSION II COMMUNICATION SKILLS

26. COMMUNICATION SKILLS I. What’s so great about listening? A. Stress Assessment /Personality Types II. Verbal and nonverbal expressions A. Nonverbal issues B. Verbal Prompts III. Common Response Styles IV. Summary Suggestions for Communication and recognizing personality traits

27. SESSION II COMMUNICATION SKILLS What's so great about listening? While many people use the terms peer counselor and peer listener interchangeably, we chose the term peer listener for your role to emphasize the importance of listening over counseling. While certainly part of your role is to help people, in this next session we will be discussing how listening is the therapist/counselor's best tool. The greatest temptation for most of us it to become anxious about "straightening people out, fixing them up, and sending them in the right direction." Even though new directions and changes in your own life have probably come about only after thoughtful reflection and struggle, we somehow assume that expediency is required when we are attempting to help others. We pressure ourselves to fix people fast, and to do that, we need to collect from the experts the right opinions, the right theories, the right questions, the right answers, and the right problem-solving techniques. Two of the cornerstone philosophies of counseling to remember is that "there are no quick fixes," and to keep in mind“ the goal of "understanding, not changing.” We have two ears and one mouth so that we can listen twice as much as we speak.  Epictetus (Greek philosopher associated with the Stoics, AD 55-c.135) Rate Yourself: 1-10-Stress Level, Listening Skills

28. STRESS ASSESSMENT Physical symptoms of stress: • Muscle tension • Headaches • Short/restricted breathing • Upset stomach • Rapid heartbeat Behaviors/Feelings: • Trouble falling sleeping • Feeling anxious • Overeating/Not eating • Feeling irritable, disorganized, or overwhelmed • Trouble relaxing • No support from others • Highly critical of yourself

29. Stressful areas: • Financial • Love relationship • Children • Extended family • Work • Recent/past significant losses • Major changes in life • Severe illness Types of Stress: • Negative (Distress) – brings damage and negative consequences • Positive (Euress) – brings motivation, energy, and mobilization The main question to ask yourself: Do I have CONTROL over it? Acceptance vs. Control

30. While theories and techniques are useful, active listening is one of the best tools of the therapist. Further, listing is itself a philosophical and theoretical approach, with specific techniques of listening to and reflecting back feelings. The problems with theories and techniques arise when, in our anxiety to do something to people to make them different, we become side-tracked into focusing on problems instead of people. The solution, then, becomes the goal of our interchange, rather than focusing on the issues and their meaning for the individual. People who seek out peer listeners will most likely be seeking out some sort of change. While the urge will be to solve their problem, listening will serve to help you understand them and to help them understand themselves. We've all had the experience of going to someone for advice and coming up with a solution as soon as we verbalized the problem. Most of us need a sounding board at some time or another. Furthermore, sometimes the problem that someone chooses to present is not really the problem, in other words, you have to learn to hear what they are not saying.

31. Communication connects people. We need to feel that whoever listens to us is nonjudgmental, empathetic, and compassionate. We need to feel that the listener is focused completely on our dialogue. In this connection between speaker and listener, we need to feel trust and safety. In any crisis situation, communicating our feelings to another is an important step to healing and coping. In fact, research has shown that people who are able to talk about their problems in a trusting situation have fewer physical and emotional symptoms. Effective communication can break barriers and open channels of hope. We all need a sense of inclusion, respect, and acknowledgement -- particularly in difficult times. As you learn to listen actively and speak clearly, you create important links in the helping and healing process. Peer Listener Video-Communication

32. VERBAL AND NONVERBAL EXPRESSIONS Nonverbal issues: Eliminate Noise 1) The physical environment • Quiet, private setting • Be sensitive to distractions in the setting or individual distractions • Be aware of body language 2) Communicating Comfortably • respect personal boundaries • 0 to 18 inches (intimate distance) • up to 4 feet (personal distance) • up to 12 feet (social distance) •greater than 12 feet (public distance)

33. 3) Negative body language • emotional cues • be careful of your own body language, as well as the message being sent by the other person • cold or clammy hands (anxiety) • tightened jaw (anger, opposition) • arms folded across chest (anger, opposition, or anxiety) • side view (anxiety, opposition, lack of trust) • intense eye contact (anger) • perspiring or shallow breathing (anxiety) • tightened muscles (anger, anxiety) • hunched shoulders (depression, helplessness) • clenched fists (anger) • altering interpersonal distance (anxiety)

34. 4) Negative body language - signs of boredom - foot jiggling - cleaning nails - leg swinging - playing with hair - finger tapping - handling objects - yawning - reading - gum chewing - watching TV - smoking - shifting positions - eating - nodding off - knuckle cracking 5) Distracting body language • lint picking • rummaging through things • scratching • playing with clothing, hair, or other objects • interrupting • tapping fingers, pencil • clicking pens • rhythmic movement of body parts • sniffing • eating; drinking • smoking

35. 6) Internal distracters • state of mind • self-esteem • worries • fears • feelings of inadequacy • feelings of superiority • nervous feelings 7) Social distracters • prejudices • relationship with receiver • religious beliefs • cultural traditions • ethnic priorities

36. VERBAL PROMPTS Levels of Communication Level I: "Small talk", informal conversation, ("It sure has been cold lately"); serves purpose of breaking the ice, establishing a mutual interest on an equalizing topic Level II: Catharsis - venting feelings, sharing problems, frustrations; someone with an intense need or who is expressing emotions needs a listener with empathy who will "just listen" --nod, say "I see," and not jump in with advice or criticism Level III: Exchange of information - provide information or "advice," help solve a problem Level IV: Persuasion - trying to influence someone, alter their emotions or plan of action

37. 1) Following Skills • door openers • minimal encouragers • infrequent questions • attentive silence 2) Door openers and encouragers active listening • "break the ice" with conversational small talk transition phrases - feeders, paraphrase, reflect feelings, summarize - “I see,” “uh huh,” “I know what you mean” (let listener know that you are attending and understand)

38. 3) Reflecting and prompting questions • Rephrase the message to clarify and insure understanding; encourage person to express their own feelings, before giving labels to emotions • Use open questions, avoid "yes - no" questions "did that make you angry?" vs. "how did that make you feel?" • Limit "why?" questions, leads to defensiveness • Avoid loaded questions "Don't you think most families have prepared for crises?" 4) Exploring alternatives and resources or, how to not give advice 5) Recognizing feelings

39. COMMON RESPONSE STYLES 1) Evaluating/Advising • makes a judgment about the relative goodness, appropriateness, effectiveness, or rightness of the sender's problem • is the most frequently used response • implies what the sender ought or should do Impact on sender: - feel threatened and defensive - feel listener assumes their judgment is superior - reinforces feelings of inferiority and low self-worth General rule: avoid in early stages, always use with caution 2) Interpreting/Analyzing • communicates intentions to tell sender the real meaning of the problem • tells sender how the sender feels about the situation; gives psychological insight to the sender • intends to point out some hidden reason that makes the sender behave as he/she does Impact on sender: - feel defensive and afraid that future thoughts and feelings will be analyzed - better if you lead them towards finding their own interpretations General rule: avoid in early stages, spend more time listening

40. 3) Supporting/Reassuring • indicates listeners concern for the sender's feelings • can communicate a lack of understanding Impact on sender: - may be received as support - may be received as a lack of understanding, or criticism of feelings, "you should not feel as you do" General rule: do not provide false reassurance, do reassure your availability to help 4) Probing/Questioning • reflects a desire for more information to understand the problem better • can encourage or discourage further communication Impact on sender: - open questions encourage people to share more thoughts and feelings, and encourage greater self-exploration General rule: ask open questions, but avoid "why"

41. 5) Understanding/Paraphrasing • indicates and intent to understand the sender's thoughts and feelings • paraphrases what the sender has said in the receiver's own words Impact on sender: - lets sender know that you have hear them and are actively trying to understand - lets sender hear their own thoughts and feelings for further clarification, understanding General rule: use frequently

42. EXAMPLES OF RESPONSE TYPES Evaluative responses I think what you should do is..... You shouldn't get so upset about.... You should learn to ...... You're not thinking straight. You're acting foolishly. Interpretive responses What's wrong with you is.... Your problem is...... You believe that.... The reason you're saying that is.... You're thinking that way because Supportive responses You'll feel better.

43. It's not so bad. Give him a chance, he'll come around. Things could be worse. Don't give up. Probing responses Why do you think that's so? Why do you feel so..? Why didn't you ....? What kind of a plan do you have to...? How do you feel when..? Understanding responses You're so upset about ... Sometimes you're so angry you feel like.... When you feel it is difficult to You're really down You feel happiest when...

44. SUMMARY SUGGESTIONS FOR COMMUNICATION 1. Stop talking. You can't listen while you are talking. 2. Get rid of distractions. Avoid "fiddling" with things. Get away from unnecessary noise such as TV or radio. Make your surroundings as free of distractions as possible. 3. Be interested and show it. Genuine concern and a lively curiosity encourage others to speak freely. Interest also sharpens your attention and builds on itself. 4. Tune in to the other person. Try to understand his or her viewpoint, assumptions, needs, and system of beliefs.

45. 5. Concentrate on the message. Focus your attention on the person's ideas and feelings related to the subject. Listen to how it is said. The persons' attitudes and emotional reactions may express as much or more meaning than the words that are spoken. Try to keep your personal feelings or biases about the individual from influencing what he/she is trying to say in this instance. 6. Look for the main ideas. Avoid being distracted by details. Focus on the key issue. You may have to dig to find it.

46. 7. Watch for feelings. Often people talk to "get something off their chests." Feelings, not facts, may be the main message. 8. Remember that you will be interpreting the person's feelings and statements based on your experience, values, viewpoint, and prejudices. Our convictions and emotions filter-- even distort--what we hear. Be sure to give feedback and check out what you think the speaker means and wants. 9. Look at the other person. Let him/her know that you are listening. Maintain eye contact. Smile, nod or grunt as appropriate. This signals the speaker that you are with them. 10. Notice non-verbal language. The face, the eyes, the hands all help to convey messages. A shrug, a smile, a nervous laugh, gestures, facial expressions and body positions speak volumes. Start to read them. And be sure to check out your interpretation of these non-verbal messages just as you do the verbal ones. 11. Hold your fire. Avoid hasty judgment. Don't jump to conclusions regarding the situation or what the person wants. Hear the speaker out. Plan your response only after you are certain that you've gotten the whole message.

47. 12. Give the other person the benefit of a doubt. We often enter conversations with our minds already made up, at least partially, on the basis of past experience. Prejudgments can shut out new messages. 13. Get feedback. Make certain you're really listening. Ask a question. Confirm with the speaker what he or she actually said. 14. Leave your personal emotions aside. Try to keep your unrelated worries, fears or problems out of the situation. They will prevent you from empathizing and listening well. 15. Share responsibility for communication. You, the listener, have an important role. When you don't understand, ask for clarification. Don't give up too soon or interrupt needlessly. Give the speaker time to express what he/she has to say. 16. Work at listening. Hearing is passive; our nervous system does the work. Listening is active; it takes mental effort and attention

48. Recognizing Personality Traits in People 4 Types of Personalities: • Dominant – assertive, task-focused, tell-oriented, independent, determined, requiring, pushy, dominating, tough-minded, pragmatic, vocal intensity, efficient • Expressive – spontaneous, enthusiastic, initiative, creative, expresses emotions, fast pace, risk-oriented, fun-loving, personable, outgoing, undisciplined, persuasive

49. Analytical – logical, slow, fact and detail-oriented, systematic, prudent, orderly, stuffy, indecisive, critical, serious, punctual, appear detached from feelings, withdrawn • Amiable – soft-spoken, quiet, supportive, patient, loyal, agreeable, dependent, team-oriented, respectful, willing, cooperative, emotional, conforming, reserved, dependable

50. Modifying to the 4 types of personalities: • With a Dominant – get to business, find equal grounds, stay on topic, focus on RESULTS • With an Expressive – praise them, paraphrase, focus on the “BIG PICTURE” and SOCIALIZING • With an Analytical – be on time, be prepared, factual, and logical, follow up in writing • With an Amiable – be genuine, patient, and relaxed, invite conversation, offer assurance