Critical IncidentCritical IncidentStress ManagementStress Management

CISM UpdateLearning from the Past, . . . Progressing into the Future

Civil Air Patrol

Annual Conference & National Board Meeting

Friday, September 4, 2009

Developed by Lt. Col. Sam D. Bernard, Ph.D.Developed by Lt. Col. Sam D. Bernard, Ph.D.CAP CISM National Team LeaderCAP CISM National Team Leader

Partial content from Chevron Publishing

WelcWelcomeomeThank you for attending this session

concerning CAP CISM Updates

Goals

To provide information concerning various To provide information concerning various CISM topics concerning:CISM topics concerning:

ICISFICISF

CISM informationCISM information

CAP CISM ProgramCAP CISM Program

ICISF

1010thth World Congress Jan-Feb 2009 World Congress Jan-Feb 2009 Corporate downsizingCorporate downsizing Staff reductionsStaff reductions Still viable and hosting regional Still viable and hosting regional

conferences nationwideconferences nationwide

Other ICISF Courses Group Basic CISMGroup Basic CISM Peer & Individual Crisis InterventionPeer & Individual Crisis Intervention Building Skills in CISMBuilding Skills in CISM Responding to School CrisisResponding to School Crisis Suicide: Prevention, Intervention & PostventionSuicide: Prevention, Intervention & Postvention Advanced Group CISMAdvanced Group CISM Strategic Response to CrisisStrategic Response to Crisis Emotional & Spiritual Care in DisasterEmotional & Spiritual Care in Disaster Pastoral Crisis Intervention I & IIPastoral Crisis Intervention I & II Stress Management for the Trauma Service ProviderStress Management for the Trauma Service Provider Team Evaluation and Management (TEAM)Team Evaluation and Management (TEAM) Grief Following TraumaGrief Following Trauma Psychological Response to Terrorism: Impact and ImplicationsPsychological Response to Terrorism: Impact and Implications The Changing Face of Crisis Response and Disaster Mental The Changing Face of Crisis Response and Disaster Mental

Health InterventionHealth Intervention

New Course!

Psychological First Aid

Certificate of Specialized Certificate of Specialized TrainingTraining

Emergency ServicesEmergency Services Mass Disaster & TerrorismMass Disaster & Terrorism Workplace & Industrial ApplicationsWorkplace & Industrial Applications Schools & Children Crisis ResponseSchools & Children Crisis Response Spiritual Care in Crisis InterventionSpiritual Care in Crisis Intervention Substance Abuse Crisis ResponseSubstance Abuse Crisis Response

InternationalCritical Incident Stress

Foundation

3290 Pine Orchard LaneSuite 106

Ellicott City, MD 21042(410) 750-9600

Fax: (410) 750-9601Emergency: (410) 313-2473

www.icisf.org

CISMCISMInformationInformation

Refresher / ReviewRefresher / Review

The Terrible 10 for CAPThe Terrible 10 for CAP

1.1. 6.6.

2.2. 7.7.

3.3. 8.8.

4.4. 9.9.

5.5. 10.10.Tak

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. . . not limited to missions!

ResistanceIf the stressor continues,the body mobilizes towithstand the stress andreturn to normal.

ExhaustionOngoing, extremestressors eventuallydeplete the body’sresources so wefunction at less than normal.

AlarmThe body initiallyresponds to a stressor with changes that lowerresistance.

StressorThe stressormay be threateningor exhilarating.

HomeostasisThe body systemsmaintain a stableand consistent(balanced) state.

Illness and DeathThe body’s resources are notreplenished and/or additionalstressors occur; the bodysuffers breakdowns.

Return to homeostasis

Illness

Death

The brain becomes more alert.Stress can contribute to headaches, anxiety,and depression.

Sleep can be disrupted.

Stress hormones can damage the brain’s ability toremember and cause neurons to atrophy and die.

Baseline anxiety level can increase.

Heart rate increases.

Persistently increased blood pressure and heart rate can lead to potential for blood clotting and increase the risk of stroke and heart attack.

Adrenal glands produce stress hormones.

Cortisol and other stress hormones can increase appetite and thus body fat.

Stress can contribute to menstrual disorders in women.

Stress can contribute to impotence and premature ejaculation in men.Muscles tense.

Muscular twitches or “nervous tics” can result.

Red = immediate response to stressBlue = effects of chronic of prolonged stress

Mouth ulcers or “cold sores” can crop up.

Breathing quickens.

The lungs can become moresusceptible to colds and infections.

Immune system is suppressed.

Skin problems such as eczema andpsoriasis can appear.

Cortisol increases glucose productionin the liver, causing renal hypertension.

Digestive system slows down.

Stress can cause upset stomachs.

Red = immediate response to stress

Blue = effects of chronic of prolonged stress

Stress Reactions

Physiological Based

not

Characteriologically Flawed

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Indicatorsof

Critical Incident Stressvs.

Disciplinary Problemsor

Character Disorders

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Identifiable traumatic eventIdentifiable traumatic event Reactions begin with an eventReactions begin with an event Reactions worsen after eventReactions worsen after event Reactions follow expected patternsReactions follow expected patterns Sudden changes are common in CISSudden changes are common in CIS CIS reactions usually reduce with:CIS reactions usually reduce with:

Peer assistance and,Peer assistance and, With the passage of timeWith the passage of time

Critical Incident StressT

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Characteriological & Disciplinary Problems - continued

Disciplinary problems have a long and Disciplinary problems have a long and diffuse historydiffuse history

Problems may have preexisted entry into Problems may have preexisted entry into the CAP jobthe CAP job

Identifiable traumatic event(s) missingIdentifiable traumatic event(s) missing Problems may exist in several other Problems may exist in several other

important areas of the person’s life.important areas of the person’s life. Problems do not easily resolve over time Problems do not easily resolve over time

even with help.even with help.Tak

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CrisisCrisis

An acute reaction to a critical incident.

A name of a particular critical incident.

Noun

vs

Verb

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Both

Recall that…

Psychological Distress/Discord in response to critical incidents is

called a

Psychological Crisis

(Everly & Mitchell, 1999, Critical Incident Stress Management)

Psychological Crisis

An acute An acute RESPONSE to a trauma, to a trauma, disaster, or other critical incident disaster, or other critical incident

wherein there is wherein there is evidence ofevidence of

clinically significant:

1. Distress,1. Distress,

2. Impairment,2. Impairment,

3. Dysfunction3. Dysfunctionadapted from Caplan, 1964, Preventive Psychiatry

EustressEustress vs vs DistressDistress vs vs DysfunctionDysfunction

EustressEustress … …positive, motivating stress… May be positive, motivating stress… May be associated with posttraumatic growth. No reliable associated with posttraumatic growth. No reliable estimations on prevalence post disaster.estimations on prevalence post disaster.

DistressDistress……dyphoria post disaster…60-90% of those dyphoria post disaster…60-90% of those directly affected experience acute distress (Rx = directly affected experience acute distress (Rx = Identify & Monitor)Identify & Monitor)

DysfunctionDysfunction…impairment of function post …impairment of function post disaster…20-49% of those directly affected may disaster…20-49% of those directly affected may experience more lasting or impairing dysfunction experience more lasting or impairing dysfunction (Rx = Identify, Assess, & Intervene)(Rx = Identify, Assess, & Intervene)

[Assessment of dysfunction may be the sine qua non of disaster mental health]

Prioritizing the InterventionPrioritizing the Intervention

Initially, given limited resources and the potential to interfere with natural coping mechanisms, intervention should be targeted to issues that are URGENT and IMPORTANT.

DISTRESS…urgent, but unimportant DISTRESS…important but not urgent DYSFUNCTION…urgent AND important

EUSTRESSEUSTRESS vs. vs. DISTRESSDISTRESS vs. vs. DYSFUNCTIONDYSFUNCTION

EustressEustress (Positive, (Positive,

motivating)motivating)

DistressDistress (benign, mild)(benign, mild)

DysfunctionDysfunction(severe, impairment, (severe, impairment,

incapacitating)incapacitating)

Identify, Assess,Identify, Assess, && MonitorMonitor

Identify, Assess, Identify, Assess, & & Take actionTake action

No Action NeededNo Action Needed

Functionality…Functionality…

may be defined as the ability of may be defined as the ability of an individual to recognize and an individual to recognize and successfully attend to his/her successfully attend to his/her

current responsibilities.current responsibilities.

Signs and Symptomsof

Distress and Dysfunction

I.I. Cognitive Cognitive

II.II. EmotionalEmotional

III.III. BehavioralBehavioral

IV.IV. PhysicalPhysical

V.V. SpiritualSpiritual

I. Cognitive I. Cognitive Distress

Inability to Concentrate Difficulty in Decision Making Preoccupation (obsessions) with Event Confusion (“dumbing down”)

I. Severe Cognitive Dysfunction

Suicidal/ Homicidal Ideation

Inability to Understand Consequences of Behavior

Delusions Hallucinations Persistent

Hopelessness/ Helplessness

II. Emotional Distress

Anxiety Irritability Anger Sadness Fear Phobia Grief

II. Severe Emotional Dysfunction

Panic Attacks Chronic Immobilizing Depression Depression & Guilt Posttraumatic Stress Disorder (PTSD)

After traumatic events, DEPRESSION is most commonly associated with LOSS.

ANXIETY, on the other hand, is commonly associated with FEAR and life-threatening exposure.

Posttraumatic stress (PTS) Posttraumatic stress (PTS) is a normal survival is a normal survival

response; Posttraumatic response; Posttraumatic Stress Disorder (PTSD) is a Stress Disorder (PTSD) is a pathologic variant of that pathologic variant of that normal survival reaction.normal survival reaction.

PTSDPTSD

A. Traumatic eventA. Traumatic event

B. Intrusive memoriesB. Intrusive memories

C. Avoidance, numbing, depressionC. Avoidance, numbing, depression

D. Stress arousalD. Stress arousal

E. Symptoms last > 30 days E. Symptoms last > 30 days

F. Impaired functioning (This is the most F. Impaired functioning (This is the most

important aspect of PTSD for the crisis important aspect of PTSD for the crisis

interventionist)interventionist)

Crisis InterventionCrisis InterventionGoals: Goals:

The Goal of Crisis Intervention is to foster The Goal of Crisis Intervention is to foster Resilience Resilience via:via:

1. Stabilization1. Stabilization

2. Symptom reduction2. Symptom reduction

3. Return to adaptive functioning, or3. Return to adaptive functioning, or

4. Facilitation of access to continued care4. Facilitation of access to continued care

(adapted from Caplan, 1964, Preventive Psychiatry)

Chevron Publishing, 2002

Crisis Characteristics

The relative balance between thought processes and emotional processes is disturbed,

The usual coping methods do not work effectively,

There is evidence of mild to severe impairment in individuals or groups exposed to the critical incident,

Pre-CRISIS Post CRISIS

THOUGHTS

FEELINGS

THOUGHTS

FEELINGS

CRISIS

Crisis CharacteristicsImprint of Horror

VisualVisual AuditoryAuditory OlfactoryOlfactory KinestheticKinesthetic GustatoryGustatory TemporalTemporal

Psychological / Perceptual Contaminants

Assessing the Need forCrisis Intervention (CISM)

Is this one of the CAP “Terrible 10”?

Are coping mechanisms working effectively for EVERYONE?

Is there evidence of mild to severe impairment in individuals or groups exposed to the critical incident?

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“1/3 Rule” - Theoretical

11 22

33

8%

Peritraumatic Stress DissociationDissociation

Depersonalization, derealization, fugue states, amnesiaDepersonalization, derealization, fugue states, amnesia Intrusive Re-ExperiencingIntrusive Re-Experiencing

Flashbacks, terrifying memories or night mares, repetitive Flashbacks, terrifying memories or night mares, repetitive automatic re-enactmentsautomatic re-enactments

AvoidanceAvoidance Agoraphobic-like social withdrawalAgoraphobic-like social withdrawal

HyperarousalHyperarousal Panic episodes, startle reactions, fighting or temper problemsPanic episodes, startle reactions, fighting or temper problems

AnxietyAnxiety Debilitating worry, nervousness, vulnerability or powerlessnessDebilitating worry, nervousness, vulnerability or powerlessness

DepressionDepression Anhedonia, worthlessness, loss of interest in most activities, Anhedonia, worthlessness, loss of interest in most activities,

awakening early, persistent fatigue, and lack of motivationawakening early, persistent fatigue, and lack of motivation Problematic Substance UseProblematic Substance Use

Abuse or dependency, self-medicationAbuse or dependency, self-medication Psychotic SymptomsPsychotic Symptoms

Delusions, hallucinations, bizarre thoughts or images, catatoniaDelusions, hallucinations, bizarre thoughts or images, catatonia Dis

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Highest Risk forExtreme Peritraumatic Stress

Life-Threatening danger, extreme violence, or Life-Threatening danger, extreme violence, or sudden death of others;sudden death of others;

Extreme loss or destruction of their homes, Extreme loss or destruction of their homes, normal lives, and communities;normal lives, and communities;

Intense emotional demands from distraught Intense emotional demands from distraught survivors survivors (rescue workers, counselors, caregivers);(rescue workers, counselors, caregivers);

Prior psychiatric or marital/family problems;Prior psychiatric or marital/family problems; Prior significant loss Prior significant loss (death of a loved one in the past year)(death of a loved one in the past year)

Cardena & Spiegel, 1993; Joseph et.al, 1994; Kooperman, et.al., 1994&5; Cardena & Spiegel, 1993; Joseph et.al, 1994; Kooperman, et.al., 1994&5; La Greca et.al.,1996; Lonigan, et.al., 1994; Schwarz & Kowalski, 1991; La Greca et.al.,1996; Lonigan, et.al., 1994; Schwarz & Kowalski, 1991; Shalev, et.al., 1993Shalev, et.al., 1993 Disaster Mental Health Services-A guidebook for Clinicians &

Administrators; Dept of Veterans Affairs, 1998

Effects of Hyper-Arousal

Trouble sleepingTrouble sleeping Difficulty Difficulty

concentratingconcentrating Heightened vigilanceHeightened vigilance Being easily startledBeing easily startled Being waryBeing wary Sudden cryingSudden crying Becoming suddenly Becoming suddenly

angryangry

Being more emotionalBeing more emotional PanickingPanicking Intensified alertnessIntensified alertness Reminders of the Reminders of the

trauma leading to trauma leading to physical reactionsphysical reactions Rapid heart beatRapid heart beat SweatingSweating etcetc

Increased anxietyIncreased anxiety

Hyper-ArousalSleep Disturbances

Longer to fall asleepLonger to fall asleep Unable to fall asleepUnable to fall asleep More sensitive to noiseMore sensitive to noise Awaken more often during the nightAwaken more often during the night Have dreams and/or nightmares about the Have dreams and/or nightmares about the

traumatrauma Repetitive trauma dreams may awaken Repetitive trauma dreams may awaken

and leave frightened and exhaustedand leave frightened and exhausted

CISM as Mitigation

Efforts attempt to prevent hazards from developing into disasters altogether, or to reduce the effects of disasters when they occur.

Differs from the other phases because it focuses on long-term measures for reducing or eliminating risk.

Implementation of mitigation strategies can be considered a part of the recovery process if applied after a disaster occurs.

CISM as Mitigation

Structural or non-structural, Is the most cost-efficient method for

reducing the impact of hazards. Does include providing regulations . . . and

sanctions against those who refuse to obey the regulations . . . potential risks to the public fema.gov

A natural mesh with Public Affairs

Mitigating C I S

Even with all the right programs, Even with all the right programs, briefings, teams, personnel, etc lined briefings, teams, personnel, etc lined up & available – there can still be up & available – there can still be CIS.CIS.

We don’t know our member’sWe don’t know our member’sbaggage. baggage. (Pre-existing conditions)(Pre-existing conditions)

Pre-Exposure Training Pre-Exposure Training can helpcan helpID potential psych/perceptualID potential psych/perceptualcontaminantscontaminantsT

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Mitigating Operational Stress (OpStress)

Frequent information / feedback to staffFrequent information / feedback to staff Frequent rest breaksFrequent rest breaks Cold or hot environments might require Cold or hot environments might require

more frequent rest breaksmore frequent rest breaks Rest areas away from stimuliRest areas away from stimuli 12 hour limit for same scene stimuli12 hour limit for same scene stimuli Assure proper rehabilitation sectorAssure proper rehabilitation sector Provide lavatory facilitiesProvide lavatory facilities

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Mitigating OpStress - continued

Provide hand washing facilitiesProvide hand washing facilities Provide medical support to staffProvide medical support to staff Monitor hyper- or hypo-thermiaMonitor hyper- or hypo-thermia Proper foodProper food Limit fat, sugar and saltLimit fat, sugar and salt Fluid replacementFluid replacement Provide drinking waterProvide drinking water Provide fruit juicesProvide fruit juices Limit use of caffeine productsLimit use of caffeine products CISM on scene support servicesCISM on scene support services

continued...continued...

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Monitor signs of emotional distressMonitor signs of emotional distress Limit overall stimuli at incidentLimit overall stimuli at incident Give clear orders to personnelGive clear orders to personnel Avoid conflicting orders to staffAvoid conflicting orders to staff Delegate authority Delegate authority Frequent rest breaks for allFrequent rest breaks for all Back up leadersBack up leaders Sectorization of the incidentSectorization of the incident Delegation of authorityDelegation of authority Credit people for proper actionsCredit people for proper actions

continued...continued...

Mitigating OpStress - continuedT

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Mitigating OpStress Mitigating OpStress - continued

Limit criticism to absolute minimumLimit criticism to absolute minimum Utilize a staging area for uninvolved Utilize a staging area for uninvolved

personnelpersonnel Limit exposure to event sights, sounds Limit exposure to event sights, sounds

and smells (reminders)and smells (reminders) Announce time periodicallyAnnounce time periodically Rotate crews to alternate dutiesRotate crews to alternate duties Others ?Others ?

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After Action Support

Thank personnel for their workThank personnel for their work Consult with CISM teamConsult with CISM team Provide demobilization services on Provide demobilization services on

large scale incidentlarge scale incident Utilize services of CISM teamsUtilize services of CISM teams Arrange defusing for unusual eventsArrange defusing for unusual events Consider debriefing for personnel if it Consider debriefing for personnel if it

appears necessary*appears necessary* continued...continued...

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After Action Support - continued

Allow follow up services by CISM team Allow follow up services by CISM team membersmembers

Critique incident operationallyCritique incident operationally Teach new procedures from lessons Teach new procedures from lessons

learnedlearned Consider the need for family supportConsider the need for family support Other ?Other ?

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Addressing C I S

Acknowledge the existence of CISAcknowledge the existence of CIS Pre-incident educationPre-incident education PlanningPlanning Drills / practiceDrills / practice Pre-deployment briefingsPre-deployment briefings Avoid avoidance of CISAvoid avoidance of CIS

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Summary of Commonly Used Crisis/ Disaster Interventions Summary of Commonly Used Crisis/ Disaster Interventions (adapted from Raphael, 1986; Everly & Langlieb, 2003; NIMH, 2002; Sheehan, et (adapted from Raphael, 1986; Everly & Langlieb, 2003; NIMH, 2002; Sheehan, et al., 2004; DHHS, 2004; Everly & Castellano, 2005; Everly & Parker, 2005; NOVA, al., 2004; DHHS, 2004; Everly & Castellano, 2005; Everly & Parker, 2005; NOVA,

2002)2002)INTERVENTIONINTERVENTION TIMING TIMING TARGET GROUP TARGET GROUP POTENTIAL GOALS POTENTIAL GOALS

1. Pre-event Planning/ Pre-event Anticipated target/victim Anticipatory guidance. Preparation. population. Foster resistance, resilience.

2. Assessment. Pre-intervention. Those directly & indirectly Determination of need for

exposed. intervention.

3. Indv. Crisis Intervention. As needed. Individuals as needed. Assessment. Screening.

(including "psyc first aid") Education. Normalization. Reduction of acute distress.

Triage. Facilitation of continued support.

4. Demobilization. Shift disengagement. Emergency personnel. Decompression.

Screening. Triage.

Education. Ease transition.

5. Respite Sector. On-going Emergency personnel. Respite.

large-scale events. Refreshment. Screening. Triage.

Support.

6. Large Group CMB As needed. Heterogeneous large Inform

& Large group groups. Control rumors.psyc first aid Inc. cohesion.

INTERVENTIONINTERVENTION TIMING TIMING TARGET GROUP TARGET GROUP POTENTIAL GOALS POTENTIAL GOALS

7. “Group Debriefing” Post event... Small homogeneous groups c/ Ventilation. Information.

(CISD, ~1-10 days acute equal trauma exposure. Often NormalizationPD, GCI, incidents; workgroups, emergency Reduce acute distress.MSD, ~3-4 wks post services, military. Inc. cohesion, resilience.CED, mass disaster Screening HERD) recovery phase. Triage.

Follow-up essential.

8. Defusing On-going events Small homogeneous groups. Stabilization. Ventilation (and small group & Post event May be similar to HERD in Reduce acute distress."psychological first aid.") (< 12 Hrs) process. Screening.

May be repeated. Information. Inc. cohesion, resilience.

9. Small Group On-going events Small groups seeking info. Information.Crisis Management & Post event. c/o delving into affect. Control rumors. Briefing (sCMB) May be repeated, Reduce acute distress

as needed. Inc. cohesion, resilience.

Screening/ Triage

INTERVENTIONINTERVENTION TIMING TIMING TARGET GROUP TARGET GROUP POTENTIAL POTENTIAL GOALSGOALS

10. Family Crisis Pre-event & Families. Consists of a wide arrayIntervention. As needed. of interventions incl. Pre-event prep., individ. intv., sCMB, debriefing,”

etc.

11. Organizational/ Leadership Pre-event & Organizations affected Improve organizational Consultation As needed. by trauma or disaster. preparedness &

response.

12. Pastoral Crisis As needed. Those who desire faith-based Faith-based support, eg,Intervention presence/ crisis intervention, eg, Info., advocacy, liaison. Individs., small groups, Ministry of presence. large groups, congregations, Religious intervention, communities. if desired.

13. Follow-up, Referral. As needed. Intv. recipients & those exposed. Assure continuity of care.

14. Strategic planning. Pre-event & Anticipated exposed/victim Improve overall during. populations. disaster MH response.

Chevron Publishing, 2002

Objectives ofObjectives ofCrisis InterventionCrisis Intervention

Stabilize situationStabilize situation Mitigate impactMitigate impact Mobilize resourcesMobilize resources Normalize reactionsNormalize reactions Restore to adaptive function Restore to adaptive function

Chevron Publishing, 2002

Crisis InterventionKey Principles

Simplicity

Brevity

Innovation

Pragmatism

Proximity

Immediacy

Positive outcome expectancy

Dose Response

Chevron Publishing, 2002

Basic Crisis Guidelines

Never go beyond one’s level of trainingNever go beyond one’s level of training

Do not open discussions unless there is Do not open discussions unless there is sufficient time to processsufficient time to process

The end of every crisis intervention occurs The end of every crisis intervention occurs when either the person is showing signs of when either the person is showing signs of recovery or it becomes evident that a recovery or it becomes evident that a referral is necessaryreferral is necessary

Critical IncidentStress Management

Comprehensive

Integrated

System utilizing a

Multi-Tactical

Crisis Intervention Approach

to Managing Traumatic Stress

CIS

M:

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ervi

ces

Pre-Crisis Preparation /EducationPre-Crisis Preparation /Education On-scene Support / ConsultationOn-scene Support / Consultation Group InterventionGroup Intervention

Demobilization Demobilization Crisis Management Briefing Crisis Management Briefing DefusingDefusing Critical Incident Stress DebriefingCritical Incident Stress Debriefing

Individual Crisis InterventionIndividual Crisis Intervention Pastoral Crisis InterventionPastoral Crisis Intervention Family / Sig. Other SupportFamily / Sig. Other Support Organizational ConsultationOrganizational Consultation Follow-up and / or ReferralFollow-up and / or Referral Post -event Education & Lessons LearnedPost -event Education & Lessons Learned

“Tactics”

Chevron Publishing, 2002

Core Competencies in CISMCore Competencies in CISM

The ability to properly assess both the The ability to properly assess both the situation and the severity of impact on situation and the severity of impact on individuals and groupsindividuals and groups

Ability to develop a strategic planAbility to develop a strategic plan Individual crisis intervention skillsIndividual crisis intervention skills Large group crisis intervention skillsLarge group crisis intervention skills Small group crisis intervention skillsSmall group crisis intervention skills Referral skillsReferral skills

Chevron Publishing, 2002

Essential CISM CoursesEssential CISM Courses(2 Days Each)(2 Days Each)

Assisting Individuals in CrisisAssisting Individuals in Crisis Basic Critical Incident Stress Basic Critical Incident Stress

Management: Group Crisis InterventionsManagement: Group Crisis Interventions

SuicideSuicide Grief Following TraumaGrief Following Trauma Advanced Critical Incident Stress Management: Group Crisis Advanced Critical Incident Stress Management: Group Crisis

InterventionsInterventions T.E.A.M.T.E.A.M. Emotional & Spiritual Care in DisastersEmotional & Spiritual Care in Disasters

Chevron Publishing, 2002

In addition to the essential In addition to the essential courses,courses,

CISM providers are CISM providers are encouraged to participate in a encouraged to participate in a

variety of other training variety of other training opportunities to enhance their opportunities to enhance their

skills.skills.

Resources

Strategic Planning

CIS

M:

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ces

Pre-Crisis Preparation /EducationPre-Crisis Preparation /Education On-scene Support / ConsultationOn-scene Support / Consultation Group InterventionGroup Intervention

Demobilization Demobilization Crisis Management Briefing Crisis Management Briefing DefusingDefusing Critical Incident Stress DebriefingCritical Incident Stress Debriefing

Individual Crisis InterventionIndividual Crisis Intervention Pastoral Crisis InterventionPastoral Crisis Intervention Family / Sig. Other SupportFamily / Sig. Other Support Organizational ConsultationOrganizational Consultation Follow-up and / or ReferralFollow-up and / or Referral Post -event Education & Lessons LearnedPost -event Education & Lessons Learned

“Tactics”

Target Type Timing Theme Team ResourcesTarget TypeOn-Scene

CMBDemob.DefuseCISD1:1

FamilyAdmin

Consult IC/CC

F/U

Strategic Planning

TimingNOW!

After ShiftTomorrow

AMBefore Going HomeAfter Been

Home 1-2 Day

ThemeVictimGriefLoss

SurvivorSurvivor

GuiltBoss

ICCC

ViolatedWorldView

TeamPeersFlight Crew

Ground TeamAdmin

CommoCadetMental Health

Outside Tm

ResourcesPeers

Friends Neighbors

FamilyFaith

CommunityWorkEAPPCP

Support Groups

Outside Tm

Fro

m C

ircle

sAKA: Tactics

Chevron Publishing, 2002

CISM TacticsCISM TacticsMust be Available for:Must be Available for:

IndividualsIndividuals GroupsGroups OrganizationsOrganizations FamiliesFamilies Significant othersSignificant others

CISM ComponentsCISM ComponentsBeforeBefore an Incidentan Incident

Education (PEP)Education (PEP) Team trainingTeam training PlanningPlanning Administrative supportAdministrative support Protocol developmentProtocol development Guideline developmentGuideline development Networking with other teamsNetworking with other teams

& resources& resources

CISM ComponentsCISM ComponentsDuringDuring an Incident an Incident

On-scene support servicesOn-scene support services One-on-one crisis interventionOne-on-one crisis intervention Advice to supervisors/ICAdvice to supervisors/IC Support to primary victims (CAP)Support to primary victims (CAP) Provision of food, fluids, rest and other Provision of food, fluids, rest and other

services to operations personnelservices to operations personnel Organizational Consultation (CC)Organizational Consultation (CC)

CISM ComponentsCISM ComponentsAfterAfter an Incidentan Incident

One-on-one crisis interventionOne-on-one crisis intervention Demobilization (post-disaster, large group)Demobilization (post-disaster, large group) Crisis Management Briefing (CMB, large Crisis Management Briefing (CMB, large

group)group) Defusing (small group)Defusing (small group) Critical Incident Stress Debriefing (CISD, Critical Incident Stress Debriefing (CISD,

small group)small group) Significant other support servicesSignificant other support services

. . . more . . . . . . more . . .

Post-incident educationPost-incident education Follow-up servicesFollow-up services Referrals according to needsReferrals according to needs

CISM ComponentsCISM ComponentsAfterAfter an Incident an Incident

continuedcontinued

CISM CISM

Typically: 3-5 contactsTypically: 3-5 contacts After that,After that,

Recovery is evidentRecovery is evidentReferral is indicatedReferral is indicated

PHYSIOLOGICAL NEEDSPHYSIOLOGICAL NEEDSBasic life needs - air, food, water, shelter

SAFTEYSAFTEYPhysical and psychological security, law & order

AFFILIATION, SUPPORTAFFILIATION, SUPPORTInterpersonal & family relationships

SELF-ESTEEMSELF-ESTEEMSelf-efficacy, empowerment

SELF-ACTUALIZATIONSELF-ACTUALIZATION Personal growth and fulfillment

Maslow’s Need HierarchyMaslow’s Need Hierarchy(1943)

Start here

CrisisCrisisInterventionIntervention

Psychotherapy

Spectrum of Care

Crisis Intervention

CISM

r

Refer as needed to any

Family Support

EAP

Chaplain

Human Resources

Family Advocate

Legal

Mental Health

Psychotherapy

Hospitalization

Rehabilitation

Other resources

Critical Incident

Treatment Referral Options Medical Care ProfessionalMedical Care Professional

MD / DOMD / DO PA / NPPA / NP

Mental Health Care ProfessionalMental Health Care Professional PsychologistPsychologist CounselorCounselor Social WorkerSocial Worker Psychiatrist / NP / PAPsychiatrist / NP / PA

Spiritual Care ProfessionalSpiritual Care Professional Faith LeaderFaith Leader ““Chaplain”Chaplain”

CISMCISM

Is not psychotherapyIs not psychotherapy

Is not a substitute for psychotherapyIs not a substitute for psychotherapy

Is not a stand-aloneIs not a stand-alone

Is not a cure for PTSD, Depression, Is not a cure for PTSD, Depression, Anxiety, etcAnxiety, etc

CISM has far more to do withgroup supportandassessment (triage)than it does withtreatment and cure.

Follow-UpFollow-UpMustMust be provided after every CISM service: be provided after every CISM service: Assess impact of interventionAssess impact of intervention Assess for uncovering prior issuesAssess for uncovering prior issues Assess trajectory of reactionsAssess trajectory of reactions

• DecreasingDecreasing• SameSame• IncreasingIncreasing

Assess for possible referral:Assess for possible referral: Health Care ProfessionalHealth Care Professional Mental Health Care ProfessionalMental Health Care Professional Spiritual Care ProfessionalSpiritual Care Professional

1 week post CISM service

1 month post CISM service

P. A. S. S.P. A. S. S.Post Action Staff SupportPost Action Staff Support

Dennis Potter, LCSW

Goals For PASSGoals For PASS

Increase longevity of team membersIncrease longevity of team members Increase learning from the experienceIncrease learning from the experience Increase stress management skillsIncrease stress management skills Decrease the chance for personal reactionsDecrease the chance for personal reactions To take care of ourselves (too)To take care of ourselves (too) Increase effectiveness of team membersIncrease effectiveness of team members Monitor team for any adverse reactionsMonitor team for any adverse reactions

Why Do It?Why Do It?

To Prevent: Vicarious Traumatization Cumulative Stress Critical Self Judgment

To Teach To Practice What We Teach

“The same professionalism we provide to others, we deserve ourselves” SDB

When Should It Be Done?When Should It Be Done?

Should be a normal part of the team’s Should be a normal part of the team’s standard operating guidelines,standard operating guidelines,

Should be done prior to the team going Should be done prior to the team going home (at least a defusing),home (at least a defusing),

At the earliest next opportunity,At the earliest next opportunity, Soon,Soon, Its never too late!Its never too late!

Where Should It Be Done?Where Should It Be Done?

Away from the site and participants, Neutral site if possible, Somewhere you will not be interrupted, If the Critical Incident is particularly difficult

you may want to consider more time or bringing in someone else,

Somewhere private if you are concerned about the difficulty of the CISM response.

How Long Does It Take?How Long Does It Take?

For “normal” events usually 10-15 minutes For “normal” events usually 10-15 minutes is adequate,is adequate,

For “abnormal” events 30-60 minutes may For “abnormal” events 30-60 minutes may be required,be required,

If you always do it, you will discover the If you always do it, you will discover the difference between a normal and difference between a normal and abnormal event.abnormal event.

Who Should Do It?Who Should Do It?

Usually the “Event Team Leader”Usually the “Event Team Leader” Probably 90% can be done by the team itselfProbably 90% can be done by the team itself

Occasionally, by someone not involved in Occasionally, by someone not involved in the response itselfthe response itself Particularly difficult or events of long durationParticularly difficult or events of long duration

Important Notice:

• All CISM services should be provided only by people who have been properly trained in Critical Incident Stress Management courses,

• Having attained an advanced academic degree alone does NOT indicate knowledge of CISM or related protocols.

CAPCAPCISMCISM

Refresher / UpdateRefresher / Update

Where We Are Now:Where We Are Now:Web-SiteWeb-Site

cism.cap.govcism.cap.gov

Staff listings & contact informationStaff listings & contact information Calendar of events / trainingsCalendar of events / trainings Forms & HandoutsForms & Handouts Send training certificates / reports to . . . Send training certificates / reports to . . .

““Certificates”Certificates” ““Wing Reports” & “Region Reports”Wing Reports” & “Region Reports”

Decentralization of StaffDecentralization of Staff

WingsWings “Get’r done dudes” – Providing Frontline Service“Get’r done dudes” – Providing Frontline Service Providing CISM servicesProviding CISM services Networking with other local non-CAP CISM teamsNetworking with other local non-CAP CISM teams

RegionsRegions “Make it happen” – Administrative Support“Make it happen” – Administrative Support Administrative support and facilitation / paperworkAdministrative support and facilitation / paperwork Technical assistance if neededTechnical assistance if needed Maintains team recordsMaintains team records Maintains ICISF Registered Team status with ICISFMaintains ICISF Registered Team status with ICISF Monthly conference calls with WingsMonthly conference calls with Wings

NationalNational “Lead into the future” – Overall Leadership“Lead into the future” – Overall Leadership Develop training based on Wing and Region needsDevelop training based on Wing and Region needs Keep everyone updated on new ideas/issuesKeep everyone updated on new ideas/issues Monthly conference calls with Region sMonthly conference calls with Region s

Staff StructureStaff Structure

WingsWings – – “Doing the CISM Work”“Doing the CISM Work” Officer/CoordinatorOfficer/Coordinator Clinical DirectorClinical Director

RegionRegion – – “Team Support & Administration”“Team Support & Administration” Officer / CoordinatorOfficer / Coordinator Clinical DirectorClinical Director

NationalNational – – “Leading into the Future”“Leading into the Future” Team LeaderTeam Leader Clinical DirectorClinical Director

Staff StructureStaff Structure

Officer / CoordinatorOfficer / Coordinator Administrator of the program within Wing or RegionAdministrator of the program within Wing or Region Point person for Wing or RegionPoint person for Wing or Region Coordinates service requests and servicesCoordinates service requests and services Maintains paperwork for Wing or RegionMaintains paperwork for Wing or Region Officiates “administration” portion of meetings/trainingsOfficiates “administration” portion of meetings/trainings

Clinical DirectorClinical Director Supervises all clinical aspects of programSupervises all clinical aspects of program Must be licensed in the state of residence and/or Wing of Must be licensed in the state of residence and/or Wing of

membershipmembership Conducts “clinical” portion of meetings/trainingsConducts “clinical” portion of meetings/trainings

Introduction to ICISF Introduction to ICISF (On-line or classroom)(On-line or classroom)

Program Orientation Program Orientation (On-line or classroom)(On-line or classroom)

CISM Basic Concepts CISM Basic Concepts (On-line or classroom)(On-line or classroom)

Group Crisis Intervention Group Crisis Intervention (Classroom only) (Classroom only)

ANDAND Peer / Individual Crisis Intervention Peer / Individual Crisis Intervention (Classroom Only)(Classroom Only)

NIMS:NIMS: NIMS 100 NIMS 100 http://training.fema.gov/IS/NIMS.asp

NIMS 700 NIMS 700 http://training.fema.gov/IS/NIMS.asp

ICS 300 and 400 is not required, but can aid in understanding command and general ICS 300 and 400 is not required, but can aid in understanding command and general staff issues.staff issues.

Required TrainingRequired Training

Renewal / Refresher:Renewal / Refresher: Group Group (2 Classroom days)(2 Classroom days)

andand

Individual Individual (2 Classroom days)(2 Classroom days)oror

Building Skills in CISM Building Skills in CISM (2 Classroom days)(2 Classroom days) oror

The Changing Face of CI and DMHIThe Changing Face of CI and DMHI(1 Classroom day or internet)(1 Classroom day or internet)

* CISM Service provision does not qualify for * CISM Service provision does not qualify for renewal/refresherrenewal/refresher

Renewal / Refresher

While other ICISF and other organization’s courses are encouraged, to maintain basic CISM skill sets and knowledge currency, the above courses are required on a 3 year rotation.

Ground team members and support personnelGround team members and support personnel Air crew member and support personnelAir crew member and support personnel Administration personnelAdministration personnel Communications personnelCommunications personnel Physical health personnel Physical health personnel (doctors, nurses, etc.)(doctors, nurses, etc.)

Mental health personnel Mental health personnel (psychologist, counselors, social (psychologist, counselors, social workers, etc)workers, etc)

Spiritual health personnel Spiritual health personnel (chaplains, character (chaplains, character development, etc)development, etc)

Cadets Cadets (training our replacements)(training our replacements)

Elders - “Recycling” . . . Elders - “Recycling” . . .

Recruiting

“Recycling” MembersBecause:

•Physical injury nor disability•Normal “aging”

does not eliminate:•Experience & insight,•Cognitive abilities & strategizing•Positive coping skills, abilities, outlooks,

The CISM Program welcomes:•Flight crews members who no longer fly•Ground teams who don’t “ground pound”•Administration and Communications folks

We still need you . . . you aren’t done yet

Cadets & CISMCadets & CISM

•Introduction to CISM at “technician” level•Cadet-to-Cadet Peer Support:

•Educate on effective listening & communication skills•Provide awareness of suicide warning signs & how to summons help•How to help a friend•Prepare for Senior Member CISM program

•Will Not:•Participate in “Senior” CISM service provision in support staff roles only,•Be considered “peer” to any “senior” member

We need you . . . We’re Training Our Replacements

TechnicianTechnician: : “Learning the program”“Learning the program” Knowledge Requirement:Knowledge Requirement: Service Requirement:Service Requirement:

SeniorSenior: : “Doing & mentoring the program”“Doing & mentoring the program” Knowledge Requirement:Knowledge Requirement: Service Requirement:Service Requirement:

MasterMaster: : “Managing the program”“Managing the program” Knowledge Requirement:Knowledge Requirement: Service Requirement:Service Requirement:

CISM Specialty Track

Knowledge Requirement:Knowledge Requirement: Introduction to ICISFIntroduction to ICISF Orientation to CAP CISM ProgramOrientation to CAP CISM Program * NIMS 100* NIMS 100 CISM Basic ConceptsCISM Basic Concepts * NIMS 700* NIMS 700 ICISF’s Group Crisis InterventionICISF’s Group Crisis Intervention ICISF’s Individual/Peer Crisis InterventionICISF’s Individual/Peer Crisis Intervention

Service Requirement:Service Requirement: Serve in support role until completion of courses (above)Serve in support role until completion of courses (above) Actively participate in 6 CISM responses as an observer onlyActively participate in 6 CISM responses as an observer only Actively participate in 4 Debriefings (non leader)Actively participate in 4 Debriefings (non leader) Actively participate in 4 Individual/Peer contactsActively participate in 4 Individual/Peer contacts Actively participate in 6 Follow-Up contactsActively participate in 6 Follow-Up contacts Actively provide 4 Intro to ICISF presentationsActively provide 4 Intro to ICISF presentations Actively provide 4 Orientation to CAP CISM Program presentationsActively provide 4 Orientation to CAP CISM Program presentations Attend 4 PEP trainingsAttend 4 PEP trainings Attend 75% of the Wing CISM meetingsAttend 75% of the Wing CISM meetings

Technician: Technician: Learning the programLearning the program

Knowledge Requirement:Knowledge Requirement: ICISF’s Advanced GroupICISF’s Advanced Group ICISF’s SuicideICISF’s Suicide ICISF’s Grief Following TraumaICISF’s Grief Following Trauma

Service Requirement:Service Requirement: Achieve Technician ratingAchieve Technician rating Mentor 4 upcoming TechniciansMentor 4 upcoming Technicians Actively participate in 6 more CISM Mission/Training responsesActively participate in 6 more CISM Mission/Training responses Actively participate in 4 more debriefings (as leader)Actively participate in 4 more debriefings (as leader) Actively provide 4 more Individual/Peer contactsActively provide 4 more Individual/Peer contacts Actively provide 6 more Follow-Up contactsActively provide 6 more Follow-Up contacts Meet with 1-2 local CISM teams 3 times minimumMeet with 1-2 local CISM teams 3 times minimum Provide 3 CISM Basic Concepts presentationsProvide 3 CISM Basic Concepts presentations Assist a Wing CISM Officer/Coordinator for 1 year (Team Coordinator, Assist a Wing CISM Officer/Coordinator for 1 year (Team Coordinator,

Clinical Director, etc)Clinical Director, etc) Attend 75% of the Wing CISM meetings/trainingsAttend 75% of the Wing CISM meetings/trainings

Senior: Senior: Doing & mentoring the programDoing & mentoring the program

Knowledge Requirement:Knowledge Requirement: Strategic Response to CrisisStrategic Response to Crisis Team Evolution and ManagementTeam Evolution and Management Emotional & Spiritual Care in DisastersEmotional & Spiritual Care in Disasters

Service Requirement:Service Requirement: Achieve Senior ratingAchieve Senior rating Mentor 4 upcoming SeniorsMentor 4 upcoming Seniors Actively participate in planning CISM involvement in 4 CAP Actively participate in planning CISM involvement in 4 CAP

Exercises/DrillsExercises/Drills Develop MOUs with 2 local non-CAP CISM teamsDevelop MOUs with 2 local non-CAP CISM teams Participate in 4 meeting/trainings with non-CAP CISM teams,Participate in 4 meeting/trainings with non-CAP CISM teams, Serve as a co-instructor (maximum of 10%) for a Group and Serve as a co-instructor (maximum of 10%) for a Group and

Individual/Peer courseIndividual/Peer course Assist a Region CISM Officer for 1 year (Team Coordinator, Assist a Region CISM Officer for 1 year (Team Coordinator,

Clinical Director, etc.)Clinical Director, etc.) Attend 75% of the Wing and Region CISM meetingsAttend 75% of the Wing and Region CISM meetings

Master: Master: Managing the programManaging the program

Where to from here?Where to from here? Satisfied with the knowledge & awarenessSatisfied with the knowledge & awareness How to do more:How to do more:

Join a teamJoin a team Attain further CISM educationAttain further CISM education Provide further CISM education & awarenessProvide further CISM education & awareness Advocate for appropriate CISM servicesAdvocate for appropriate CISM services Provide more:Provide more:

Within your Squadron, Group, Wing, RegionWithin your Squadron, Group, Wing, Region With your familyWith your family At your place of workAt your place of work In your communityIn your community For yourselfFor yourself

How To Become a MemberHow To Become a Member

Complete basic trainings Complete basic trainings (technician)(technician) Complete application & be accepted to a teamComplete application & be accepted to a team Participate in quarterly Team trainingsParticipate in quarterly Team trainings Participate in CAP CISM functionsParticipate in CAP CISM functions Maintain currencyMaintain currency Participate in non-CAP CISM teams & functionsParticipate in non-CAP CISM teams & functions

CISM Team membership is a privilege not a right.CISM Team membership is a privilege not a right.

“Knowledge itself is power”Sir Francis Bacon

““Action is the proper fruit Action is the proper fruit of knowledge”of knowledge”

Thomas Fuller

Feedback

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ReactionsReactions

Lt Col Sam D. Bernard, PhDLt Col Sam D. Bernard, PhDNational CISM Team LeaderNational CISM Team Leader

(423) 322-3297 (423) 322-3297 sam@sambernard.info

Maj Chris LatockiMaj Chris LatockiAdministrative OfficerAdministrative Officer

( 813) 412-9231 clatocki@cism.cap.gov( 813) 412-9231 clatocki@cism.cap.gov

National StaffNational Staff

________________NameName________________________Region CISM OfficerRegion CISM Officer

Telephone / e-mailTelephone / e-mail

________________NameName________________________Region Clinical DirectorRegion Clinical Director

Telephone / e-mailTelephone / e-mail

Region StaffRegion Staff

________________NameName________________________Wing CISM Officer / CoordinatorWing CISM Officer / Coordinator

Telephone / e-mailTelephone / e-mail

________________NameName________________________Wing Clinical DirectorWing Clinical Director

Telephone / e-mailTelephone / e-mail

Wing StaffWing Staff

Thank You!

. . .and just one more thing. . .

Critical Incident Stress Critical Incident Stress ManagementManagement

Lt. Col. Sam D. Bernard, Ph.D.Lt. Col. Sam D. Bernard, Ph.D.National CAP CISM Team LeaderNational CAP CISM Team Leader

(423) 322-3297(423) 322-3297CellCell

sam@sambernard.info

www.sambernard.info

cism.cap.govcism.cap.gov

Critical IncidentCritical IncidentStress ManagementStress Management

CISM UpdateLearning from the Past, . . . Progressing into the Future

Developed by Lt. Col. Sam D. Bernard, Ph.D.Developed by Lt. Col. Sam D. Bernard, Ph.D.CAP CISM National Team LeaderCAP CISM National Team Leader

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