critical incident stress management command officer
DESCRIPTION
Critical Incident Stress Management Command Officer Course 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. Welcome Thank you for attending this session - PowerPoint PPT PresentationTRANSCRIPT
Critical IncidentCritical IncidentStress ManagementStress Management
Command OfficerCourse
Learning from the Past, . . . Progressing into the Future
Developed by Lt. Col. Sam D. Bernard, Ph.D.Developed by Lt. Col. Sam D. Bernard, Ph.D.CAP CISM National Team LeaderCAP CISM National Team Leader
Partial content from Chevron Publishing
WelcWelcomeomeThank you for attending this sessionconcerning CAP Command Officers
RationaleRationale
To provide Command Staff & Incident Commanders with basic knowledge to:
• Recognize the need for CISM,• Implament the CISM program,• Understand basic CISM principles,• Identify distressed personnel under
their supervision,• Access CISM services.
GoalsTo provide the knowledge to:To provide the knowledge to:Mitigate critical incident stress,Mitigate critical incident stress,Prepare for critical incident stress,Prepare for critical incident stress, Identify critical incident stress,Identify critical incident stress,Support interventions for active critical Support interventions for active critical
incident stress intervention,incident stress intervention,Recover from a critical incident while Recover from a critical incident while
supporting members & the organizationsupporting members & the organizationin CAP members while performing CAP duties.in CAP members while performing CAP duties.
Agenda
Jeffrey T. Mitchell, Ph.D., CTS&
George S. Everly, Jr., Ph.D., CTS
• Stress & Types of StressStress & Types of Stress• Management of Cumulative Management of Cumulative
StressStress• Recognizing Critical Recognizing Critical
Incident Stress (CIS)Incident Stress (CIS)• Preventing Critical Incident Preventing Critical Incident
Stress (CIS)Stress (CIS)• Mitigating Op StressMitigating Op Stress• After Action SupportAfter Action Support• Indicators of CIS vs. Indicators of CIS vs.
Disciplinary Problems Disciplinary Problems or Character Disorders or Character Disorders
• CISM ResourcesCISM Resources• General Functions of General Functions of
CISM TeamsCISM Teams• Follow-Up ServicesFollow-Up Services• P.A.S.S.P.A.S.S.• CAPR 60-5 & CAPR 60-5 &
UpdatesUpdates• LiabilityLiability• ChargeCharge• Contact InformationContact Information
CAP Personality TraitsCAP Personality Traits1.1.
2.2.
3.3.
4.4.
5.5.
6.6.
7.7.
8.8.
9.9.
10.10.
Stress
Stress
Stress is a state of:• Physical• Cognitive• Behavioral• Emotional and • Spiritual arousal.
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Chevron Publishing, 2002
Once physical, cognitive, Once physical, cognitive, emotional and spiritual emotional and spiritual
arousal occurs, behaviors arousal occurs, behaviors change.change.
Primary Types of Stress
General StressGeneral StressCumulative StressCumulative StressCritical Incident StressCritical Incident StressStress Related DisorderStress Related Disorder
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NormalNormalPathologicalPathological
Chevron Publishing, 2002
Having stress is not bad, in itself.Having stress is not bad, in itself.
What What isis bad is experiencing bad is experiencing excessive or prolonged stress.excessive or prolonged stress.
ResistanceIf the stressor continues,the body mobilizes towithstand the stress andreturn to normal.
ExhaustionOngoing, extremestressors eventuallydeplete the body’sresources so wefunction at less than normal.
AlarmThe body initiallyresponds to a stressor with changes that lowerresistance.
StressorThe stressormay be threateningor exhilarating.
HomeostasisThe body systemsmaintain a stableand consistent(balanced) state.
Illness and DeathThe body’s resources are notreplenished and/or additionalstressors occur; the bodysuffers breakdowns.
Return to homeostasis
Illness
Death
The brain becomes more alert.Stress can contribute to headaches, anxiety,and depression.Sleep can be disrupted.
Stress hormones can damage the brain’s ability toremember and cause neurons to atrophy and die.
Baseline anxiety level can increase.
Heart rate increases.Persistently increased blood pressure and heart rate can lead to potential for blood clotting and increase the risk of stroke and heart attack.
Adrenal glands produce stress hormones.
Cortisol and other stress hormones can increase appetite and thus body fat.
Stress can contribute to menstrual disorders in women.
Stress can contribute to impotence and premature ejaculation in men.Muscles tense.Muscular twitches or “nervous tics” can result.
Red = immediate response to stressBlue = effects of chronic of prolonged stress
Mouth ulcers or “cold sores” can crop up.
Breathing quickens.
The lungs can become moresusceptible to colds and infections.
Immune system is suppressed.
Skin problems such as eczema andpsoriasis can appear.
Cortisol increases glucose productionin the liver, causing renal hypertension.
Digestive system slows down.
Stress can cause upset stomachs.
Red = immediate response to stress
Blue = effects of chronic of prolonged stress
Hea
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Per
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Stress arousal
Maximum adaptive arousal
Stress Curve
Chevron Publishing, 2002
Cumulative Stress
Destructive pathway of stressDestructive pathway of stressPiled up, unresolved general stressPiled up, unresolved general stressTakes timeTakes timeProduces negative changes in:Produces negative changes in:
Mental & physical healthMental & physical health PerformancePerformance RelationshipsRelationships PersonalityPersonality
Cumulative StressA chronic state of disturbing stress A chronic state of disturbing stress
which can cause physical & changes in which can cause physical & changes in personality over time.personality over time.
Takes months or years to develop.Takes months or years to develop.May be a combination of work or home May be a combination of work or home
life.life.Often referred to as “burnout”.Often referred to as “burnout”.Often needs professional help for Often needs professional help for
recovery especially if in late stages.recovery especially if in late stages.continued...continued...
Cumulative Stress - continued
Develops in four stages:Develops in four stages:Early WarningEarly WarningMild SymptomsMild SymptomsEntrenchedEntrenchedSevere SymptomsSevere Symptoms
Characterized by gradually declining Characterized by gradually declining performance, increasing problem in job.performance, increasing problem in job.
continued...continued...
Cumulative Stress - continued
Early Symptoms:Early Symptoms:Vague anxietyVague anxietyBoredomBoredomGeneral fatigueGeneral fatigue
Mild Symptoms:Mild Symptoms:All of the Early SymptomsAll of the Early Symptoms IrritabilityIrritabilityChronic tensionChronic tensionDepressionDepression continued...continued...
Mild Symptoms FrustrationFrustrationFrequent sighsFrequent sighsSleep disturbanceSleep disturbanceChronic worryChronic worryLoss of interest in workLoss of interest in workMore frequent coldsMore frequent coldsMild rashesMild rashesHeadachesHeadachesWithdrawal from othersWithdrawal from othersetc..etc..
Cumulative Stress - continued
Entrenched SymptomsEntrenched SymptomsChronic depressionChronic depressionLoss of joy of lifeLoss of joy of lifeChronic angerChronic anger Increased drinking / druggingIncreased drinking / druggingThoughts of suicideThoughts of suicideEmotional outburstsEmotional outburstsMarital or relationship discordMarital or relationship discordConflict with fellow workersConflict with fellow workersConflict with supervisorsConflict with supervisors Increasing discipline problemsIncreasing discipline problems
continued...continued...
Entrenched symptoms - continuedIncreased self destructive behaviors (i.e.?)Withdrawal from loved ones
Continued... Loss of trust in othersIncreasing paranoia Loss of ambitionTendency to blame othersInability to take responsibility for one’s own
actionsMinor property destructionActing out behaviorsetc.. (?)
Severe SymptomsRage reactionsHomicidal thinkingSuicidal thinking / actsEasily angeredVerbally violent outburstsActs of violenceThreats to othersExcessive drinking / druggingSevere depressionSevere paranoia continued...
Severe Symptoms - continuedBreak up of relationships over minor issuesCompulsive thinking about bothersome
topicsEasily frustratedSense of hopelessnessSense of helplessnessSeriously declining performanceMost symptoms from previous levelsetc..
Burnout
Changes attitudesChanges attitudes
Avoids workAvoids work
Or, becomes totally immersedOr, becomes totally immersed
Develops negative outlookDevelops negative outlook
Flame-out
Exhaustion, hyperactivityExhaustion, hyperactivity
Overwhelming negative Overwhelming negative emotionsemotions
Denial of symptomsDenial of symptoms
Loss of objectivityLoss of objectivity
Stress Reactions
Physiological
not
Characteriological
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Management of Cumulative Stress Reactions
Stress management educationStress management educationBalance in life - work - home, etc..Balance in life - work - home, etc..RecreationRecreationVacationVacationLimiting overtimeLimiting overtimeEmphasis on home lifeEmphasis on home lifeProfessional counseling when neededProfessional counseling when needed
continued...continued...
Management - continued
ExerciseProper foodClear job expectationsReduction of one worker performing two jobsEffective leadershipAdministrative supportStress reduction techniquesHealthy livingEffective training
Critical Incident
An eventthat has the power to
overwhelm the coping abilities of an individual or group.
Chevron Publishing, 2002
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The Terrible 10 for CAPThe Terrible 10 for CAP
1.1. 6.6.
2.2. 7.7.
3.3. 8.8.
4.4. 9.9.
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. . . not limited to missions!
CrisisCrisis
An acute reaction to a critical incident.A name of a particular critical incident.
Nounvs
Verb
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Both
Chevron Publishing, 2002
Crisis Characteristics
The relative balance between thought processes and emotional processes is disturbed,
The usual coping methods do not work effectively,
There is evidence of mild to severe impairment in individuals or groups exposed to the critical incident,
Pre-CRISIS Post CRISIS
THOUGHTS
FEELINGS
THOUGHTS
FEELINGS
CRISIS
Assessing the Need forCrisis Intervention (CISM)
Is this one of the CAP “Terrible 10”?
Are coping mechanisms working effectively for EVERYONE?
Is there evidence of mild to severe impairment in individuals or groups exposed to the critical incident?
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Critical Incident Stress (CIS)
Also called “traumatic stress”Also called “traumatic stress”Not caused by general stress or Not caused by general stress or
cumulative stress, but produced by a cumulative stress, but produced by a specific terrible eventspecific terrible event
All people are vulnerableAll people are vulnerableEmergency personnel may be more Emergency personnel may be more
vulnerable because of exposure to vulnerable because of exposure to traumatic eventstraumatic events
continued...continued...
C I S - continued
Some may react more strongly than othersSome may react more strongly than othersUsually resolves in a reasonable period of Usually resolves in a reasonable period of
timetimeMay need some form of brief support serviceMay need some form of brief support serviceCan turn into a serious problem for a few Can turn into a serious problem for a few
people if it is not resolvedpeople if it is not resolvedSupervisors are able to recognize the problemSupervisors are able to recognize the problem
continued...continued...
Chevron Publishing, 2002
C I S - continued
Some people have several Critical Incident Stress reactions during their careers
Reactions can be reduced by early intervention
Critical Incident Stress can be an opportunity for positive change and growth
Chevron Publishing, 2002
Reactions to Stress
PhysicalCognitiveEmotionalBehavioralSpiritual
Chevron Publishing, 2002
PhysicalSigns and Symptoms of Critical
Incident StressThirstThirstFatigueFatigueNauseaNauseaTwitchesTwitchesVomitingVomitingDizzinessDizzinessElevated B/PElevated B/PMuscle tremorsMuscle tremorsGrinding teethGrinding teeth
Visual difficultiesProfuse sweatingDifficulty breathingFainting / LoCWeakness/numbessChest painHeadachesRapid heart rate
Chevron Publishing, 2002
CognitiveCognitiveSigns and Symptoms of Critical Signs and Symptoms of Critical
Incident StressIncident Stress ConfusionConfusion NightmaresNightmares UncertaintyUncertainty HypervigilenceHypervigilence SuspiciousnessSuspiciousness Intrusive imagesIntrusive images Blaming someoneBlaming someone Poor problem solvingPoor problem solving Poor abstract thinkingPoor abstract thinking Change in Change in
attention/decisionattention/decision
Poor concentration or Poor concentration or memorymemory
DisorientationDisorientation Change in alertnessChange in alertness Suicide/homicideSuicide/homicide Hallucinations/delusionsHallucinations/delusions Paranoid ideasParanoid ideas Disabling guiltDisabling guilt HopelessnessHopelessness HelplessnessHelplessness
Chevron Publishing, 2002
BehavioralSigns and Symptoms of Critical
Incident Stress WithdrawalWithdrawal Inability to restInability to rest Intensified pacingIntensified pacing Erratic movementsErratic movements Changes in social Changes in social
activityactivity Changes in speechChanges in speech Changes in appetiteChanges in appetite Hyper-alertnessHyper-alertness
Changes in alcohol or Changes in alcohol or drug consumptiondrug consumption
Antisocial actsAntisocial acts Abuse of othersAbuse of others Diminished personal Diminished personal
hygienehygiene ImmobilityImmobility Self medicationSelf medication ViolenceViolence
Chevron Publishing, 2002
EmotionalSigns and Symptoms of Critical
Incident Stress Guilt Grief Denial Anxiety Agitation Irritability Depression Anger Apprehension
Emotional shockEmotional shock Emotional outburstEmotional outburst Feeling overwhelmed overwhelmed Loss of emotional Loss of emotional
controlcontrol Inappropriate Inappropriate
emotional responsesemotional responses Infantile emotionsInfantile emotions Panic attacksPanic attacks
Chevron Publishing, 2002
SpiritualSigns and Symptoms of Critical
Incident Stress
Angry at “God” Asking “why” questions Cessation of practice of faith Faith rituals fail to have meaning Religious hallucinations or delusions
Cumulative CIS
High frequency of activationHigh frequency of activation
Long duration of serviceLong duration of service
High intensity of service provisionHigh intensity of service provision
Cumulative CIS
Loss of purposeLoss of purposeLoss of connectionLoss of connectionLoss of autonomyLoss of autonomyLoss of integrityLoss of integritySpiritual depletionSpiritual depletion Kendall Johnson, 1993Kendall Johnson, 1993
Chevron Publishing, 2002
Factors Effecting Crisis Reactions
SuddennessSuddenness IntensityIntensity DurationDuration Level of lossLevel of loss AgeAge Injury or death to Injury or death to
relatives or friendsrelatives or friends
Availability of Availability of resourcesresources
Level of education / Level of education / trainingtraining
Availability of coping Availability of coping mechanismsmechanisms
Crisis Intervention
An active and temporary entry into the life of an individual or a
group during a period of significant distress.
Crisis Intervention
Emotional “first aid” designed to assist the person in a crisis
state to return to adaptive functioning.
Chevron Publishing, 2002
Objectives ofObjectives ofCrisis InterventionCrisis Intervention
Stabilize situationStabilize situationMitigate impactMitigate impactMobilize resourcesMobilize resourcesNormalize reactionsNormalize reactionsRestore to adaptive function Restore to adaptive function
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Dose Response
“1/3 Rule” - Theoretical
11 22
33
8%
Imprint of Horror
VisualVisualAuditoryAuditoryOlfactoryOlfactoryKinestheticKinestheticGustatoryGustatoryTemporalTemporal
Psychological / Perceptual Contaminants
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 SEven with all the right programs, Even with all the right programs, briefings, teams, personnel, etc lined briefings, teams, personnel, etc lined up & available – there can still be up & available – there can still be CIS.CIS.We don’t know our member’sWe don’t know our member’sbaggage. baggage. (Pre-existing conditions)(Pre-existing conditions)Pre-Exposure Training Pre-Exposure Training can helpcan helpID potential psych/perceptualID potential psych/perceptualcontaminantscontaminantsTa
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Mitigating Operational Stress (OpStress)
Frequent information / feedback to staffFrequent information / feedback to staffFrequent rest breaksFrequent rest breaksCold or hot environments might require Cold or hot environments might require
more frequent rest breaksmore frequent rest breaksRest areas away from stimuliRest areas away from stimuli12 hour limit for same scene stimuli12 hour limit for same scene stimuliAssure proper rehabilitation sectorAssure proper rehabilitation sectorProvide lavatory facilitiesProvide lavatory facilities
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Mitigating OpStress - continued
Provide hand washing facilitiesProvide hand washing facilitiesProvide medical support to staffProvide medical support to staffMonitor hyper- or hypo-thermiaMonitor hyper- or hypo-thermiaProper foodProper foodLimit fat, sugar and saltLimit fat, sugar and saltFluid replacementFluid replacementProvide drinking waterProvide drinking waterProvide fruit juicesProvide fruit juicesLimit use of caffeine productsLimit use of caffeine productsCISM on scene support servicesCISM on scene support services
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Monitor signs of emotional distressMonitor signs of emotional distressLimit overall stimuli at incidentLimit overall stimuli at incidentGive clear orders to personnelGive clear orders to personnelAvoid conflicting orders to staffAvoid conflicting orders to staffDelegate authority Delegate authority Frequent rest breaks for allFrequent rest breaks for allBack up leadersBack up leadersSectorization of the incidentSectorization of the incidentDelegation of authorityDelegation of authorityCredit people for proper actionsCredit people for proper actions
continued...continued...
Mitigating OpStress - continuedTa
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Mitigating OpStress Mitigating OpStress - continued
Limit criticism to absolute minimumLimit criticism to absolute minimumUtilize a staging area for uninvolved Utilize a staging area for uninvolved
personnelpersonnelLimit exposure to event sights, sounds Limit exposure to event sights, sounds
and smells (reminders)and smells (reminders)Announce time periodicallyAnnounce time periodicallyRotate crews to alternate dutiesRotate crews to alternate dutiesOthers ?Others ?
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Peritraumatic Stress DissociationDissociation
Depersonalization, derealization, fugue states, amnesiaDepersonalization, derealization, fugue states, amnesia Intrusive Re-ExperiencingIntrusive Re-Experiencing
Flashbacks, terrifying memories or night mares, repetitive Flashbacks, terrifying memories or night mares, repetitive automatic re-enactmentsautomatic re-enactments
AvoidanceAvoidance Agoraphobic-like social withdrawalAgoraphobic-like social withdrawal
HyperarousalHyperarousal Panic episodes, startle reactions, fighting or temper problemsPanic episodes, startle reactions, fighting or temper problems
AnxietyAnxiety Debilitating worry, nervousness, vulnerability or powerlessnessDebilitating worry, nervousness, vulnerability or powerlessness
DepressionDepression Anhedonia, worthlessness, loss of interest in most activities, Anhedonia, worthlessness, loss of interest in most activities,
awakening early, persistent fatigue, and lack of motivationawakening early, persistent fatigue, and lack of motivation Problematic Substance UseProblematic Substance Use
Abuse or dependency, self-medicationAbuse or dependency, self-medication Psychotic SymptomsPsychotic Symptoms
Delusions, hallucinations, bizarre thoughts or images, catatoniaDelusions, hallucinations, bizarre thoughts or images, catatonia Dis
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Highest Risk forExtreme Peritraumatic Stress
Life-Threatening danger, extreme violence, or Life-Threatening danger, extreme violence, or sudden death of others;sudden death of others;
Extreme loss or destruction of their homes, Extreme loss or destruction of their homes, normal lives, and communities;normal lives, and communities;
Intense emotional demands from distraught Intense emotional demands from distraught survivors survivors (rescue workers, counselors, caregivers);(rescue workers, counselors, caregivers);
Prior psychiatric or marital/family problems;Prior psychiatric or marital/family problems; Prior significant loss Prior significant loss (death of a loved one in the past year)(death of a loved one in the past year)
Cardena & Spiegel, 1993; Joseph et.al, 1994; Kooperman, et.al., 1994&5; Cardena & Spiegel, 1993; Joseph et.al, 1994; Kooperman, et.al., 1994&5; La Greca et.al.,1996; Lonigan, et.al., 1994; Schwarz & Kowalski, 1991; La Greca et.al.,1996; Lonigan, et.al., 1994; Schwarz & Kowalski, 1991; Shalev, et.al., 1993Shalev, et.al., 1993 Disaster Mental Health Services-A guidebook for Clinicians &
Administrators; Dept of Veterans Affairs, 1998
Effects of Hyper-Arousal
Trouble sleepingTrouble sleeping Difficulty Difficulty
concentratingconcentrating Heightened vigilanceHeightened vigilance Being easily startledBeing easily startled Being waryBeing wary Sudden cryingSudden crying Becoming suddenly Becoming suddenly
angryangry
Being more emotionalBeing more emotional PanickingPanicking Intensified alertnessIntensified alertness Reminders of the Reminders of the
trauma leading to trauma leading to physical reactionsphysical reactions Rapid heart beatRapid heart beat SweatingSweating etcetc
Increased anxietyIncreased anxiety
Hyper-ArousalSleep Disturbances
Longer to fall asleepLonger to fall asleepUnable to fall asleepUnable to fall asleepMore sensitive to noiseMore sensitive to noiseAwaken more often during the nightAwaken more often during the nightHave dreams and/or nightmares about the Have dreams and/or nightmares about the
traumatraumaRepetitive trauma dreams may awaken Repetitive trauma dreams may awaken
and leave frightened and exhaustedand leave frightened and exhausted
After Action Support
Thank personnel for their workThank personnel for their workConsult with CISM teamConsult with CISM teamProvide demobilization services on Provide demobilization services on
large scale incidentlarge scale incidentUtilize services of CISM teamsUtilize services of CISM teamsArrange defusing for unusual eventsArrange defusing for unusual eventsConsider debriefing for personnel if it Consider debriefing for personnel if it
appears necessary*appears necessary* continued...continued...
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After Action Support - continued
Allow follow up services by CISM team Allow follow up services by CISM team membersmembers
Critique incident operationallyCritique incident operationallyTeach new procedures from lessons Teach new procedures from lessons
learnedlearnedConsider the need for family supportConsider the need for family supportOther ?Other ?
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Indicatorsof
Critical Incident Stressvs.
Disciplinary Problemsor
Character Disorders
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Identifiable traumatic eventIdentifiable traumatic eventReactions begin with an eventReactions begin with an eventReactions worsen after eventReactions worsen after eventReactions follow expected patternsReactions follow expected patternsSudden changes are common in CISSudden changes are common in CISCIS reactions usually reduce with:CIS reactions usually reduce with:
Peer assistance and,Peer assistance and,With the passage of timeWith the passage of time
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Characteriological & Disciplinary Problems - continued
Disciplinary problems have a long and Disciplinary problems have a long and diffuse historydiffuse history
Problems may have preexisted entry into Problems may have preexisted entry into the CAP jobthe CAP job
Identifiable traumatic event(s) missingIdentifiable traumatic event(s) missingProblems may exist in several other Problems may exist in several other
important areas of the person’s life.important areas of the person’s life.Problems do not easily resolve over time Problems do not easily resolve over time
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Addressing C I S
Acknowledge the existence of CISAcknowledge the existence of CISPre-incident educationPre-incident educationPlanningPlanningDrills / practiceDrills / practicePre-deployment briefingsPre-deployment briefingsAvoid avoidance of CISAvoid avoidance of CIS
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Critical IncidentStress ManagementComprehensive
Integrated
System utilizing a
Multi-Tactical Crisis Intervention Approach to Managing Traumatic Stress
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CISM: Menu of ServicesCISM: Menu of ServicesPre-Crisis PreparationPre-Crisis PreparationGroup InterventionGroup Intervention
Demobilization Demobilization Crisis Management Briefing Crisis Management Briefing DefusingDefusingCritical Incident Stress DebriefingCritical Incident Stress Debriefing
Individual Crisis InterventionIndividual Crisis InterventionPastoral Crisis InterventionPastoral Crisis InterventionFamily CISMFamily CISMOrganizational ConsultationOrganizational ConsultationFollow-up/ ReferralFollow-up/ Referral
“Tactics”
Chevron Publishing, 2002
CISM TacticsCISM TacticsMust be Available for:Must be Available for:
IndividualsIndividualsGroupsGroupsOrganizationsOrganizationsFamiliesFamiliesSignificant othersSignificant others
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Chevron Publishing, 2002
Core Competencies in CISMCore Competencies in CISM
The ability to properly The ability to properly assessassess both the both the situation and the severity of impact on situation and the severity of impact on individuals and groupsindividuals and groups
Ability to develop a Ability to develop a strategic planstrategic plan Individual Individual crisis intervention skillscrisis intervention skillsLarge group Large group crisis intervention skillscrisis intervention skillsSmall group Small group crisis intervention skillscrisis intervention skillsReferral skillsReferral skills
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Treatment Referral OptionsMedical Care ProfessionalMedical Care Professional
MD / DOMD / DOPA / NPPA / NP
Mental Health Care ProfessionalMental Health Care ProfessionalPsychologistPsychologistCounselorCounselorSocial WorkerSocial WorkerPsychiatrist / NP / PAPsychiatrist / NP / PA
Spiritual Care ProfessionalSpiritual Care ProfessionalFaith LeaderFaith Leader““Chaplain”Chaplain”Ta
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CAP Legal:
Treat like a physical injury
Chevron Publishing, 2002
Essential CISM CoursesEssential CISM Courses(2 Days Each)(2 Days Each)
Assisting Individuals in CrisisAssisting Individuals in CrisisBasic Critical Incident Stress Basic Critical Incident Stress
Management: Group Crisis InterventionsManagement: Group Crisis Interventions
SuicideSuicide Grief Following TraumaGrief Following Trauma Advanced Critical Incident Stress Management: Group Crisis Advanced Critical Incident Stress Management: Group Crisis
InterventionsInterventions T.E.A.M.T.E.A.M. Emotional & Spiritual Care in DisastersEmotional & Spiritual Care in Disasters
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CISM ComponentsCISM ComponentsBeforeBefore an Incidentan Incident
Education (PEP)Education (PEP)Team trainingTeam trainingPlanningPlanningAdministrative supportAdministrative supportProtocol developmentProtocol developmentGuideline developmentGuideline developmentNetworking with other teamsNetworking with other teams
& resources& resources
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CISM ComponentsCISM ComponentsDuringDuring an Incident an Incident
On-scene support servicesOn-scene support servicesOne-on-one crisis interventionOne-on-one crisis interventionAdvice to supervisors/ICAdvice to supervisors/ICSupport to primary victims (CAP)Support to primary victims (CAP)Provision of food, fluids, rest and other Provision of food, fluids, rest and other
services to operations personnelservices to operations personnelOrganizational Consultation (CC)Organizational Consultation (CC)
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CISM ComponentsCISM ComponentsAfterAfter an Incidentan Incident
One-on-one crisis interventionOne-on-one crisis interventionDemobilization (post-disaster, large group)Demobilization (post-disaster, large group)Crisis Management Briefing (CMB, large Crisis Management Briefing (CMB, large
group)group)Defusing (small group)Defusing (small group)Critical Incident Stress Debriefing (CISD, Critical Incident Stress Debriefing (CISD,
small group)small group)Significant other support servicesSignificant other support services
. . . more . . . . . . more . . . Take
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Post-incident educationPost-incident educationFollow-up servicesFollow-up servicesReferrals according to needsReferrals according to needs
CISM ComponentsCISM ComponentsAfterAfter an Incident an Incident
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CISM CISM
Typically: 3-5 contactsTypically: 3-5 contactsAfter that,After that,
Recovery is evidentRecovery is evidentReferral is indicatedReferral is indicated
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CISMCISM
Is not psychotherapyIs not psychotherapy
Is not a substitute for psychotherapyIs not a substitute for psychotherapy
Is not a stand-aloneIs not a stand-alone
Is not a cure for PTSD, Depression, Is not a cure for PTSD, Depression, Anxiety, etcAnxiety, etc
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CISM has far more to do withgroup supportandassessment (triage)than it does withtreatment and cure.
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Follow-UpFollow-UpMustMust be provided after every CISM service: be provided after every CISM service:Assess impact of interventionAssess impact of interventionAssess for uncovering prior issuesAssess for uncovering prior issuesAssess trajectory of reactionsAssess trajectory of reactions
• DecreasingDecreasing• SameSame• IncreasingIncreasing
Assess for possible referral:Assess for possible referral: Health Care ProfessionalHealth Care Professional Mental Health Care ProfessionalMental Health Care Professional Spiritual Care ProfessionalSpiritual Care ProfessionalTa
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Can be accomplished telephonically
P. A. S. S.P. A. S. S.Post Action Staff SupportPost Action Staff Support
Dennis Potter, LCSW
Goals For PASSGoals For PASS
Increase longevity of CISM team membersIncrease longevity of CISM team members Increase learning from the experienceIncrease learning from the experience Increase stress management skillsIncrease stress management skillsDecrease the chance for personal reactionsDecrease the chance for personal reactionsTo take care of ourselves (too)To take care of ourselves (too) Increase effectiveness of team membersIncrease effectiveness of team membersMonitor team for any adverse reactionsMonitor team for any adverse reactions
Why Do It?Why Do It?
To Prevent:Vicarious TraumatizationCumulative StressCritical Self Judgment
To TeachTo Practice What We Teach
“The same professionalism we provide to others, we deserve ourselves” SDB
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.
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InternationalCritical Incident Stress
Foundation
3290 Pine Orchard LaneSuite 106
Ellicott City, MD 21042(410) 750-9600
Fax: (410) 750-9601Emergency: (410) 313-2473
www.icisf.org
CAPR 60-5
Administratively authorizes CISM,Administratively authorizes CISM,Provides background information and Provides background information and
“how to” information,“how to” information,Mandates each Wing to name a CISM Mandates each Wing to name a CISM
Officer,Officer,Please read and review 60-5Please read and review 60-5
CAP Personality TraitsCAP Personality Traits1.1. Need to rescue or be neededNeed to rescue or be needed2.2. Strong intrinsic motivationStrong intrinsic motivation3.3. Stimulation seeking/easily boredStimulation seeking/easily bored4.4. Need for immediate feedbackNeed for immediate feedback5.5. Action orientedAction oriented6.6. Desire to do a perfect jobDesire to do a perfect job7.7. Need to be in controlNeed to be in control8.8. Strive for consistencyStrive for consistency9.9. Risk takerRisk taker10.10.High dedicationHigh dedication11.11.Likes uniformsLikes uniforms
CAP Personality Traits
Those 10 traits make us very good at what we do – our jobs in CAP,
Those same 10 traits put us at high risk: Cumulative Stress Critical Incident Stress Depression Anxiety
Panic Attacks PTSD
Substance Abuse Relationship Problems Antisocial traits (isolation, etc)
Questions . . .
1. Do CAP members have the potential for attaining physical injury?Yes
2. What is done to address this potential?Safety briefings, Regulations, Checklists, Medical Officers, First Aid kits, Disciplinary actions, etc.
3. Do CAP member have the potential for attaining psychological injury? Yes – direct and indirect
4. What is done to address this potential?CISM program, Regulation 60-5, PEP Talks, Briefings
U.S. Supreme Court concluded that inadequacy U.S. Supreme Court concluded that inadequacy of police training may serve as a basis for of police training may serve as a basis for municipal liability where failure to train amounts municipal liability where failure to train amounts to deliberate indifference for the rights of persons to deliberate indifference for the rights of persons with whom the police come into contact.with whom the police come into contact.
The Court said that the City of Canton, Ohio was The Court said that the City of Canton, Ohio was negligent in failing to train their police officers in negligent in failing to train their police officers in first aid on a regular basis because the first aid on a regular basis because the probability of needing to use first aid in police probability of needing to use first aid in police work was so high.work was so high.
Lt. Michael S. Woody, Ret. Akron Ohio Police Dept, Jan 6, 2003Lt. Michael S. Woody, Ret. Akron Ohio Police Dept, Jan 6, 2003
““Deliberate Indifference”Deliberate Indifference”
Let’s not put CAP at risk – acknowledge and support the CAP CISM program.
“Knowledge itself is power”Sir Francis Bacon
““Action is the proper fruit Action is the proper fruit of knowledge”of knowledge”
Thomas Fuller
What “Actions” from here?What “Actions” from here?Acknowledge the CAP CISM programAcknowledge the CAP CISM programDesignate a CISM Officer or CoordinatorDesignate a CISM Officer or Coordinator Incorporate CISM into each missionIncorporate CISM into each missionDesignate CISM specific taskings during Designate CISM specific taskings during
evalsevalsAllow CISM to support your team and staff Allow CISM to support your team and staff
by:by:Triaging mental health issuesTriaging mental health issuesHelping them cope with their experiences,Helping them cope with their experiences,Getting them back into serviceGetting them back into serviceOffer referrals if neededOffer referrals if needed
Feedback
ThoughtsThoughts
CommentsComments
ReactionsReactions
Lt Col Sam D. Bernard, PhDLt Col Sam D. Bernard, PhDNational CISM Team LeaderNational CISM Team Leader
(423) 322-3297 (423) 322-3297 [email protected]
Maj Chris LatockiMaj Chris LatockiAdministrative OfficerAdministrative Officer
( 813) 412-9231 [email protected]( 813) 412-9231 [email protected]
National StaffNational Staff
________________NameName________________________Region CISM OfficerRegion CISM OfficerTelephone / e-mailTelephone / e-mail
________________NameName________________________Region Clinical DirectorRegion Clinical Director
Telephone / e-mailTelephone / e-mail
Region StaffRegion Staff
________________NameName________________________Wing CISM Officer / CoordinatorWing CISM Officer / Coordinator
Telephone / e-mailTelephone / e-mail
________________NameName________________________Wing Clinical DirectorWing Clinical Director
Telephone / e-mailTelephone / e-mail
Wing StaffWing Staff
Who’s needs am I meeting, Just because you can, doesn’t mean you should, Everything that is countable, doesn’t always count;
everything is counts is not always countable, Do not confuse effort with results, Listen to the words for the underlying meaning, Have a good day, unless you have made other plans, Timing is all, Bring cognition to chaos, It’s not about you, No one is immune, You will walk with a limp, Hear with your ears, see with your eyes, and think
with your brain, It’s bigger than you,Sa
m’s
Pea
rls o
f Wis
dom
Critical Incident Stress Critical Incident Stress ManagementManagement
Lt. Col. Sam D. Bernard, Ph.D.Lt. Col. Sam D. Bernard, Ph.D.National CAP CISM Team LeaderNational CAP CISM Team Leader
(423) 322-3297(423) 322-3297CellCell
cism.cap.govcism.cap.gov
Thank You!
. . .and just one more thing. . .
Critical IncidentCritical IncidentStress ManagementStress Management
Command OfficerCourse
Learning from the Past, . . . Progressing into the Future
Developed by Lt. Col. Sam D. Bernard, Ph.D.Developed by Lt. Col. Sam D. Bernard, Ph.D.CAP CISM National Team LeaderCAP CISM National Team Leader
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