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Critical Incident Stress Management
- 1. Critical Incident Stress Management (CISM) Headquarters Southwest Region Civil Air Patrol/USAF-Auxiliary
- 2. CISM PEP Talk Pre-Exposure Preparation Talk A
- 4. CISM is a Mandated Operations Program! It is not just a Chaplain’s program!
- 5. Just What is Stress? “ A state of physical and emotional arousal .”
- 6. Where Does Stress Come From? Stimulus Stressor stimulus/demand Response Stress Response
- 9. 2 “Varieties” of Stress ... “ Eustress” equals Good Stress --- Positive, motivating stress “ Distress” equals Bad Stress --- Negative, excessive, debilitating stress
- 13. Personality The way people are “hard-wired.”
- 14. Stress is Cumulative It builds up over time ...
- 18. An Example of Cumulative Stress ... The De Havilland “Comet” -- The World’s First Commercial Jet Airliner
- 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. 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. Cumulative stress can exacerbate critical incident stress.
- 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. How to Recognize Excessive Stress?
- 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
- 35. Crisis Intervention Is but one aspect of a continuum of care. It requires specialized and unique training .
- 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.
- 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. CISM is a comprehensive, systematic maintenance program for the overall well-being of our most valuable assets … our members .
- 43. CISM deals with the current circumstances, the current event or crisis … NOT … personal histories. It is First Aid, not definitive care.
- 44. Some Key Elements of CISM ...
- 51. CISDs consist of 7 stages ... Mitchell, 1991
- 55. All CISM Interventions Are Strictly Confidential!
- 56. How well does CISM work? Let’s compare two airliner crashes to see ...
- 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. 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. 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. CISM Works!
- 61. CISM in the Civil Air Patrol
- 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. 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
- 72. Any Questions?
- 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
Editor's Notes
- ================================= Welcome remarks: Good morning (afternoon, etc.). I would like to welcome you to this PEP Talk on critical incident stress management. I’m (your name) . Tell a little bit about yourself. As appropriate, tend to any “housekeeping” chores, eg, location of exits, bathrooms, break and lunch times, etc.
- We call this presentation a PEP Talk… A “pre-exposure preparation talk.” It is not designed to train you to be a Critical Incident Stress Team member, but it is designed to give you an in-depth over-view of CISM and how we use it in the Civil Air Patrol.
- ================================= Read slide
- ================================= Within CAP, CISM is not just a Chaplain’s program, and it’s not a mental health program. It is a peer-driven Operations program with mental health oversight (Click to put red oval around “Operations.”) mandated by CAP Regulation 60-5 (E). (Click to put red oval around “CAP Reg.”) “ This regulation prescribes concepts, policies, and standards that govern all CAP personnel in the training, qualification and implementation of Critical Incident Stress Teams (CIST).” CAPR 60-5 Let’s start off by talking a little about stress. (go to next slide)
- ================================= Read slide title. Ask participants for their definitions. Then click again for answer to appear. We’ve all been here at one time or another.
- ================================= For every stimulus, there is some sort of response. Ask for examples: eg, kick a ball, it rolls away; call “ten hut,” and cadets, hopefully, snap to attention. :-) ; smell a pot roast cooking, begin to salivate. Likewise, for every stressor or demand in our lives, there is also a physical or psychological response. Let’s back up a bit and review a few definitions. Click to next slide.
- ================================= These definitions are taken directly from Mitchell and Everly’s CISM manual “Critical Incident Stress Management: Group Crisis Intervention.” Read slide. Imagine a stressor like being caught in a traffic jam. What might the stress responses and target organs be? Elicit student responses. The stress response may be increased adrenaline or feelings of anxiety. The target organs then might be increased heart rate, increased blood pressure, or anxiety. Click to next slide.
- ================================= Here’s an example to which many of us can relate. Read or paraphrase each bullet. After the third bullet: And what does that give us? Click to bring in “airsickness.”
- ================================= Read slide. Depending on time frame, ask participants to give some examples of good and bad stressors or provide these yourself. Some examples: Good stressors: Physical exercise Flying Birth of a child Holidays Bad stressors: Late to an appointment Work project behind schedule or over budget Traffic Disasters: natural or man-made Death of family or colleague
- ================================= Some generic sources of stress are biogenic, environmental, and individual personality. Click to next slide.
- ================================= Read slide. FYI WARNING: Phenylpropanolamine can still be found in some cold remedies; however, PPA increases the risk of hemorrhagic stroke (bleeding into the brain or into tissue surrounding the brain), and the FDA recommends that consumers not use any products that contain PPA. Theophyline is a bronchodilator used to relieve acute bronchospasms. It can cause central nervous system, cardiovascular, gastrointestinal and respiratory reactions. Now let’s talk about environmental stressors. Ask for some examples, then click to next slide.
- ================================= Read slide. What are some ways that these environmental stressors affect our bodies and psychological states? Get a couple of examples from the group. Click to next slide.
- ================================= We’re all hard-wired differently, each with our own personalities and ways of coping with stresses that come our way. Of course, something that stresses any one of us may have little effect or a different effect on others of us. However… Click to next slide.
- ================================= Read slide.
- ================================= Cumulative stress is stress that can pile up or snowball. As it increases over time, it can ultimately cause deterioration of your performance (both at work and at play), in your relationships, and/or in your health.
- ================================= We used to call this cumulative stress “burnout.” I’m sure we’ve all seen this manifested in many ways, such as… Read slide. These things can happen both at work and in our volunteer activities.
- ================================= Here are some signs and symptoms that one might experience with cumulative stress. Read off a few from the slide. We may all feel some of these things from time to time. They become a problem as they build up and increase in number.
- ================================= One of the most tragic stories of the jet age revolves around the unfortunate de Havilland Comet (D.H.106 Comet). Following World War II, de Havilland developed and flew the first commercial jet aircraft in 1949. Because it represented such a revolutionary advance in commercial travel, the Comet was put through an extensive series of test flights and certifications over the next three years. These 500 hours worth of flight crew training and proving flights included long overseas flights, tropical operations, and high altitude takeoffs. Having successfully completed these tests with no apparent difficulties, launch customer BOAC received permission to begin commercial operations in early 1952. The first hint of trouble with the design came exactly one year after these operations began when a Comet mysteriously crashed shortly after takeoff on May 2, 1953. Two similar crashes in early 1954 forced British authorities to ground the entire fleet pending investigation. Over the following months, extensive tests were performed on the aircraft to determine what could have caused these mysterious accidents. The answer finally came after a fuselage had been submerged in a tank of water and repeatedly pressurized and depressurized to represent repeated flight cycles. After several thousand of these cycles, fatigue cracks were found to be spreading from the square edges of the windows in the passenger cabin. These cracks would eventually reach a critical size where they would grow rapidly resulting in a catastrophic depressurization that would destroy an aircraft in flight. http://aerospaceweb.org/aircraft/jetliner/comet/index.shtml
- ================================= Read first paragraph of slide. Click to have graphic appear. Then click for last of text and read it.
- ================================= Read slide. In other words, critical incident stress is a NORMAL REACTION in NORMAL PEOPLE to an ABNORMAL EVENT .
- ================================= Cumulative stress CAN make critical incident stress even worse.
- ================================= Read slide. Not all critical incidents will create significant distress or overwhelm our coping mechanisms, but the potential is there, nonetheless. This is what we all must be aware of and watch for.
- ================================= Now let’s talk a little bit about recognizing excessive stress. Ask participants to identify some signs of stress in this picture from 9/11. Be sure to note that even the animals react to stress in their environment and need care as well.
- ================================= Stress can manifest itself in several ways: Physical…the way our body responds Cognitive…the way we think or perceive Emotional…the way we feel Behavioral…the way we act
- ================================= Physical manifestations include such things as…. Read slide.Click to make each line of text appear. If time permits, ask one or two participants to describe a personal example of their physical response to either good or bad stress (their first solo, a near miss in flight, their wedding ceremony, or whatever).
- ================================= Cognitive manifestations include such things as…. Read slide. If time permits, ask one or two participants to describe a personal example of their cognitive response to either good or bad stress (their first solo, a near miss in flight, their wedding ceremony, or whatever).
- ================================= Emotional signs include such things as…. Read slide. If time permits, ask one or two participants to describe a personal example of their emotional response to either good or bad stress (their first solo, a near miss in flight, their wedding ceremony, or whatever).
- ================================= Behavioral signs include such things as…. Read slide. If time permits, ask one or two participants to describe a personal example of their behavioral response to either good or bad stress (their first solo, a near miss in flight, their wedding ceremony, or whatever).
- ================================= Responses to stress generally fall into 3 groups w/respect to time. Immediate--up to 24 hours after the event. Ask for examples. Refer back to previous slides (cognitive, emotional, behavioral reactions. Delayed--one to three days after the event. Ask for examples. Refer back to previous slides (cognitive, emotional, behavioral reactions. Cumulative--as stress builds up over time. Ask for examples. Refer back to previous slides (cognitive, emotional, behavioral reactions.
- ================================= Read slide. Emphasize that post-traumatic stress is NORMAL, whereas post-traumatic stress disorder is an unhealthy response to PTS.
- ================================= 90% of US citizens will be exposed to a traumatic event during their lifetime. (Breslau, et al., 1998) Here are some examples of critical incidents. Left click to add each example.
- ================================= Click to bring in each component. A crisis is a response to an event wherein: 1. an individual’s psychological homeostasis, or psychological balance, is disrupted, 2. one’s usual coping mechanisms have failed, and 3. there is evidence of distress and significant functional impairment. (Everly and Mitchell, 1999)
- ================================= This brings us to crisis intervention.
- ================================= Crisis intervention is psychological or emotional “first-aid.” Read slide. By way of analogy, then, crisis intervention is to psychotherapy, as physical first-aid is to surgery. Crisis intervention has 4 goals: 1. To stabilize symptoms of distress or impairment and prevent them from worsening 2. To reduce symptoms of distress 3. To re-establish functional capacity, or 4. To seek further assessment and/or a higher level of care.
- ================================= Read slide.
- ================================= Crisis intervention procedures have evolved from: the studies of grieving conducted after a major nightclub fire; from military writings on the three basic principles in crisis work--immediacy of interventions, proximity to the occurrence of the event, and the expectancy that the victim will return to adequate functioning; and an emphasis on primary and secondary prevention through community mental health programs. Crisis intervention may be thought of as urgent and acute psychological intervention. The hallmarks of these first interventions are: Click twice to have graphic and text appear.
- ================================= There is no single model of crisis intervention. CISM is a relatively new term that has emerged in the mental health literature within the last decade. CISM is a comprehensive, systematic program designed to mitigate stress resulting from a critical incident.
- ================================= Read slide.
- ================================= Read slide.
- ================================= Read slide.
- ================================= CISM involves a number of different kinds of interventions depending on need. List each item on this and the next slide.
- ================================= Continue reading list. We’ll discuss some of these in a bit more depth in a moment.
- ================================= CISM is not designed to deal with personal histories. It deals with the current event or crisis only. It is not designed to provide definitive care or psychotherapy. It does provide mental health “first aid” and referrals if further care is needed.
- ================================= Now let’s talk about the key elements of CISM in a bit more detail.
- ================================= Pre-crisis preparation and education is delivered to groups and organizations to provide general information on critical incident stress, To help set expectations for actual experiences, and To teach stress management and coping skills.
- ================================= Demobilizations are held to inform and consult, allow psychological decompression, and for stress management. They help transition large groups of emergency workers from large-scale disaster work to routine duties and home. Most sessions last about 30 minutes and allow an opportunity to assess group needs and alert workers to the possible effects of stress. These sessions are always followed by a more in-depth critical incident stress DEBRIEFING within a week.
- ================================= Defusings are symptom driven and occur within 12 hours of the incident. They are shortened versions of the CIS Debriefing, which is a much more intensive intervention that can take 2-3 hours. Defusings outnumber the formal debriefings by almost 2 to 1. Defusings are designed to mitigate symptoms and intense reactions to trauma, provide closure, and facilitate triage and the identification of those needing referral for follow-up.
- ================================= Defusings are conducted in a 3-step process. Click to have dancers appear.Then click again for each line to appear. During the INTRODUCTION, the facilitator will do such things as state the purpose and goals for the session, motivate participants, set the rules, stress confidentiality, and describe the process. In the EXPLORATION phase, the facilitator will ask members of the group to describe what happened and share their experiences and reactions, and will assess the members need for further help. In the final INFORMATION phase, the facilitator will sum up the session, explain that the experiences and reactions are normal, and teach the participants stress survival skills.
- ================================= Both defusings and CISDs are group meetings or discussions about a traumatic event(s). They are based in crisis intervention and educational intervention theories. Although CISDs are guided by a mental health professional, they are peer driven. That is, the CISTeam will have members who have training and experience similar to the group being debriefed. This helps to establish trust and validate the experience. CISDs are held from 1-10 days after the event and last from 1-3 hours. They are held in a closed-circle format: no one enters or leaves once the debriefing starts. It is considered highly confidential. What is said in the room, stays in the room. However, CISDs are NOT psychotherapy.
- ================================= The objectives of the CISD are to : Provide EDUCATION about stress and the effects of a critical incident on those involved Allow for VENTILATION of emotions in a supportive environment. Provide REASURANCE Provide POSITIVE CONTACT with a MH professional Improve INTERAGENCY COOPERATION Increase group COHESIVENESS Restore SELF-CONFIDENCE Facilitate FOLLOW-UP
- ================================= The CISD process consists of 7 stages that begin on the COGNITIVE domain, progress into the EMOTIONAL domain, an ultimately return to the COGNITIVE domain. The process begins with INTRODUCTIONS, an explanation of the process and expectations. FACT: Describe the traumatic event from each participant’s perspective on a cognitive level. THOUGHT: Describe cognitive reactions and transition to emotional reactions REACTION: Identify the most traumatic aspect of the event and emotional reactions to it SYMPTOMS: Identify personal symptoms of distress and transition to cognitive level TEACHING: Educate participants about normal stress reactions and coping mechanisms. This provides a cognitive anchor. RE-ENTRY: Time to clarify ambiguities and provide “psychological closure.”
- ================================= Read slide.
- ================================= Read slide .
- ================================= Follow-up is an essential element in all CISM interventions. It can be made by phone calls, station or workplace visits, or by home visits as appropriate.
- ================================= All CISM interventions are strictly confidential. Anything--thoughts, feelings, and behaviors--brought out in an intervention are not talked about outside of the intervention.
- ================================= Let’s take a look at how well CISM works by comparing the responses to two airliner crashes.
- ================================= As you can see, both crashes are similar with respect to loss of life, damage, and number of emergency service personnel involved.
- ================================= After the San Diego crash, only sporadic 1-on-1 crisis interventions were performed. After the Cerritos crash, a number of crisis interventions were used including: critical incident stress debriefings, demobilizations, a crisis hotline, and follow-up referrals to mental health professionals. Here are the results of the interventions. Click to next slide.
- ================================= Take a look at the personnel losses among responders within 1 year of the event. San Diego clearly had greater losses, especially among EMS responders, while Cerritos lost only 1 responder from their fire department. There is also significantly greater utilization of mental health services in San Diego vs Cerritos.
- ================================= Click to bring in graphic. As you can see, CISM works!
- ================================= Now let’s talk a bit about CISM in the Civil Air Patrol.
- ================================= Read slide.
- ================================= Read slide.
- ================================= Whenever possible, the CAP encourages the use of a local, non-CAP team which will limit the use of trained CAP teams to some extent and preserve resources.
- ================================= Read slide.
- ================================= A CAP CIST consists of trained peer and mental health senior members. --Mental health professionals include psychiatrists, clinical psychologists, Licensed Professional Counselors, Licensed Social Workers, mental health RNs, etc. --Peer representatives include chaplains, pilots, flight crews, ground team members, etc, who perform functions similar to those persons being helped.
- ================================= Read slide.
- ================================= Read slide.
- ================================= Each of the CAP regions is eligible for limited funding from National HQ; however, CAP CIS teams normally receive NO reimbursement for food and lodging. While team members usually must pay these expenses, such costs can usually be itemized on their tax returns. When feasible, host families may be used to defray housing costs.
- ================================= Read slide.
- ================================= Read slide.
- ================================= Read slide and answer questions.
- ================================= Ask participants to describe how the characters in each panel could be responding to this incident. Include cognitive, emotional, and behavioral responses. Note the two characters in the background of the third panel. What might be going on there? What kinds of teams might be involved in this scenario?