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Helping the traumatized .... through
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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 ResponseKatrinas Coming!!!!! Phone call among
Dr. Jeffrey Mitchell ICISF,
Director American Red Cross,
Dr. Charles Figley Green Cross
Lets 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 ones 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
+ natures 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 helpers inadequacy, nor indicative of the toxicity or badness of the client
Is a result of ones 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 professionals 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 professionals 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