Managing difficult emotions in the aftermath of disaster

• Administer the DASS
• Are they employing adaptive coping strategies?
• Would they benefit from learning additional coping strategies?
• Is referral to a general practitioner or specialist mental health practitioner warranted?

Emotional responses to disaster vary. In order to select the strategies most likely to assist in the management of those emotions, it can be helpful for disaster-impacted individuals to have a clear picture of the situations that trigger their emotional responses, and the intensity of the emotions experienced.

It is also helpful for the health practitioner to have an accurate understanding of the strategies that the individual has already employed to manage the situation, and the degree to which those strategies have been effective. Monitoring can assist to build this picture. Ongoing monitoring, in particular of the use and impact of the various strategies to be implemented gives a picture of their effectiveness and allows for adjustments in the interventions offered as necessary. It may be helpful to provide disaster-impacted individuals with this monitoring form.

Psychoeducation
It can be very useful for disaster-impacted individuals to increase their understanding of the nature of disaster and common mental health impacts. This Disaster Mental Health Hub has a number of handouts that can be downloaded and provided directly to community members, or can act as a basis for conversations between health practitioners and clients. See our Community resources web page.

A fundamentally important component of psychoeducation when introducing the use of skills to manage difficult emotions is the relationship between elevated baseline levels of arousal or distress and the acute escalations. For some survivors of disaster, vigilance or heightened awareness of any future signs of threat remain fairly constant. Baseline levels of arousal therefore remain high and leave the individual more vulnerable to acute escalations of distress. When acute escalations occur the individual is more likely to tip across the threshold into the experience of extreme emotions such as panic or intense anger outbursts. Being aware of and having skills to manage arousal and distress at both levels is therefore important.

Increasing self-awareness regarding emotional reactions and their intensity
Tracking emotional responses and their intensity is key to effectively implementing self-help strategies. Noticing distressing emotional reactions at lower levels of intensity and before they reach extremes allows individuals to manage their responses more effectively. Most people will find that they can more successfully implement self-help strategies at lower levels of distress, thereby acting as a circuit breaker, limiting the likelihood of distress increasing to less manageable heights.

SUDS
Introduce the concept of rating emotional reactions on a 0-10 scale, whereby a rating of 0 = complete relaxation, and 10 = maximum intensity distress. This is referred to as a Subjective Units of Distress Scale, and it can be helpful to employ this method of gauging distress on a SUDS scale because individuals use different words to describe intensity of distress. One individual might say they are “OK” when asked to describe their current level of distress, when in fact they are experiencing distress at a 9/10 level on the SUDS scale. Another individual might use the word “OK” to describe a rating of 3/10 on the SUDS scale. Anchoring descriptions of intensity of distress in SUDS ratings increases clarity of communication.

Calming Skills – Controlled breathing
Acute episodes of stress, and in particular, the experience of chronic stress, can change breathing patterns. With chronic stress, breathing patterns can become shallower, more rapid and unbalanced. These changes can result in physiological responses that mimic feelings of fear and anxiety, in particular the aspects of those emotions that are experienced physically, e.g., increased heart rate, sweaty hands, and muscle tension. A powerful way to deal with distressing emotions, and counteract tense breathing and associated physical reactions, is to use controlled breathing techniques. Read this Controlled breathing techniques factsheet. Controlled breathing techniques prioritise slower, deeper breathing that balances inhalation and exhalation. Controlled, slow and balanced breathing underpins many effective relaxation and meditation techniques. While the regular practice of controlled breathing techniques can help to reduce baseline levels of arousal, they are particularly helpful during acute or high level escalations of distress, findings that are strongly supported by empirical evidence.

Calming Skills – Here and now “grounding” techniques
Grounding techniques can be particularly useful when a person is feeling emotionally overwhelmed, or finds themselves dwelling on the past or focussing too much on what may or may not happen in the future. Grounding techniques pull attention from the past and future by focussing attention on the sensory details of the immediate environment, here and now. In this way they can act as an effective ‘circuit breaker’, the use of which may then be followed by other activities such as distraction, exercise, engagement in pleasant events, or problem-solving. The 5, 4, 3, 2, 1 exercise is one example of a here-and-now grounding technique. For this exercise disaster impacted individuals are asked to notice and think about things they can experience with your senses. For example, they are asked to think about ….
… 5 things they can see
… 4 things they can hear
… 3 things they can feel or touch
… 2 things they can smell or like the smell of, and
… 1 thing they like about where they are.

This technique can be repeated until the individual feels calmer. It is easily taught and acquired, and can be used anywhere and anytime the person needs.

Reducing baseline arousal and tension levels – progressive muscular relaxation
Progressive muscular relaxation is an evidence-based technique that with regular practice, is effective in reducing baseline levels of arousal. Further, learning to relax muscles at the same time as controlling breathing will help survivors to learn to associate controlling the pace of breathing with becoming more relaxed in various muscle groups throughout the body. Effective sessions of PMR take approximately 20 minutes. Follow this link to a progressive muscle relaxation script, which can be followed by the health practitioner and recorded by the disaster impacted individual on a smart phone or other device. PMR should be practiced daily and SUDS ratings taken before and after practice.

Taking time for relaxing and pleasurable activities
Suggesting that people make time for relaxing activities can be met with resistance. It is important that the suggestion does not appear patronising, as if to imply that taking a bubble bath will fix everything. However, it is helpful to acknowledge that rebuilding lives, families and communities in the aftermath of disaster can be a prolonged process, with many hurdles to overcome. Sustaining health and wellbeing across that time will require effort. Taking time for relaxing and pleasurable activities supports health and wellbeing in the long term, and through what may be for many individuals, months and years of effort. So, just as some activities increase stress, others can help to decrease it. Encouraging people to recall the kinds of activities that they have engaged in previously, and scheduling those in advance, can be a small, but useful part of an overall recovery plan. Activities might include listening to or playing music, reading, watching a favourite television show, walking the dog, or engaging in creative pursuits. Of course, the disaster may have created limitations to accessing previously enjoyed activities, and other options may need to be found.

Looking for relaxing and pleasurable activities that can be done with others may also be valuable. A sense of social connectedness is a positive predictor of outcome following disaster, and spending time engaging in pleasant activities can be beneficial. Activities might include walking with a friend, participating in a yoga or tai chi class, or rebuilding a community garden.

Managing strong emotions in the aftermath of disaster can take time and effort. A toolbox metaphor can be helpful where individuals are encouraged to trial a variety of potentially helpful strategies, and by monitoring the use of the strategies, a picture can be built up over time of the usefulness of each. Individuals often have a preferred tool for a job, and disaster-impacted individuals can be encouraged to build up their toolbox by adding different strategies and tools over time.

Barlow, D. H., Farchione, T. J., Sauer-Zavala, S., Latin, H. M., Ellard, K. K., Bullis, J. R., … & Cassiello-Robbins, C. (2017). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. Oxford University Press.