CRISIS REACTIONS FOLLOWING

TRAUMATIC INCIDENTS

JUNE 18, 2009NUI MAYNOOTH

Helping the traumatized .... through education, certification and deployment.

www.greencross.org

Dr. Dan Casey, CTDirector, UMTTI

11959 77th St. Clear Lake, MN 55319

320-282-2436320-743-4119 F

dlcasey@frontiernet.net www.jec-counseling.com

• ICISF & Green Cross Trained trainer – International- Basic, Advanced, Individual, School, College & Suicide trainings, Compassion Fatigue, Field Traumatology, ICS

• Green Cross & ICISF Board member• Coordinator for three Crisis teams• 25 years wild land fire fighter- incident

commander 800+ fires• 7 years University instructor/ counselor SJU,

UMM, UMB• Provide 100 interventions per year on average• 22 years -2000 interventions- trained 10,000

Dr. Daniel Casey, CT

DEALING WITH Emergency Services Personnel

• ON SCENE

• SOON AFTER - a few days

• LATER - a few weeks

Traumatizing events

• Auto accident• Abuse• Robbery• Injury death to ones

child or a child• Suicide• Line of duty death• homicide (s)• Tornadoes

• Earthquake• Hurricane• Fires• Flood• Pollution• Multiple injury/fatality• Terrorism• Community disasters

A Model Response…Katrina’s Coming!!!!!Katrina’s Coming!!!!!

• Phone call among • Dr. Jeffrey Mitchell – ICISF,

• Director – American Red Cross,• Dr. Charles Figley – Green Cross

• “Let’s Not Compete”

• ICISF – Serve First Responders • Red Cross – Serve Victims/Evacuees

• Green Cross – Serve Volunteers and Non Traditional First Responders

WHAT IN THE WORLD IS HAPPENING ???

• PSYCHOLOGICAL FIRST AID (PFA)

• COMPASSION FATIGUE (CF)

• CRITICAL INCIDENT STRESS MANAGEMENT

Psychological First Aid A set of skills that helps

community residents care for their families, friends, neighbors, and themselves by providing basic psychological support in the aftermath of traumatic events…

Psychological First Aid

• A model that:– Integrates public health and community and

individual psychology.– Includes preparedness for communities,

work places, schools, faith communities, and families.

– Does not rely on direct services by mental health professionals.

– Uses skills you probably already have…

Psychological First Aid Skills

Part I – Understanding common symptoms and responses associated with trauma

Part II - Active Listening

Improving a skill you already possess

Part III – Resource Awareness

COMPASSION FATIGUECOMPASSION FATIGUE “There is a cost to caring. People who listen to others’

stories of fear, pain, and suffering may feel similar

fear, pain and suffering because they care.

Sometimes we feel we are losing our sense of self to

… those we serve…”

It is the cost of working with people. The better you are

at your work, the more compassion is expended, and

the more compassion fatigue is experienced.

COMPASSION FATIGUE Post-Traumatic Stress Disorder

• Exposure is core factor in risk

• Sympathy is the vehicle of transmission

COMPASSION FATIGUE• A state of tension and preoccupation with

traumatized individual(s) by

• Re-experiencing the traumatic events,

• Avoidance/numbing of reminders, and

• Persistent arousal (e.g., anxiety)

signs of COMPASSION FATIGUE signs of COMPASSION FATIGUE• Loss of sense of humor• Difficulty separating work and personal life• Lowered frustration tolerance• Dread (of working with certain clients or of certain calls)

• Disruption of one’s frames of reference (sense of identity, world view, and spirituality)

• Ineffective or self-destructive self-soothing behaviors

CRITICAL INCIDENT STRESS MANAGEMENT (CISM)

A comprehensive, integrated, systematic, and multi -

component

approach to crisis / disaster intervention.

The Brain

REASON

EMOTION

AUTOMATIC

Disasters and CISM• Situations beyond the resources of the

local community• Produce a great deal of emotional

response usually requiring CISM services

• Victims, survivors, rescuers and community members need a variety of types of assistance

Disasters are Different

• Know Crisis services before you work a disaster

• Requires a high level of skill

• Needs most highly experienced

• Tendency towards overreaction

• Timing is essential

• Group processes out of place initally

10th World Congress on

Stress, Trauma & Coping

COST OF CARINGHow we know we are stressed

CHEMICAL & PHYSIOLOGICAL STRESS REACTIONS

Chemistry of Survival

Catecholamines• Excites the system• Triggers increased nervous system• “flight or fight” response

Corticosteroids• Moderates and controls extremes of

catecholamines• Keep ‘flight or fight’ in check

Endogenous Opiods• Creates heightened threshold of pain• Causes dissociative reactions• Causes blunting of emotions• Causes feelings of euphoria• with catecholamines, causes amnesiac

reactions

PHYSIOLOGICAL REACTIONS Ch. 7 RER

• ADRENAL GLANS KICK IN • Cortisone levels rise

+-protects from reactions- Immune system depleted

-Body goes into starvation mode

• Thyroid kicks in + everything is working at peak performance– burnout faster

Physiological reactions

• Endorphins

+ nature’s opium- no pain

- little hurts become big

Physiological reactions

Shutdown of digestive tract + Blood diverted to muscles and engine room- no lubrication

• Sex Drive is reduced+ Survival mode

- Menstrual cycles disrupted- Erectile disfunction

Physiological reactions

• Sugar+ short distance energy

– tough on diabetics

• Cholesterol + long distance energy –loads arteries

Physiological reactions

• Heart + pumps thickened blood

beats harder and faster – bad heart/ blood pressure?• Lungs + collecting more oxygen - tough on smokers

PHYSIOLOGICAL REACTIONS

• Skin

+ largest organ protects us

- dry skin and scaly• All six senses

+ more acute and focused

– more prone to accident

COMPASSION

“a feeling of deep sympathy and sorrow for

another who is stricken by suffering or

misfortune, accompanied by a strong desire to

alleviate the pain or remove its cause.”

- Webster-EUDEL

10th World Congress on

Stress, Trauma & Coping

COMPASSION STRESS

The cost of providing compassionate care. What we invest of ourselves to do our work

COMPASSION SATISFACTION

• What we gain by the work we do.

• What keeps us doing what we do.

• What defines how we are mentally, physically, emotionally, spiritually, and behaviorally

COMPASSION FATIGUECOMPASSION FATIGUE “There is a cost to caring. People who listen to (and

witness) others’ stories of fear, pain, and suffering

may feel similar fear, pain and suffering because

they care. Sometimes we feel we are losing our

sense of self to … those we serve…”

Charles Figley

COMPASSION FATIGUECOMPASSION FATIGUE

“Those who have enormous capacity for feeling

and expressing empathy tend to be more at

risk of compassion fatigue.”

(Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatized, Charles Figley, Editor, 1995)

COMPASSION FATIGUE Results

COMPASSION FATIGUE Results

• Diminished sense of purpose/ enjoyment of career

• Reduced ego functioning (time, volition, identity, language, cognition)

• Lowered functioning in non- professional situations

• Diminished capacity for intimacy

• Loss of hope

More RESULTSMore RESULTS

• Subtle manipulation to avoid painful/traumatic material

• Loss of confidence• Diminished effectiveness• Dread

• Victim < …. > Perpetrator

• Diminished capacity to listen and communicate

WHAT DOES IT MEAN?• Not a reflection of the helper’s

inadequacy, nor indicative of the toxicity or badness of the client

Is a result of one’s strengths: empathy, involvement and helping

• Is an occupational hazard for trauma workers, regardless of their profession

• Is a form of PTSD, and can be repaired.

is a strategic intervention system.

It possesses numerous tactical interventions

CISM

All CISM Services Must Be:

• Timely

• Efficient

• Consistent

• Thorough

Never Interfere With On-going Operations

• Ability to function is more important than a display of emotions

• Low profile CISM services

• Do only what is necessary

• Do not “push” your support

• Go easy

Planning and Education

• Basic /Advanced CISM training

• Peer support / Family Training

• Psychotraumatology training

• Disaster response training

• Strategic planning

• Written plans

• Training and practice

• Carefully select staff

• Drill

• Critique

• Rewrite the plan

• Practice again

• Continue In-Service training

CISM protocols are likely to break down if

they have not been preplanned and

practiced

ACCOMPLISHED?

• NATIONAL INTERAGENCY INCIDENT MANAGEMENT SYSTEM [NIIMS]

• INCIDENT MANAGEMENT SYSTEM [ICS]

• IRELAND HEALTH SERVICES USES MIMS

Positive Redundancy

• Two separate groups working on identical information with the intention of developing a comprehensive plan of action

• Some overlap

• Some new ideas

• Clarification of potential problems

10th World Congress on

Stress, Trauma & Coping

SCENARIO

FIRE

AMBULANCE

GARDAI

CISM INTERVENTIONS

• DEMOBILIZATION

• CRISIS MANAGEMENT BRIEFINGS

• INDIVIDUAL INTERVENTIONS

• SMALL GROUP INTERVENTIONS

• FOLLOW UP– IMMEDIATELY- & AFTER

Demobilization

• Quick information and rest session

• 10 minutes of information 20 minutes of food and rest

• Applied at 1.) end of first shift or 2.) before teams are released from incident

• Provided to teams of workers

• Provided by CISM team members

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Stress, Trauma & Coping

Crisis Management Briefing

This large group process is one of the most versatile tools to be used in disaster related CISM services. It lowers anxiety and guides people toward effective action

Crisis Management Briefing

• Keep groups as homogeneous as possible• Representative of organization presents

information• Sometimes question / answer period is allowed• CISM team member presents information• Specific practical advice is presented to manage

the stress associated with the situation

One on one

ATSM SAFER

• OBSERVE and identify

• CONNECT• GROUND• SUPPORT• NORMALIZE• PREPARE

• STABILIZE• ACKNOWLEDGE• FACILITATE• ENCOURAGE• RESTORE/REFER

SAFE-R model

content goal• STABILIZE mitigate effective escalation• ACKNOWLEDGE ventilation, reduce arousal, build

rapport, sense of safety• FACILITATE view symptoms as normal• ENCOURAGE improve imm. & short term coping,

develop plan• RESTORE/REFER okay/ need help?

DEFUSING• SMALL GROUP DISCUSSION following

critical event.• TIMING: Typically provided within 8 hours of

the event.• STRUCTURE: 3 phases• DURATION: less than 1 hour• LOCATION: Best in secluded room

adequate for the purpose• GROUP: Homogeneous group only

DEFUSING GOALS

• Normalization / lower tension

• Set expectations, provide information

• Discuss coping methods

• Identify those who need additional support

DEFUSING: 3 PHASES• INTRODUCTION – Introduce team; lay out the

guidelines; lower anxiety about the process

• EXPLORATION – Allows a brief discussion of the experience. A brief “story” of the event

• INFORMATION – Provide information, normalize, teach, guidance, summarize key points

Critical Incident Stress Debriefing(CISD)

• A structured GROUP discussion concerning a critical incident.

• First described by Mitchell (1983) for use with small groups of emergency services personnel.

• Historical roots in military psychiatry (see HERD, S.L.A. Marshall)

• Requires a team approach

CISD GOALS

• Mitigate distress.• Facilitate psychological normalization and

psychological “closure” (reconstruction).• Set appropriate expectations for psychological /

behavioral reactions.• Serve as a forum for stress management education.• Identification of external coping resources.• Serve as a platform for psychological triage and

referral.

Phases of a CISD

COGNITIVE

AFFECTIVE

INTRODUCTION

FACT

REACTION

THOUGHT SYMPTOM

TEACHING

RE-ENTRY

MHP

Door

Peer

Peer

Peer

INTRODUCTION• Introduces team members• Sets expectations• Describes “ground rules.”• Ground rules anticipate potential problems

and attempts to address them in advance.• Addresses confidentiality.• Participation in discussion is VOLUNTARY.• Preview questions.

FACT PHASE

• Possible prompt: “Tell who you are and what happened from your perspective.”

• May still be used when group exposed to multiple stressors, as in disaster out -processing, or culmination of a tour of duty

THOUGHT PHASE *

• “What was the first or most prominent thought that entered your mind regarding the incident?”

• Any unusual or disquieting thoughts?

REACTION PHASE

• “What was the worst part of this event for you?” What feelings go with that? OR

• Any aspects of the event that have caused you the most pain or distress?

OR• If you had the power to erase one single aspect

what would you most want to eliminate from the total experience?

SYMPTOM PHASE• “What physical or behavioral changes

have you experienced since the event?”

• Or, “What has life been like for you since the event?”

• Or, “What signals of distress have you noticed in yourself since this happened?”

TEACHING PHASE

• Team members normalize reactions of group members, then provide anticipatory guidance, teach stress management, describe external resources available.

RE-ENTRY PHASE

• Reiterate normalization

• Q & A, if indicated”

• Develop a plan –group or individual

• Foster group cohesion, if indicated

10th World Congress on

Stress, Trauma & Coping

FOLLOW UP

24 Hours

3 days

3 weeks

3-6 months

51 weeks