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Critical Incident Stress Management


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A presentation for chaplains courtesy of Fr. George Morelli

Published in: Health & Medicine
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Critical Incident Stress Management

  1. 1. Critical Incident Stress Management (CISM) Headquarters Southwest Region Civil Air Patrol/USAF-Auxiliary
  2. 2. CISM PEP Talk Pre-Exposure Preparation Talk A
  3. 3. Objectives of this presentation: <ul><li>A review of the causes and effects of stress </li></ul><ul><li>Some cues to identify stress and tools to manage it </li></ul><ul><li>An overview of critical incident stress, crisis management, and critical incident stress management (CISM) </li></ul><ul><li>An orientation to CAP’s CISM program </li></ul>To provide the participants with ...
  4. 4. CISM is a Mandated Operations Program! It is not just a Chaplain’s program!
  5. 5. Just What is Stress? “ A state of physical and emotional arousal .”
  6. 6. Where Does Stress Come From? Stimulus Stressor stimulus/demand Response Stress Response
  7. 7. Some Definitions ... <ul><li>Stressor -- a stimulus that causes, evokes, or is otherwise strongly associated with the stress response </li></ul><ul><li>Stress response -- Nonspecific response of the body to a demand(s) </li></ul><ul><li>Target organ(s) -- The part of the body, or mind, that is the recipient of the stress response and which develops the signs & symptoms of over-arousal </li></ul>
  8. 8. For example ... <ul><li>While flying, the stressors of heat and G-forces affect the body. </li></ul><ul><li>Next a stress response occurs in the inner ear leading to a condition known as “vertigo.” </li></ul><ul><li>Then the target organ of the stomach is over-aroused and decides to “get rid of food!” </li></ul>… airsickness
  9. 9. 2 “Varieties” of Stress ... “ Eustress” equals Good Stress --- Positive, motivating stress “ Distress” equals Bad Stress --- Negative, excessive, debilitating stress
  10. 10. Some Generic Sources of Stress ... <ul><li>Biogenic </li></ul><ul><li>Environmental </li></ul><ul><li>Personality </li></ul>
  11. 11. Some Biogenic Stressors ... <ul><li>Caffeine </li></ul><ul><li>Nicotine </li></ul><ul><li>Amphetamines </li></ul><ul><li>Cold & allergy medicines </li></ul><ul><li>Theophylline </li></ul><ul><li>Illness </li></ul><ul><li>Lack of sleep </li></ul>
  12. 12. Some Environmental Stressors ... <ul><li>Rain </li></ul><ul><li>Temperature extremes </li></ul><ul><li>Sounds --- screams </li></ul><ul><li>Mud </li></ul><ul><li>Smells </li></ul><ul><li>G-forces </li></ul><ul><li>Time of day </li></ul>
  13. 13. Personality The way people are “hard-wired.”
  14. 14. Stress is Cumulative It builds up over time ...
  15. 15. Cumulative Stress <ul><li>Piles up ( snowballs ). </li></ul><ul><li>Increases with time. </li></ul><ul><li>Deteriorates: </li></ul><ul><li> * Performance </li></ul><ul><li> * Relationships </li></ul><ul><li> * Health </li></ul>Is stress that ...
  16. 16. We Used to Call it “Burnout” <ul><li>Increased cynicism. </li></ul><ul><li>Increased physical lethargy. </li></ul><ul><li>Procrastination. </li></ul><ul><li>In the extreme … even … suicidal or homicidal thoughts or ideations. </li></ul>
  17. 17. Some Signs & Symptoms of Cumulative Stress <ul><li>Tardiness </li></ul><ul><li>Fatigue </li></ul><ul><li>Detachment </li></ul><ul><li>Depression </li></ul><ul><li>Medication or drug use. </li></ul><ul><li>Irritability </li></ul><ul><li>“ Gallows” humor </li></ul><ul><li>Paranoia, or irrational fears. </li></ul><ul><li>Derogatory speech or labeling of others. </li></ul><ul><li>Denial </li></ul><ul><li>Increased workplace absences. </li></ul><ul><li>Irresponsibility </li></ul>
  18. 18. An Example of Cumulative Stress ... The De Havilland “Comet” -- The World’s First Commercial Jet Airliner
  19. 19. Like With The Airliner ... Stress is the “wear and tear” on our human coping systems. Over time minor stresses can have major and damaging effects. This is the cumulative effect of stress. … and we can crash too!
  20. 20. Critical Incident Stress “Any event in which there is a stressful impact sufficient enough to overwhelm the usually effective coping skills of either an individual or a group.” (Everly & Mitchell, 1999)
  21. 21. Cumulative stress can exacerbate critical incident stress.
  22. 22. Critical Incidents are events that have the potential to create significant human distress and can overwhelm the usual coping mechanisms of individuals and/or groups.
  23. 23. How to Recognize Excessive Stress?
  24. 24. Manifestations of Distress Can Take a Number of Forms... <ul><li>Physical </li></ul><ul><li>Cognitive </li></ul><ul><li>Emotional </li></ul><ul><li>Behavioral </li></ul>
  25. 25. Physical Manifestations <ul><li>Excessive sweating </li></ul><ul><li>Nausea and/or vomiting </li></ul><ul><li>Elevated pulse rate </li></ul><ul><li>Elevated blood pressure </li></ul><ul><li>Rapid breathing </li></ul><ul><li>Dizziness </li></ul>
  26. 26. Cognitive Signs <ul><li>Confusion. Mumbling of words </li></ul><ul><li>Difficulty making decisions </li></ul><ul><li>Decreased concentration </li></ul><ul><li>Memory dysfunction </li></ul>
  27. 27. Emotional Signs <ul><li>Emotional Shock </li></ul><ul><li>Anger </li></ul><ul><li>Grief </li></ul><ul><li>Depression </li></ul><ul><li>Feeling totally overwhelmed </li></ul>
  28. 28. Behavioral Signs <ul><li>Changes in ordinary behavior </li></ul><ul><li>Changes in eating habits </li></ul><ul><li>Decreased personal hygiene </li></ul><ul><li>Prolonged silences </li></ul><ul><li>Withdrawal </li></ul>
  29. 29. Stress Response Timelines <ul><li>Immediate -- up to 24 hours post event. </li></ul><ul><li>Delayed -- 24 to 72 hours post event. </li></ul><ul><li>Cumulative -- buildup of stress over time. </li></ul>
  30. 30. Post-Traumatic Stress is ... “… a normal reaction in a normal person, to an abnormal event .” “… a survival mechanism , whereas (PTSD) is a pathogenic (unhealthy) variation of that normal survival mechanism.” Post-Traumatic Stress Disorder
  31. 31. Examples of Critical Incidents <ul><li>Line of duty death or death at workplace </li></ul><ul><li>Serious line of duty injury or workplace injury </li></ul><ul><li>Suicide of coworker, friend, family member </li></ul><ul><li>Multiple casualty incidents (MCI’s), disasters </li></ul><ul><li>Significant events involving children </li></ul><ul><li>Prolonged events especially with loss </li></ul><ul><li>Any powerful event which overwhelms a person’s normal coping mechanisms </li></ul>
  32. 32. A Crisis <ul><li>One’s normal psychological balance (homeostasis) has been disrupted, </li></ul><ul><li>One’s usual coping mechanisms have failed to reestablish the needed homeostasis, or </li></ul><ul><li>There is evidence of functional impairment. </li></ul>A response to an event wherein ...
  33. 33. Crisis Intervention
  34. 34. Crisis Intervention is ... <ul><li>An exercise in psychological damage control. Stopping the bleeding! </li></ul><ul><li>Not a cure </li></ul><ul><li>An opportunity for assessment and for follow-up </li></ul><ul><li>Guided by a mental health professional (MHP) </li></ul>The provision of timely “emotional first aid:”
  35. 35. Crisis Intervention Is but one aspect of a continuum of care. It requires specialized and unique training .
  36. 36. Crisis Intervention Principles ... <ul><li>Spell B - I - S - E - P </li></ul><ul><ul><ul><li>Brevity </li></ul></ul></ul><ul><ul><ul><li>Immediacy </li></ul></ul></ul><ul><ul><ul><li>Simplicity </li></ul></ul></ul><ul><ul><ul><li>Expectancy </li></ul></ul></ul><ul><ul><ul><li>Proximity </li></ul></ul></ul>B I S E P
  37. 37. Critical Incident Stress Management (CISM) is one type of crisis intervention. It is a comprehensive, systematic program for the mitigation of critical- incident related stress.
  38. 38. The goals of CISM ... <ul><li>Prevent traumatic stress </li></ul><ul><li>Mitigate traumatic stress </li></ul><ul><li>Intervene to assist recovery from traumatic stress </li></ul><ul><li>Accelerate recovery </li></ul><ul><li>Restore function </li></ul><ul><li>Maintain worker health and welfare </li></ul>
  39. 39. By way of analogy ... According to the Wing Aircraft Maintenance Officer, HQ-TX Wing expects to spend approximately $187,000.00 this year to maintain our fleet of airplanes. But … how much are we spending to maintain our most valuable asset… OUR PEOPLE ?
  40. 40. CISM is a comprehensive, systematic maintenance program for the overall well-being of our most valuable assets … our members .
  41. 41. CISM involves many facets ... <ul><li>Pre-crisis preparation and education </li></ul><ul><li>Demobilization (for large groups) </li></ul><ul><li>Crisis management briefings (large groups also) </li></ul><ul><li>Defusings </li></ul><ul><li>Critical incident stress debriefing (CISD) </li></ul>
  42. 42. CISM also involves ... <ul><li>One-on-one, individual crisis intervention </li></ul><ul><li>Pastoral crisis intervention </li></ul><ul><li>Family CISM </li></ul><ul><li>Organizational crisis intervention / consultations </li></ul><ul><li>Follow-up and referral mechanisms </li></ul>
  43. 43. CISM deals with the current circumstances, the current event or crisis … NOT … personal histories. It is First Aid, not definitive care.
  44. 44. Some Key Elements of CISM ...
  45. 45. Pre-Incident Education <ul><li>General information: stress, trauma, etc. </li></ul><ul><li>Set expectations for actual experiences </li></ul><ul><li>Teach stress management and coping skills </li></ul>
  46. 46. Demobilizations <ul><li>Decompression </li></ul><ul><li>Transition workers from disaster work (large-scale incident) to routine duties or home </li></ul><ul><li>Used with large numbers of people </li></ul><ul><li>A 10- to 30-minute session </li></ul><ul><li>An opportunity for assessment of group needs </li></ul><ul><li>Alert workers to possible stress effects </li></ul><ul><li>Always followed by a CISD (debriefing, usually within one week </li></ul>
  47. 47. Defusing <ul><li>A small group intervention conducted within hours of the incident, usually within 12 hours </li></ul><ul><li>Shortened version (20-45 mins) of the CIS- Debriefing </li></ul><ul><li>May eliminate the need for, or increase effectiveness of, CISD; opportunity to assess the need for CISD </li></ul><ul><li>Seeks to reduce intense reactions to a trauma </li></ul><ul><li>Seeks to “normalize” the effects of the event </li></ul>
  48. 48. The Defusing 3-Step ... <ul><li>*Introduction </li></ul><ul><li>*Exploration </li></ul><ul><li>*Information </li></ul>
  49. 49. The Critical Incident Stress Debriefing (CISD) <ul><li>A group discussion of a traumatic event </li></ul><ul><li>Peer driven </li></ul><ul><li>Clinician (MHP) guided </li></ul><ul><li>Lasts 1-3 hours </li></ul><ul><li>Closed circle format </li></ul><ul><li>Held 1 - 10 days post event </li></ul><ul><li>NOT psychotherapy! </li></ul>C I S D
  50. 50. Objectives of the CISD <ul><li>Education </li></ul><ul><li>Ventilation </li></ul><ul><li>Reassurance and forewarning </li></ul><ul><li>Positive contact with a MHP </li></ul><ul><li>Improvement of interagency cooperation </li></ul><ul><li>Increase group cohesiveness </li></ul><ul><li>Restore self-confidence </li></ul><ul><li>Facilitation of follow-up </li></ul>
  51. 51. CISDs consist of 7 stages ... Mitchell, 1991
  52. 52. Family Support <ul><li>An essential component of a comprehensive CISM program </li></ul><ul><li>Consists of: * Educational programs * CISD for significant others * Bereavement support -- grief and crisis counseling </li></ul><ul><li>Provided by peers, MHP, clergy, trained spouses </li></ul><ul><li>Includes children and elderly as well </li></ul>
  53. 53. Referral ... <ul><li>Is made to obtain a more thorough a process of assessment and evaluation, </li></ul><ul><li>The mental health provider should understand the “culture” of the agency in which the person is employed, and </li></ul><ul><li>should have specialized training/experience in post-traumatic stress. </li></ul>
  54. 54. Follow-up ... <ul><li>Essential element in all CISM interventions. </li></ul><ul><li>Can be made by: * Phone calls * Station / workplace visits * Home visits </li></ul>
  55. 55. All CISM Interventions Are Strictly Confidential!
  56. 56. How well does CISM work? Let’s compare two airliner crashes to see ...
  57. 57. San Diego 1978 v. Cerritos 1986 San Diego , PSA-182: 9/25/1978 Cerritos , Aeromexico: 8/31/1986 San Diego Cerritos Total Killed 125 82 Aircraft Survivors 0 0 Homes Destroyed 16 16 Killed on Ground 15 15 ESP used 300 300 Body Parts Recovered 10,000+ 10,000+
  58. 58. San Diego v. Cerritos cont’d … Types of Critical Incident Interventions Provided San Diego 1978 Cerritos 1986 Sporadic 1 on 1 12 CISDs Crisis Interventions Demobilizations Crisis hotline Follow-ups with MHP’s
  59. 59. San Diego v. Cerritos Personnel losses, among responders, within 1 year of event: Increase in MH utilization within community within 1 year: 31% 1% SD CER Ranking PD 5 0 FD Personnel 7 1 EMS Personnel 17 0
  60. 60. CISM Works!
  61. 61. CISM in the Civil Air Patrol
  62. 62. CAP’s CISM Program <ul><li>Mandated by CAPR 60-5 </li></ul><ul><li>Not optional </li></ul><ul><li>Specifically an operations program </li></ul><ul><li>Implementation is assigned to Region Commanders by CAPR 60-5. </li></ul>
  63. 63. CAP’s CISM Program cont’d <ul><li>Wings are to “… assess the need for a CIST.” </li></ul><ul><li>All personnel are encouraged to receive CIS training. </li></ul>
  64. 64. CAP’s CISM Program ... “ The use of qualified, local, non-CAP teams to respond to incident stress-affected CAP members is highly encouraged … The use of local non-CAP teams will somewhat limit the need to dispatch a trained CAP CIS [Team]” --CAPR 60-5 (2)e
  65. 65. CAP’s CISM Program ... “… Each active duty Air Force base is required to have a CIST, which, with prior coordination, may be able to support CAP” --CAPR 60-5 (2)e
  66. 66. A CAP CIST <ul><li>Consists of: </li></ul><ul><ul><li>Mental Health Professionals (MHP) </li></ul></ul><ul><ul><li>Peer Representatives </li></ul></ul><ul><ul><li>CAPR 60-5 (3)a 2 </li></ul></ul>
  67. 67. Request & Deployment <ul><li>After a SAR or DR mission “ … a review of the need for CIS intervention should be made for all personnel ...” </li></ul><ul><li>The incident commander or unit commander will pass a request to wing commander. </li></ul><ul><li>In consultation with staff, the wing CC will coordinate use of a local non-CAP team or request one of the Region teams. </li></ul>
  68. 68. Funding CISM <ul><li>CISM is not, presently, a specifically USAF funded mission (by itself). </li></ul><ul><li>CAP CISM may be funded through an existing mission’s funding. </li></ul>
  69. 69. Funding CISM <ul><li>The CAP Natl HQ has approved limited funding to support CISM missions nationally. </li></ul><ul><li>Housing and feeding of a team will normally NOT be reimbursed. </li></ul><ul><li>The “… use of host families…” is encouraged to mitigate housing costs. </li></ul>
  70. 70. For More Information ... <ul><li>Visit the web site of the International Critical Incident Stress Foundation (ICISF) at . </li></ul><ul><li>Join the ICISF. </li></ul><ul><li>Review CAPR 60-5. </li></ul>
  71. 71. For More Information ... <ul><li>Call Chaplain Don Brown at (936) 394-3310 or email him at [email_address] . </li></ul><ul><li>Sign up for the “Basic Critical Incident Stress Management” and other ICISF CISM courses. </li></ul>
  72. 72. Any Questions?
  73. 74. Credits Lt Col Sherry Jones, RN, CAP Special Advisor to the National Commander for CISM Ch, Lt Col DONALD R. BROWN II, CAP SWR Deputy Chaplain and CISM Director 1st Lt Penny Herndon-Finuf, RN, CAP SWR/TXWNG CISM Educational Officer