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Supportive Systems, LLC
EAP and Corporate Development 1
Crisis Response: What Do We Do Now?
Pam Ruster, LCSW, CEAPSupportive Systems, LLC
Indianapolis, INwww.supportivesystems.com
Objectives• Explore the history, physiology and psychology of critical
incident response • Familiarize participants regarding the implications of use for
crisis response• Identify opportunities for application in the workplace and
application of skills
Supportive Systems, LLC
EAP and Corporate Development 2
Discussion of CISM
• What is CISM?• When do you do a CISM activity?• What is Psychological First Aid?• When do you apply that model?• What are the differences and what
came before?
Prevalence• 80% of Americans will be exposed to a traumatic
event (1)• 9% will develop PTSD (2)• 40-70% in rape or torture (2)• Disasters may create significant impairment in
40%-50% of those exposed (3)
• 1. Breslau 2. Surgeon General 1999 3. Norris 2001 SAMHSA
Supportive Systems, LLC
EAP and Corporate Development 3
Prevalence• 10-15% of law enforcement personnel• 10-13% of those in fire suppression• 16% of Vietnam Veterans• 12% of Iraq War Veterans• 40% of those exposed to Mass disasters
1909 Cherry Hill, IL Mining Fire
• Early Crisis Intervention as Emotional First Aid–Not a Cure…–Not psychotherapy
Supportive Systems, LLC
EAP and Corporate Development 4
Crisis Intervention
• Targets the Response, not the Event• An active, short-term supportive helping
process• Acute intervention designed to mitigate the
crisis response• Not psychotherapy or a substitute for
psychotherapy
Definition: Critical Incidents• Unusually challenging events that have the
potential to create significant human distress and can overwhelm one’s usual coping mechanisms.
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EAP and Corporate Development 5
Definitions: Psychological Crisis
• The psychological distress in response to critical incidents as in an acute response to a trauma, disaster, or other critical event where:
– Psychological balance is disrupted– One’s usual coping mechanism’s have
failed– There is evidence of significant distress,
impairment, dysfunction
Psychiatric Casualties
• Civil War 3.3/1000 29 Soldiers Heart• WWI 4/1000 28 Shell shock• WWII 4.4/1000 26 War Neurosis
Combat Fatigue• Korean 4.6/1000 23 Combat Fatigue• Vietnam 5/1000 19 PTSD/PTAN• Iraq 12/100 23 PTSD
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EAP and Corporate Development 6
The Stats
• 50-70 % of US adults experience Trauma• 30% of those will suffer from PTSD (20% women/8% men)• 5% of Americans are diagnosed with PTSD at any given time• 8% of Americans will have a diagnosis of PTSD at some time in
their lifetime• Those with PTSD 8x more likely to attempt suicide• If have PTSD and Depression, number becomes 16x more
likely
Resistance-Resilience-Recovery
• An outcome driven continuum of careCreate resistance Enhance Resiliency Speed RecoveryAssessment Assessment AssessmentIntervention Intervention interventionEvaluation Evaluation Evaluation
Kaminsky, et.al. (2005) Resistance, Resiliency, Recovery. In Everly & Parker, Mental Health Aspects of Disaster, Public Health Preparedness and Response. Balto; Johns Hoskins Center for Public Health Preparedness
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EAP and Corporate Development 7
Resistance may be
• Thought of as a form of psychological/behavioral immunity to distress and dysfunction.
• Pre-incident training /preparation is thought to be the best way to build resistance.
Resilience refers to the ability
• to rapidly and effectively rebound from psychological and or behavioral interruptions associated with critical incidents, terrorism and even mass disasters.
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EAP and Corporate Development 8
Hope• Left frontal lobe of brain is activated when praying,
meditating • Instilling hope
• Physiologically impossible to experience hope and fear at the same time
• The impact of the event depends on the clients degree of hope, resilience and their capacity to transcend the event.
• Transcendence: I believe I can rise above this.
Recovery refers to
• the ability to adaptively function, both psychologically and behaviorally in the wake of a significant clinical distress, impairment, or dysfunction subsequent to critical incidents, terrorism and even mass disasters.
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EAP and Corporate Development 9
Lessons learned from Community Mental Health
• Early psychological intervention may reduce need for further intensive services. Langsley, Makota & Flomenhaft, 1971, Am J Psyc; Decker & Stubblebine, 1972, Am J Psyc.
• Early psychological intervention may mitigate acute distress Flannery & Everly, 2004, Aggression & Violent Beh
• Early Psychological intervention may reduce ETOH (alcohol use) (Deahl et al, 2000, Br. J Med Psychology; Boscarino, et. Al. 2005
Let’s Start at the Beginning
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EAP and Corporate Development 10
Stressors• ANY environmental
event that produces an…ANSR
• Autonomic• Nervous• System• Response
Typical Symptoms of Stress• What is your Body Talk?
• Headaches• Gastrointestinal
disturbance• Change in eating/sleeping• Overwhelmed• Anger/Irritability• Vertigo• Muscle Spasms
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EAP and Corporate Development 11
Two Types of Stress• Eustress
– Positive motivating stress
• Distress– Negative excessive
debilitating stress events
Two Types of DistressCumulative (burnout)
• Slow erosion of functioning
• Cynicism• Incomplete work• Lateness• Impulsive need for
change• Chronic physical illness
Critical Incident (traumatic)
• Normal coping overwhelmed
• Adaptive functioning interrupted
• Symptoms of post traumatic stress evident
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EAP and Corporate Development 12
Flight. Fight. Freeze.• Normal Survival
Reactions
• What do animals do when frightened?
Typical Stress Response
• Increased heart rate• Elevated blood pressure• Increased muscle tone• Dilated pupils• Increased perspiration
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EAP and Corporate Development 13
Stress Response• Secretion of
Epinephrine and other hormones
• Increase in oxygen uptake
• Mobilization of Glucose and Fatty Acids
Cumulative Stress Reaction• A problem born of good intentions,• Unrealistic expectations
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EAP and Corporate Development 14
Cumulative Stress
• Derogatory labels
• Intellectualization
• Psychological distancing• Drugs/alcohol
• Mismanagement of resources
• Patient/Client abuse
• Unappreciated
• Detached
• Self-separated
• Paranoid
• Cynicism
• Denial
• Jargon
Behavioral Aspects• Anger• Irritability• Constant talking• Crying • Fear• Laughter• Avoidance• Changes in
concentration
• Loss– If loss has occurred it is
not possible to begin the grief process until the immediate effects of the crisis have been mitigated
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EAP and Corporate Development 15
Cumulative Stress Reactions• Unrealistic expectations• Health complications• Changes in concentration• Ineffective coping techniques• BUT THIS IS NOT WHAT WE ARE TALKING ABOUT
A Critical Incident: Definition
• Any event which has a significant emotional power sufficient enough to overwhelm a person’s or groups ability to cope and causes impairment in work or personal activity.
• Officially recognized definition by the United Nations
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EAP and Corporate Development 16
Examples of Critical Incidents
• Suicide of a colleague• Line of Duty Death • Serious on the job injury• Disaster or a multi-casualty incident• Police shooting• Killing or wounding of any person in a routine
operation• Any event with significant threat to those involved
Examples of Critical Incidents
• Events involving children• Relative of a known victim• Prolonged incidents especially with a loss• Events with excessive media interest• Any significant event
Supportive Systems, LLC
EAP and Corporate Development 17
Intensity of the Impact Determinants
• Personal relevance• Duration• Sense of loss• Previous history• Social support & coping skills• Guilt• Hopelessness/helplessness
Characteristics of the Crisis• Characteristics provide the layer of perception
thru which the crisis is experienced. These perceptions then provide the context from which individuals respond to the crisis and associated loss.– Warning/None – Time of day – Duration – Natural vs Man-made
Supportive Systems, LLC
EAP and Corporate Development 18
Characteristics of the Crisis
– Intentionality– Scope of impact– Post-crisis environment– Preventability of the event– Did anyone suffer
High Risk Determinants
• Severity and duration of the event• History of childhood abuse• Personal and/or family history of psychiatric illness• Poor or negative social support• Substance abuse• Previous exposure to trauma• Inability/difficulty attaching to others
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EAP and Corporate Development 19
Emotional Trauma
• Blow to the Psyche that breaks through one’s defenses suddenly, with such force that one cannot respond effectively.
Trauma looks like… A Normal reaction
in Normal people
to an Abnormal event
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EAP and Corporate Development 20
Purpose of PTS
Post Traumatic Stress is a Survival Mechanism
PTSD results from Violation
• Expectations• Deeply Held
Beliefs–(world views)
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EAP and Corporate Development 21
Core Beliefs/World Views• Belief in a just and fair world• Our need to trust others• Self-esteem, Self efficacy• Need for a predictable and SAFE world• Spirituality, belief in an order and congruence in
life and the universe• Morality is in place
Purpose
• The memory of the event is set as a light switch to “ON”
• Designed to help you remember so it won’t happen again.
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EAP and Corporate Development 22
Goals
• Acute Stabilization• Mitigating critical incident stress• Mitigating escalation of distress• Provide opportunity to assess and
potentially follow-up and/or refer
Types of Interventions• Pre-incident Education• On scene support services• Defusing• Demobilization• Formal CISD• Psychological First Aid• Significant Other support
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EAP and Corporate Development 23
Objectives of CISM• Education• Ventilation• Reassurance• Confront fallacy of uniqueness• Confront fallacy of abnormality• Increase group cohesion• Restore self confidence
Structure of a CISD Meeting
• Peers• Mental Health Provider• Neutral setting• Disruption free (as possible)• Establish confidentiality• Separate participants according to
involvement
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EAP and Corporate Development 24
Stages of a Debriefing• Introduction• Fact• Thought• Reaction• Symptoms• Teaching• Re-entry
Be Mindful
• Must taste your words before you speak them.
– old eskimo saying
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EAP and Corporate Development 25
When debriefings fail
• Team not trained• No mental health practitioner present• Not held confidentially• Discussed other debriefings• Insensitivity to participants
Reactions• Common concerns
– Rational versus irrational safety concerns
– Flashbacks visual/auditory– Sleep disturbance– Meal disruption– Concentration– Physical ailments
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EAP and Corporate Development 26
Reactions
• Returning to work–Fears–Questions–Non-involved persons reactions–Accommodations
Reactions
• Taking care of each other• Guilt• Relief• Fear of retribution• Fear of discipline
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EAP and Corporate Development 27
Cautions• Sugar• Caffeine• Alcohol
Follow-up
• Crucial to follow up with anyone for whom you have concerns
• Reassure they will continue to improve over a period of time.
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EAP and Corporate Development 28
Defusing• Small group
• More informal
• More common
What makes groups unique?
• Learning from others• Catharsis• Group cohesion• Personal insight• World View awareness• Universality• Instillation of hope
• Yalom, 1970
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EAP and Corporate Development 29
Defusing
Small Group discussion• Timing: Usually
between 8-10 hours of event
• Structure: 3 phases• Duration: less than 1 hr. • Location: secluded
room• Group: Homogeneous
Goals:– Normalization – Reduce tension– Set expectations– Discuss coping
methods– Identify those who
require additional support
Defusing: 3 Phases
• Introductions of team; layout, what to expect• Exploration: A brief story of the event• Provide information , normalize, teach,
guidance, summarize key points
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EAP and Corporate Development 30
Introduction Phase• Introduce team • State purpose/describe process• Motivate participants• Set ground rules• Stress confidentiality• Not investigative• Non one forced to speak• All viewpoints are important
Exploration Phase
• Ask for brief description of event
• Ask clarifying questions• Group members share
experiences on the event if they choose
• Look for themes/concerns
• Assess need for help• Reassure as necessary
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EAP and Corporate Development 31
Information Phase• Acknowledge/ summarize the exploration
provided by the group• Normalize key experiences and or reactions• Teach key stress survival skills• Emphasize taking care of self• Rest/family life/stress management• Offer additional help such as one on ones
Defusing not indicated when• Overwhelming emotions• Affective lability• Dysfunctional arousal• Group cohesion fragile
• Option: Consider small group information session• Assemble group• Presentation of facts• Typical symptoms persons may experience• Suggestions for coping, stress reduction
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EAP and Corporate Development 32
Critical incident response is main stream
• The more prepared we are, the more routine the responses will be.
• Preparation is key.
CISM Summary• Requests for CISM may include response to:
– Robbery– Suicide– Employee death– Family member death– Fatal automobile accidents involving employee
or family – Workplace accidental death
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EAP and Corporate Development 33
Types of Interventions• Pre-incident Education• On scene support services• Defusing• Demobilization• Formal CISD• Psychological First Aid• Significant Other support
How to Apply this information• Next Steps….How to implement
• Will you have a team on site?
• Who else knows this stuff?
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EAP and Corporate Development 34
Contact Information• Pam Ruster, LCSW, CEAP• President & CEO• Supportive Systems, LLC• 25 Beachway Drive, Suite C• Indianapolis, IN 46224• www.supportivesystems.com• 317-788-4111• 800-660-6645
• Women Business Enterprise certified by State of Indiana and City of Indianapolis