dealing with emergency services personnel

1: CRISIS REACTIONS FOLLOWING TRAUMATIC INCIDENTSJUNE 18, 2009NUI MAYNOOTH

Slide 2:Thank you for what YOU do� you change the world.Thank you for what YOU do� you change the world.

3: Dr. Dan Casey, CTDirector, UMTTI 11959 77th St. Clear Lake, MN 55319320-282-2436320-743-4119 F dlcasey@frontiernet.net www.jec-counseling.com

4: ICISF & Green Cross Trained trainer � International- Basic, Advanced, Individual, School, College & Suicide trainings, Compassion Fatigue, Field Traumatology, ICS Green Cross & ICISF Board member Coordinator for three Crisis teams 25 years wild land fire fighter- incident commander 800+ fires 7 years University instructor/ counselor SJU, UMM, UMB Provide 100 interventions per year on average 22 years -2000 interventions- trained 10,000

5: DEALING WITH Emergency Services Personnel ON SCENE SOON AFTER - a few days LATER - a few weeks

6: Traumatizing events Auto accident Abuse Robbery Injury death to ones child or a child Suicide Line of duty death homicide (s) Tornadoes Earthquake Hurricane Fires Flood Pollution Multiple injury/fatality Terrorism Community disasters

7: A Model Response�Katrina�s Coming!!!!! Phone call among Dr. Jeffrey Mitchell � ICISF, Director � American Red Cross, Dr. Charles Figley � Green Cross �Let�s Not Compete� ICISF � Serve First Responders Red Cross � Serve Victims/Evacuees Green Cross � Serve Volunteers and Non Traditional First Responders

8: WHAT IN THE WORLD IS HAPPENING ??? PSYCHOLOGICAL FIRST AID (PFA) COMPASSION FATIGUE (CF) CRITICAL INCIDENT STRESS MANAGEMENT

9: Psychological First Aid A set of skills that helps community residents care for their families, friends, neighbors, and themselves by providing basic psychological support in the aftermath of traumatic events� You will be practicing these skills later on in the training.You will be practicing these skills later on in the training.

10: Psychological First Aid A model that: Integrates public health and community and individual psychology. Includes preparedness for communities, work places, schools, faith communities, and families. Does not rely on direct services by mental health professionals. Uses skills you probably already have� Integrates�.in times of disaster or critical incidents that have an impact on the community, public health and community psychology are called upon to respond. Your supervisors (people available to you for questions, support and referral sources) are community psychologists, social workers, counselors and ministers. They are part of an expanding response network. The specific organization of this response will be reviewed later in the training. Includes�. Does not rely�.but mental health professionals are available for support. Individual resilience and community resilience are anchored to the ind and comm psychology.Integrates�.in times of disaster or critical incidents that have an impact on the community, public health and community psychology are called upon to respond. Your supervisors (people available to you for questions, support and referral sources) are community psychologists, social workers, counselors and ministers. They are part of an expanding response network. The specific organization of this response will be reviewed later in the training. Includes�. Does not rely�.but mental health professionals are available for support. Individual resilience and community resilience are anchored to the ind and comm psychology.

11: Psychological First Aid Skills Part I � Understanding common symptoms and responses associated with trauma Part II - Active Listening Improving a skill you already possess Part III � Resource Awareness There are two major parts of the Skills Section of the training. Part I covers compassion and understanding the symptoms of stress for adults and children. This is a cognitive training session and will be tested with a multiple choice quiz. Part II covers active listening. This is a practical training session and will be tested with a demonstration exercise.There are two major parts of the Skills Section of the training. Part I covers compassion and understanding the symptoms of stress for adults and children. This is a cognitive training session and will be tested with a multiple choice quiz. Part II covers active listening. This is a practical training session and will be tested with a demonstration exercise.

12: COMPASSION FATIGUE �There is a cost to caring. People who listen to others� stories of fear, pain, and suffering may feel similar fear, pain and suffering because they care. Sometimes we feel we are losing our sense of self to � those we serve�� It is the cost of working with people. The better you are at your work, the more compassion is expended, and the more compassion fatigue is experienced.

13: COMPASSION FATIGUE Post-Traumatic Stress Disorder Exposure is core factor in risk Sympathy is the vehicle of transmission

14: COMPASSION FATIGUE A state of tension and preoccupation with traumatized individual(s) by Re-experiencing the traumatic events, Avoidance/numbing of reminders, and Persistent arousal (e.g., anxiety)

15: signs of COMPASSION FATIGUE Loss of sense of humor Difficulty separating work and personal life Lowered frustration tolerance Dread (of working with certain clients or of certain calls) Disruption of one�s frames of reference (sense of identity, world view, and spirituality) Ineffective or self-destructive self-soothing behaviors

16: CRITICAL INCIDENT STRESS MANAGEMENT (CISM) A comprehensive, integrated, systematic, and multi - component approach to crisis / disaster intervention.

17: The Brain David - Some basic physiology and general body stress reactions 30/60David - Some basic physiology and general body stress reactions 30/60

19: Disasters and CISM Situations beyond the resources of the local community Produce a great deal of emotional response usually requiring CISM services Victims, survivors, rescuers and community members need a variety of types of assistance The type, number and duration of crisis support services can overwhelm any CISM team. The type, number and duration of crisis support services can overwhelm any CISM team.

20: Disasters are Different Know Crisis services before you work a disaster Requires a high level of skill Needs most highly experienced Tendency towards overreaction Timing is essential Group processes out of place initally Disasters demand more energy from a CISM team than almost any other incident other than a line of duty death. Development of a strategic approach to the disaster interventions is crucial. Disasters demand more energy from a CISM team than almost any other incident other than a line of duty death. Development of a strategic approach to the disaster interventions is crucial.

21: COST OF CARINGHow we know we are stressed CHEMICAL & PHYSIOLOGICAL STRESS REACTIONS

22: Chemistry of Survival Catecholamines Excites the system Triggers increased nervous system �flight or fight� response Corticosteroids Moderates and controls extremes of catecholamines Keep �flight or fight� in check

23: Endogenous Opiods Creates heightened threshold of pain Causes dissociative reactions Causes blunting of emotions Causes feelings of euphoria with catecholamines, causes amnesiac reactions

24: PHYSIOLOGICAL REACTIONS Ch. 7 RER ADRENAL GLANS KICK IN Cortisone levels rise +-protects from reactions - Immune system depleted -Body goes into starvation mode Thyroid kicks in + everything is working at peak performance � burnout faster 

25: Physiological reactions Endorphins + nature�s opium- no pain - little hurts become big

26: Physiological reactions Shutdown of digestive tract + Blood diverted to muscles and engine room - no lubrication Sex Drive is reduced + Survival mode - Menstrual cycles disrupted - Erectile disfunction

27: Physiological reactions Sugar + short distance energy � tough on diabetics Cholesterol + long distance energy �loads arteries

28: Physiological reactions Heart + pumps thickened blood beats harder and faster � bad heart/ blood pressure? Lungs + collecting more oxygen - tough on smokers

29: PHYSIOLOGICAL REACTIONS Skin + largest organ protects us - dry skin and scaly All six senses + more acute and focused � more prone to accident

30: COMPASSION �a feeling of deep sympathy and sorrow for another who is stricken by suffering or misfortune, accompanied by a strong desire to alleviate the pain or remove its cause.� - Webster-EUDEL

31: COMPASSION STRESS The cost of providing compassionate care. What we invest of ourselves to do our work

32: COMPASSION SATISFACTION What we gain by the work we do. What keeps us doing what we do. What defines how we are mentally, physically, emotionally, spiritually, and behaviorally

33: COMPASSION FATIGUE �There is a cost to caring. People who listen to (and witness) others� stories of fear, pain, and suffering may feel similar fear, pain and suffering because they care. Sometimes we feel we are losing our sense of self to � those we serve�� Charles Figley

34: COMPASSION FATIGUE �Those who have enormous capacity for feeling and expressing empathy tend to be more at risk of compassion fatigue.� (Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatized, Charles Figley, Editor, 1995)

35: COMPASSION FATIGUE Results Diminished sense of purpose/ enjoyment of career Reduced ego functioning (time, volition, identity, language, cognition) Lowered functioning in non- professional situations Diminished capacity for intimacy Loss of hope

36: More RESULTS Subtle manipulation to avoid painful/traumatic material Loss of confidence Diminished effectiveness Dread Victim < �. > Perpetrator Diminished capacity to listen and communicate

Slide 37:Diminished capacity to listen and communicateDiminished capacity to listen and communicate

38: WHAT DOES IT MEAN? Not a reflection of the helper�s inadequacy, nor indicative of the toxicity or badness of the client Is a result of one�s strengths: empathy, involvement and helping Is an occupational hazard for trauma workers, regardless of their profession Is a form of PTSD, and can be repaired.

39: is a strategic intervention system. It possesses numerous tactical interventions

40: All CISM Services Must Be: Timely Efficient Consistent Thorough This slide does not need elaboration. This slide does not need elaboration.

41: Never Interfere With On-going Operations Ability to function is more important than a display of emotions Low profile CISM services Do only what is necessary Do not �push� your support Go easy This slide does not need elaboration.This slide does not need elaboration.

42: Planning and Education Basic /Advanced CISM training Peer support / Family Training Psychotraumatology training Disaster response training Strategic planning Written plans Training and practice Carefully select staff Drill Critique Rewrite the plan Practice again Continue In-Service training This slide outlines what preparations need to be made to prepare a CISM to manage a disaster response. This slide outlines what preparations need to be made to prepare a CISM to manage a disaster response.

43: CISM protocols are likely to break down if they have not been preplanned and practiced This slide does not need elaboration. This slide does not need elaboration.

44: ACCOMPLISHED? NATIONAL INTERAGENCY INCIDENT MANAGEMENT SYSTEM [NIIMS] INCIDENT MANAGEMENT SYSTEM [ICS] IRELAND HEALTH SERVICES USES MIMS

45: Positive Redundancy Two separate groups working on identical information with the intention of developing a comprehensive plan of action Some overlap Some new ideas Clarification of potential problems Positive redundancy is a disaster management method in which two separate groups of planners meet in two different rooms and develop a plan of action using the same information. Both plans groups present their plan to the manager. The manager takes the best of each plan and develops the final plan. Positive redundancy is a disaster management method in which two separate groups of planners meet in two different rooms and develop a plan of action using the same information. Both plans groups present their plan to the manager. The manager takes the best of each plan and develops the final plan.

46: SCENARIO FIRE AMBULANCE GARDAI

47: CISM INTERVENTIONS DEMOBILIZATION CRISIS MANAGEMENT BRIEFINGS INDIVIDUAL INTERVENTIONS SMALL GROUP INTERVENTIONS FOLLOW UP IMMEDIATELY- & AFTER

48: Demobilization Quick information and rest session 10 minutes of information 20 minutes of food and rest Applied at 1.) end of first shift or 2.) before teams are released from incident Provided to teams of workers Provided by CISM team members

49: Crisis Management Briefing This large group process is one of the most versatile tools to be used in disaster related CISM services. It lowers anxiety and guides people toward effective action The purpose of this slide is to remind not teach the concept as if for the first time. The purpose of this slide is to remind not teach the concept as if for the first time.

50: Crisis Management Briefing Keep groups as homogeneous as possible Representative of organization presents information Sometimes question / answer period is allowed CISM team member presents information Specific practical advice is presented to manage the stress associated with the situation This slide presents only some broad overview of the Crisis Management Briefing tool for large heterogeneous groups involved in a disaster. This slide presents only some broad overview of the Crisis Management Briefing tool for large heterogeneous groups involved in a disaster.

51: One on one

52: ATSM SAFER OBSERVE and identify CONNECT GROUND SUPPORT NORMALIZE PREPARE STABILIZE ACKNOWLEDGE FACILITATE ENCOURAGE RESTORE/REFER

53: SAFE-R modelcontent goal STABILIZE mitigate effective escalation ACKNOWLEDGE ventilation, reduce arousal, build rapport, sense of safety FACILITATE view symptoms as normal ENCOURAGE improve imm. & short term coping, develop plan RESTORE/REFER okay/ need help?

54: DEFUSING SMALL GROUP DISCUSSION following critical event. TIMING: Typically provided within 8 hours of the event. STRUCTURE: 3 phases DURATION: less than 1 hour LOCATION: Best in secluded room adequate for the purpose GROUP: Homogeneous group only Please refer the student to the section on defusing in their manuals. Please refer the student to the section on defusing in their manuals.

55: DEFUSING GOALS Normalization / lower tension Set expectations, provide information Discuss coping methods Identify those who need additional support

56: DEFUSING: 3 PHASES INTRODUCTION � Introduce team; lay out the guidelines; lower anxiety about the process EXPLORATION � Allows a brief discussion of the experience. A brief �story� of the event INFORMATION � Provide information, normalize, teach, guidance, summarize key points The easiest way to get the exploration phase going is to say something like this, �My team mate and I were not here when this happened. It would be helpful if you could give us an overview of what happened. We do not need a great deal of detail. We are more interested in the big picture of the event. Perhaps you could tell us what happened first and then next after that and so on.� The easiest way to get the exploration phase going is to say something like this, �My team mate and I were not here when this happened. It would be helpful if you could give us an overview of what happened. We do not need a great deal of detail. We are more interested in the big picture of the event. Perhaps you could tell us what happened first and then next after that and so on.�

57: Critical Incident Stress Debriefing(CISD) A structured GROUP discussion concerning a critical incident. First described by Mitchell (1983) for use with small groups of emergency services personnel. Historical roots in military psychiatry (see HERD, S.L.A. Marshall) Requires a team approach Peers play an absolutely vital role in CISD. The process can be a little complex, however, and a CISM trained mental health professional is required. Ironically, the mental health professional�s main objective is use their skills to keep the process from turning into therapy. Peers play an absolutely vital role in CISD. The process can be a little complex, however, and a CISM trained mental health professional is required. Ironically, the mental health professional�s main objective is use their skills to keep the process from turning into therapy.

58: CISD GOALS Mitigate distress. Facilitate psychological normalization and psychological �closure� (reconstruction). Set appropriate expectations for psychological / behavioral reactions. Serve as a forum for stress management education. Identification of external coping resources. Serve as a platform for psychological triage and referral. The most important goals of a CISD are to a) mitigate the impact of the traumatic event by lowering tension, b) facilitate the recovery process for normal people who are having normal reactions to an abnormal event, and c) to identify individuals within the group who might benefit from additional support or, in a few cases, a referral for psychotherapy. The most important goals of a CISD are to a) mitigate the impact of the traumatic event by lowering tension, b) facilitate the recovery process for normal people who are having normal reactions to an abnormal event, and c) to identify individuals within the group who might benefit from additional support or, in a few cases, a referral for psychotherapy.

59: Phases of a CISD Everything above a dotted line is a little closer to the cognitive domain. Everything below a dotted line is closer to the affective domain. Everything above a dotted line is a little closer to the cognitive domain. Everything below a dotted line is closer to the affective domain.

Slide 60:Participants are not necessarily equally placed around the room, but the CISM team members are strategically placed. Participants are not necessarily equally placed around the room, but the CISM team members are strategically placed.

61: INTRODUCTION Introduces team members Sets expectations Describes �ground rules.� Ground rules anticipate potential problems and attempts to address them in advance. Addresses confidentiality. Participation in discussion is VOLUNTARY. Preview questions.

62: FACT PHASE Possible prompt: �Tell who you are and what happened from your perspective.� May still be used when group exposed to multiple stressors, as in disaster out -processing, or culmination of a tour of duty Most of the time the discussion goes right around the room in the fact phase of a CISD. Skip over anyone who does not wish to contribute anything to the discussion. Do not force anyone to speak if they choose not to speak. Most of the time the discussion goes right around the room in the fact phase of a CISD. Skip over anyone who does not wish to contribute anything to the discussion. Do not force anyone to speak if they choose not to speak.

63: THOUGHT PHASE * �What was the first or most prominent thought that entered your mind regarding the incident?� Any unusual or disquieting thoughts? The thought phase is the only other time when we proceed around the room offering every participant and opportunity to speak. The thought phase is the only other time when we proceed around the room offering every participant and opportunity to speak.

64: REACTION PHASE �What was the worst part of this event for you?� What feelings go with that? OR Any aspects of the event that have caused you the most pain or distress? OR If you had the power to erase one single aspect what would you most want to eliminate from the total experience? Do not proceed around the room from this point on in a CISD. Let anyone who wishes to speak do so. Those who prefer silence are allowed to keep silent. Do not proceed around the room from this point on in a CISD. Let anyone who wishes to speak do so. Those who prefer silence are allowed to keep silent.

65: SYMPTOM PHASE �What physical or behavioral changes have you experienced since the event?� Or, �What has life been like for you since the event?� Or, �What signals of distress have you noticed in yourself since this happened?�

66: TEACHING PHASE Team members normalize reactions of group members, then provide anticipatory guidance, teach stress management, describe external resources available.

67: RE-ENTRY PHASE Reiterate normalization Q & A, if indicated� Develop a plan �group or individual Foster group cohesion, if indicated It is important for every CISM team member to say a few concluding words in the re-entry phase. It is important for every CISM team member to say a few concluding words in the re-entry phase.

68: FOLLOW UP 24 Hours 3 days 3 weeks 3-6 months 51 weeks