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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
Welcome
Thank you for attending this session
  concerning CAP CISM Updates
Goals
To provide information concerning
 various CISM topics concerning:

   ICISF

   CISM information

   CAP CISM Program
ICISF

   10th World Congress Jan-Feb 2009
   Corporate downsizing
   Staff reductions
   Still viable and hosting regional
    conferences nationwide
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
                                           Ps    N
   Strategic Response to Crisis              ych ew C
                                                 olo   ou
   Emotional & Spiritual Care in Disaster          gic rse
                                                       al F !
   Pastoral Crisis Intervention I & II                    irs
                                                              tA
   Stress Management for the Trauma Service Provider           id
   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
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
International
Critical Incident Stress
       Foundation
 3290 Pine Orchard Lane
          Suite 106
 Ellicott City, MD 21042
      (410) 750-9600
   Fax: (410) 750-9601
Emergency: (410) 313-2473
       www.icisf.org
CISM
   Information
Refresher / Review
Take Home Message   The Terrible 10 for CAP

              1.                            6.
                          ...
                                not
              2.                    l   imi 7.
                                           ted
                                               to   mis
              3.                            8.            sio
                                                                ns !

              4.                            9.

              5.                            10.
Resistance
   If the stressor continues,
   the body mobilizes to                   Exhaustion
   withstand the stress and                Ongoing, extreme
   return to normal.                       stressors eventually
                                           deplete the body’s
                                           resources so we
Alarm                                      function at less
The body initially                         than normal.
responds to a
stressor with
changes that lower
resistance.

                                                  Return to
                                                  homeostasis

                       Homeostasis
Stressor               The body systems
The stressor           maintain a stable
may be threatening     and consistent
or exhilarating.       (balanced) state.
                                                    Illness
               Illness and Death
               The body’s resources are not
               replenished and/or additional
               stressors occur; the body               Death
               suffers breakdowns.
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 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
Red = immediate response     premature ejaculation in men.
       to stress             Muscles tense.
Blue = effects of chronic    Muscular twitches or “nervous tics” can
       of prolonged stress   result.
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
Critical incident-stress-managment-update386
Take Home Message     Stress Reactions


                       Physiological Based

                               not

                    Characteriologically Flawed
Indicators
Take Home Message


                                of
                    Critical Incident Stress
                               vs.
                    Disciplinary Problems
                                or
                     Character Disorders
Critical Incident Stress
Take Home Message

                       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
Characteriological &
                    Disciplinary Problems - continued
Take Home Message

                       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 person’s life.
                       Problems do not easily resolve over time
                        even with help.
Take Home Message                 Crisis


                                   Noun        Bo
                                    vs           th
                                   Verb


                    An acute reaction to a critical incident.
                    A name of a particular critical incident.
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 RESPONSE to a trauma,
 disaster, or other critical incident
   wherein there is evidence of
      clinically significant:
            1. Distress,
          2. Impairment,
         3. Dysfunction
    adapted from Caplan, 1964, Preventive Psychiatry
Eustress vs Distress vs
                      Dysfunction
   Eustress …positive, motivating stress… May be
    associated with posttraumatic growth. No reliable
    estimations on prevalence post disaster.

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

   Dysfunction…impairment of function post
    disaster…20-49% 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]
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
EUSTRESS vs. DISTRESS vs.
               DYSFUNCTION


   Eustress               No Action Needed
(Positive, motivating)


    Distress              Identify, Assess,
    (benign, mild)           & Monitor

 Dysfunction              Identify, Assess,
(severe, impairment,      & Take action
   incapacitating)
Functionality…

may be defined as the ability of
an individual to recognize and
successfully attend to his/her
   current responsibilities.
Signs and Symptoms
           of
Distress and Dysfunction

    I.     Cognitive
    II.    Emotional
    III.   Behavioral
    IV.    Physical
    V.     Spiritual
I. Cognitive Distress


 Inability to Concentrate
 Difficulty in Decision Making

 Preoccupation (obsessions) with Event

 Confusion (“dumbing down”)
I. Severe Cognitive
            Dysfunction
 Suicidal/          Delusions
  Homicidal          Hallucinations
  Ideation           Persistent
 Inability to
                      Hopelessness/
  Understand          Helplessness
  Consequences of
  Behavior
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)
    is a normal survival
 response; Posttraumatic
Stress Disorder (PTSD) is a
 pathologic variant of that
 normal survival reaction.
PTSD
A. Traumatic event
B. Intrusive memories
C. Avoidance, numbing, depression
D. Stress arousal
E. Symptoms last > 30 days
F. Impaired functioning (This is the most
important aspect of PTSD for the crisis
interventionist)
Crisis Intervention
Goals:
 The Goal of Crisis Intervention is to foster
Resilience via:

1. Stabilization
2. Symptom reduction
3. Return to adaptive functioning, or
4. Facilitation of access to continued care

 (adapted from Caplan, 1964, Preventive Psychiatry)
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,

                  Chevron Publishing, 2002
Pre-CRISIS                     Post CRISIS

                                             FEELINGS
THOUGHTS




           FEELINGS

                               THOUGHTS




                      CRISIS
Crisis Characteristics
      Imprint of Horror
 Visual
 Auditory

 Olfactory

 Kinesthetic

 Gustatory

 Temporal

    Psychological / Perceptual
         Contaminants
Assessing the Need for
                    Crisis Intervention (CISM)
Take Home Message

                       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?
“1/3 Rule” - Theoretical



       1        2


           3


           8%
Peritraumatic Stress
   Dissociation
       Depersonalization, derealization, fugue states, amnesia




                                                                           Disaster Mental Health Services-A guidebook for Clinicians & Administrators; Dept of Veterans
   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




                                                                           Affairs, 1998
   Psychotic Symptoms
       Delusions, hallucinations, bizarre thoughts or images, catatonia
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
Effects of Hyper-Arousal

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

                    Even with all the right programs,
                    briefings, teams, personnel, etc
                    lined up & available – there can still
                    be CIS.
                    We don’t know our member’s
                    baggage.
                    (Pre-existing conditions)
                    Pre-Exposure Training can help
                    ID potential psych/perceptual
                    contaminants
Mitigating Operational
                               Stress (OpStress)
Take Home Message

                       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...
Mitigating OpStress - continued
                       Provide hand washing facilities
Take Home Message

                       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...
Mitigating OpStress - continued
                       Monitor signs of emotional distress
Take Home Message

                       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...
Take Home Message       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           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       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 ?
Addressing C I S
Take Home Message


                       Acknowledge the existence of CIS
                       Pre-incident education
                       Planning
                       Drills / practice
                       Pre-deployment briefings
                       Avoid avoidance of CIS
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-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.
INTERVENTION                   TIMING             TARGET GROUP                     POTENTIAL GOALS

   7. “Group Debriefing”          Post event...      Small homogeneous groups c/      Ventilation. Information.
    (CISD,                        ~1-10 days acute    equal trauma exposure. Often     Normalization
    PD, 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
INTERVENTION                          TIMING                 TARGET GROUP                        POTENTIAL GOALS



   10. Family Crisis                    Pre-event &        Families.                            Consists of a wide array
    Intervention.                        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.
Objectives of
Crisis Intervention

   Stabilize situation
   Mitigate impact
   Mobilize resources
   Normalize reactions
   Restore to adaptive function


          Chevron Publishing, 2002
Crisis Intervention
            Key Principles
   Simplicity                     Proximity

   Brevity                        Immediacy

   Innovation                     Positive outcome
                                    expectancy
   Pragmatism

                 Chevron Publishing, 2002
Dose Response
Basic Crisis Guidelines
   Never go beyond one’s level of training

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

   The end of every crisis intervention occurs
    when either the person is showing signs of
    recovery or it becomes evident that a
    referral is necessary
                   Chevron Publishing, 2002
Critical Incident
     Stress Management
Comprehensive
Integrated
System utilizing a
Multi-Tactical
Crisis Intervention Approach
  to Managing Traumatic Stress
   Pre-Crisis Preparation /Education
                            On-scene Support / Consultation
                             Group Intervention
CISM: Menu of Services
                         
                               Demobilization                   “T
                             
                                                                   ac
                              Crisis Management Briefing            ti c
                              Defusing
                                                                         s”
                              Critical Incident Stress Debriefing

                            Individual Crisis Intervention
                            Pastoral Crisis Intervention
                            Family / Sig. Other Support
                            Organizational Consultation
                            Follow-up and / or Referral
                            Post -event Education & Lessons Learned
Core Competencies in CISM

   The ability to properly assess both the
    situation and the severity of impact on
    individuals and groups
   Ability to develop a strategic plan
   Individual crisis intervention skills
   Large group crisis intervention skills
   Small group crisis intervention skills
   Referral skills
                   Chevron Publishing, 2002
Essential CISM Courses
                         (2 Days Each)

   Assisting Individuals in Crisis
   Basic Critical Incident Stress
    Management: Group Crisis Interventions

   Suicide
   Grief Following Trauma
   Advanced Critical Incident Stress Management: Group Crisis
    Interventions
   T.E.A.M.
   Emotional & Spiritual Care in Disasters

                           Chevron Publishing, 2002
In addition to the essential
           courses,
     CISM providers are
encouraged to participate in a
   variety of other training
opportunities to enhance their
            skills.
           Chevron Publishing, 2002
Strategic Planning




Resources
   Pre-Crisis Preparation /Education
                            On-scene Support / Consultation
                             Group Intervention
CISM: Menu of Services
                         
                               Demobilization                   “T
                             
                                                                   ac
                              Crisis Management Briefing            ti c
                              Defusing
                                                                         s”
                              Critical Incident Stress Debriefing

                            Individual Crisis Intervention
                            Pastoral Crisis Intervention
                            Family / Sig. Other Support
                            Organizational Consultation
                            Follow-up and / or Referral
                            Post -event Education & Lessons Learned
Strategic Planning
                AKA: Tactics
Target Type Timing Theme Team Resources
                                Team Resources
      On-Scene NOW! Victim Peers        Peers
 From Circles


         CMB After Shift Grief Flight  Friends
       Demob. Tomorrow Loss Crew Neighbors
       Defuse AM Survivor Ground Family
         CISD Before Survivor Team      Faith
          1:1   Going    Guilt Admin Community
       Family Home       Boss Commo     Work
       Admin After        IC    Cadet   EAP
       Consult Been       CC Mental     PCP
        IC/CC Home 1-2 Violated Health Support
          F/U    Day     World Outside Groups
                         View    Tm Outside Tm
CISM Tactics
Must be Available for:

       Individuals
       Groups
       Organizations
       Families
       Significant others


          Chevron Publishing, 2002
CISM Components
Before an Incident
   Education (PEP)
   Team training
   Planning
   Administrative support
   Protocol development
   Guideline development
   Networking with other teams
    & resources
CISM Components
        During an Incident
   On-scene support services
   One-on-one crisis intervention
   Advice to supervisors/IC
   Support to primary victims (CAP)
   Provision of food, fluids, rest and other
    services to operations personnel
   Organizational Consultation (CC)
CISM Components
           After an Incident
   One-on-one crisis intervention
   Demobilization (post-disaster, large group)
   Crisis Management Briefing (CMB, large
    group)
   Defusing (small group)
   Critical Incident Stress Debriefing (CISD,
    small group)
   Significant other support services
                   . . . more . . .
CISM Components
     After an Incident
            continued


   Post-incident education
   Follow-up services
   Referrals according to needs
CISM


 Typically: 3-5 contacts
 After that,

   Recovery is evident

   Referral is indicated
Maslow’s Need Hierarchy
                                (1943)




                      SELF-ACTUALIZATION
                          Personal growth and fulfillment


Psychotherapy                   SELF-ESTEEM
                           Self-efficacy, empowerment


                       AFFILIATION, SUPPORT
   Crisis             Interpersonal & family relationships

Intervention                       SAFTEY
                Physical and psychological security, law & order

Start here             PHYSIOLOGICAL NEEDS
                  Basic life needs - air, food, water, shelter
Spectrum of Care
        Critical Incident
                                       Family Support
                                       EAP
Crisis Intervention         r
                                       Chaplain
                                       Human Resources

    CISM                    Refer as
                                       Family Advocate
                            needed     Legal
                            to any
                                       Mental Health
                                       Psychotherapy
                                       Hospitalization
                                       Rehabilitation
                                       Other resources
Treatment Referral Options
    Medical Care Professional
      MD / DO
      PA / NP

    Mental Health Care Professional
      Psychologist
      Counselor

      Social Worker

      Psychiatrist / NP / PA

    Spiritual Care Professional
      Faith Leader
      “Chaplain”
CISM

   Is not psychotherapy

   Is not a substitute for psychotherapy

   Is not a stand-alone

   Is not a cure for PTSD, Depression,
    Anxiety, etc
CISM has far more to do with
group support
and
assessment (triage)
than it does with
treatment and cure.
Follow-Up
Must be provided after every CISM service:
 Assess impact of intervention

 Assess for uncovering prior issues

 Assess trajectory of reactions
   •   Decreasing              1w
  •    Same                  1 m eek p
                                ont    ost
  •    Increasing                   hp     CIS
                                      ost     Ms
 Assess for possible referral:           CIS     erv
                                              Ms       ice
   Health Care Professional                     erv
                                                     i ce
      Mental Health Care Professional
      Spiritual Care Professional
P. A. S. S.
Post Action Staff Support
      Dennis Potter, LCSW
Goals For PASS

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

   Should be a normal part of the team’s
    standard operating guidelines,
   Should be done prior to the team going
    home (at least a defusing),
   At the earliest next opportunity,
   Soon,
   Its never too late!
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?

   For “normal” events usually 10-15 minutes
    is adequate,
   For “abnormal” events 30-60 minutes may
    be required,
   If you always do it, you will discover the
    difference between a normal and
    abnormal event.
Who Should Do It?

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


   Occasionally, by someone not involved in
    the response itself
       Particularly 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.
CAP
      CISM
Refresher / Update
Where We Are Now:
                      Web-Site

               cism.cap.gov

   Staff listings & contact information
   Calendar of events / trainings
   Forms & Handouts
   Send training certificates / reports to . . .
     “Certificates”
     “Wing Reports” & “Region Reports”
Decentralization of Staff
Wings     “Get’r done dudes” – Providing Frontline Service
       Providing CISM services
       Networking with other local non-CAP CISM teams

Regions       “Make it happen” – Administrative Support
       Administrative support and facilitation / paperwork
       Technical assistance if needed
       Maintains team records
       Maintains ICISF Registered Team status with ICISF
       Monthly conference calls with Wings

National      “Lead into the future” – Overall Leadership
       Develop training based on Wing and Region needs
       Keep everyone updated on new ideas/issues
       Monthly conference calls with Region s
Staff Structure
 Wings   – “Doing the CISM Work”
   Officer/Coordinator

   Clinical   Director
 Region   – “Team Support & Administration”
   Officer / Coordinator
   Clinical Director

 National     – “Leading into the Future”
   Team   Leader
   Clinical Director
Staff Structure
 Officer   / Coordinator
   Administrator of the program within Wing or Region
   Point person for Wing or Region

   Coordinates service requests and services

   Maintains paperwork for Wing or Region

   Officiates “administration” portion of meetings/trainings

 Clinical   Director
   Supervises all clinical aspects of program
   Must be licensed in the state of residence and/or Wing of
    membership
   Conducts “clinical” portion of meetings/trainings
Required Training
   Introduction to ICISF (On-line or classroom)
   Program Orientation (On-line or classroom)
   CISM Basic Concepts (On-line or classroom)
   Group Crisis Intervention (Classroom only)
    AND
   Peer / Individual Crisis Intervention (Classroom Only)
   NIMS:
     NIMS 100         http://training.fema.gov/IS/NIMS.asp

     NIMS 700         http://training.fema.gov/IS/NIMS.asp
ICS 300 and 400 is not required, but can aid in understanding command and general
   staff issues.
Renewal / Refresher
           Renewal / Refresher:
                   Group (2 Classroom days)
                    and
                   Individual (2 Classroom days)
                    or
                   Building Skills in CISM (2 Classroom days)
                   or
                   The Changing Face of CI and DMHI
                 (1 Classroom day or internet)
           * CISM Service provision does not qualify for
           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.
Recruiting
   Ground team members and support personnel
   Air crew member and support personnel
   Administration personnel
   Communications personnel
   Physical health personnel (doctors, nurses, etc.)
   Mental health personnel (psychologist, counselors, social
    workers, etc)
   Spiritual health personnel (chaplains, character
    development, etc)
   Cadets (training our replacements)
   Elders - “Recycling” . . .
“Recycling” Members
Because:
  •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 & 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
e need you . . . We’re Training Our Replacements
CISM Specialty Track

 Technician:   “Learning the program”
   Knowledge Requirement:
   Service Requirement:

 Senior:   “Doing & mentoring the program”
   Knowledge Requirement:
   Service Requirement:

 Master:   “Managing the program”
   Knowledge Requirement:
   Service Requirement:
Technician: Learning the program
   Knowledge Requirement:
      Introduction to ICISF

      Orientation to CAP CISM Program                  * NIMS 100
      CISM Basic Concepts                              * NIMS 700
      ICISF’s Group Crisis Intervention

      ICISF’s Individual/Peer Crisis Intervention

   Service Requirement:
      Serve in support role until completion of courses (above)

      Actively participate in 6 CISM responses as an observer only

      Actively participate in 4 Debriefings (non leader)

      Actively participate in 4 Individual/Peer contacts

      Actively participate in 6 Follow-Up contacts

      Actively provide 4 Intro to ICISF presentations

      Actively provide 4 Orientation to CAP CISM Program presentations

      Attend 4 PEP trainings

      Attend 75% of the Wing CISM meetings
Senior:            Doing & mentoring the program
   Knowledge Requirement:
      ICISF’s Advanced Group

      ICISF’s Suicide

      ICISF’s Grief Following Trauma

   Service Requirement:
      Achieve Technician rating

      Mentor 4 upcoming Technicians

      Actively participate in 6 more CISM Mission/Training responses

      Actively participate in 4 more debriefings (as leader)

      Actively provide 4 more Individual/Peer contacts

      Actively provide 6 more Follow-Up contacts

      Meet with 1-2 local CISM teams 3 times minimum

      Provide 3 CISM Basic Concepts presentations

      Assist a Wing CISM Officer/Coordinator for 1 year (Team Coordinator,
       Clinical Director, etc)
      Attend 75% of the Wing CISM meetings/trainings
Master:            Managing the program
   Knowledge Requirement:
      Strategic Response to Crisis

      Team Evolution and Management

      Emotional & Spiritual Care in Disasters

   Service Requirement:
      Achieve Senior rating

      Mentor 4 upcoming Seniors

      Actively participate in planning CISM involvement in 4 CAP
       Exercises/Drills
      Develop MOUs with 2 local 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
       Individual/Peer course
      Assist a Region CISM Officer for 1 year (Team Coordinator,
       Clinical Director, etc.)
      Attend 75% of the Wing and Region CISM meetings
Where to from here?
   Satisfied with the knowledge & awareness
   How to do more:
     Join a team
     Attain further CISM education
     Provide further CISM education & awareness
     Advocate for appropriate CISM services
     Provide more:
         Within your Squadron, Group, Wing, Region
         With your family
         At your place of work
         In your community
         For yourself
How To Become a Member

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

      CISM Team membership is a privilege not a right.
“Knowledge itself is power”
         Sir Francis Bacon




 “Action is the proper fruit
      of knowledge”
           Thomas Fuller
Feedback


Thoughts

Comments

Reactions
National Staff

Lt Col Sam D. Bernard, PhD
      National CISM Team Leader
(423) 322-3297 sam@sambernard.info


       Maj Chris Latocki
          Administrative Officer
( 813) 412-9231 clatocki@cism.cap.gov
Region Staff

________Name____________
      Region CISM Officer
       Telephone / e-mail


________Name____________
     Region Clinical Director
       Telephone / e-mail
Wing Staff

________Name____________
   Wing CISM Officer / Coordinator
         Telephone / e-mail


________Name____________
        Wing Clinical Director
         Telephone / e-mail
. . .and just one more thing. . .




Thank You!
Critical Incident Stress
        Management

Lt. Col. Sam D. Bernard, Ph.D.
     National CAP CISM Team Leader
       (423) 322-3297Cell
     sam@sambernard.info
     www.sambernard.info


       cism.cap.gov
Critical Incident
   Stress Management

        CISM Update
Learning from the Past, . . . Progressing into the Future




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

                 Partial content from Chevron Publishing

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Critical incident-stress-managment-update386

  • 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  10th World 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 Ps N  Strategic Response to Crisis ych ew C olo ou  Emotional & Spiritual Care in Disaster gic rse al F !  Pastoral Crisis Intervention I & II irs tA  Stress Management for the Trauma Service Provider id  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
  • 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, MD 21042 (410) 750-9600 Fax: (410) 750-9601 Emergency: (410) 313-2473 www.icisf.org
  • 8. CISM Information Refresher / Review
  • 9. Take Home Message The Terrible 10 for CAP 1. 6. ... not 2. l imi 7. ted to mis 3. 8. sio ns ! 4. 9. 5. 10.
  • 10. Resistance If the stressor continues, the body mobilizes to Exhaustion withstand the stress and Ongoing, extreme return to normal. stressors eventually deplete the body’s resources so we Alarm function at less The body initially than normal. responds to a stressor with changes that lower resistance. Return to homeostasis Homeostasis Stressor The body systems The stressor maintain a stable may be threatening and consistent or exhilarating. (balanced) state. Illness Illness and Death The body’s resources are not replenished and/or additional stressors occur; the body Death suffers breakdowns.
  • 11. 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 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 Red = immediate response premature ejaculation in men. to stress Muscles tense. Blue = effects of chronic Muscular twitches or “nervous tics” can of prolonged stress result.
  • 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
  • 14. Take Home Message Stress Reactions Physiological Based not Characteriologically Flawed
  • 15. Indicators Take Home Message of Critical Incident Stress vs. Disciplinary Problems or Character Disorders
  • 16. Critical Incident Stress Take Home Message  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
  • 17. Characteriological & Disciplinary Problems - continued Take Home Message  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 person’s life.  Problems do not easily resolve over time even with help.
  • 18. Take Home Message Crisis Noun Bo vs th Verb An acute reaction to a critical incident. A name of a particular critical incident.
  • 19. Recall that… Psychological Distress/Discord in response to critical incidents is called a Psychological Crisis (Everly & Mitchell, 1999, Critical Incident Stress Management)
  • 20. Psychological Crisis An acute RESPONSE to a trauma, disaster, or other critical incident wherein there is evidence of clinically significant: 1. Distress, 2. Impairment, 3. Dysfunction adapted from Caplan, 1964, Preventive Psychiatry
  • 21. Eustress vs Distress vs Dysfunction  Eustress …positive, motivating stress… May be associated with posttraumatic growth. No reliable estimations on prevalence post disaster.  Distress…dyphoria post disaster…60-90% of those directly affected experience acute distress (Rx = Identify & Monitor)  Dysfunction…impairment of function post disaster…20-49% 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. EUSTRESS vs. DISTRESS vs. DYSFUNCTION Eustress No Action Needed (Positive, motivating) Distress Identify, Assess, (benign, mild) & Monitor Dysfunction Identify, Assess, (severe, impairment, & Take action incapacitating)
  • 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 of Distress and Dysfunction I. Cognitive II. Emotional III. Behavioral IV. Physical V. Spiritual
  • 26. I. Cognitive Distress  Inability to Concentrate  Difficulty in Decision Making  Preoccupation (obsessions) with Event  Confusion (“dumbing down”)
  • 27. I. Severe Cognitive Dysfunction  Suicidal/  Delusions Homicidal  Hallucinations Ideation  Persistent  Inability to Hopelessness/ Understand Helplessness Consequences of Behavior
  • 28. II. Emotional Distress  Anxiety  Irritability  Anger  Sadness  Fear  Phobia  Grief
  • 29. II. Severe Emotional Dysfunction  Panic Attacks  Chronic Immobilizing Depression  Depression & Guilt  Posttraumatic Stress Disorder (PTSD)
  • 30. After traumatic events, DEPRESSION is most commonly associated with LOSS.  ANXIETY, on the other hand, is commonly associated with FEAR and life-threatening exposure.
  • 31. Posttraumatic stress (PTS) is a normal survival response; Posttraumatic Stress Disorder (PTSD) is a pathologic variant of that normal survival reaction.
  • 32. PTSD A. Traumatic event B. Intrusive memories C. Avoidance, numbing, depression D. Stress arousal E. Symptoms last > 30 days F. 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 foster Resilience via: 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. 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, Chevron Publishing, 2002
  • 35. Pre-CRISIS Post CRISIS FEELINGS THOUGHTS FEELINGS THOUGHTS CRISIS
  • 36. Crisis Characteristics Imprint of Horror  Visual  Auditory  Olfactory  Kinesthetic  Gustatory  Temporal Psychological / Perceptual Contaminants
  • 37. Assessing the Need for Crisis Intervention (CISM) Take Home Message  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?
  • 38. “1/3 Rule” - Theoretical 1 2 3 8%
  • 39. Peritraumatic Stress  Dissociation  Depersonalization, derealization, fugue states, amnesia Disaster Mental Health Services-A guidebook for Clinicians & Administrators; Dept of Veterans  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 Affairs, 1998  Psychotic Symptoms  Delusions, hallucinations, bizarre thoughts or images, catatonia
  • 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  Being more emotional  Difficulty  Panicking concentrating  Intensified alertness  Heightened vigilance  Reminders of the  Being easily startled trauma leading to  Being wary physical reactions  Rapid heart beat  Sudden crying  Sweating  Becoming suddenly  etc angry  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 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.
  • 44. 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
  • 45. Mitigating C I S Take Home Message Even with all the right programs, briefings, teams, personnel, etc lined up & available – there can still be CIS. We don’t know our member’s baggage. (Pre-existing conditions) Pre-Exposure Training can help ID potential psych/perceptual contaminants
  • 46. Mitigating Operational Stress (OpStress) Take Home Message  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...
  • 47. Mitigating OpStress - continued  Provide hand washing facilities Take Home Message  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...
  • 48. Mitigating OpStress - continued  Monitor signs of emotional distress Take Home Message  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...
  • 49. Take Home Message 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 ?
  • 50. Take Home Message 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...
  • 51. Take Home Message 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 ?
  • 52. Addressing C I S Take Home Message  Acknowledge the existence of CIS  Pre-incident education  Planning  Drills / practice  Pre-deployment briefings  Avoid avoidance of CIS
  • 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-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.
  • 54. INTERVENTION TIMING TARGET GROUP POTENTIAL GOALS  7. “Group Debriefing” Post event... Small homogeneous groups c/ Ventilation. Information. (CISD, ~1-10 days acute equal trauma exposure. Often Normalization PD, 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
  • 55. INTERVENTION TIMING TARGET GROUP POTENTIAL GOALS  10. Family Crisis Pre-event & Families. Consists of a wide array Intervention. 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.
  • 56. Objectives of Crisis Intervention  Stabilize situation  Mitigate impact  Mobilize resources  Normalize reactions  Restore to adaptive function Chevron Publishing, 2002
  • 57. Crisis Intervention Key Principles  Simplicity  Proximity  Brevity  Immediacy  Innovation  Positive outcome expectancy  Pragmatism Chevron Publishing, 2002
  • 59. Basic Crisis Guidelines  Never go beyond one’s level of training  Do not open discussions unless there is sufficient time to process  The end of every crisis intervention occurs when either the person is showing signs of recovery or it becomes evident that a referral is necessary Chevron Publishing, 2002
  • 60. Critical Incident Stress Management Comprehensive Integrated System utilizing a Multi-Tactical Crisis Intervention Approach to Managing Traumatic Stress
  • 61. Pre-Crisis Preparation /Education  On-scene Support / Consultation Group Intervention CISM: Menu of Services  Demobilization “T  ac  Crisis Management Briefing ti c  Defusing s”  Critical Incident Stress Debriefing  Individual Crisis Intervention  Pastoral Crisis Intervention  Family / Sig. Other Support  Organizational Consultation  Follow-up and / or Referral  Post -event Education & Lessons Learned
  • 62. Core Competencies in CISM  The ability to properly assess both the situation and the severity of impact on individuals and groups  Ability to develop a strategic plan  Individual crisis intervention skills  Large group crisis intervention skills  Small group crisis intervention skills  Referral skills Chevron Publishing, 2002
  • 63. Essential CISM Courses (2 Days Each)  Assisting Individuals in Crisis  Basic Critical Incident Stress Management: Group Crisis Interventions  Suicide  Grief Following Trauma  Advanced Critical Incident Stress Management: Group Crisis Interventions  T.E.A.M.  Emotional & Spiritual Care in Disasters Chevron Publishing, 2002
  • 64. In addition to the essential courses, CISM providers are encouraged to participate in a variety of other training opportunities to enhance their skills. Chevron Publishing, 2002
  • 66. Pre-Crisis Preparation /Education  On-scene Support / Consultation Group Intervention CISM: Menu of Services  Demobilization “T  ac  Crisis Management Briefing ti c  Defusing s”  Critical Incident Stress Debriefing  Individual Crisis Intervention  Pastoral Crisis Intervention  Family / Sig. Other Support  Organizational Consultation  Follow-up and / or Referral  Post -event Education & Lessons Learned
  • 67. Strategic Planning AKA: Tactics Target Type Timing Theme Team Resources Team Resources On-Scene NOW! Victim Peers Peers From Circles CMB After Shift Grief Flight Friends Demob. Tomorrow Loss Crew Neighbors Defuse AM Survivor Ground Family CISD Before Survivor Team Faith 1:1 Going Guilt Admin Community Family Home Boss Commo Work Admin After IC Cadet EAP Consult Been CC Mental PCP IC/CC Home 1-2 Violated Health Support F/U Day World Outside Groups View Tm Outside Tm
  • 68. CISM Tactics Must be Available for:  Individuals  Groups  Organizations  Families  Significant others Chevron Publishing, 2002
  • 69. CISM Components Before an Incident  Education (PEP)  Team training  Planning  Administrative support  Protocol development  Guideline development  Networking with other teams & resources
  • 70. CISM Components During an Incident  On-scene support services  One-on-one crisis intervention  Advice to supervisors/IC  Support to primary victims (CAP)  Provision of food, fluids, rest and other services to operations personnel  Organizational Consultation (CC)
  • 71. CISM Components After an Incident  One-on-one crisis intervention  Demobilization (post-disaster, large group)  Crisis Management Briefing (CMB, large group)  Defusing (small group)  Critical Incident Stress Debriefing (CISD, small group)  Significant other support services . . . more . . .
  • 72. CISM Components After an Incident continued  Post-incident education  Follow-up services  Referrals according to needs
  • 73. CISM  Typically: 3-5 contacts  After that,  Recovery is evident  Referral is indicated
  • 74. Maslow’s Need Hierarchy (1943) SELF-ACTUALIZATION Personal growth and fulfillment Psychotherapy SELF-ESTEEM Self-efficacy, empowerment AFFILIATION, SUPPORT Crisis Interpersonal & family relationships Intervention SAFTEY Physical and psychological security, law & order Start here PHYSIOLOGICAL NEEDS Basic life needs - air, food, water, shelter
  • 75. Spectrum of Care Critical Incident Family Support EAP Crisis Intervention r Chaplain Human Resources CISM Refer as Family Advocate needed Legal to any Mental Health Psychotherapy Hospitalization Rehabilitation Other resources
  • 76. Treatment Referral Options  Medical Care Professional  MD / DO  PA / NP  Mental Health Care Professional  Psychologist  Counselor  Social Worker  Psychiatrist / NP / PA  Spiritual Care Professional  Faith Leader  “Chaplain”
  • 77. CISM  Is not psychotherapy  Is not a substitute for psychotherapy  Is not a stand-alone  Is not a cure for PTSD, Depression, Anxiety, etc
  • 78. CISM has far more to do with group support and assessment (triage) than it does with treatment and cure.
  • 79. Follow-Up Must be provided after every CISM service:  Assess impact of intervention  Assess for uncovering prior issues  Assess trajectory of reactions • Decreasing 1w • Same 1 m eek p ont ost • Increasing hp CIS ost Ms  Assess for possible referral: CIS erv Ms ice  Health Care Professional erv i ce  Mental Health Care Professional  Spiritual Care Professional
  • 80. P. A. S. S. Post Action Staff Support Dennis Potter, LCSW
  • 81. Goals For PASS  Increase longevity of team members  Increase learning from the experience  Increase stress management skills  Decrease the chance for personal reactions  To take care of ourselves (too)  Increase effectiveness of team members  Monitor team for any adverse reactions
  • 82. 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
  • 83. When Should It Be Done?  Should be a normal part of the team’s standard operating guidelines,  Should be done prior to the team going home (at least a defusing),  At the earliest next opportunity,  Soon,  Its never too late!
  • 84. 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.
  • 85. How Long Does It Take?  For “normal” events usually 10-15 minutes is adequate,  For “abnormal” events 30-60 minutes may be required,  If you always do it, you will discover the difference between a normal and abnormal event.
  • 86. Who Should Do It?  Usually the “Event Team Leader”  Probably 90% can be done by the team itself  Occasionally, by someone not involved in the response itself  Particularly difficult or events of long duration
  • 87. 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.
  • 88. CAP CISM Refresher / Update
  • 89. Where We Are Now: Web-Site cism.cap.gov  Staff listings & contact information  Calendar of events / trainings  Forms & Handouts  Send training certificates / reports to . . .  “Certificates”  “Wing Reports” & “Region Reports”
  • 90. Decentralization of Staff Wings “Get’r done dudes” – Providing Frontline Service  Providing CISM services  Networking with other local non-CAP CISM teams Regions “Make it happen” – Administrative Support  Administrative support and facilitation / paperwork  Technical assistance if needed  Maintains team records  Maintains ICISF Registered Team status with ICISF  Monthly conference calls with Wings National “Lead into the future” – Overall Leadership  Develop training based on Wing and Region needs  Keep everyone updated on new ideas/issues  Monthly conference calls with Region s
  • 91. Staff Structure  Wings – “Doing the CISM Work”  Officer/Coordinator  Clinical Director  Region – “Team Support & Administration”  Officer / Coordinator  Clinical Director  National – “Leading into the Future”  Team Leader  Clinical Director
  • 92. Staff Structure  Officer / Coordinator  Administrator of the program within Wing or Region  Point person for Wing or Region  Coordinates service requests and services  Maintains paperwork for Wing or Region  Officiates “administration” portion of meetings/trainings  Clinical Director  Supervises all clinical aspects of program  Must be licensed in the state of residence and/or Wing of membership  Conducts “clinical” portion of meetings/trainings
  • 93. Required Training  Introduction to ICISF (On-line or classroom)  Program Orientation (On-line or classroom)  CISM Basic Concepts (On-line or classroom)  Group Crisis Intervention (Classroom only) AND  Peer / Individual Crisis Intervention (Classroom Only)  NIMS:  NIMS 100 http://training.fema.gov/IS/NIMS.asp  NIMS 700 http://training.fema.gov/IS/NIMS.asp ICS 300 and 400 is not required, but can aid in understanding command and general staff issues.
  • 94. Renewal / Refresher Renewal / Refresher:  Group (2 Classroom days) and  Individual (2 Classroom days) or  Building Skills in CISM (2 Classroom days)  or  The Changing Face of CI and DMHI (1 Classroom day or internet) * CISM Service provision does not qualify for 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.
  • 95. Recruiting  Ground team members and support personnel  Air crew member and support personnel  Administration personnel  Communications personnel  Physical health personnel (doctors, nurses, etc.)  Mental health personnel (psychologist, counselors, social workers, etc)  Spiritual health personnel (chaplains, character development, etc)  Cadets (training our replacements)  Elders - “Recycling” . . .
  • 96. “Recycling” Members Because: •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
  • 97. Cadets & 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 e need you . . . We’re Training Our Replacements
  • 98. CISM Specialty Track  Technician: “Learning the program”  Knowledge Requirement:  Service Requirement:  Senior: “Doing & mentoring the program”  Knowledge Requirement:  Service Requirement:  Master: “Managing the program”  Knowledge Requirement:  Service Requirement:
  • 99. Technician: Learning the program  Knowledge Requirement:  Introduction to ICISF  Orientation to CAP CISM Program * NIMS 100  CISM Basic Concepts * NIMS 700  ICISF’s Group Crisis Intervention  ICISF’s Individual/Peer Crisis Intervention  Service Requirement:  Serve in support role until completion of courses (above)  Actively participate in 6 CISM responses as an observer only  Actively participate in 4 Debriefings (non leader)  Actively participate in 4 Individual/Peer contacts  Actively participate in 6 Follow-Up contacts  Actively provide 4 Intro to ICISF presentations  Actively provide 4 Orientation to CAP CISM Program presentations  Attend 4 PEP trainings  Attend 75% of the Wing CISM meetings
  • 100. Senior: Doing & mentoring the program  Knowledge Requirement:  ICISF’s Advanced Group  ICISF’s Suicide  ICISF’s Grief Following Trauma  Service Requirement:  Achieve Technician rating  Mentor 4 upcoming Technicians  Actively participate in 6 more CISM Mission/Training responses  Actively participate in 4 more debriefings (as leader)  Actively provide 4 more Individual/Peer contacts  Actively provide 6 more Follow-Up contacts  Meet with 1-2 local CISM teams 3 times minimum  Provide 3 CISM Basic Concepts presentations  Assist a Wing CISM Officer/Coordinator for 1 year (Team Coordinator, Clinical Director, etc)  Attend 75% of the Wing CISM meetings/trainings
  • 101. Master: Managing the program  Knowledge Requirement:  Strategic Response to Crisis  Team Evolution and Management  Emotional & Spiritual Care in Disasters  Service Requirement:  Achieve Senior rating  Mentor 4 upcoming Seniors  Actively participate in planning CISM involvement in 4 CAP Exercises/Drills  Develop MOUs with 2 local 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 Individual/Peer course  Assist a Region CISM Officer for 1 year (Team Coordinator, Clinical Director, etc.)  Attend 75% of the Wing and Region CISM meetings
  • 102. Where to from here?  Satisfied with the knowledge & awareness  How to do more:  Join a team  Attain further CISM education  Provide further CISM education & awareness  Advocate for appropriate CISM services  Provide more:  Within your Squadron, Group, Wing, Region  With your family  At your place of work  In your community  For yourself
  • 103. How To Become a Member  Complete basic trainings (technician)  Complete application & be accepted to a team  Participate in quarterly Team trainings  Participate in CAP CISM functions  Maintain currency  Participate in non-CAP CISM teams & functions CISM Team membership is a privilege not a right.
  • 104. “Knowledge itself is power” Sir Francis Bacon “Action is the proper fruit of knowledge” Thomas Fuller
  • 106. National Staff Lt Col Sam D. Bernard, PhD National CISM Team Leader (423) 322-3297 sam@sambernard.info Maj Chris Latocki Administrative Officer ( 813) 412-9231 clatocki@cism.cap.gov
  • 107. Region Staff ________Name____________ Region CISM Officer Telephone / e-mail ________Name____________ Region Clinical Director Telephone / e-mail
  • 108. Wing Staff ________Name____________ Wing CISM Officer / Coordinator Telephone / e-mail ________Name____________ Wing Clinical Director Telephone / e-mail
  • 109. . . .and just one more thing. . . Thank You!
  • 110. Critical Incident Stress Management Lt. Col. Sam D. Bernard, Ph.D. National CAP CISM Team Leader (423) 322-3297Cell sam@sambernard.info www.sambernard.info cism.cap.gov
  • 111. Critical Incident Stress Management CISM Update Learning from the Past, . . . Progressing into the Future Developed by Lt. Col. Sam D. Bernard, Ph.D. CAP CISM National Team Leader Partial content from Chevron Publishing

Notes de l'éditeur

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  5. Learning Lab DO08: CISM Update Sam D. Bernard, PhD (Lt Col) National CISM Team Leader 9/4/09 1:30-3:00 pm
  6. Learning Lab DO08: CISM Update Sam D. Bernard, PhD (Lt Col) National CISM Team Leader 9/4/09 1:30-3:00 pm
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  55. Resources Raphael, B. (1986). When Disaster Strikes…NY: Basic Books. NIMH. (2002). Mental Health and Mass Violence. NIH Pub. # 02-5138. Wash.DC: US Govt Printing Office. Everly, G.S., Jr. &amp; Castellano, C. (2005) Psychological Counterterrorism &amp; World War IV. Ellicott City, MD: Chevron Pub. Everly, G.S., Jr. &amp; Parker, C.I. (Eds) (2005). Mental Health Aspects of Mass Disasters: Public Health Preparedness and Response. Balto: Johns Hopkins Center for Public Health Preparedness. 9/4/09 1:30-3:00 pm Sam D. Bernard, PhD (Lt Col) National CISM Team Leader Learning Lab DO08: CISM Update
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  106. Customize for National CISM Staffers 9/4/09 1:30-3:00 pm Sam D. Bernard, PhD (Lt Col) National CISM Team Leader Learning Lab DO08: CISM Update
  107. Customize for Region CISM Staffers 9/4/09 1:30-3:00 pm Sam D. Bernard, PhD (Lt Col) National CISM Team Leader Learning Lab DO08: CISM Update
  108. Customize for Wing CISM staffers 9/4/09 1:30-3:00 pm Sam D. Bernard, PhD (Lt Col) National CISM Team Leader Learning Lab DO08: CISM Update
  109. Learning Lab DO08: CISM Update Sam D. Bernard, PhD (Lt Col) National CISM Team Leader 9/4/09 1:30-3:00 pm
  110. This slide should be customized for the presenter to provide specific contact information for participants. 9/4/09 1:30-3:00 pm Sam D. Bernard, PhD (Lt Col) National CISM Team Leader Learning Lab DO08: CISM Update
  111. 9/4/09 1:30-3:00 pm Sam D. Bernard, PhD (Lt Col) National CISM Team Leader Learning Lab DO08: CISM Update