Critical Incident - An event that is sudden, unexpected, and of a magnitude that is beyond the norm of what usually happens to people at work, potentially overwhelming normal coping abilities. Sudden deaths (suicides, homicides, natural), natural disasters that damage the workplace, shootings, robberies. Source: Blum, Dorothy & Paul, Jan. Workplace Disaster Preparedness and Response: The Employee Assistance Program Continuum of Services. The International Journal of Emergency Mental Health. Volume 7, Number 3. Summer 2005. pp. 169-178The source of this chart is from Greenwood, et al. (2006) Responding in Times of Crisis-An Exploratory Study of Employer Requests for Critical Incident Response Services. Journal of Workplace Behavioral Health . 21(3/4):171-189.Two interesting observations from this slide The financial industry has by far the largest percent of robberies; and The financial industry has the lowest percent of deaths.
CISD - The intention of CISD is to provide some sort of psychological “closure” upon the traumatic, or critical, incident – when closure is not possible, the CISD may service as a useful mechanism for psychological triage so as to identify those who will need more advanced care.Psychological first aid is an application of early critical incident/crisis response suitable for use by non-mental health professionals. Relying on a strengths-based perspective, it involves providing a basic level of support and information to victims immediately following a critical incident/emergency/disaster. It is designed to reduce the initial distress of traumatic events and foster coping abilities. A CISM program is comprehensive, it promotes pre-event stress and crisis management education; planning and policy development; as well as training and preparation for management of traumatic stress. It also contains a set of interventions which are helpful for when a traumatic event is in progress and interventions that are useful in the aftermath of a traumatic event. It is integrated --the components of a CISM program are linked and blended together into a cohesive approach for use in crisis intervention. It is systematic,the elements of a CISM program are applied in a logical, step-by-step manner. It is multi-component, having many parts that are interlocked, encouraging a strategic, multi-faceted and interlinked approach to crisis management.
A large part of the debate over debriefings is whether they are a treatment or a preventative exercise. Is the goal of debriefings to improve resiliency rather than to prevent or alleviate illness?Several findings suggest that there are positive effects from short term CISD interventions, but it should be understood that regardless of early intervention, there is a significant percentage of victims who may develop symptoms and receive a diagnosis of PTSD, depression and/or generalized anxietySince debriefings are voluntary, perhaps only those employees who are truly upset about the incident may choose to attend the session. Some may be upset about the incident but don’t choose to attend. This may skew the numbers when research on the effectiveness and efficacy of CISDs is being performedIf a single intervention is all that is offered, perhaps the sessions do more harm than good. It’s been suggested that a debriefing should be considered as “one component of a comprehensive multi-component crisis intervention program.”
Professional Competency (Knowledge of current best practice)Worksite Needs Assessment (Organizational/Client Knowledge)Capacity for Crisis Response (Adequate Infrastructure & Staffing)Clinical Resources (On-site response & Referral network)Psychoeducation (Employees, Supervisors & Management)
Recommendations about when to conduct a sessionAsk questions about gender of de-briefing staff
Goals of PFA are similar to First Aid:Stabilize individual’s psychological functioning through meeting basic physical needs, then by addressing the most basic of psychological needsMitigate psychological dysfunction/distressAssist with attainment of acute adaptive psychological/behavioral functioning, and/orFacilitate referral/access to next level of care
Psychoeducation can take place in one-on-one discussion or in groups and by any qualified health professional.In the group setting, participants are informed about the condition simultaneously, which can encourage a shared experience. Additionally, exchanges of common experiences between participants and mutual support can contribute to the healing process.
The range of emotions and reactions that individuals experience is neither a list nor a continuum -- some may feel one, others two in succession, or perhaps even all of them over the course of days, weeks, or months.Some researchers of the robbery/critical incident phenomena have speculated that continuing to return to in the previously-safe workplace environment may account for a persistence of stress-related trauma symptoms in some individuals, and thus contribute to a longer, more severe recovery process.
The term Psychological First Aid does have a number of different meanings. In today’s short training we are focusing on using the term merely as an approach for managers and supervisors to provide support and information in the direct aftermath of a critical incident, particularly a robbery – rather than a formal training whereby non-mental health professionals receive a more extensive training leading to a certification, which does actually exist.The Psychological First Aid paradigm does not assume all victims will develop severe mental health problems following a traumatic event. Rather, it is based on the understanding that victims will experience a broad range of early reactions: physical, psychological, and behavioral seen in victims of trauma. What we have learned is that there is a definite space and time between the event and, for example the time of any formal defusing or debriefing that management, supervisors and even co-workers can provide a basis level of support and information – and that providing this is very beneficial to those impacted by the event.Now, clearly some of these reactions may cause enough distress to an individual to interfere with the normal adaptive coping and recovery process – that is the secondary purpose of PFA -- to help identify those individuals that may benefit from further assessment and assistance by mental health professionals.
The Goal: Provide a sense of safety, calm, connectedness, hope and optimism in a manner that is non-intrusive, yet supportive and educational by demonstrating competence and concern for the organization’s human capital with the aim of encouraging both individuals and the work group to return to normal functioning.
Current best practices in providing post workplace critical incident response include the following principles: 1) Administer an initial “dose” of support & education, or debriefing within 48-72 hours, or as soon as practical thereafter. 2) Attendance for work group members is strongly suggested, however active (verbal) participation is absolutely voluntary. 3) The primary focus of an initial de-briefing should be educational and use a strengths-based approach; information about critical incident stress and common responses; psychological self-care recommendations for post-acute recovery; encouragement of self-monitoring of mental health symptoms; details of various sources of counseling - professional, community, faith-based.4) During any group debriefings and individual crisis counseling sessions, EAPs and other mental health professionals are guided by their observations of individuals and use of routine mental status assessments which provide may evidence of possible recommendations for further services.5) The voluntary nature of service use is critical, mandates for counseling sessions are not recommended, however suggestions from trusted managers, supportive co-workers or concerned family members are often instrumental in a victim’s decision to seek help.
In my pre-training discussion with HR Representatives, this was an area we might discuss further – the idea of using non-judgmental language and avoiding labels.To clarify, what I am suggesting is that its helpful to remember that not every individual’s response to an incident is likely to be identical.From a strictly gender perspective, it may be that any males present will react in one fashion, while females in another. Males in our society are socialized to be stoic, to shrug off trauma and “apply a task oriented” approach to difficult situations, whereas women may be more likely to verbalize their reactions. Which is better? The short answer is neither – the danger lies in taking a position which assumes one is more appropriate for all those involved.My experience in providing CISDs and recent research tells me that a cookie cutter approach is not the way to go. Purposefully checking in with individuals, then would be my suggestion in how to ascertain their level of stress
Would like to emphasize these findings are anecdotal – they represent only one training and ongoing discussions with one organization.
EAP Response to Bank Robberies: A Comprehensive Approach
Presenters: Bernie McCann & Keith Crochiere MA/RI Chapter of EAPA Annual Symposium Waltham, MA May 10, 2012
Presenter Bios Bernie McCann, Ph.D., CEAP is an experienced Employee Assistance consultant, workplace trainer, university instructor and behavioral health researcher. His prior work experience includes Research Associate at Brandeis University, Policy Analyst at the White House Office of National Drug Control Policy, Member Assistance Specialist for the Laborers Health & Safety Fund of North America; Employee Assistance Counselor at Baltimore Gas & Electric, and Project Manager on workplace wellness programs funded by NIH, CDC, SAMHSA and the Robert Woods Johnson Foundation. Keith Crochiere, CEO of Employee Assistance Network, is a psychologist with 20+ years of EAP experience. A published expert on employee performance and behavior issues and is frequently asked to speak on a variety of human resource topics such as: Working with Difficult People, Conflict Negotiation, The Art of Giving and Receiving Criticism, and Listening Skills, Keith has held graduate faculty positions at University of Massachusetts, Bridgewater State College, and Western New England College, lecturing on Chemical Dependency, Organizational Management and Organizational Behavior. EAP Network provides counseling and consultation services to 100 New England organizations.
Presentation Agenda Background/Introduction to the issue Responding to initial notification of the traumatic event Assessing the nature & extent of the incident Addressing concerns of employer representatives regarding affected employees Providing EA services to affected employees On-site response, psychoeducation, triage for acute stress Follow-up support & referrals to higher levels of care Training curriculum for bank branch managers Request for assistance in reducing post-robbery stress & resignations Development & implementation of presentation in providing psychological first aid to bank line employees.
Critical Incidents by Industry Incident Type Workplace Accidental Downsizing/Industry Type Death Injury Layoffs Robbery SuicideManufacturing 51.5% 12.1% 25.8% 2.0% 8.6%Transportation/Communications/ 70.6% 15.8% 4.5% 3.2% 5.9%UtilitiesServices 66.7% 16.7% 3.7% 0% 13.0%Financial 26.9% 3.8% 7.7% 61.5% 0%
Bank Crimes & Worker ImpactSurveyed employees in one large banking company whoexperienced one or more robbery provided these reactions: 80% reported concentration/productivity negatively affected 67% reported experiencing anger or stress 63% reported experiencing hypervigilance 60% reported feeling not safe 60% reported feeling suspicious of those resembling the perpetrator 1/3 reported other symptoms (insomnia, headaches, stomachaches, nightmares, etc.) Source: Burke et al. (1999)
CSID, PFA, or CISM? DefinitionsCritical Incident Stress Debriefing (CISD) – A technique, originallydeveloped for use in one-on-one interventions with first responders (the MitchellModel) and later expanded to wider application for virtually any type of group post-trauma response.Psychological First Aid (PFA) – A more recent technique, primarily a publichealth approach to disaster response employing a holistic view of victim safety,attention to basic needs, and psychological triage.Critical Incident Stress Management (CISM) – A comprehensive,integrated, systematic and multicomponent crisis intervention approach. Componentsmay include pre-incident preparedness, acute crisis support & defusing, referralmechanisms, post-incident follow up, etc. *For all the above, the existing research on effectiveness and outcomes can be characterized as having both gaps and contradictory findings.
Critical Incident Stress Research Most individuals who received critical incident stress debriefings endorsed it as helpful (Carlier et al, 2000; Small et al., 2000) Rose et al., (2001) concluded “there is no current evidence that psychological debriefing is useful for prevention of PTSD after traumatic events and compulsory debriefings should cease.” Boscarino (2005) followed 1681 NY adults after 9/11 in a 2 year follow up, PFA/crisis intervention resulted in lowered binge drinking, alcohol dependence, PTSD symptoms, major depression and anxiety. Comparing two groups of employees who received a single group intervention (CISD) and an integrated approach (CISM); the CISM group had significantly less post-trauma morbidity at 3-12 mo. follow-ups compared to CISD alone (Richards, 2001).
A Comprehensive Approach1. Professional Competency (Knowledge of current best practice)2. Worksite Needs Assessment (Organizational/Client Knowledge)3. Capacity for Crisis Response (Adequate Infrastructure & Staffing)4. Clinical Resources (On-site response & Referral network)5. Psychoeducation (Employees, Supervisors & Management)
Initial Response to Critical Incidents Timing is important - A key element is when to do the debriefing. Too soon and people are still in shock/denial and too preoccupied with providing information to police and following internal security protocols. Proper coordination with management and onsite leadership is essential. Having a protocol to follow, a code word to share the information with others, who is to contact whom, scheduling the on-site session -- and not leaving the decision to the onsite contact (who may be emotionally unable to make a good decision regarding staff needs), are all crucial considerations. Obtain as much information as possible (from all contacts) before arriving to conduct an on-site session.
Onsite Critical Incident ResponseFollowing notice of a workplace critical incident and after receiving arequest for onsite EAP response, some logistical suggestions are: Bring sufficient educational materials, EAP brochures, etc. Arrive early, introduce yourself to and talk casually with staff if possible Provide each employee with an EAP brochure & any handouts used Provide managers additional materials & extra copies of brochures Notify participants that you will remain after session to speak individually/privately to anyone who desires, be visible during this time period
Conducting Onsite Critical Incident SessionsWhen conducting the onsite session: Personally invite all employees to join session to encourage attendance, even those who may not have been present during the incident – the goal is to create a sense of shared support for the work group and those affected, that “we are all in this together” During the session, provide information to participants on: Purpose of the session, why EAP is responding Typical responses to traumatic events Any additional psychoeducational details How the EAP works, confidentiality, etc. Take this opportunity to describe the many other types of support/assistance available from the EAP (i.e., normalizing the idea of contacting the EAP)
Post-Session Follow up After providing an on-site session, EAP critical incident follow up services may include:1. Employees identified as suffering particularly severe acute stress symptoms - for these individuals it may be appropriate to recommend continuing EAP involvement via phone or in- person counseling, individually or in group sessions.2. Management/HR/on-site supervisors – to ascertain staff recovery from the incident; their satisfaction with on-site sessions; additional training or organizational development needs
Psychoeducation & Stress Response Psychoeducation can provide important information for individuals with psychological concerns. A primary goal is to assist individuals to better understand conditions and to better deal with symptoms. The individuals own strengths, resources and coping skills are reinforced, in order to encourage improved functioning/wellness, feel less helpless and avoid relapse. As an element of Psychological First Aid and Critical Incident Response to bank crimes, psychoeducation content may include: Common symptoms & duration of stress reactions Self-care following traumatic incidents The benefit of support from co-workers, supervisors, families, etc. Data on the likelihood of injuries or fatalities during bank crimes Additionally, psychoeducation also has the function of contributing to the de- stigmatization of psychological concerns and diminish resistance to treatment.
Presenting OD Issue & EA Response Situation: Multiple requests to provide post-robbery EA services to a number of local banks in the Boston area Additional data: Subsequent discussion with HR Manager at one of the largest credit unions in Massachusetts revealed that often after robberies, a percentage of line employees (particularly novice staff members) would resign/miss work From exit interviews and other discussions, HR Manager ascertained these resignations and absences were due to: Novice employees being frightened of “unsafe work environment” Family pressure on employees to resign or stay home
Branch Manager Training Based on the HR Manager’s concerns about bank line employee absences and retention following robberies; we suggested and developed a 90 minute training presentation for a quarterly bank branch managers meeting. This training focused on the following: • Data about bank crimes & likely employee responses to robberies • An orientation to Psychological First Aid • Encouraging use of services • Helping families/friends cope to reduce employee stress
The Critical Incident Stress ResponseWhen a robbery occurs, employees are likely tofeel a variety of emotions; these include shock,fear, anxiety, disconnectedness, and even anger. The time span of these emotions may continue for days, weeks, months -- although typically these feelings become less intense in frequency, duration and intensity. Given that bank employees typically return to the same environment where the robbery occurred, some may experience a ‘triggering effect’ when they encounter certain stimuli.
‘Psychological First Aid’ Psychological first aid is an application of early critical incident/crisis response suitable for use by non-mental health professionals. Relying on a strengths-based perspective, it involves providing a basic level of support and information to victims immediately following a critical incident/emergency/disaster. It is designed to reduce the initial distress of traumatic events and foster coping abilities.
Providing ‘Psychological First Aid’ When victims want to talk, be prepared to listen. When listening, focus on patiently hearing what speakers are trying to say. Respond in ways that address immediate goals and how you can be of assistance. Speak slowly, clearly and calmly. Clarify answers repeatedly as necessary. Update victims and others as new information becomes available. Inform them of available resources and how they can access them easily.
Encouraging the use of services Inform employees that a EAP representative/mental health professional will be conducting an initial debriefing session (and provide date and time if available). Strongly encourage all employees (not just those present during the incident) to attend. For those unable or unwilling to attend the initial debriefing service, make certain they understand that additional counseling services are available now and will continue to be provided through the EAP. Furnish EAP contact information to employees (and family members as appropriate).
Ways to help employees cope First priority: Make sure everyone is safe – visual staff inspections are just part of a complete picture. Expressing your concern by engaging/inquiring directly of each employee as to how they are doing will help gauge their state of mind and the level of their stress reaction. Keep in mind the potential variety of individual responses and range of emotions in such events – avoid judgmental language or labeling of anyone’s particular responses, the initial focus should be on checking in with each individual and reassurance.
Branch Manager Training Results Comments from branch managers during the training were remarkably similar to those often heard from supervisors and managers during workplace substance abuse and EAP orientations – they expressed an uneasiness when entering into areas considered “psychological” or commenting on employee’s family life, etc. Post-training feedback from HR Manager was positive, she felt the training had given branch managers an understanding of the principles of PFA and how they might apply them with employees after a robbery. Additionally, a slight increase in requests for post-robbery EAP response did occur following the training.
Concluding Remarks While not all EAPs will be confronted with the task of responding to bank crimes, we believe this aspect of EA services provides a good illustration of how to develop and apply a comprehensive approach to workplace critical incident stress management. Research on the evolving best practices for supporting employees (and others) during crises/traumatic events indicates that an approach which fosters resistance to stress and resilience through appropriate levels of support, psychoeducation, and referral to higher levels of care when indicated, can be an effective EAP approach.