COVID-19 and the Diathesis-Stress Model: How to Relieve Stress under Extraordinary Circumstances

March 31, 2020 Mark Wilhelm

Everyone experiences periods of increased stress in their life. These may be mild and recurrent, such as the stress involved in working or raising children, or they may be more severe and unique, like the stress of losing a job or getting a divorce. When we encounter a stressful situation, we can usually get through it without any lasting repercussions. However, extreme or prolonged periods of distress can sometimes have negative effects on our mental well-being.

The diathesis-stress model, which is sometimes also called the stress-diathesis model, is a psychological framework for understanding how stress affects our mental health. According to this model, every person has a certain amount of vulnerability toward depression, anxiety, and other mental health problems and conditions. Although some people do not struggle with these issues under normal circumstances, extreme distress can sometimes cause symptoms to develop where none existed before. And for people who do struggle with a mental health condition under normal circumstances, additional distress can worsen their symptoms and make management of their condition more difficult.

As the public health crisis created by the COVID-19 disease continues, it’s important that everyone be prepared for the ways this additional stress might affect their health. Even individuals with no preexisting behavioral health conditions may find themselves feeling more worried, anxious or depressed over the coming weeks. Fortunately, we can all lessen the negative effects of this particular stressor by taking precautions to boost our emotional resilience.

To learn more about what to expect and how to manage behavioral health issues during this difficult time, we spoke with Margot Everitt, one of our Team Leads for school-based services in Marion County. Below, Margot explains how a person’s health might be impacted and what they can do to relieve stress during this or any other extraordinary situation.

Explaining the Mental Health Risks Posed by COVID-19

As stated above, most people should expect to experience some amount of increased distress due to the ongoing situation with coronavirus disease. Individuals who have an existing mood or anxiety disorder are the most likely to experience worsened symptoms as a result of this added stress. While symptoms of increased distress will vary from person to person, Margot anticipates that they will follow two main trends.

First, a person might experience reduced well-being right now, as we are living through the crisis day-to-day. “When there is a stressful situation like what we’re going through right now, if you already have anxiety, for instance, you’ll likely feel increased symptoms,” Margot says. “When people are worried about getting their basic needs met, that’s when we see things like depression and anxiety come into play.”

These effects could be more pronounced if a person’s employment status has changed, if their normal daily routines have been greatly interrupted, or if they spend a lot of time following the situation’s development. “You could see increased symptoms if you’ve lost a job, if you’re watching the news, or if you’re not able to do things that help you relieve that stress,” Margot says.

Second, a person might also experience increased distress when they must transition back to normal life at the end of this crisis. For some people, this stress could be the result of employment changes and financial difficulties. For others, it could occur due to the strain of returning to old habits and routines, as Margot explains:

“For example, some kids have a lot of anxiety and struggle with going to school because of that anxiety. My concern is that this whole situation will make the transition back to school much more difficult. Right now, they’re getting used to being in their homes and in their ‘cocoon,’ so I think they’re going to have a harder time transitioning back to school. In the same way, getting back into the workforce may be difficult for adults who aren’t working or have been laid off.”

What You Can Do to Guard Against Distress

Once we understand how additional distress could impact our mental health, it’s important that we take measures to counteract these negative effects. One of the best ways to manage distress is to continue normal wellness behaviors like exercising frequently, eating nutritious food and maintaining a regular sleep schedule. These behaviors have been proven to boost resilience and improve mental health, so continuing them during times of crisis is critical.

Since many of us are currently spending a great deal of time at home, we might find it difficult to continue our regular wellness routines. However, we can work within existing constraints to continue our wellness behaviors to the best of our abilities, as Margot explains:

“For sleep, you should keep a consistent sleep schedule and have a good bedtime routine. Do something that relaxes you before going to bed, and get up at the same time you always get up. If you’re staying up all night and sleeping late into the day, that’s going to change your body chemistry, and then how are you going to function when you have to go back to your regular hours? For exercise, any kind of movement is beneficial, and there are things you can do to modify your normal exercise routine. Take a walk, or if you live in a neighborhood where you don’t feel safe walking outside, then walk around your house. Get a milk jug and lift it as a weight, or do jumping jacks. For nutrition, practice healthy eating and try not to snack all day. Have dedicated times for eating breakfast, lunch and dinner. You should do all the same things you were doing before and figure out how to modify those behaviors for the present circumstances.”

In addition to these wellness behaviors, Margot emphasizes the importance of building structure into our day even if we aren’t leaving the house for school or work. “It’s very important for kids and even adults to create structure, although it’s going to look different than normal. They need to get up, take a shower, eat breakfast—whatever their routine is—even if they don’t leave the house. I think people will feel a lot better if they keep a structured day,” she says.

Finally, it’s a good idea to limit your exposure to anxiety-inducing information and news about the crisis. While it’s important to stay informed of new developments, spending excessive amounts of time tracking the situation will likely increase your level of distress. “I think people have to be really careful,” Margot explains. “There’s so much information out there that’s just going to increase anxiety and paranoia. Right now, I don’t watch the news unless it’s something like Good Morning America, and when I get on social media, if I start seeing too many things about the coronavirus, I get off. Some people might need to limit or eliminate these things if they’re causing too much stress.”

In times of heightened anxiety and distress, we must also be sure to continue regular appointments with behavioral health professionals. Although Cummins BHS is limiting face-to-face sessions during the COVID-19 crisis, our providers are still conducting sessions via telephone and video conference. Call us at (888) 714-1927 Ext. 1500 if you’d like to schedule an appointment, or dial extension 1501 if you are experiencing a mental health crisis and need to speak with someone immediately.

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Cummins Behavioral Health’s Response to COVID-19

March 21, 2020 Mark Wilhelm

The rapid worldwide spread of the COVID-19 disease, also known as the coronavirus disease, has created a public health crisis the likes of which have not been seen for many years. Cummins Behavioral Health is closely monitoring developments in this unfolding situation, and the safety and well-being of our consumers and employees continues to be of utmost importance to us. First and foremost, if you are experiencing a mental health crisis during this challenging time, we encourage you to call our 24-hour emergency phone line at (888) 714-1927 Ext 1501.

We understand this crisis is impacting everyone’s daily life in various ways. We are dedicated to ensuring your safety while limiting the impact this health event has on the services we provide. We will continue to follow guidelines from the Centers for Disease Control (CDC) as well as federal, state and local governments to help prevent the spread of the COVID-19 disease in our community. We are keenly focused on maintaining a safe environment for our employees and consumers while continuing to provide services.

We have robust integrated behavioral health processes in place, and they are managed by a dedicated team of professionals committed to ensuring your well-being and keeping our operations running as smoothly as possible during these trying times. As such, we have put the following response plan into action, effective immediately:

New Policies to Prevent the Spread of COVID-19:

Anyone exhibiting symptoms of COVID-19 and/or acute respiratory illness should not come in for therapy or counseling sessions. This policy applies to both consumers and members of our staff. Click here to reference the CDC’s official list of COVID-19 symptoms. Individuals who are ill and in need of hospitalization may be permitted entrance into our facilities in some circumstances.
Until further notice, therapy sessions and other services will be conducted via telephone or video conference whenever possible. Individuals who are not ill and who have an imperative need for face-to-face care will be permitted into our facilities on a case-by-case basis. Your care provider will inform you how your sessions will be handled moving forward.
Additionally, we have temporarily suspended our Open Access for initial assessments. Please call our offices at (888) 714-1927 Ext 1500 to schedule an initial appointment.
All consumers and staff should follow the hygiene protocols laid out by the CDC both inside and outside Cummins’ facilities. These include frequently washing your hands with soap and water for at least 20 seconds, using hand sanitizer with at least 60% alcohol when soap and water isn’t available, coughing and sneezing into a tissue or the inside of your elbow instead of your hand, and refraining from touching your face with unclean hands. We invite you to visit the CDC’s webpages on handwashing and coughing and sneezing etiquette for more information.
All individuals should practice social distancing to prevent the spread of illness. This means staying home when possible and only leaving the home when absolutely necessary, staying six or more feet away from other people, and reducing or eliminating large group gatherings.

We will continue to monitor this fluid situation and modify our response as necessary to ensure essential services to our consumers and our community. Check back with this page for further updates and changes to our policies as more information becomes available. We also recommend reviewing this COVID-19 Quick Facts Sheet prepared by the CDC.

For decades, Cummins has demonstrated unwavering support to our consumers. In dealing with the present circumstances, we will continue to use every effort to deliver essential services to all our clients to the utmost of our ability. On behalf of everyone here at Cummins, we appreciate your cooperation and support as we forge a path ahead during this uncertain time.

Observing Self-Harm Awareness Month: Cummins CCO Robb Enlow on 13 Myths and Misconceptions of Suicide

March 13, 2020 Mark Wilhelm

“Suicide is a solitary event, and yet it often has far-reaching repercussions for many others. It is rather like throwing a stone into a pond; the ripples spread and spread.” — Alison Wertheimer

Although most of us would prefer otherwise, everyone feels negative emotions in life. Feelings like sorrow, grief, guilt, shame, hopelessness and worthlessness can be extremely difficult to deal with and taxing on our mental well-being. Often we find the strength to hold on until the feeling passes, but sometimes, for one reason or another, we might feel the urge to phyically harm ourselves in order to escape intense emotional pain. In the most extreme cases, we might consider ending our own life to make the pain go away.

Suicide is a major public health concern throughout much of the world. It affects all races and genders, and in the United States, it is the 10th leading cause of death. In addition to deaths by suicide, the American Foundation for Suicide Prevention estimates that there were 1.4 million suicide attempts in 2018. However, suicide remains highly stigmatized in America and elsewhere, and it is often misunderstood as a result.

March is internationally recognized as Self-Harm Awareness Month (or Self-Injury Awareness Month), and in observance, Cummins Behavioral Health hopes to improve understanding and erode the taboo surrounding suicide, the most drastic of all forms of self-injury. Persistent myths and fallacies about suicide not only isolate those who have contemplated or attempted it, but they can also prevent people from receiving help during a time of emotional crisis.

To get to the bottom of what is and isn’t true about suicide and suicidal behavior, we spoke with Robb Enlow, Chief Clinical Officer at Cummins BHS. Robb provided us with an evidence-based curriculum he assembled that explains and debunks 13 of the most common fallacies about suicide and those who struggle with the urge to take their own lives.

13 Common Fallacies about Suicide, Explained

Fallacy #1: Most suicides are caused by a single traumatic event.

Too often, people assume that the decision to take one’s life is made following a single highly upsetting event. As a result, they might believe that suicide happens so quickly that it cannot be prevented. In reality, a sudden traumatic event is unlikely to be the only cause of suicidal ideation. “More typically, these events are one of other contributing events and feelings which have occurred over time. The stressful event and the person’s reaction to that event should be viewed as invitations to help,” Robb’s curriculum states.

Fallacy #2: Most suicides occur with little or no warning.

A similar misconception is that people decide to end their lives in secret, without giving any indication that they’re thinking about doing so. As with the previous fallacy, this belief can lead to a sense of futility toward suicide prevention efforts. However, most people who have suicidal thoughts communicate their feelings and struggles with others before actually attempting suicide. According to Robb’s curriculum, “These invitations for others to offer help come in the form of direct statements, physical signs, emotional reactions, or behavioral cues indicating the person may be considering suicide as a solution to their problems.”

Fallacy #3: Youth suicides occur with little or no warning.

Teenagers and adolescents are often thought to be flighty and emotionally volatile, which can make caretakers feel even more hopeless about the possibility of preventing suicidal behavior. But just as with adults, young people usually communicate their distress in one form or another prior to attempting suicide. “Although youth may appear to be constantly changing, change is seldom made without purpose or thought,” the curriculum points out. “Not all youth act with haste. Additionally, young persons who do act in haste (impulse) often have a history of other risky behaviors such as substance abuse, reckless driving or unprotected sex.”

Fallacy #4: You shouldn’t talk about suicide with someone who you think might be at risk.

Some people still believe the myth that talking about suicide can “plant” the idea in a person’s head. As a result, they might think it best to avoid the topic altogether when they believe someone is at risk. On the contrary, serious talk about suicide reduces risk rather than creating or increasing it. As the curriculum explains, “Open talk and genuine concern about someone’s thoughts of suicide are a source of relief for them and are often the key elements in preventing the immediate danger of suicide. Avoidance leaves the person at risk, feeling more alone and perhaps too anxious to risk asking someone else to help.”

Fallacy #5: People who talk about suicide won’t do it.

On the other hand, some people may believe that anyone who talks about suicide is not seriously considering it. They might think the person is only seeking attention or pity and therefore choose not to offer any help. As we mentioned above, people who attempt suicide usually talk about their intentions before they act, so any talk of suicide should be taken seriously. “Most people who die by suicide talk about it in some way before they act. Not taking this talk seriously may be a contributing cause in many deaths by suicide,” the curriculum states.

Fallacy #6: A nonfatal outcome means it was only an attention-getting behavior.

In the same way people may dismiss talk about suicide as nothing serious, they might also believe that a nonfatal attempt proves the person doesn’t really intend to go through with it. With this in mind, they might ignore the person’s behavior so as not to reward or encourage it. This belief is false, as nonfatal suicide behaviors are often a desperate invitation for help. “If help is not offered, the person may conclude that help will never come and others not taking them seriously could be another reason for dying,” the curriculum states.

Fallacy #7: Suicidal people want to die.

Perhaps one of the biggest misconceptions about suicidal behavior is that the person who is engaging in it wants to die. In actuality, most people who are suicidal are deeply conflicted and unsure about dying, often up to the very moment of acting. It’s very important that others understand this so they won’t be discouraged from attempting to help. “Most people are looking for help to avoid suicide even if they aren’t immediately aware that they want help. The vast majority of people who are suicidal at some time in their life find a way to continue living,” the curriculum explains.

Fallacy #8: All people who take their own lives are mentally ill.

It’s true that there is a correlation between suicidal behavior and mental illness. However, this doesn’t mean that all suicidal people are mentally ill or that treating mental illness eliminates the risk of suicidal behavior. Rather, mental illness and suicide risk must be managed concurrently in order to give the person the best chance of recovery. In the curriculum’s words, “Not all people who die by suicide are mentally ill, nor are all who are mentally ill likely to die by suicide. Risk behaviors are treated parallel to mental illness.”

Fallacy #9: Once a person attempts suicide, they won’t do it again.

Yet another false belief about suicide is that if a person attempts to take their life and fails, then they won’t try again. Rather than alerting friends and family to the need for intervention, this belief may convince them that the risk of suicide has ended with the unsuccessful attempt. The truth is that many people who attempt suicide will do so again in the future. According to the curriculum, “The rate of suicide for those who have attempted before is 40 times higher than that of the general population. Prior suicide behavior is a major risk factor.”

Fallacy #10: When a person feels better, the danger is over.

When someone who has been struggling with suicidal thoughts and behaviors appears to suddenly improve, many people assume this means the danger of suicide has passed. While this may be true in some cases, in others it may signify that the person has made up their mind to take their life. Therefore, efforts to mitigate risk should continue. “Feeling better can have different meanings: a decision for life, or the person has made the decision to die and is no longer in emotional conflict. Continued discussion is needed,” the curriculum cautions.

Fallacy #11: Most people who kill themselves just couldn’t make it in society.

One extremely harmful myth about suicide is that it’s inevitable for some people. Some may believe that suicidal individuals are so dysfunctional that they can never succeed in the world, so it’s better to just let them end their lives. This line of thinking is incorrect, as most people who think about suicide never act on the idea, and most only seriously consider suicide once in their lives. “Suicide is a choice anyone can make, although almost no one wants to be suicidal. Your efforts to help may be enough to support a person through a difficult and dangerous period of their life,” the curriculum explains.

Fallacy #12: People who kill themselves are taking the easy way out.

In a similar vein as the previous fallacy, some people believe that those who contemplate, attempt or complete suicide are morally weak. They may think that suicidal individuals do not deserve help, or worse yet, that society would be better off without them. This view ignores the tremendous emotional burden of suicidal thoughts, and it also reduces the chance that a suicidal person will recover. “Most people at risk are desperately looking for another way out of their situation. Labeling people at risk in such a negative way serves only to make it harder for them and for other persons at risk to reach out for support,” the curriculum states.

Fallacy #13: Suicide is an individual choice.

Finally, even those who have the best intentions and who would like to help a suicidal person may believe it isn’t their place to do so. They might think that if a person says they want to die, it isn’t right to intervene. However, it’s important to remember that suicide is rarely a person’s preferred choice, and it is therefore not disrespectful to exercise prevention measures. “The decision for suicide may be made in the midst of many turbulent feelings and is seldom the result of informed decision-making about all the possibilities,” the curriculum states.

In order to reduce stigma surrounding suicide and lower rates of suicidal behavior, it’s crucial that everyone understands what is and isn’t true about suicide and individuals who consider or attempt it. In honor of Self-Harm Awareness Month, we encourage you to spread awareness of these suicide myths and misconceptions and open a dialogue with anyone you know who might be struggling with self-injury or suicidal thoughts.

Here at Cummins Behavioral Health, our therapists and counselors use a model known as “Assessing and Managing Suicide Risk” (AMSR) to detect and intervene on suicidal tendencies. If you or someone you know struggles with self-injury or suicidal ideation, feel free to call us at (888) 714-1927 to discuss treatment options.

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Trauma-Informed Care: What It Means and How It Can Be Implemented in Behavioral Health

March 6, 2020 Mark Wilhelm

“Trauma leaves ‘fingerprints’ on the victim. These don’t fade when the bruises do.” — Dr. Ellen Taliaferro, physician and author specializing in domestic violence and abuse

Violent events—whether they occur on purpose or by accident, and whether they are physically or emotionally violent—leave a mark on a person’s psyche. Long after an event has passed, its memory can cause psychological suffering for those who experienced it. In some cases, this prolonged suffering may be diagnosed as post-traumatic stress disorder, but the event and its emotional consequences are also referred to more generally as trauma.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), trauma “results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” Statistics from SAMHSA show that 61% of men and 51% of women are exposed to a traumatic event sometime in their lives, and 90% of clients in public behavioral health care settings have experienced trauma.

We’ve previously explained how interventions like yoga can help to reduce symptoms of post-traumatic stress, but most of the time, trauma is so deep-seated that it must be addressed by professional therapy or counseling. However, it’s crucial that behavioral health care is delivered in a way that’s attentive to the needs of trauma victims. The last thing that’s wanted is for treatment to trigger residual feelings of stress and anxiety, which is why all care must be trauma-informed.

Trauma-informed care is a framework for treatment that helps clients feel safe, respected and in control while minimizing any risk of re-traumatization. Here at Cummins Behavioral Health, we strive to integrate the principles of trauma-informed care into every interaction between care providers and consumers. We spoke with Rebecca Bradford, Team Lead at our Marion County outpatient office, to learn more about trauma-informed care and how it can be effectively implemented in behavioral health care.

The Six Principles of Trauma-Informed Care, Explained

As mentioned above, trauma affects more than half of all adults in the U.S., and the percentages are even higher among people who seek out behavioral health services. Interestingly enough, a higher than average number of behavioral health workers may have also experienced some form of trauma in the past. As a result, a trauma-informed approach to care is important for the well-being of consumers as well as employees within an organization.

“Trauma-informed care is important because there are so many people who have experienced trauma,” Rebecca says. “Whether they have a diagnosable condition like PTSD or not, it is likely that at some point in their life, a large majority of the population we serve has experienced some sort of trauma in their life. It even affects a lot of our providers, because we know that people sometimes go into the helping fields because they’ve experienced things in their own life that make them want to help others.”

But what does a trauma-informed approach to care mean, exactly? According to SAMHSA, trauma-informed care is treatment that adheres to six guiding principles:

Safety: throughout the organization, both staff and the people they serve feel physically and psychologically safe. As Rebecca explains, this is one of the first things that a person who has experienced trauma considers when entering a treatment environment. “If I’m talking to someone who has trauma, their safety has likely been threatened or taken away from them at some point in their life, so that’s going to keep them guarded. We need to make sure the physical space is presented as safe as well as the emotional space, which is often done through rapport-building with consumers,” she says.
Trustworthiness and transparency: organizational operations are conducted with transparency in order to build trust among staff, consumers, and consumers’ family members. This can be achieved with consumers through open communication about everything that happens during treatment. “We use collaborative documentation so consumers know what’s being written about them and what the provider is documenting,” Rebecca says. “Being transparent about the parameters of the therapeutic relationship is very important, as well, and those boundaries get established up-front.”
Peer support: consumers have access to peer recovery specialists who have experienced trauma in their own lives and can provide additional emotional support. Due to their unique position in the organization, peer specialists can often engage with consumers in ways that might be inappropriate for a therapist or counselor. “With trauma, people often feel isolated, so sometimes they feel more comfortable opening up to somebody that has had that experience versus a therapist who may not disclose, even if they have had that experience, just to keep those therapeutic boundaries,” Rebecca explains.
Collaboration and mutuality: consumers act as partners with staff in their own treatment, and the balance of power remains equal between consumer and provider as well as among staff. According to Rebecca, one part of collaboration means that consumers take equal responsibility for their recovery. “A huge part of treatment is that we’re always giving it back to the consumer and not just doing things for them. We teach them how to do things themselves, or we do it with them if they can’t do it themselves just yet,” she says.
Empowerment, voice and choice: consumers are encouraged to take control of their treatment and freely express their concerns and desires. Care providers are facilitators of recovery rather than controllers of recovery, and they strive to support consumers in shared goal-setting and decision-making. “We let the consumer know that they can control the pace of treatment. That’s a big part of Empowerment as well as Safety and Collaboration,” Rebecca says.
Cultural, historical and gender issues: the organization ignores cultural and gender stereotypes and is responsive to the racial, ethnic, cultural and gender-specific needs of consumers. At Cummins, this is partially achieved through the Cultural Competency Committee, which researches and disseminates best practices for treating people from diverse populations. “It’s a matter of continuing to educate our providers on diversity and gender issues and making sure that we’re not imposing our own belief systems on any other person,” Rebecca explains.

Putting Trauma-Informed Care into Practice

Once the core principles of trauma-informed care are understood, the real challenge lies in implementing these principles throughout the organization. In its guidelines for trauma-informed care, SAMHSA lists ten domains for implementation: governance and leadership; policy; physical environment; engagement and involvement; cross-sector collaboration; screening, assessment and treatment services; training and workforce development; progress monitoring and quality assurance; financing; and evaluation.

In Rebecca’s experience, workforce training is among the most crucial of these domains. In order for trauma-informed care to truly make a difference, its principles must be upheld at every point of consumer contact within the organization. “From that first person a consumer meets when scheduling an appointment all the way up to the CEO, everyone should know about these things,” Rebecca says.

Trauma-informed care is typically implemented from the “top” of an organization by means of policy choices, but employees at all levels of the organization should be encouraged to offer input. This helps to ensure that policies remain as current and effective as possible, as Rebecca illustrates:

“At Cummins, leadership is always open to hearing what providers have to say about treatment environments and treatment modalities. For example, my providers were recently discussing needs with the Chief Clinical Officer and identified a book that had some protocols to address poverty, which often goes hand-in-hand with trauma. The Chief Clinical Officer took that input and came back to us two months later, presented his interpretation of the basic ideas, and changed the way we do our onboarding system as a result of reading this book that was suggested by my providers.”

Finally, behavioral health care providers must be careful to avoid common stumbling blocks like burnout and compassion fatigue, which can undermine their ability to administer effective trauma-informed care. For this reason, regular self-care is important for everyone in the organization. “Something we talk about a lot is good supervision and open communication with the provider, with me being able to say, ‘I think you need to take a step back,’ and them also being able to come and say that to me,” Rebecca explains.

Due to the high prevalence of trauma among behavioral health care consumers, it’s imperative that treatment recognizes the challenges faced by trauma survivors and empowers them to improve their own lives. We continually strive for this goal at Cummins Behavioral Health as we work toward our mission of inspiring the hope of recovery in every person we serve.

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