From Maltreatment to Well-Being: Imaginative Applications from Trauma Intervention for People with Disabilities Critical Incident Stress Defusing Debriefing Immediate Steps that can be Taken to reduce the progression to Post-Traumatic Stress and related Disorders Workshop Outline 11 am – 12:00 am
From Maltreatment to Well-Being: Imaginative Applications from Trauma Intervention for People with Disabilities Group Case Exercise 1:00 pm–2:00 pm Feedback, Questions and Discussion 2:00-2:45 Workshop Outline 1 pm – 2:45 pm
From Maltreatment to Well-Being: Imaginative Applications from Trauma Intervention for People with Disabilities Intermediate-Term Steps to reduce and eliminate the effects of Post-Traumatic Stress and related Disorders Long-Term Steps to reduce and eliminate the effects of Post-Traumatic Stress and related Disorders Questions and Answers Discussion and Next Steps Workshop Outline 3:00 pm – 4:00 pm
From Maltreatment to Well-Being: Imaginative Applications from Trauma Intervention for People with Disabilities Trauma Assessment Begins at the Same Time as Intervention Begins Medical Attention Re-assess psychological impact at every subsequent stage Critical Incident Stress Debriefing and Early Trauma Intervention Treat for Shock Provide Reassurance and Steady Presence Provide Advocacy without removing all Control from Victim Watch out for “Vicarious Trauma” Pursuit of Prosecution Police Involvement Documentation Evidence Gathering and Maintenance Immediate Issues Following Discovery of Abuse/Trauma
&quot;Children are not resilient, children are malleable.&quot; RESILIENT Marked by the ability to recover readily, as from misfortune. Capable of returning to an original shape or position, as after having been compressed. MALLEABLE Capable of being shaped or formed, as by hammering or pressure: a malleable metal. Easily controlled or influenced; tractable. Able to adjust to changing circumstances; adaptable.
the worst thing you can do when others have experienced a Critical Incident, is to criticize others before they are emotionally debriefed. The second worst thing is not to facilitate some form of psychological debriefing.
Do's and Don'ts of Dealing with Disclosures Do: 1. let the person know that you have heard them 2. reassure the person that s/he has done nothing wrong 3. take your time listening to the person 4. use the person's words 5. briefly find out who, what and when so that the risk can be assessed (e.g. does the alleged offender have current access to the person) 6. find out what the person wants to happen 7. deal with unrealistic expectations 8. explain that you may have to report to your supervisor, to CAS (if a youth under 16) and/or to police. This is a legal and ethical responsibility.
Do's and Don'ts of Dealing with Disclosures Don't: 1. react with horror, alarm, or disgust as this may be misinterpreted by the person as directed toward them 2. criticize the alleged offender; the person may still care for them or have conflicting feelings about them 3. tell the person you won't tell anyone or will keep it a secret 4. ever ask a person why s/he let it happen to them 5. ask leading questions 6. put words in the person's mouth 7. make promises you can't keep 8. attempt to assess the truth of the report by yourself
From Maltreatment to Well-Being: Imaginative Applications from Trauma Intervention for People with Disabilities Immediate Steps to Minimize Trauma And Reduce Likelihood of Longer Term Effects of Trauma and Post-Traumatic Stress
The Defusing Process The goals of the defusing process are: To mitigate the impact of the event To help speed up the recovery process To assess the need for a full-scale debriefing To mitigate extreme reactions and facilitate normal reactions to trauma.
The Defusing Process The goals of the defusing process are (continued): Provide a safe opportunity for emotional release and to prevent the suppression and denial of symptoms relating to trauma. Normalize the stress reaction through group sharing and education. Create expectations for recovery.
The Defusing Process The goals of the defusing process are (continued): Reframe irrational and negative thinking. Provide preventative maintenance for those who have not yet been affected by the incident. Provide information on support services available to staff in the organization which has been affected by the trauma.
“ What to Do Until the Doctor (of Psychology) Comes” Limit exposure to sights, sounds and odours Provide an immediate rest break of at least 15 minutes Have a friend stay with the distressed person. Do not leave them alone. Provide fluids, non-alcoholic and non-caffeinated. Provide foods low in salt, sugar and fat.
“ What to Do Until the Doctor (of Psychology) Comes” Allow the person to talk about the experience. But mainly just listen - don’t do a lot of talking yourself. Do not rush the person to return to work Protect the person from bystanders and certainly from the media Reassure the person that the stress experience is normal; most people recover very well from stress - such things as “this too shall pass - you can get through this” etc.
“ What to Do Until the Doctor (of Psychology) Comes” Show appreciation for the person's work, efforts, or courage as appropriate. Do nothing to embarrass the person. Help the person make decisions if they are needed. Stay calm, unhurried, don’t pressure the person to make decisions that are not absolutely needing a decision right away.
Next Step in Immediate Therapeutic Intervention in Trauma Debriefing takes place within a few days after a Critical Incident has occurred. Unlike Defusing, this is a planned intervention.
“ Traditional” Seven Step De-Briefing Introduction - leader, group members, what the process is, basic ground rules for the group. Fact phase - what happened, where, how, when, etc. Thoughts phase - what people thought at the time of the incident, are thinking now, have thought about since the incident. Reactions phase - what else are people experiencing, feeling, or interpreting with respect to the incident.
“ Traditional” Seven Step De-Briefing Symptoms phase - what is happening to group members since the incident. Teaching phase - teaching about reactions to acute stress, physical, intellectual, emotional and behavioural sequelae to acute stress; what can be done about this, coping mechanisms, etc. Re-entry phase. Readiness to return to equilibrium, work, “normalcy”
The Mitchell Model of Critical Incident Debriefing Introduction and explanation of the ground rules. Finding out all the facts about the event. Discovery of the thoughts associated with the facts. Move to the emotional reactions affecting participants. Description of the unusual symptoms experienced. Provision of information on Traumatic Stress. Re-entry: recap of the debriefing and pointers to strengths of participants.
The Nova Model of Critical Incident Stress De-Briefing Focus on issues of safety and security. Allow ventilation and supply validation. Consider prediction and preparation.
Cognitive Distortions 1. Categorical Thinking : Things are seen in &quot;either‑or&quot;, &quot;black or white&quot; categories, with no &quot;middle ground&quot;, &quot;grey areas&quot;. Example: &quot;If you're not my friend you're my enemy.&quot; 2. Overgeneralizing : A single event or only a few instances of something occurring in some situations is perceived as part of a reliable, continuous trend that holds in all situations. Examples: &quot;I'm on a losing streak!&quot; 3. Mental Filtering : Events of only negative value are perceived, while events of positive value are unrecognized. Can also occur in reverse. Examples: &quot;He hasn't done anything right since he came back to work&quot;. &quot;If we just believe enough in ourselves, we'll win.&quot;
Cognitive Distortions 4. Personalizing : Things are attributed to oneself that are actually unrelated. &quot;It's all my fault that the staff went on strike.&quot; 5. Jumping to Conclusions : An interpretation or judgement is made despite limited supporting information. Example: &quot;If you don't like this draft, I'll can the whole project. It just won't be worth doing.&quot; 6. Exaggerating : The importance of or meaning of something is &quot;blown out of proportion&quot;. Example: &quot;He turned down my proposal. He must think I'm a total jerk!&quot; Also called “Awfulizing”! 7. Minimizing or Trivializing : The importance of or meaning of something is under‑estimated or artificially diminished. &quot;Just because he made a pass at you doesn't mean it's sexual harrassment.&quot;
Cognitive Distortions 8. Moralizing : An outlook in which &quot;should&quot; and &quot;shouldn't&quot; positions dominate thinking, usually with an underlying attitude of punishment or threat of punishment. Example: &quot;Workers should be available to their clients. If I had taken my beeper on my holidays I could have prevented this tragedy.&quot; Also called “Shoulding on yourself”! 9. Mind Reading : Assuming perceptions or thoughts by another when they have not voiced or given such evidence. Example: &quot;I just know she doesn't like me ‑ don't ask me why&quot;. 10. Labelling : Terms are used to describe a simple behaviour or characteristic which connote much more, much of which is groundless, and often labels the person rather than the behaviour. Example: &quot;He's a moron&quot;.
Cognitive Distortions 11. Fortune Telling : Assuming a prediction will come true with much greater certainty than warranted. Example: &quot;If this isn't done, the whole program will fall apart&quot;. 12. Emotionalizing : Perceptions are coloured by emotion. Example: &quot;I feel so depressed ‑ I'll never be able to solve this problem, it's so hard!&quot;. 13. Disqualifying the Positive : Positive reinforcement or positive attributions toward the self are denied. Examples: attributing achievements to &quot;luck&quot;, or compliments to &quot;ulterior motives&quot; of others.
Cognitive Distortions These common cognitive distortions may begin at the time of an event, or be part of a more stable “personality” style. Addressing these distortions is thus important immediately after an event, and in the longer-term intervention process with a person who has suffered trauma or is in current distress.
Critical Incident Stress De-Briefing Process Begin by explaining ground rules and by assuring people that they are safe in the present environment. Encourage people to describe their experiences during the event, where they were, who were they with, what they saw, heard, sensed, etc. Safety and security issues are always very high on the list even if the trauma was in the past.
Critical Incident Stress De-Briefing Process People describe what has happened to them in the aftermath of an event, i.e. memories of the event that stand out, what has happened to them, or others, in the last 24 hours or so, and what they might remember seeing or hearing during that time. Get members to open up and ventilate all their unusual and overwhelming memories and reflections and reactions, including anger, turmoil, fear, frustration, confusion etc. Validate all expressions of emotional reaction but respond with calm, composed, reassurance. Quiet voice, slow pace of speech, unhurried movements.
Critical Incident Stress De-Briefing Process Get people to predict how they are going to get through the next short while (predict for themselves how to cope). What range of emotions might they experience in the ensuing months? How will their family life, job, or social life be affected? How will they deal with nightmares or other disturbing and intrusive thoughts? How do they “normally” deal with life’s challenges or disappointments? How do they imagine others will deal with troubles?
Critical Incident Stress De-Briefing Process People develop workable coping skills over the years, as well as dysfunctional coping habits. Reinforce successful techniques as they are identified. Suggest alternatives to dysfunctional methods. Group process can be helpful by supplying examples of successful coping from people in “the same boat”, having thereby more credibility. Be careful not to criticize a person. Opportunities for discussion of unhealthy coping methods can also help prevent group members from inadvertently adopting these in the absence of such advice (i.e. drinking, or withdrawal).
Critical Incident Stress De-Briefing Process The final step is about: regaining equilibrium, returning to “normal”, getting back to work, facing the future, and developing resilience and immunity to the expected continuation of some disturbing symptoms Dedicate time to teaching participants about “normal” effects of traumatic events, using materials such as brochures and other handouts, and referring to on-going support available through various support programs such as Human Resources and EAP. Be observant of members who appear to be at risk for continued or more severe post-incident trauma, who might be offered individual time in a discreet fashion.
The BATHE De-Briefing Process B = BACKGROUND – find out what happened. A = AFFECT – what kind of a mood response was there. T = TROUBLE – what troubles you the most. H = HANDLING – how are you handling that. E = EMPATHY – this must have been difficult for you.
Hints for Inquiry During De-Briefing Allow participants to tell the story and find out about the initial impact. This can be done by saying something like “Tell me what I need to know so that I can understand what happened”. Assess the lingering impact and how the event is viewed presently. In this way you will discover how participants are functioning now. This can be done by using some of the following questions: Impact – what has changed in your life? Ruminations – do you find yourself thinking about it ? Intrusions – do memories trigger pain ? Avoidance – do you avoid certain things due to the memories? Physical Symptoms – are you jumpy, irritable? Sleep Patterns - how are you sleeping? Nightmares?
Critical Incident Stress De-Briefing Normally takes place 24-48 hours after the event, allowing an opportunity to attempt to engage in some of the normal daily routine. Takes place in a private and confidential room that can accommodate the complete group comfortably. The group is typically arranged in horseshoe formation, and preferably there will not be a table between the group members, as this only serves to distance the participants, at a time when more closeness is healthy.
Conducting Critical Incident Stress De-Briefing As a developmental service worker, you are much more likely to be a victim or witness to a critical stress incident. However, if you find yourself in situation where leading or promoting a “debriefing” because it is believed to be necessary, here are some guidelines to consider: 1. Not everyone can conduct debriefings. Those best suited have: a. good interpersonal skills b. know from experience that Critical Incident Stress is real and a normal reaction to acute trauma c. are comfortable with the expression of emotion in themselves and others; d. are trusted by those they plan to assist. e. Knowledge of crisis intervention, grief and loss is also important and an asset.
Conducting Critical Incident Stress De-Briefing 2. You must be seen as an ally to the group you plan to debrief. Sometimes even the warmest and most supportive supervisor cannot lead a debriefing due to attitudes held toward management or an existing difficult climate between workers and management. Debriefers should be clearly identified by the beneficiaries of the process as functioning at the peer level. If there is no one else, inform the group or individual that your role is as a supportive colleague, not as a “boss”. If you cannot confidently believe you will be able to achieve this level of trust, get someone else to debrief. 3. Make the rules clear. This is not a critique. The purpose of the session is to share feelings, and debrief a situation that is having or will be predicted to have, a traumatic impact. It is not to criticize. Also make sure participants agree that the proceedings will be held in strictest confidence. 4. Pick a time and place that is comfortable and where there will be no interruptions. The debriefing should be a continuous and focused process, with no interruptions and with no one wandering in and out.
Conducting Critical Incident Stress De-Briefing 5. Do not assume how participants are feeling. 6. Explain your mission and qualifications or the felt need or assignment to conduct the debriefing. Then simply invite participants to individually respond to how the incident has impacted them. 7. Observe any signs of emotional vulnerability or defensiveness. 8. Let the situation flow and let the group establish its own emotional level. Peers are often the best facilitators of group discussion and expression of impact and emotion. 9. Remember that expression of extreme emotion is a healthy, normal process that emergency workers and social services workers may have learned to suppress. However, they, like everyone, including you, are human and the effects as well as the preferred method of debriefing, are essentially beyond training and will to conduct properly.
Conducting Critical Incident Stress De-Briefing 10. Don't force the group process, but do get each individual to contribute at least once. One suggestion is to follow the traditional debriefing steps and have participants discuss what they actually said and heard at the scene. If individuals have been traumatized, it normally shows through their tone of voice. When this happens, let them express themselves. Affirm that what they are experiencing is normal given the circumstances. 11. Stop, immediately, any criticism of others. A critique will no doubt follow, later, but if individuals start to complain or criticize others’ behaviour, redirect by saying something like: &quot;we will be doing a review and critique later. The purpose of this session is to debrief, that is, share our initial reactions about the situation. Tell us how you were thinking, how you felt during the time the [disclosure, incident] was happening&quot; Being criticized before you are debriefed can be more traumatic than the incident itself.
Conducting Critical Incident Stress De-Briefing 12. Do not permit tough, insensitive comments or any gallows humor directed towards sensitive members of the group or sensitive expressions by members. This will suppress expression of personal feelings, particularly among those who might be severely affected. 13. Watch for the non-participant especially the one who is visibly shaken. Touch base later, in private, to make sure they are not simply reluctant to talk in a group setting. 14. If the debriefing becomes emotional, do not stop until all the grief and pain is out. Even if you have gone through the entire group without any expression of feelings until the last person shares emotional pain, make sure you allow time to go around the group again allowing others to do the same. 15. End the debriefing with a &quot;Where do we go from here?&quot; discussion. After such an emotional discussion there is a need for a transition. Talking about action plans provides such a transition, gives time for individuals to internalize what has happened, and allows members to get ready to return home or to work. 16. Debrief yourself.
Self-help Suggestions for Surviving Critical Incident Stress Be with other people who you can trust and rely upon. Don’t be reluctant to impose on others Have a caring person at your side – of your own choosing if possible. Ask for the help you feel you need. Getting back in control of your circumstances is very important. Let other people help. Don't let foolish pride stand in the way of receiving what you truly need from relatives, neighbours, friends and concerned volunteers. Talk about your feelings. Go ahead and talk about your fears, frustrations and sadness ‑ you're not &quot;just feeling sorry for yourself.&quot; While it's true that eventually you need to put the trauma &quot;behind&quot; you, you can't do that by ignoring your feelings or trying to erase those memories. That's impossible. You have to face and deal with these feelings ‑ the sooner the better. get the information and advice you need.
Self-help Suggestions for Surviving Critical Incident Stress You probably are handling many of your problems on your own, however you may not be seeing things objectively. You may need to ask someone for some information, advice, or suggestions. Reassure yourself. You can remind yourself that you are now safe and that there is nothing wrong with you for having these reactions. Prepare for future incidents. That way, you can either handle future incidents without getting so upset, or at least believe you can. Either way, you will feel more in control, and less disturbed about events. Take good care of yourself. You have plenty of work to do, but you won't be able to do it if you're sick or incapacitated by being so upset. Eat well, get plenty of sleep, and take some time off for yourself. Be careful with alcohol and other drugs. It's easy to abuse them. Get professional help if you're having severe problems, especially if you're having extreme reactions, such as repeated nightmares, &quot;flashbacks&quot; of the events, crying spells, behaviour problems, and panic reactions.