CISM Presentation


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  • Please explain what the International Critical Incident Stress Foundation is and why it is important for people engaged in crisis intervention work to be a member.
  • It is important to know the basics about crisis and crisis intervention before moving into the practice of group crisis intervention skills.
  • Point out that the starting point for Post Traumatic Stress Disorder (PTSD) is the same critical incident that started Critical Incident Stress or “Post Traumatic Stress”. If the CIS or PTS does not get resolved, it may turn into the disorder (PTSD).
  • Point out that the starting point for Post Traumatic Stress Disorder (PTSD) is the same critical incident that started Critical Incident Stress or “Post Traumatic Stress”. If the CIS or PTS does not get resolved, it may turn into the disorder (PTSD).
  • Critical Incidents are the starting point for crisis reactions. Without critical incidents we would not have acute psychological reactions and there would be no need for crisis intervention.
  • These three factors are the basis of a crisis response. If they are not present, there is no crisis.
  • We do not provide crisis intervention services just because an event has occurred. There must be evidence of distress, impairment or dysfunction. Therefore, one of the most important skills for a crisis team is the ability to properly assess the group and the individuals who make up that group. Do not focus on the event alone. Look most at the reactions of the people. Stress is broad, lots of people affected. Impairment is limited, fewer people affected. Dysfunction is small, few people affected.
  • In crisis intervention, it is important for us to make contact with the distressed person, do something helpful and drop back from contact when the person improves and no longer needs our help. The crisis services that are provided by those providing psychological first aid should be short-term and focused on support, not psychotherapy.
  • These four are key goals whenever crisis intervention services are applied.
  • Salmon points out the value of early psychological intervention with his reports on soldiers in WWI.
  • Proximity: Need to be there Immediacy: Get there quickly Expectancy: “I know that this is hard, but you will get through this…” Innovation: “Not everything will be in a text book, you may need some creativity…” Brevity: Short Simplicity The military focused most on proximity (providing services as near the operational zone as practical and safe), immediacy (providing services as soon after the critical incident as practical), and expectancy (assurances to soldiers that they would most likely return to their units and resume their duties). As crisis intervention knowledge and skills expanded around the time of WWII, brevity, simplicity and pragmatism were added to the list. Innovation became part of the list as crisis intervention specialists became aware that circumstances sometimes required creative applications of crisis intervention principles.
  • If you really review the literature in the CISM field you will see that the studies are by far and large very positive in their outcomes. In Ritchie’s review, the specific small group crisis intervention process, CISD, was helpful when it was used in accordance with established standards of practice.
  • Evidence exists, as least as far back as forty years, that crisis intervention is effective in reducing distress and in preventing or shortening psychiatric hospitalizations.
  • Boscarino’s recent study on the use of group crisis is one of the strongest studies to date on the use of crisis support groups.
  • The higher the Cohen’s “d” score, the more powerful is the intervention. Obviously, trained crisis interveners are substantially more effective than untrained crisis workers. Anything over .25 is significantly good
  • The most important item here is that a multiple crisis intervention program generates better results than a single tactic only approach. Two or three contacts was more helpful than just a single contact. The use of several crisis intervention tactics was more helpful than just a single tactic. Anything over 3 was not significantly different
  • The Cohen “d” is a measure of the strength of the intervention. If the d = 0 then the intervention has no effect. If the d were to equal a negative number, then the intervention would be considered harmful. CISM was obviously helpful and it played a huge role in reducing the use of alcohol. It helped to cut back on PTSD symptoms as well. The Cohen’s “d” numbers on this slide and the next were derived from the Boscarino study.
  • Likewise, on this slide about the Boscarino study, CISM services are considered enormously helpful in controlling anxiety after a traumatic event.
  • This conclusion supports much earlier studies from 40 or more years ago that early psychological intervention is effective in preventing long- term impairment.
  • What this tells us is that it is very difficult for people to accept formal psychological services (psychotherapy) even when they have sustained emotional shocks from powerful traumatic events. Emergency personnel are often the least likely to accept professional psychological assistance. Crisis intervention may be the very best chance for us to provide assistance since it is provided by trained peers and it is not psychotherapy. It has far less chance of being rejected by emergency and military personnel than does formal psychological assistance.
  • People can recognize that traumatic effects have had a negative impact on them. But it is very hard for people to accept formal psychotherapeutic help to manage the distress they feel. Therefore, crisis intervention plays a key role in rendering assistance for groups who are reluctant to accept help.
  • It should be noted here that single session debriefings with individuals has never been recommended by ICISF. In fact, ICISF holds that it is inappropriate to use a small group crisis intervention process like the Critical Incident Stress Debriefing (CISD) on individuals especially those who are primary victims. Virtually every negative outcome study where some form of a “debriefing” was given to individuals violated this criteria for its use. Negative outcome studies were done on individual dog bite victims, sexual assault victims, burn victims, and auto accident victims. The CISD process was never intended for these populations. In addition, every negative study was performed with the flawed idea of substituting a CISD for psychotherapy. The CISD process is crisis intervention, not psychotherapy. There are over sixty studies showing that if CISD is applied by trained personnel and if the providers appropriately follow the protocols, the process is helpful to small groups and does not cause harm. NIMH: National Institute of Mental Health Page 37 in white book)
  • A strategic approach that applies the right intervention at the right time, in the right place and by the right people is essential.
  • Sometimes even critics of psychological debriefing have to admit that the group support service is useful and helpful for emergency services personnel.
  • From its inception Critical Incident Stress Management has been a program based on enhancing resistance to stress, resiliency and as rapid a recovery as possible.
  • CISM teams should be able to provide all six core competencies shown on this slide and on the following slide. If your team can not provide all these services, either train up or get out.
  • Let’s put things in balance. Not all psychotherapies are successful as we can see on this slide. That does not stop clinicians from providing psychotherapy. The clinicians are aware of the limitations of psychotherapies and are willing to try different types of therapies with their clients. Likewise, Crisis Intervention may not always be successful and crisis interventionists should be willing to change their tactics if what they are attempting is not working. Arguments about psychotherapy being all good and crisis intervention being all bad or vice versa are counterproductive. There are times and circumstances in which crisis intervention has an important role and there are times and circumstances in which psychotherapy will play an important role. Sometimes both will have a role to play. Crisis intervention comes first and a referral for unresolved issues comes later.
  • Like anything else human beings do, crisis intervention can be harmful. This is especially so if one is untrained or if one is not following the standards of practice in the field. The points on this slide raise the flags of caution. We should avoid doing any of these things when we are providing crisis intervention. Skilled crisis interventionists who are properly trained and who follow standard practices will avoid causing harm. Not good to allow someone to go on and on in disclosure/catharsis. “Are you sure you’re fine?” -- or stop normal responses (crying, etc.) Not smart to put dispatcher in with field team who experienced overly graphic field – not same level of exposure. Coercive pressure to talk. Blaming – we wouldn’t even be here if it weren’t for (person in group).
  • There are no studies that show any harm done with crisis intervention if trained personnel are providing crisis services according to commonly accepted standards of practice. Never experienced interference with natural coping, no research to support it, need to follow guidelines, but not good to make debriefing mandatory – unless sell it to those as being a supportive gesture to peers. “You may not need it, but you might be helpful to one of your co-workers.”
  • Everything above a dotted line is a little closer to the cognitive domain. Everything below a dotted line is closer to the affective domain. Goal is not to bring people to tears, though if they cry – that’s OK.
  • Every effort must be made to carefully train CISM personnel and to have them provide services according to acceptable standards of crisis intervention practice. CISD should never be a stand alone intervention, should at the least include follow-up (minimally hanging around at the end of the CISD).
  • Please remind students that carefully trained crisis interventionists who follow the CISM standards have avoided these problems. The slide should be viewed as warning, however, so that people realize that harm can be done if procedures are not followed. Pathognomonic : Characteristic or symptomatic of a particular disease or condition
  • CISM services including the small group CISD process have been around for over thirty years and crisis intervention (which is the source of CISM) has been around for a hundred years. There are no studies in all these years that show specific harm done if the standards of practice were followed. The guidelines presented here are important to help us to avoid causing any harm. If groups are not ready for debriefing 24 hours after fact, do 1:1s until group is ready – go when people are psychologically ready for the group response. Mitchell’s personal average is that debriefings happen 5 days post event: Work schedules Readiness conditions for the response Keep doing crisis intervention until there are very good signs of recovery or it is clear that there needs to be referral for continued to support.
  • 4. Mandatory reporting. 5. Denial, family support, etc.
  • It is a good idea to remind people again that providing services according to commonly accepted standards of practice is extremely important.
  • Nearly forty years of research and experience supports the use of peer support personnel. This is not an exhaustive list of the research – for those who do not think there is evidence for this working.
  • A circle is used because if all the CISM team members sat on one side of the room during a CISD, they would set up an “us and them” view of the world. In addition it is easier to have team member eyes on every member of the group when the CISM team is spread throughout the circle rather than all on one side of the room.
  • The four largest organization providing disaster mental health services include the American Red Cross, The National Organization of Victim’s Assistance, The Salvation Army and the International Critical Incident Stress Foundation. All four endorsed the consensus paper on early psychological intervention described in the following slides. These 4 groups provide more psych response services in the world than any other groups. NVOAD: 4 groups which is cooperating and collaborating (encourage training from NOVA and Red Cross) for disaster response, actual agreement is available through ICISF Red Cross – relief tents -- Salvation Army NOVA ICISF
  • Remember, this is the stat-of-the art in crisis intervention as judged by the organizations that are most involved in the provision of crisis intervention services.
  • Need to have linkages from Crisis support (Early Psychological Intervention) to link to psych services.
  • Global CI (Crisis Intervention) Disaster response Abuse response services (elder, sexual, child, etc.) Group/Community responses Hotlines ETC. CISM: Multiphasic (smaller group of services from all CI services) PFA (psychological first aid) even more limited than CISM Only three systems Johns Hopkins, National Institute for PTSD, International Red Cross All involve Basic needs support (food, shelter, safety) Information Limited 1:1 support Does not really allow for processing of the event.
  • The Employee Assistance Programs that serve thousands of businesses and industries also endorse a multi-component approach to crisis intervention.
  • In 2005, the Employee Assistance Program Association issued a policy statement that more clearly outlined its recommended multi-component approach to crisis intervention. The recent policy again encouraged the use of a comprehensive, integrated, systematic and multi-tactic approach to crisis intervention.
  • CISM Presentation

    1. 1. CISM: Does It Help or Not? <ul><li>Rev. KC Schuler, MDiv, BCC </li></ul><ul><li>Supervising Chaplain </li></ul><ul><li>ThedaCare </li></ul><ul><li>(and ICISF Trained Trainer) </li></ul><ul><li>[email_address] </li></ul>Most slides borrowed from ICISF: Group Crisis Response Training
    2. 2. At the heart of any field of study or practice resides a basic vocabulary . Unfortunately, the field of crisis and disaster mental health intervention has been plagued by the lack of a standardized nomenclature. So, we will begin with a review of several key terms and concepts that will help clarifiy some of the issues and the materials later presented.
    3. 3. Critical Incident Stress ( CIS ) is also known as Post Traumatic Stress ( PTS ) , which is not the same as Post Traumatic Stress Disorder (PTSD) .
    4. 4. CIS/PTS is a normal response of normal people to an abnormal event . CIS/PTS reactions may look similar to some symptoms of PTSD . If the CIS/PTS does not get resolved, it may turn into the disorder ( PTSD ). Only a trained, Mental Health professional can diagnose PTSD .
    5. 5. Definitions <ul><li>CRITICAL INCIDENTS are unusually challenging events that have the potential to create significant human DISTRESS and can overwhelm one’s usual coping mechanisms. </li></ul><ul><li>In other words, and abnormal event that evokes a normal response (CIS/PTS) to that abnormal event </li></ul>
    6. 6. Definitions <ul><li>The psychological DISTRESS in response to critical incidents such as emergencies, disasters, traumatic events, terrorism, or catastrophes is called a </li></ul><ul><li>P SYCHOLOGICAL CRISIS </li></ul><ul><li>(Everly & Mitchell, 1999) </li></ul>
    7. 7. Psychological Crisis <ul><li>An acute RESPONSE to a trauma, disaster, </li></ul><ul><li>or other critical incident wherein: </li></ul><ul><li>Psychological homeostasis (balance) is disrupted (increased stress) </li></ul><ul><li>One’s usual coping mechanisms have failed </li></ul><ul><li>There is evidence of significant distress, impairment, dysfunction (PTS/CIS) </li></ul><ul><li>(adapted from Caplan, 1964, Preventive Psychiatry ) </li></ul>
    8. 8. IMPORTANT ! Crisis intervention targets the RESPONSE , not the EVENT , per se. Thus, crisis intervention and disaster mental health interventions must be predicated upon assessment of need .
    9. 9. Crisis Intervention (CI) <ul><li>An active, short-term, supportive, helping process. </li></ul><ul><li>Acute intervention designed to mitigate the crisis response ( CIS/PTS ). </li></ul><ul><li>NOT psychotherapy or a substitute for psychotherapy. </li></ul>
    10. 10. Crisis Intervention (CI) <ul><li>Goals: </li></ul><ul><ul><li>1. Stabilization </li></ul></ul><ul><ul><li>2. Symptom reduction </li></ul></ul><ul><ul><li>3. Return to adaptive functioning, or </li></ul></ul><ul><ul><li>4. Facilitation of access to continued care </li></ul></ul><ul><li>(adapted from Caplan, 1964, Preventive Psychiatry ) </li></ul>
    11. 11. Crisis Intervention (CI) : Lessons Learned From The Military <ul><li>Salmon (1919, NY Med J) “Nothing could be more striking than the comparison between the cases treated near the front and those treated far behind the lines…As soon as treatment near the front became possible, symptoms disappeared… with the result that sixty percent with a diagnosis of psychoneurosis were returned to duty from the field hospital ” (p. 994). </li></ul>
    12. 12. Principles of Crisis Intervention (CI) : (Most Were Developed By The Military) <ul><li>Proximity </li></ul><ul><li>Immediacy </li></ul><ul><li>Expectancy </li></ul><ul><li>Innovation </li></ul><ul><li>Brevity </li></ul><ul><li>Simplicity </li></ul><ul><li>Pragmatism </li></ul>
    13. 13. Crisis Intervention: Leadership Communication <ul><li>Intentional or unintentional communication: </li></ul><ul><ul><li>Compassion : Deep awareness of the suffering of another coupled with the wish to relieve it </li></ul></ul><ul><ul><li>Disdain : To regard or treat with contempt; despise </li></ul></ul><ul><ul><li>Indifference : Having no particular interest or concern; apathetic </li></ul></ul>The American Heritage® Dictionary of the English Language, Fourth Edition Copyright © 2006 by Houghton Mifflin Company.
    14. 14. The Need in EMS? <ul><li>Incidence of Posttraumatic Stress with EMS in urban setting (NYC) (9.3%) met the strict DSM-III-R criteria for PTSD </li></ul><ul><li>Another (10%) had the required number and combination of symptoms for PTSD, but these symptoms had not persisted for the 1 month required by the DSM-III-R criteria. </li></ul><ul><li>Thus, a total of 19.3% of subjects who completed the survey were shown to be suffering from PTSD symptoms. </li></ul>Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers , Medscape Psychiatry & Mental Health eJournal 2(5), 1997. © 1997 Medscape
    15. 15. The Need in EMS? (cont.) <ul><li>The interaction between age and several other factors, however, was significant, including: </li></ul><ul><ul><li>Study participants between the ages of 18 and 24 who graduated from a rural high school were nearly 3 times as likely to have PTSD as those from urban or suburban high schools </li></ul></ul><ul><ul><li>The prevalence of PTSD increased significantly with the total number of previous medical emergency work jobs </li></ul></ul>Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers , Medscape Psychiatry & Mental Health eJournal 2(5), 1997. © 1997 Medscape
    16. 16. Review for Canadian Armed Forces Ritchie, P. (2002) <ul><li>Literature suggests value in “debriefing” </li></ul><ul><li>CISD (“debriefing”) should only use group format </li></ul><ul><li>CISD should be offered as part of a larger integrated intervention system (CISM) </li></ul><ul><ul><li>Participation is Voluntary and involves informed consent </li></ul></ul><ul><ul><li>CISD contraindicated if basic physiological, shelter, & safety needs not met </li></ul></ul><ul><ul><li>Positive outcome may be other than prevention of PTSD (provides information, support, may increase cohesion, positively viewed) </li></ul></ul>
    17. 17. Lessons Learned From Community Mental Health <ul><li>Early Psychological Intervention may reduce the need for more intensive psych services. </li></ul><ul><li>(Langsley, Machotka, & Flomenhaft, 1971, Am J Psyc; Decker, & Stubblebine, 1972, Am J Psyc) </li></ul><ul><li>Early Psychological Intervention may mitigate acute distress . </li></ul><ul><li>(Bordow & Porritt, 1979, Soc Sci & Med; Bunn & Clarke, 1979, Br. J Med. Psychol; Campfield & Hills, 2001, JTS; Flannery & Everly, 2004, Aggression & Violent Beh.) </li></ul>
    18. 18. Lessons Learned From Community Mental Health <ul><li>Early psychological Intervention may reduce EtOH use. </li></ul><ul><li>(Deahl, et al, 2000, Br J Med Psychol; Boscarino, et al., 2005) </li></ul>
    19. 19. Lessons Learned From Consultation Psychiatry (Stapleton, Medical Crisis Intervention, 2004) <ul><li>Early Psychological Intervention is improved by increased training in a standardized CI paradigm </li></ul><ul><ul><li>Results: </li></ul></ul><ul><ul><ul><li>trained d=.57 vs. </li></ul></ul></ul><ul><ul><ul><li>untrained d=.29 </li></ul></ul></ul>
    20. 20. Lessons Learned From Consultation Psychiatry (Stapleton, Medical Crisis Intervention, 2004) <ul><li>Early Psychological Intervention outcome is enhanced via multiple sessions </li></ul><ul><li>(multiple contacts d=.60 vs. single contact d=.33) </li></ul><ul><li>(plateau at 2-3 sessions, Boscarino, et al., 2005) </li></ul><ul><li>Early Psychological Intervention is enhanced via the use of multiple interventions on PTS </li></ul><ul><li>(multiple interventions d=.62 vs. single interventions d=.55) </li></ul>
    21. 21. Lessons Learned From The Workplace <ul><li>Post disaster crisis intervention (CISM) was associated with reduced risk for: </li></ul><ul><ul><li>binge drinking (d=.74) </li></ul></ul><ul><ul><li>alcohol dependence (d=.92) </li></ul></ul><ul><ul><li>PTS symptoms (d=.56) </li></ul></ul><ul><ul><li>(Boscarino, et al, IJEMH, 2005). </li></ul></ul>
    22. 22. Lessons Learned From The Workplace <ul><li>Post disaster crisis intervention (CISM) was associated with reduced risk for: </li></ul><ul><ul><li>major depression (d=.81) </li></ul></ul><ul><ul><li>anxiety disorder (d=.98) </li></ul></ul><ul><ul><li>global impairment (.66) </li></ul></ul><ul><ul><li>compared with comparable individuals who did not receive this intervention </li></ul></ul><ul><ul><li>(Boscarino, et al, IJEMH, 2005). </li></ul></ul>
    23. 23. “ There is now emerging evidence that prompt delivery of brief, acute phase services in the first weeks after an event can lead to sustained reduction in morbidity years later , reducing the burden of secondary functional impairment, presumed daily average life years lost (DALYS), and costs to both the individual and the public” (p. 15). Schreiber, M. (Summer, 2005). PsySTART rapid mental health triage and incident command system. The Dialogue: A Quarterly Technical Assistance Bulletin on Disaster Behavioral Health, 14-15.
    24. 24. Value Added of Crisis Intervention: Screening & Increasing Access To Care <ul><li>Only 11% of victims of violent crime responded to institutional invitations to express attitudes regarding crime & punishment </li></ul><ul><li>Less than 7% of sexual assault victims chose to utilize free psychotherapy within walking distance of their home </li></ul><ul><li> (Rose, et al., Psychological Medicine, 1999). </li></ul><ul><li>Formal mental health utilization post 9/11 increased only ~3% in civilians and emergency personnel even though prevalence of PTSD estimated at 7-20% and depression at ~9% </li></ul><ul><li>(see Johns Hopkins Center for Public Health Preparedness -- JHCPHP, 2005) </li></ul>
    25. 25. Value Added of Crisis Intervention: Screening & Increasing Access To Care <ul><li>First responders are often resistant to seeking Mental Health treatment, therefore crisis intervention may be their only access to “mental health services” </li></ul><ul><li>(North, et al., 2002, J. T. Stress) </li></ul><ul><li>While ~ 85% of military sampled who served in Iraq/Afghanistan recognized problems, only ~44% were willing to seek assistance </li></ul><ul><li>(Hoge et al., NEJM, 2004) </li></ul><ul><li>Less than 50% of civilian disaster workers, who screened + for mental health concerns sought treatment </li></ul><ul><li>(Jayasinghe, et al, 2005, IJEMH) </li></ul>
    26. 26. Reasonable Evidence-based Conclusions <ul><li>More and better controlled research is still needed </li></ul><ul><li>Care must be taken in setting up a support response </li></ul><ul><li>Data reviewed support use of group “debriefing” with emergency services personnel (Arendt & Elklit, 2001) </li></ul><ul><li>Data reviewed tend to support use of group “debriefing” subsequent to disasters, war, robbery </li></ul><ul><li>(see NIMH, 2002, tables 2-3) </li></ul>
    27. 27. Reasonable Evidence-based Conclusions <ul><li>The research does not support single session, individualized interventions after medical, surgical distress with minimal training (nurses with 15 min training) </li></ul><ul><li>The research does support multi-component intervention systems </li></ul><ul><li>NIMH (2002), Institute of Medicine (2003), NVOAD (2005) recommend acute phase “psychological first aid” </li></ul>
    28. 28. “ In all the controversy, criticism and research debate on the merits of debriefing [early intervention], certain constants are emerging. The most effective methods for mitigating the effects of exposure to trauma…, those which will help keep our people healthy and in service, are those which use early intervention, are multi-modal and multi-component. That is, they use different ‘active ingredients’ …, and these components are used at the appropriate time with the right target group.” Dr. Hayden Duggan International Association of Fire Chiefs’ ICHIEFS on-line resource, Sept 1, 2002
    29. 29. Acceptance of Psychological Debriefings (PD) <ul><li>“ Since PD is fully accepted as standard practice for emergency services personnel and well-received by group members and organizations, it is hard to find fault in its application in a mass disaster such as the terrorist attacks…on september 11, 2001.” (Litz, et al., Clin. Psyc. 2002) </li></ul>
    30. 30. Crisis Intervention (CI): Key Points <ul><li>Crisis Intervention is not intended to be the practice of psychiatry, psychology, social work, nor counseling, per se, it is simply psychological/emotional first aid </li></ul><ul><li>Consistent with NIMH guidelines and Federal “crisis counseling” models, crisis intervention may be practiced by mental health clinicians, as well as, medical personnel, clergy, & community volunteers (although we believe mental health guidance, supervision, or oversight is essential) </li></ul><ul><li>AGAIN, Crisis intervention does not appear to “prevent” PTSD in primary victims. </li></ul>
    31. 31. Resistance , Resilience, & Recovery <ul><li>In the present context, the term Resistance refers to the ability of an individual, a group, an organization, or even an entire population, to literally resist manifestations of clinical distress, impairment, or dysfunction associated with critical incidents, terrorism, and even mass disasters. </li></ul>
    32. 32. Resistance , Resilience, & Recovery <ul><li>Resistance may be thought of as a form of psychological/ behavioral immunity to distress and dysfunction. </li></ul><ul><li>Pre-incident training/preparation may be best way to build resistance </li></ul>
    33. 33. Resistance, Resilience , & Recovery <ul><li>In the present context, the term Resilience refers to the ability of an individual, a group, an organization, or even an entire population, to rapidly and effectively rebound from psychological and/or behavioral perturbations associated with critical incidents, terrorism, and even mass disasters. </li></ul>
    34. 34. Resistance, Resilience , & Recovery <ul><li>Resilience is an ordinary , not extraordinary response associated with: </li></ul><ul><ul><li>Capacity to make and follow out realistic plans </li></ul></ul><ul><ul><li>Positive view of self, strength, and abilities </li></ul></ul><ul><ul><li>Communication and problem solving skills </li></ul></ul><ul><ul><li>Capacity to manage strong feelings </li></ul></ul><ul><li>Crisis and disaster mental health intervention may be the best way to enhance natural Resiliency , in addition to pre-incident preparation. </li></ul>
    35. 35. Resistance, Resilience, & Recovery <ul><li>The term Recovery refers to the ability of an individual, a group, an organization, or even an entire population, to literally recover the ability to adaptively function, both psychologically and behaviorally, in the wake of a significant clinical distress, impairment, or dysfunction (PTS/CIS) subsequent to critical incidents, terrorism, and even mass disasters. </li></ul><ul><li>Crisis intervention, Treatment, and rehabilitation speeds Recovery . </li></ul>
    36. 36. An outcome-driven continuum of care Create Resistance Enhance Resiliency Speed Recovery Assessment Assessment Assessment Intervention Intervention Intervention Evaluation Evaluation Evaluation [Kaminsky, et al, (2005) RESISTANCE, RESILIENCE, RECOVERY. In Everly & Parker, Mental Health Aspects of Disaster: Public Health Preparedness and Response. Balto: Johns Hopkins Center for Public Health Preparedness.] Goals of a Multi-Component Crisis Intervention System
    37. 37. CISM is a strategic intervention system. It possesses numerous tactical interventions of which CISD is one.
    38. 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. 39. Core Competencies Of Comprehensive Crisis Intervention <ul><li>Assessment/triage benign vs. malignant symptoms </li></ul><ul><li>Strategic planning and utilizing an integrated multi-component crisis intervention system within an incident command system </li></ul><ul><li>One-on-one crisis intervention </li></ul><ul><li>Small group crisis intervention </li></ul><ul><li>Large group crisis intervention </li></ul><ul><li>Follow-up and Referral </li></ul>
    40. 40. Can Intervention Be Harmful ? The Case of Psychotherapy... <ul><li>Smith, Glass, & Miler (Benefits of Psychotherapy, 1980) meta-analytic review of 400 studies --> 9% negative outcome </li></ul><ul><li>Shapiro & Shapiro (Psychol. Bulletin, 1982) over 1800 “effects” --> 11% negative, 30% null effect </li></ul><ul><li>Lambert (2003) estimated 5-10% of patients deteriorate during treatment </li></ul>
    41. 41. Can Crisis Intervention Be Harmful ? Theoretical Mechanisms/ Issues ( see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003) <ul><li>Excessive catharsis, disclosure, rumination </li></ul><ul><li>Pathologizing otherwise “normal” reactions </li></ul><ul><li>Vicarious traumatization in groups </li></ul><ul><li>Coercive peer pressure in groups </li></ul><ul><li>Scapegoating in groups </li></ul>
    42. 42. Can Crisis Intervention Be Harmful ? Theoretical Mechanisms/ Issues ( see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003) <ul><li>Triggering of previous traumatic memories </li></ul><ul><li>Intervention may be premature (inappropriate timing) </li></ul><ul><li>May be inappropriate with highly aroused persons </li></ul><ul><li>May interfere with natural coping mechanisms </li></ul><ul><li>May not be accompanied by adequate assessment or follow-up </li></ul>
    44. 44. Reducing Risk of Adverse Reactions <ul><li>Keep CISD within the multi-component context of CISM : </li></ul><ul><ul><li>CISD should never be a stand alone intervention. It should only be used when it is part of a package of interventions which includes follow-up services. </li></ul></ul>
    45. 45. Reducing Risk of Adverse Reactions <ul><li>The group CISD process should never be used for individuals since it was designed for groups </li></ul><ul><li>CISD should not be used to achieve psychotherapeutic outcome: CISD is not psychotherapy nor a substitute for psychotherapy </li></ul>
    46. 46. Reviews which have been critical of small group “debriefing” cite 3 primary concerns: <ul><ul><li>Traumatic story-telling may traumatize other participants (Watson, et al., 2003, in Trauma & Disaster; Stokes, 2002, Cautions & Contraindications for Debriefings) </li></ul></ul><ul><ul><li>Probing into affective domain with those who experience numbing & avoidance may trigger pathognomonic re-traumatization </li></ul></ul><ul><ul><li>(North, 2003, in Trauma & Disaster; Stokes, 2002) </li></ul></ul><ul><ul><li>Inappropriate timing for hyper-aroused individuals </li></ul></ul><ul><ul><li>(NIMH, 2002) </li></ul></ul>
    47. 47. To address concerns related to group “debriefing” <ul><ul><li>Maintain/facilitate an educational and story-telling format (Shalev, et al., 2003, Terrorism & Disaster) </li></ul></ul><ul><ul><li>Utilize homogeneous groups so as to prevent traumatization from “new” information (similar levels of exposure and function: </li></ul></ul><ul><ul><ul><li>do not include bystanders, etc. with professionals </li></ul></ul></ul><ul><ul><ul><li>Judgement call about mixing professions (Fire, EMS, Law Enforcement) note: ICISF discourages mixing </li></ul></ul></ul><ul><ul><li>Avoid delving into the affective aspects with groups that are experiencing heightened arousal, avoidance, or numbing (North, 2003; Stokes, 2002) </li></ul></ul>
    48. 48. To address concerns related to group “debriefing” <ul><li>Unless the magnitude of impairment is such that the individual represents a threat to self or others, crisis intervention should be voluntary. </li></ul><ul><li>The interventionist must be careful not to interfere with natural recovery or adaptive compensatory mechanisms. </li></ul><ul><li>The CISD has not ended until the majority of the group has returned to the cognitive domain – and/or may require individual referrals to higher level of care </li></ul>
    49. 49. Summary Risks vs. Benefits of CISM <ul><li>The risk of adverse outcome is associated with all human intervention and helping practices including medicine, surgery, and counseling. </li></ul><ul><li>Improper, inadequate training would appear the greatest risk factor associated with crisis intervention, as well as those practices just mentioned. </li></ul><ul><li>Thus, training and supervision may be the best way to reduce the risk of adverse outcome, rather than simply calling for an end to such helping practices. </li></ul>
    50. 50. Effectiveness Of Peer Support Personnel References <ul><li>Peer Support Personnel are essential in the CISM process </li></ul><ul><ul><li>Authentic Normalization </li></ul></ul><ul><ul><li>Rapport </li></ul></ul><ul><ul><li>Clarification of protocol/process </li></ul></ul><ul><ul><li>Etc. </li></ul></ul><ul><li>Truax & Carkhuff, 1967, Toward Effective Counseling </li></ul><ul><li>Durlak, 1979, Psychological Bulletin </li></ul><ul><li>Hattie, Sharpley, Rogers, 1984, Psychological Bulletin </li></ul>
    51. 51. Important CISD Considerations & Ground Rules <ul><li>Strict Confidentiality agreed upon by participants and team </li></ul><ul><li>Timing is important </li></ul><ul><li>Location and physical environment appropriate </li></ul><ul><li>Closed circle format </li></ul><ul><li>Participation voluntary </li></ul><ul><li>No notes, recording devices </li></ul><ul><li>No breaks (Try to limit breaks until after group is finished) </li></ul><ul><li>Not operational critique, not investigation </li></ul><ul><li>Not a “blame” session </li></ul><ul><li>Not therapy, nor substitute for treatment </li></ul>
    52. 52. Questions?
    53. 53. Additional Information and More Slides <ul><li>International Critical Incident Stress Foundation </li></ul><ul><li> </li></ul><ul><li> </li></ul><ul><li>Crisis Intervention and Critical Incident Stress Management: A Defense of the Field </li></ul><ul><li> </li></ul><ul><li>National Organization for Victim Assistance NOVA </li></ul><ul><li> </li></ul>
    54. 54. THE NEED <ul><li>Over 80% Americans (general population) will be exposed to a traumatic event (Breslau) About 9% of those exposed develop PTSD (40-70% in cases involving rape/torture) </li></ul><ul><ul><li>(Surgeon General, 1999, Report on Mental Illness) </li></ul></ul><ul><li>Disasters may create significant impairment in 40-50% of those exposed </li></ul><ul><ul><li>(Norris, 2001, SAMHSA) </li></ul></ul>
    55. 55. THE NEED <ul><li>About 50% of disaster workers likely to develop significant distress </li></ul><ul><ul><li>(Myers & Wee, 2005, Dis. Men. Hlth) </li></ul></ul><ul><li>As many as 45% of those Directly Exposed to mass disasters may develop PTSD or Depression </li></ul><ul><li>(North, et al., 1999, JAMA) </li></ul><ul><li>Dose-response relationship with exposure is a key factor in development of PTS D (DSM-IV R) </li></ul>
    56. 56. THE NEED <ul><li>PTSD PREVALENCE: 10-15% OF LAW ENFORCEMENT PERSONNEL </li></ul><ul><li>(see Everly & Mitchell, 1999) </li></ul><ul><li>PTSD PREVALENCE: 10-30% OF THOSE IN FIRE SUPPRESSION (see Everly & Mitchell, 1999) </li></ul><ul><li>By comparison: PTSD PREVALENCE: VIETNAM VETERANS 16% (National PTSD Study) </li></ul>
    57. 57. THE NEED <ul><li>PTSD PREVALENCE: ~12%, Iraq – Desert Storm VETERANS (Hoge, et al., 2004, NEJM) </li></ul><ul><li>PTSD PREVALENCE: unknown% with current Iraq/ Afghanistan War Veterans </li></ul><ul><li>(VA system receiving public criticism for lack of support and experts anticipating high numbers, May 2007 NYTimes) </li></ul>
    58. 58. By way of background… The National Volunteer Organizations Active in Disaster (NVOAD) represents a consortium of non-governmental agencies providing disaster relief. NVOAD member organizations represent the largest group of non-governmental providers of disaster mental health services in North America.
    59. 59. NVOAD Consensus Points (2005) <ul><li>Early Psychological Intervention ( EPI ) is valued </li></ul><ul><li>EPI is a multi-component system to meet the needs of those impacted </li></ul><ul><li>Specialized training in early psychological intervention is necessary </li></ul>
    60. 60. NVOAD Consensus Points (2005) <ul><li>EPI is one point on a continuum of psychological care. This spectrum ranges from pre-incident preparedness to post-incident psychotherapy -- when needed </li></ul><ul><li>Cooperation, communication, coordination and collaboration are essential to the delivery of EPI </li></ul>
    61. 61. NVOAD Interventions (2005) <ul><ul><ul><li>Pre-incident preparation </li></ul></ul></ul><ul><ul><ul><li>Incident assessment and strategic planning </li></ul></ul></ul><ul><ul><ul><li>Risk and crisis communication </li></ul></ul></ul><ul><ul><ul><li>Acute psychological assessment and triage </li></ul></ul></ul><ul><ul><ul><li>Crisis intervention with large groups </li></ul></ul></ul><ul><ul><ul><li>Crisis intervention with small groups </li></ul></ul></ul><ul><ul><ul><li>Crisis intervention with individuals, face-to-face and hotlines </li></ul></ul></ul>
    62. 62. NVOAD Interventions (2005) <ul><ul><ul><li>Crisis planning and intervention with communities </li></ul></ul></ul><ul><ul><ul><li>Crisis planning and intervention with organizations </li></ul></ul></ul><ul><ul><ul><li>Psychological first aid (PFA) </li></ul></ul></ul><ul><ul><ul><li>Facilitating of access to appropriate levels of care when needed </li></ul></ul></ul>
    63. 63. NVOAD Interventions (2005) <ul><ul><li>Assisting special and diverse populations </li></ul></ul><ul><ul><li>Spiritual assessment and care </li></ul></ul><ul><ul><ul><li>All NVOAD recognize need for spiritual care </li></ul></ul></ul><ul><ul><li>Self care and family care including safety and security </li></ul></ul><ul><ul><li>Post incident evaluation and training based on lessons learned </li></ul></ul>
    64. 64. Employee Assistance Professional’s Association Disaster Response Task Force (EAPA, 2002) <ul><li>EAPS should develop workplace disaster plans </li></ul><ul><li>Plans should consist of a continuum of interventions, including: </li></ul><ul><ul><li>Pre-Incident Training/Coordination (early CISM intervention training, resiliency training, risk assessment, policy development) </li></ul></ul><ul><ul><li>Acute response protocols </li></ul></ul>
    65. 65. Employee Assistance Professional’s Association Disaster Response Task Force (EAPA, 2002) <ul><li>Plans should consist of a continuum of interventions including: </li></ul><ul><ul><li>Post-Incident Response (defusing, CISD, crisis management briefings, assessment/ referral, self-care) </li></ul></ul><ul><ul><li>Follow-up (supervisory briefings, assessment, training) </li></ul></ul><ul><ul><li>Post-Incident Review and Plan Reformulation </li></ul></ul>