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Critical Incident Critical Incident Stress Management 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. Developed by Lt. Col. Sam D. Bernard, Ph.D. CAP CISM National Team Leader CAP CISM National Team Leader Partial content from Chevron Publishing

Critical Incident Stress Managment Update

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  • 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:
  • ICISF
  • CISM information
  • CAP CISM Program

4. ICISF

  • 10 thWorld Congress Jan-Feb 2009
  • Corporate downsizing
  • Staff reductions
  • Still viable and hosting regional conferences nationwide

5. Other ICISF Courses

  • Group Basic CISM
  • Peer & Individual Crisis Intervention
  • Building Skills in CISM
  • Responding to School Crisis
  • Suicide: Prevention, Intervention & Postvention
  • Advanced Group CISM
  • 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)
  • Grief Following Trauma
  • 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

  • Emergency Services
  • 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:
    • Peer assistance and,
    • With the passage of time

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

  • Cognitive
  • Emotional
  • Behavioral
  • Physical
  • Spiritual

26. I. CognitiveDistress

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

27. I. Severe CognitiveDysfunction

  • Suicidal/ Homicidal Ideation
  • Inability to Understand Consequences of Behavior
  • Delusions
  • Hallucinations
  • Persistent Hopelessness/ Helplessness

28. II. EmotionalDistress

  • Anxiety
  • Irritability
  • Anger
  • Sadness
  • Fear
  • Phobia
  • Grief

29. II. Severe EmotionalDysfunction

  • Panic Attacks
  • Chronic Immobilizing Depression
  • Depression & Guilt
  • 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

  • Visual
  • Auditory
  • Olfactory
  • Kinesthetic
  • Gustatory
  • Temporal

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

  • Dissociation
    • Depersonalization, derealization, fugue states, amnesia
  • Intrusive Re-Experiencing
    • Flashbacks, terrifying memories or night mares, repetitive automatic re-enactments
  • Avoidance
    • Agoraphobic-like social withdrawal
  • Hyperarousal
    • Panic episodes, startle reactions, fighting or temper problems
  • Anxiety
    • Debilitating worry, nervousness, vulnerability or powerlessness
  • Depression
    • Anhedonia, worthlessness, loss of interest in most activities, awakening early, persistent fatigue, and lack of motivation
  • Problematic Substance Use
    • Abuse or dependency, self-medication
  • Psychotic Symptoms
    • 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

  • Trouble sleeping
  • Difficulty concentrating
  • Heightened vigilance
  • Being easily startled
  • Being wary
  • Sudden crying
  • Becoming suddenly angry
  • Being more emotional
  • Panicking
  • Intensified alertness
  • Reminders of the trauma leading to physical reactions
    • Rapid heart beat
    • Sweating
    • etc
  • Increased anxiety

42. Hyper-Arousal Sleep Disturbances

  • Longer to fall asleep
  • Unable to fall asleep
  • More sensitive to noise
  • 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
  • Frequent rest breaks
  • 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
  • Proper food
  • Limit fat, sugar and salt
  • Fluid replacement
  • Provide drinking water
  • Provide fruit juices
  • 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
  • Delegate authority
  • Frequent rest breaks for all
  • Back up leaders
  • Sectorization of the incident
  • Delegation of authority
  • 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
  • Others ?

Take Home Message 50. After Action Support

  • Thank personnel for their work
  • Consult with CISM team
  • 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
  • Other ?

Take Home Message 52. Addressing C I S

  • Acknowledge the existence of CIS
  • Pre-incident education
  • Planning
  • Drills / practice
  • Pre-deployment briefings
  • Avoid avoidance 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
  • 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 continuedsupport.
  • 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 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.") (