Crisis Intervention Strategies: Supporting Individuals in Critical Incidents

1. CRITICAL INCIDENT STRESS MANAGEMENT: ASSISTING INDIVIDUALS IN CRISIS

2. SECTION ONE INTRODUCTION TO CRITICAL INCIDENT STRESS MANAGEMENT (CISM)

3. THE NEED • OVER 80% OF AMERICANS WILL BE EXPOSED TO A TRAUMATIC EVENT • ABOUT 9% OF THOSE EXPOSED MAY DEVELOP PTSD • PTSD PREVALENCE: 10-15% OF LAW ENFORCEMENT PERSONNEL • PTSD PREVALENCE: 10-30% OF THOSE IN FIRE SUPPRESSION • PTSD PREVALENCE: 16% VIETNAM VETERANS • AS MANY AS 35% OF THOSE DIRECTLY EXPOSED TO MASS DISASTERS MAY DEVELOP PTSD

4. THE NEED • U.S. Center for Mental Health Services estimated 1.5 million persons in the NYC area will need counseling for terrorism-related complaints post Sept. 11th • Over 50% of disaster workers can be expected to develop significant posttraumatic distress (Wee & Myers, 2001) • Mass disasters and terrorism will create more psychological casualties than physical (10:1 post Sarin Tokyo) • Random survey of Manhattan: 7% PTSD, 9% depression, 20% PTSD close to WTC • Dow Industrial Average dropped 30% and took 2 months to recover compared to 10% drop and 2 week recovery for European markets (psychological effects of 9-11)

5. Research has shown that human-made disasters are more psychologically pathogenic than are natural disasters. Terrorism may be the most pathogenic of all due to its UNPREDICTABLE and UNRESTRAINED nature.

6. CRITICAL INCIDENTS are events that have the potential to create significant human distress and can overwhelm one’s usual coping mechanisms.

7. The psychological DISTRESS in response to critical incidents such as mass disasters, traumatic events, or terrorist attacks, is called a PSYCHOLOGICAL CRISIS(Everly & Mitchell, 1999)

8. PSYCHOLOGICAL CRISIS An acute RESPONSE to a trauma, disaster, or other critical incident wherein: 1. Psychological homeostasis (balance) is disrupted (increased stress) 2. One’s usual coping mechanisms have failed 3. Evidence of significant distress, impairment, dysfunction

9. In response to the acute mental health needs of those in crisis, the field of CRISIS INTERVENTION was born.

10. There is a strong argument for providing acute psychological first-aid as early as is practical following a traumatic event.(Bisson, et al, 2000, ISTSS Treatment Guidelines)

11. Effectiveness of psychological support increases as a function of both temporal and physical proximity to the stressor event.

12. CRISIS INTERVENTION Psychological “first aid” Goals: 1. Stabilization 2. Symptom reduction 3. Return to adaptive functioning, or 4. Facilitation of access to continued care

13. As physical first aid is to surgery;Crisis intervention is topsychotherapy.

14. CRISIS INTERVENTION (CI) Is one aspect in an overall continuum of care. It requires specialized training.

15. Crisis Intervention Timeline Incident CI EAP CRT’s Psychotherapy Hospitalization CISM Rehab

16. MILITARY PRINCIPLES • IMMEDIACY • PROXIMITY • EXPECTANCY • BREVITY • SIMPLICITY • PRAGMATISM

17. 5 CORE COMPETENCIES OF CRISIS INTERVENTION & EMERGENCY MENTAL HEALTH • Triage Benign vs. Malignant Symptoms • One-on-one Crisis Intervention • Small Group Crisis Intervention • Large Group Crisis Intervention • Strategic Planning

18. IN 1990, THE BRITISH PSYCHOLOGICAL SOCIETY RECOMMENDED THAT CRISIS INTERVENTION SHOULD BE MULTI-COMPONENT IN NATURE.

19. Recent recommendations for early intervention include the use of a variety of interventions matched to the needs of the situation and the recipient populations(Mass Violence & Early Intervention Wkshp, 2002, DoD, DoJ, NCPTSD)

20. CRITICAL INCIDENT STRESS MANAGEMENT (CISM)(Everly & Mitchell, 1997, 1999) A comprehensive integrated, multi-component continuum approach to crisis intervention (See Table 1 and Figure 1)

21. ELEMENTS OF CISM(Everly & Mitchell, 1997, 1999, 2002) • Pre-incident education, preparation • Demobilizations (large groups of public safety) • Crisis Management Briefings (large groups of primary, secondary (emergency personnel), and tertiary (family, co-workers, etc) victims) • Defusings (small groups) • Critical Incident Stress Debriefing (CISD; small groups) • One-on-one crisis intervention • Family CISM • Organizational/ Community intervention, consultation • Pastoral crisis intervention • Follow-up and referral for continued care

22. PRE-INCIDENT PREPARATION • Assessment of risk • Risk reduction • Assessment of physical and psychological response preparedness • Training to reduce vulnerabilities • Training to enhance response capabilities

23. LIMITATIONS:Traumatic stress typically emerges from 2 main sources:1. Violated expectations2. Violated core beliefs (worldviews).Pre-incident training can usually alter expectations, not worldviews.

24. DEMOBILIZATIONSare psychosocial decompression (respite) areas constructed at the disaster venue to provide support (beverages, light food, protection from weather, and provision of psychological support / stress management) to emergency personnel.

25. CRISIS MANAGEMENT BRIEFINGS (CMB) (Everly, 2000)Structured large group community/organizational “town meetings” designed to provide information about the incident, control rumors, educate about symptoms of distress, inform about basic stress management, and identify resources available for continued support, if desired. Especially useful in response to violence/ terrorism.

26. DEFUSINGSSmall group (< 20) structured 3-phase group discussion regarding a critical incident. Typically done with homogenous work groups within 12 hours of the event.May be repeated for ongoing events.

27. “DEBRIEFING” The term “debriefing” has been used frequently in the theory and practice of crisis intervention.

28. Used within the context of CISM, the term “debriefing” refers to a 7-phase structured small group crisis intervention more specifically named Critical Incident Stress Debriefing (CISD).

29. CRITICAL INCIDENT STRESS DEBRIEFING (CISD) (Mitchell & Everly, 2001)A structured 7-phase group discussion typically conducted with homogenous groups 2-10 days (3+ weeks in mass disasters) post incident.Designed to mitigate distress, facilitate psychological closure, or facilitate access to continued care.

30. In 1983, Mitchell’s original paper used the term CISD to refer to both the overarching response system and the small group discussion. This resulted in semantic confusion.Now, the term Critical Incident Stress Management (CISM) is used to denote the overarching response system, while CISD is used to refer to the 7-phase small group discussion.

31. The term “debriefing,” when used alone, has been used in so many different ways, it has lost its meaning and adds to confusion. For example, research from the UK often uses the term to describe 1:1 counseling with medical patients. Unfortunately, studies using this terminology to describe such forms of counseling have been inappropriately cited in the Cochrane Review as evidence of the ineffectiveness of all forms of “debriefing,” even CISD!

32. INDIVIDUAL (1:1) INTERVENTIONMost crisis intervention is done individually, one-on-one, either face-to face or telephonically.

33. FAMILY CISMTraumatic distress can be “contagious;” family members are often adversely affected by those who initially develop posttraumatic distress.AND Families of victims require support, especially when loved ones are seriously injured or killed.

34. ORGANIZATIONAL/ COMMUNITY CRISIS RESPONSEconsists of risk assessment, pre- and post incident strategic planning, tactical training and intervention, and the development of a comprehensive crisis plan.

35. PASTORAL CRISIS INTERVENTION (PCI) The functional integration of the principles and practices of psychological crisis intervention with the principles and practices of pastoral support. (Everly, 2000)

36. FOLLOW-UP & REFERRALAll forms of crisis intervention should possess some form of follow-up.In addition, one of the most cogent reasons for instituting a crisis intervention program is to identify those who require or desire continued care, and to facilitate access to that care.

37. RELEVANT RESEARCH • UK version of 1:1 “debriefing” (one-time counseling with medical patients) ineffective (Cochrane Review, 1998, 2002) • Small group debriefings found to be effective (Everly, Boyle, & Lating, 1999) • Contrary to popular belief, no evidence that group CISD harmful • RCT of CISD found effective for reducing ETOH use, some reduction stress sx (Deahl, et al. 2000) • RCT of CISD found early intervention superior to later intervention (Campfield & Hills, 2001) • CISM repeatedly found to be effective (Richards, 2001; Flannery, 2001) • 10 year analysis of ASAP CISM reveals method to be effective (Flannery, 2001) • ASAP referenced by OSHA

38. The challenge in crisis intervention is not only developing TACTICAL skills in the “core intervention competencies,” but is in knowing when to best STRATEGICALLY employ the most appropriate intervention for the situation.

39. CRISIS INTERVENTION STRATEGIC PLANNING FORMULA1. TARGET (Who should receive services? ID target groups.)2. TYPE (What interventions should be used?)3. TIMING (When should the interventions be implemented, with what target groups?)4. RESOURCES (What intervention resources are available to be mobilized, for what target groups, when?)

40. REMEMBER! CISD / CISM are not substitutes for psychotherapy. Rather, they are elements within the emergency mental health system designed to precede and complement psychotherapy, i.e., part of the full continuum of care.

41. Crisis Intervention Timeline Incident CI EAP CRT’s Psychotherapy Hospitalization CISM Rehab

42. Spectrum Of Care Incident Crisis EAP Intervention CRT’s Legal Chaplain CISMMental Health Psychotherapy Hospitalization Refer where needed…Family Support Rehab

43. Whether face-to-face or over the telephone,more crisis intervention contacts will be done one-to-one than in any other format.

44. SECTION TWO ARE YOU LISTENING?

45. GROUP EXERCISE

46. HAVING COMPLETED THE GROUP EXERCISE • WHAT ROLE DID “ASSUMPTIONS” PLAY? • WHAT ROLE DID VALUES PLAY? • WHAT ARE THE IMPLICATIONS FOR COUNTERTRANSFERENCE REACTIONS, ESPECIALLY WITH REGARD TO PEER INTERVENTIONISTS?

47. SECTION THREE CRISIS COMMUNICATIONS

48. CRISIS COMMUNICATION TECHNIQUES • PARACOMMUNICATIONS: SILENCE AND NONVERBAL BEHAVIOR • “MIRROR” TECHNIQUES • QUESTIONS • ACTION DIRECTIVES

49. BEWARE!Excessive use of silence in crisis situations can communicate lack of interest, thus causing an escalation.

50. Nonverbal behavior sends a powerful message. Often, the first impression you make is based upon how you look. The challenge is how to make that impression useful in the service of crisis intervention.