- 1. Critical Incident Stress Management CISM Update Learning
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. CAP CISM National
Team Leader Partial content from Chevron Publishing
2. Welcome Thank you for attending this session concerning CAP
CISM Updates 3. Goals
- To provide information concerning various CISM topics
concerning:
4. ICISF
- 10 thWorld Congress Jan-Feb 2009
- Still viable and hosting regional conferences nationwide
5. Other ICISF Courses
- Peer & Individual Crisis Intervention
- Responding to School Crisis
- Suicide: Prevention, Intervention & Postvention
- Strategic Response to Crisis
- Emotional & Spiritual Care in Disaster
- Pastoral Crisis Intervention I & II
- Stress Management for the Trauma Service Provider
- Team Evaluation and Management (TEAM)
- Psychological Response to Terrorism: Impact and
Implications
- The Changing Face of Crisis Response and Disaster Mental Health
Intervention
New Course! Psychological First Aid 6. Certificate of
Specialized Training
- Mass Disaster & Terrorism
- Workplace & Industrial Applications
- Schools & Children Crisis Response
- Spiritual Care in Crisis Intervention
- Substance Abuse Crisis Response
7. International Critical Incident Stress Foundation 3290 Pine
Orchard Lane Suite 106 Ellicott City, MD21042 (410) 750-9600 Fax:
(410) 750-9601 Emergency: (410) 313-2473 www.icisf.org 8. CISM
Information Refresher / Review 9. The Terrible 10 for CAP 1. 6. 2.
7. 3. 8. 4. 9. 5. 10. Take Home Message . . . not limited to
missions! 10. Resistance If the stressor continues, the body
mobilizes to withstand the stress and return to normal. Exhaustion
Ongoing, extreme stressors eventually deplete the bodys resources
so we function at lessthan normal. Alarm The body initially
responds to astressor withchanges that lower resistance. Stressor
The stressor may be threatening or exhilarating. Homeostasis The
body systems maintain a stable and consistent (balanced) state.
Illness and Death The bodys resources are not replenished and/or
additional stressors occur; the body suffers breakdowns. Return
tohomeostasis Illness Death 11. The brain becomes more alert.
Stress can contribute to headaches, anxiety, and depression. Sleep
can be disrupted. Stress hormones can damage the brains ability to
remember 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 canresult. Red = immediate responseto stress Blue =
effects of chronicof prolonged stress 12. Mouth ulcers or cold
sores can crop up. Breathing quickens. The lungs can become more
susceptible to colds and infections. Immune system is suppressed.
Skin problems such as eczema and psoriasis can appear. Cortisol
increases glucose production in 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 13. 14. Stress Reactions Physiological
Based not Characteriologically Flawed Take Home Message 15.
Indicators of Critical Incident Stress vs. Disciplinary Problems or
Character Disorders Take Home Message 16.
- Identifiable traumatic event
- Reactions begin with an event
- Reactions worsen after event
- Reactions follow expected patterns
- Sudden changes are common in CIS
- CIS reactions usually reduce with:
Critical Incident Stress Take Home Message 17.
Characteriological & Disciplinary Problems -continued
- Disciplinary problems have a long and diffuse history
- Problems may have preexisted entry into the CAP job
- Identifiable traumatic event(s) missing
- Problems may exist in several other important areas of the
persons life.
- Problems do not easily resolve over time even with help.
Take Home Message 18. Crisis An acutereactionto a critical
incident. Anameof a particular critical incident. Noun vs Verb Take
Home Message Both 19. Recall that P sychological Distress/Discordin
response to critical incidents is called a Psychological Crisis
(Everly & Mitchell, 1999, Critical Incident Stress Management)
20. Psychological Crisis An acuteRESPONSEto a trauma, disaster, or
other critical incident wherein there isevidence of clinically
significant: 1.Distress, 2.Impairment, 3.Dysfunction adapted from
Caplan, 1964, Preventive Psychiatry 21. Eustress
vsDistressvsDysfunction
- Eustress positive, motivating stressMay be associated with
posttraumatic growth. No reliable estimations on prevalence post
disaster.
- Distress dyphoria post disaster60-90% of those directly
affected experience acute distress (Rx = Identify &
Monitor)
- Dysfunction impairment of function post disaster20-49% of those
directly affected may experience more lasting or impairing
dysfunction (Rx = Identify, Assess, & Intervene) [Assessment of
dysfunction may be the sine qua non of disaster mental health]
22. Prioritizing 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
23. EUSTRESSvs.DISTRESSvs.DYSFUNCTION Eustress (Positive,
motivating) Distress (benign, mild) Dysfunction (severe,
impairment, incapacitating) Identify, Assess, & Monitor
Identify, Assess, &Take action No Action Needed 24.
Functionality may be defined as the ability of an individual to
recognize and successfully attend to his/her current
responsibilities. 25. Signs and Symptoms
ofDistressandDysfunction
26. I. CognitiveDistress
- Difficulty in Decision Making
- Preoccupation (obsessions) with Event
27. I. Severe CognitiveDysfunction
- Suicidal/ Homicidal Ideation
- Inability to Understand Consequences of Behavior
- Persistent Hopelessness/ Helplessness
28. II. EmotionalDistress
29. II. Severe EmotionalDysfunction
- Chronic Immobilizing Depression
- Posttraumatic Stress Disorder (PTSD)
30.
- After traumatic events,DEPRESSIONis most commonly associated
withLOSS .
- ANXIETY , on the other hand, is commonly associated withFEARand
life-threatening exposure.
31. Posttraumatic stress (PTS) is a normal survival response;
Posttraumatic Stress Disorder (PTSD) is a pathologic variant of
thatnormal survival reaction. 32. PTSD A.Traumatic event
B.Intrusive memories C.Avoidance, numbing, depression D.Stress
arousal E.Symptoms last > 30 daysF.Impaired functioning (This is
the most important aspect of PTSD for the crisis interventionist)
33. Crisis Intervention Goals:The Goal of Crisis Intervention is to
fosterResiliencevia: 1. Stabilization 2. Symptom reduction 3.
Return to adaptive functioning, or 4. Facilitation of access to
continued care (adapted from Caplan, 1964,Preventive Psychiatry )
34. Chevron Publishing, 2002 Crisis Characteristics
- The relativebalance
betweenthoughtprocessesandemotionalprocessesis disturbed,
- The usualcoping methods do not workeffectively,
- There is evidence of mild to severeimpairmentin individuals or
groups exposed to the critical incident,
35. Pre-CRISIS Post CRISIS THOUGHTS FEELINGS THOUGHTS FEELINGS
CRISIS 36. Crisis Characteristics Imprint of Horror
Psychological / Perceptual Contaminants 37. Assessing the Need
for Crisis Intervention (CISM)
- Is this one of the CAP Terrible 10?
- Arecoping mechanisms workingeffectively for EVERYONE?
- Is there evidence of mild to severeimpairmentin individuals or
groups exposed to the critical incident?
Take Home Message 38. 1/3Rule - Theoretical 1 2 3 8% 39.
Peritraumatic Stress
-
- Depersonalization, derealization, fugue states, amnesia
- Intrusive Re-Experiencing
-
- Flashbacks, terrifying memories or night mares, repetitive
automatic re-enactments
-
- Agoraphobic-like social withdrawal
-
- Panic episodes, startle reactions, fighting or temper
problems
-
- Debilitating worry, nervousness, vulnerability or
powerlessness
-
- Anhedonia, worthlessness, loss of interest in most activities,
awakening early, persistent fatigue, and lack of motivation
- Problematic Substance Use
-
- Abuse or dependency, self-medication
-
- Delusions, hallucinations, bizarre thoughts or images,
catatonia
Disaster Mental Health Services-A guidebook for Clinicians &
Administrators;Dept of Veterans Affairs, 1998 40. Highest Risk for
Extreme Peritraumatic Stress
- Life-Threatening danger, extreme violence, or sudden death of
others;
- Extreme loss or destruction of their homes, normal lives, and
communities;
- Intense emotional demands from distraught survivors(rescue
workers, counselors, caregivers);
- Prior psychiatric or marital/family problems;
- Prior significant loss(death of a loved one in the past
year)
- Cardena & Spiegel, 1993; Joseph et.al, 1994; Kooperman,
et.al., 1994&5; La Greca et.al.,1996; Lonigan, et.al., 1994;
Schwarz & Kowalski, 1991; Shalev, et.al., 1993
Disaster Mental Health Services-A guidebook for Clinicians &
Administrators;Dept of Veterans Affairs, 1998 41. Effects of
Hyper-Arousal
- Reminders of the trauma leading to physical reactions
42. Hyper-Arousal Sleep Disturbances
- Awaken more often during the night
- Have dreams and/or nightmares about the trauma
- Repetitive trauma dreams may awaken and leave frightened and
exhausted
43. CISM as Mitigation
- Efforts attempt toprevent hazards from developing into
disastersaltogether, or toreduce the effectsof disasters when they
occur.
- Differs from the other phases because it focuses onlong-term
measuresfor reducing or eliminating risk.
- Implementation of mitigation strategies can be considered a
part of therecovery processifappliedaftera disaster occurs.
44. CISM as Mitigation
- Structural or non-structural,
- Is themost cost-efficient method for reducing the impact of
hazards .
- Does include providingregulations . . .and sanctions against
those who refuse to obey the regulations . .. potential risks to
the publicfema.gov
A natural mesh with Public Affairs 45. Mitigating C I S Even
with all the right programs, briefings, teams, personnel, etclined
up & available there can still be CIS. We dont know our members
baggage.(Pre-existing conditions) Pre-Exposure Trainingcan help ID
potential psych/perceptual contaminants Take Home Message 46.
Mitigating Operational Stress (OpStress)
- Frequent information / feedback to staff
- Cold or hot environments might require more frequent rest
breaks
- Rest areas away from stimuli
- 12 hour limit for same scene stimuli
- Assure proper rehabilitation sector
- Provide lavatory facilities continued...
Take Home Message 47. Mitigating OpStress -continued
- Provide hand washing facilities
- Provide medical support to staff
- Monitor hyper- or hypo-thermia
- Limit fat, sugar and salt
- Limit use of caffeine products
- CISM on scene support services continued...
Take Home Message 48.
- Monitor signs of emotional distress
- Limit overall stimuli at incident
- Give clear orders to personnel
- Avoid conflicting orders to staff
- Frequent rest breaks for all
- Sectorization of the incident
- Credit people for proper actions continued...
Mitigating OpStress -continued Take Home Message 49. Mitigating
OpStress- continued
- Limit criticism to absolute minimum
- Utilize a staging area for uninvolved personnel
- Limit exposure to event sights, sounds and smells
(reminders)
- Announce time periodically
- Rotate crews to alternate duties
Take Home Message 50. After Action Support
- Thank personnel for their work
- Provide demobilization services on large scale incident
- Utilize services of CISM teams
- Arrange defusing for unusual events
- Consider debriefing for personnel if it appears necessary*
continued...
Take Home Message 51. After Action Support- continued
- Allow follow up services by CISM team members
- Critique incident operationally
- Teach new procedures from lessons learned
- Consider the need for family support
Take Home Message 52. Addressing C I S
- Acknowledge the existence of CIS
Take Home Message 53. Summary of Commonly Used Crisis/ Disaster
Interventions(adapted from Raphael, 1986; Everly & Langlieb,
2003; NIMH, 2002; Sheehan, et al., 2004; DHHS, 2004; Everly &
Castellano, 2005; Everly & Parker, 2005; NOVA, 2002)
- INTERVENTION TIMING TARGET GROUP POTENTIAL GOALS
- 1. Pre-event Planning/Pre-eventAnticipated
target/victimAnticipatory guidance. Preparation.population. Foster
resistance, resilience.
- 2. Assessment. Pre-intervention.Those directly &
indirectlyDetermination of need for
- 3. Indv. Crisis Intervention.As needed. Individuals as
needed.Assessment. Screening.
- (including "psyc first aid") Education. Normalization.
Reduction of acute distress.
- Triage. Facilitation of continuedsupport.
- 4. Demobilization. Shift disengagement.Emergency
personnel.Decompression.
- Education. Ease transition.
- 5. Respite Sector. On-going Emergency personnel.Respite.
- large-scale events. Refreshment. Screening. Triage.
Support.
- 6. Large Group CMBAs needed.Heterogeneous largeInform
- & Large groupgroups.Control rumors.
- psyc first aidInc. cohesion.
54.
- INTERVENTION TIMING TARGET GROUP POTENTIAL GOALS
- 7. Group Debriefing Post event... Small homogeneous groups
c/Ventilation. Information.
- (CISD,~1-10 days acuteequal trauma exposure.
OftenNormalization
- PD, GCI, incidents;workgroups, emergencyReduce acute
distress.
- MSD,~3-4 wkspostservices, military. Inc. cohesion,
resilience.
- CED, mass disaster Screening
- HERD) recovery phase. Triage.Follow-up essential.
- 8. Defusing On-going eventsSmall
homogeneousgroups.Stabilization. Ventilation (and small group &
Post eventMay be similar to HERD inReduce acute distress.
- "psychological first aid.") (