Welcome to the Pennsylvania Dual Diagnosis Direct Support Curriculum presentation on Stress Management for the Direct Supporter.

The Commonwealth of Pennsylvania’s Office of Mental Health and Substance Abuse Services (OMHSAS) and the Office of Developmental Programs (ODP) have undertaken a joint initiative to address the needs of people who have an intellectual disability as well as mental health challenges. People who have both of these challenges are commonly referred to as those who have Dual Diagnosis. For the purpose of this training, Dual Diagnosis is not referring to co-occurring mental health challenges and substance abuse or dependence, although people can have substance abuse or dependence issues as well as a Dual Diagnosis of an intellectual disability and mental health challenges. The curriculum was designed for Direct Supporters, Supports Coordinators and others who work in either the intellectual disability field or the mental health field. The ultimate goal of this training curriculum is to provide information that can aid in the understanding of the struggles and the triumphs of those you support or will support. This curriculum was designed to demonstrate the complexity of Dual Diagnosis and the factors that need to be considered to best support those with whom you come into contact. The Pennsylvania Dual Diagnosis Direct Support Curriculum was also designed to demonstrate that all people in this world, regardless of their challenges, are much more alike than they are different.

The information presented to you today is to increase your awareness. It is not intended to replace medical advice. If you believe you or someone you support have these conditions or concerns, please seek the advice of a physician.

• By the end of this presentation, you will:

• Understand how stress affects the whole person; • Identify external and internal stress factors; and • Learn to incorporate stress reduction techniques into your daily life

and the lives of people with a dual diagnosis.

Hopefully the picture on this slide does not show how you feel everyday! We are going to discuss stress. Stress is a normal part of life. It can either help us learn and grow, or it can cause significant problems. Too little stress results in boredom. Small amounts of stress can work to your benefit by making you more productive. Manageable stress can fuel personal achievement and make you more creative. Everyone has an OPTIMAL level of stress. Any change can make us feel stressed whether the change is positive or negative. It is not just the change itself, but how we react to it that makes a difference. Stress is individualized. For example, someone may become stressed by getting a promotion while most people would think of it as positive.

• In 2015, the American Psychological Association related that 58% of employees report that work is a significant source of stress. In 2009, they reported that 41% of employees say they typically feel tense or stressed out during the work day and 51% of employees said they were less productive at work as a result of stress.

• According to the Bureau of Labor Statistics, in 2001 the average number of days away from work as a result of anxiety, stress and related disorders was 25. This is substantially greater than the average of 6 days away from work for all nonfatal injury and illness cases.

• Data released by the 2013 Work Stress Survey conducted by Harris Interactive on behalf of Everest College indicates that more than 8 in 10 employed Americans say they are stressed out on the job amid heavier workloads and lower pay.

• All of these survey results indicate that stress in the workplace is a significant problem!

• Physical stress is defined as our body’s response to any demand made on it. An example of such stress is working out or running a marathon. Mental stress is the response we have when faced with events we perceive as endangering our physical or psychological well-being. Feelings of stress are caused by the body’s instinct to defend itself.

• The stress response or “fight or flight” reaction happens when a threat is processed in the hypothalamus, which is a tiny area in the base of the brain that sets off an alarm. Signals are sent to the adrenal glands which are located on the kidneys to increase the release of adrenaline and cortisol hormones. The adrenaline increases the heart rate and elevates the blood pressure. Cortisol increases sugar in the blood stream, enhances the brain’s use of sugar, and increases the availability of substances that repair tissues. It alters the immune system responses as well as suppressing the digestive system, the reproductive system, and growth processes. The stress response system regulates itself. Once a crisis is passed, it decreases hormone levels and allows the body to return to normal. This process occurs in both physical and psychological threats. The less control we have over potential stress-inducing events, the more uncertainty they create, and the more likely we are to be stressed. Unlike physical threats, the day to day demands of living, such as work, can contribute to activating the body’s stress response. What is good for your body in the short term may be harmful over long periods of time.

• Long term activation of the stress-response system and the overexposure to cortisol and other stress hormones can disrupt almost all of your body’s processes, increasing your risk of obesity, insomnia, digestive problems, heart disease, depression, memory impairment, physical illness, and complications.

• A study out of Pennsylvania State University found that stress was not the

problem, but rather how we react to stressors. It appeared that how patients react to stress is a predictor of their health a decade later.

• The results of an American Psychological Association survey listed the top three stressors for the participant’s as money, work, and the economy.

• In 1981, a sample of middle aged people were observed over a nine month period. The following is a list of the 10 most common events or “daily hassles” that produce stress:

• Concerns about weight

• Health of a family member

• Rising prices

• Home maintenance

• Too many things to do

• Misplacing or losing things

• Yard work or outside home maintenance

• Property, investments, or taxes

• Crime, and

• Physical appearance • Some examples of external stress factors may be trauma or crisis,

small daily hassles, conflicts, having to deal with unpleasant people, excessive or impossible work demands, and boring or lonely jobs.

• Some examples of internal stress factors may be irrational ideas about how things must or should be done, believing you are helpless or can’t handle a situation, and assigning fault for bad and uncontrollable events on yourself and others.

• We are all different and external and internal factors are individualized for us, as well as for the people we support. How we view our daily hassles, as well as the large stressors that come and go in our life is more important than the stressor itself. Think about yourself. Are you a “glass half empty” or a “glass half full” type of person?

• Think about how you react to stressors.

The physical symptoms of stress include most body systems. Some examples of the physical signs of stress are: back pain, chest pain, cold hands, constipation, diarrhea, headaches, indigestion, muscle tension, racing heart, shortness of breath, changes in blood sugar, sleep problems, tiredness, changes in sex drive, quivering muscles, eye strain or tension, tense body posture, teeth grinding, irritable bowel and other GI concerns, and insomnia. This is not an all-inclusive list as there can be other signs as well. Stress causes the release of powerful hormones that can have the following effects: • the body’s need for oxygen increases, • breathing rate increases, • heart rate and blood pressure increases, • the blood vessels in your skin contract, • muscles tense, • digestion slows down, • body temperature rises, • blood sugar levels rise, • blood has an increased tendency to clot, • cells pour stored fat into your blood, and • urinary function slows down. These effects put a tremendous strain on the body and cannot be kept up for very long. Over time, continued stress will cause our organ systems to weaken and fail.

• Psychological symptoms of stress may include: anxiety, trouble thinking clearly, forgetfulness, frustration, trouble making decisions, racing thoughts, restlessness, short temper, and nervousness, as well as, sadness, apathy, and even clinical depression.

• Some of these symptoms are similar to signs of hypoglycemia, or low blood sugar. If you or someone you support experiences these symptoms, it may be caused by low blood sugar which would need intervention or treatment. Don’t assume that it is always stress.

• Many behaviors that increase in times of stress are maladaptive ways of coping with stress. These behaviors may include overeating or under eating, substance abuse and/or dependence including overuse of pain and anxiety medications, binge drinking or drinking more frequently, smoking, anger outbursts, relationship issues, social withdrawal, over-spending, and sexual promiscuity. These behaviors may provide some distractions from a stressful situation but ultimately will cause more stress for a person.

• We now know what factors can contribute to stress. We also have talked about the signs and symptoms of stress. We are now going to discuss mental and physical techniques to combat stress. We will start with mental techniques.

• Avoidance is not being irresponsible. Avoidance is about prioritizing what is ACTUALLY important. It is a way to not participate in activities that provide no real benefit to ourselves or others.

• Think about your life. Are there stressful situations that you take upon yourself that you have the ability to avoid? Have you allowed yourself to become everyone’s therapist, nurse, doctor, psychiatrist etc.? Do a lot of people in your life call you only to get you to listen or solve their problems? Do you take on everyone else’s stress and get more involved in other people’s problems than you have to? If so, then utilizing this technique would be very helpful for you.

• If you know a situation is going to be unpleasant and the situation will bring no benefit to you, it may be possible to avoid or limit exposure to it. Think about those people who call you to vent their problems but tend to do nothing to resolve them. Can you avoid those phone calls and reduce your stress? Most likely the answer is YES!

• Supporters have more self-defeating thoughts than you might think. There is also a lot of guilt associated with being exhausted and no longer being able to help. Thought stopping is a technique to remind yourself that you are more than just a supporter. Sometimes taking care of yourself is more important than caring for others. If you don’t take care of yourself, you are less likely to be able to provide optimal care. When you feel like you are letting others down, remind yourself about what YOU need in order to optimize your supporting.

• Provide yourself with a brief period of conscious relaxation.

• When you have negative thoughts, take time to think about the good you do and, more important, think of the good you have done. Remind yourself that you are in control of your destiny. Your stress level is often based on how you think about a situation, rather than, the situation itself. YOU CAN OFTEN CONTROL YOUR OWN LEVEL OF STRESS! Remind yourself of the many things you can do. You are in control of your life and you can learn from your mistakes.

Supportive work includes situations that we think are urgent. Many situations are not as urgent as people would like us to believe. We sometimes jump to conclusions or react without first analyzing the situation. If everything is viewed as a crisis, it intensifies the stress level for all who are involved. Taking a step back to analyze a situation is vital when it involves supportive work. Ask yourself these questions. • Is the situation life threatening to myself or others? Probably not. • Will this event change my life or another person’s life? Probably not. • If everything goes wrong will it matter in 6 months? Probably not.

Carefully consider how you respond to stressors. If you are the kind of person that thinks everything is an emergency, your stress level will never go down. Prioritizing situations by their importance is something we need to do for ourselves and for the people we support.

• Imagery is literally about finding your “peaceful place” or “quiet place.” Imagine a scene, place, or event that is peaceful, restful, beautiful, and makes you happy. Go there in your mind and experience all the sounds, smells, tastes, and feelings in your “place.” This place is your retreat from stress and pressure. You can also visualize the stress flowing out from your body.

• If you feel you do not have a “peaceful place”, we are now going to try an imagery exercise called “The Peaceful Scene”.

• Close your eyes and concentrate on what I am about to say. • “You’re walking along a beautiful deserted beach. You are barefoot

and can feel the firm white sand beneath your feet as you walk along the sea shore. You can hear the sound of the surf as the waves ebb and flow. The sound is hypnotic, relaxing you more and more. The water is a beautiful turquoise blue flecked with whitecaps far out where the waves are cresting. Near the horizon, you can see a small sailboat gliding smoothly along. The sound of the waves breaking on the shore lulls you deeper and deeper into relaxation. You draw in the fresh, salty smell of the air with each breath. Your skin glows in the warmth of the sun. You can feel a gentle breeze against your cheek ruffling your hair. Taking in the whole scene, you feel very calm and at ease.”

• Another strategy to use is planning and rehearsal. It can be helpful to take time to analyze what is causing stress and plan how you will respond to it. If you rehearse your response, you can build confidence and be better prepared when the stressful event or action takes place. A good plan concretely identifies a problem and develops problem solving options.

• Let’s look at an example: When John’s friend, Billy, comes to visit him, he always touches his CDs and puts them in a different order than what John likes. Every time Billy says he is coming over, John becomes stressed out about his CD collection being handled and disorganized. John decided that if he puts his CD collection away before Billy comes over, he does not mess with it. If Billy asks to see John’s CD collection, John has decided to tell him that it is put away and he would rather not take it out.

• Worrying has a life of it’s own. It disturbs and interferes with every thought. Our goal is to interrupt the negative thought and replace it. A technique called “Clearing Space” is a way to quiet the ruminating mind.

• “Clearing Space” involves the following strategy:

• Sit quietly with your eyes closed. • Take four deep breaths breathing in through the nose and out

through the mouth. • Think about the things or issues that might be causing stress or

bothering you. • Focus upon opening a container. • Visualize and name an issue and imagine placing it into the

container.

• Mentally put a lid on the container and put it away until you need to get something from it.

• Once the container is away, think about the next most important issue you have.

• Have fun!! We often take life too seriously and fail to have enough fun. We only see potential problems and do not see the happy parts of our lives. Schedule more play time. Laugh, joke, and find pleasure and delight in every day.

• Humor is an excellent stress buster! It can be a fun and healthy activity. Laughter has been called ”inner jogging” and is a wonderful way to relieve anxiety and stress.

• There are many benefits to laughter and humor. The short-term benefits of laughter are organ stimulation. When you laugh you take in more oxygen. This stimulates the heart, lungs, and muscles and increases the endorphins, which are chemicals in our brain that make us feel good. Laughter can also help digestion and stimulate circulation, which helps to reduce some of the physical symptoms of stress. Long-term effects of laughter include an improved immune system. Negative thoughts can cause chemical reactions that can bring more stress and decrease immunity. Positive thoughts help fight stress and serious illnesses. Laughter can also relieve pain. Laughter may ease pain by causing the body to produce its own natural pain killers. Laughter also increases personal satisfaction. One study of nurses who work in emergency rooms found that the nurses who use humor in dealing with their patients and co-workers, experience greater job satisfaction and feelings of personal accomplishment than those who do not find any humor in stressful situations (Laugh Your Way to Stress Relief, Mayo Clinic Staff, 7/20/2006).

• A positive attitude can dramatically reduce stress very quickly. The more negative the attitude, the more stress it brings to both yourself and others. Positive attitudes, like negative attitudes are contagious. Being positive makes others around you more positive. Try to see the silver lining of every cloud. Problems, no matter how big, are temporary. How you approach them is up to you.

Breathing helps to slow down or even stop the stress response. Breathing control takes time to practice. People who do not learn how to breathe correctly will not use it consistently. It’s important to learn breathing control until it becomes an automatic habit. Practice 15 times a day for 1 minute. Practice breathing control every time you are waiting for something such as in line or at work. Here is how to do it.

• Slowly inhale counting to 1, pause for a moment, and slowly exhale counting to 2.

• Now, slowly inhale counting to 3, pause for a moment and slowly exhale counting to 4.

• Continue inhaling and counting to 5, pause for a moment and slowly exhale counting to 6.

• Inhale counting up to 7, pause for a moment, and slowly exhale counting to 8.

Try to feel the cool air as you inhale and the warmth of your breath as you exhale. Repeat this for another 4 breaths.

• Let us practice meditation. Close your eyes and breathe. Notice your body, how your heart beats, how the intake of air feels, how your stomach feels. Keep your eyes closed. Shift your awareness away from your body to everything else that you can smell, hear, sense, and feel through your skin.

• Learning to meditate takes time and it can feel uncomfortable at first. • While practicing, try to shift back and forth between what is going on in your

body and what is going on around you.

• Self-hypnosis can feel a lot like meditation. If you are interested in self-hypnosis this is what is recommended:

• Pick a quiet spot and close your eyes. Imagine waves of relaxation washing over you, from your head down your body, in time with your breathing.

• Say, “I am feeling relaxed and comfortable. With every breath I am becoming more relaxed and more comfortable.”

• Give it a try!

• A healthy diet is more important than you think when it comes to reducing stress. A poor diet leads to more fatigue, more stress, and a higher likelihood for depression. It is important to care for yourself by eating right. Follow a routine to keep your body healthy, balanced and resilient. As much as possible, avoid sugar, nicotine, alcohol, and caffeine. These substances overstimulate the body. They also produce highs and lows that can lead to distress.

• Frequent exercise is one of the best stress-reduction techniques. It increases the flow of blood to your brain and organs. It releases endorphins into your bloodstream which give you a feeling of happiness and well-being.

• Muscle relaxation can relax the body when muscles are tense from stress. • Let’s give muscle relaxation a try.

• Alternately tighten and relax groups of muscles (for example, wrinkle your brow and squint).

• Tighten muscles while breathing in, then relax the muscles while breathing out.

• Move down your body, tightening and then relaxing the major muscle groups from your head to your toes.

• If any muscle or groups of muscles are not relaxed, you may repeat the tightening and releasing technique.

• Enjoy the relaxation for a few moments.

• Lack of sleep is a stressor. Adults should try to sleep 6-8 hours per night or per day for those who work night shifts. If your schedule keeps you from getting the rest or sleep you need, try taking naps. Even the little amount of sleep you can get from an extra nap can help to reduce the effects of stress.

• Think about something peaceful while drifting off to sleep. Reduce watching TV and looking at a computer screen at least for one hour before bed because the light from the TV and computer trick the mind into staying awake longer. Consider using alarm clocks that gradually wake you up rather than very loud alarms that wake you up instantly.

• Create a pleasant environment that will help you relax and sleep. • When creating this type of environment, it is important to improve air

quality, use soft lighting, and reduce background noises. Keep your home and workspace pleasantly decorated and clean. Provide comfortable furniture and use a firm mattress to sleep.

• You can have a stress plan in place to use when there are changes in your life. Change is inevitable. We need to recognize the type of changes that can lead to stress. We need to learn the warning signs of stress, such as anxiety, sleep problems, and irritability. We also need to find healthy strategies for dealing with the stressors that we can and can’t control.

• There may be times when we need professional help. There is nothing wrong with finding support for ourselves whether it be from family, friends, supervisors, peers, or professionals. Managing stress is about managing life!

• Try to practice good stress coping strategies like those we talked about! Don’t be afraid to share your stress coping strategies with friends, family, and those you support as well.

Congratulations, you have successfully completed the Stress

Management for the Direct Supporter training.

Thank you for your participation in this training.