8Do you know where to go to reach out for help? HOW DID YOU COPE?When you are involved, either directly or indirectly (even watching TV or radio news, and seeing the headlines in your newspaper may cause trauma too) with trauma it places stress on your mental health. How do you cope or deal with these feelings? How do you “chase away the demons”?Keeping “it” inside can be the cause of loss of attention, anxiety, thoughts of hurting yourself or others, chemical abuse, depression andmany other clinically diagnosed psychosis similar to that ofcombat stress and even PTSD.Carrying your feelings inside ultimately festers and becomesa severe burden on you, your family and your friends.Do you know where to go to reach out for help?There are many programs which are available but in all cases help is best offered while the events are “fresh” in your mind. You can call your local Law Enforcement Center for contact information of your local area CISM team.
9WHAT CAUSITIVE REACTIONS DO CRITICAL INCIDENTS PRODUCE? A Critical Incident is any event that generates such intenseemotional energy that it overwhelms an individual’s or group’sability to cope and causes impairmentin work or personal activitiesA crisis is an acute emotional reaction to a critical incidentCritical Incident Stress is the cognitive physical, and emotionalstate of arousal that is part of the crisis responseCritical Incident Stress (CIS) is also known as“Post Traumatic Stress”.This is NOT the same as PTSD.CIS is a normal response of normal People to an abnormal event
10DomesticViolenceCrimeRiots and TerrorRapeFireThere are many everyday events which may cause personal psychological stress, it’s not just war & violence that professionals deal with, weare all vulnerable…Natural DisasterWeatherWarAccidental Tragedy
11How do you react normally to an abnormal event? What constitutes mental trauma?Line of duty deathsSuicide of a colleagueSerious work related injuryMulti-casualty / disaster / terrorism incidentsEvents with a high degree of threat to the personnelSignificant events involving childrenEvents in which the victim is known to the personnelEvents with excessive media interestEvents that are prolonged and end with a negative outcomeAny significantly powerful, overwhelming distressing eventHow do you react normally to an abnormal event?DefusingDebriefingFollow-Up
12HELP IS AVAILABLE! C I S M Critical Incident Stress Management PsychologicalFirstAidPFAHopeCompassion Fatigue Therapy
13WHAT KIND OF HELP IS AVAILABLE? Incidents come and go but their memories may linger forever…Military members are apt to see/experience atrocities, olderVeterans just kept the memories to themselves. Perhaps theywere too painful to talk about or it was just the “manly” thingto do because it was a sign of “weakness”.Left untreated these memories can manifest into more severclinically diagnosed issues such as depression and Post TraumaticStress Disorder (PTSD).These issues have been recognized in many more than just themilitary and counseling is routinely performedfollowing traumatic incidents for EmergencyResponders, Health Care Workers, Family,and Law Enforcement. These sessions arereferred to as Critical Incident StressManagement (CISM) & PsychologicalFirst Aid (PFA). There is help for thecaregiver too, Compassion Fatigue Therapy.
14CISM: Definition“Critical incident stress management (CISM) is an adaptive short term helping process that focuses solely on an immediate and identifiable problem. It spans pre-incident preparedness to acute crisis to post-crisis follow up. Its purpose is to enable people to return to their daily routine more quickly and with less likelihood of experiencing Post Traumatic Stress Disorder (PTSD).“
15What is Critical Incident Stress Management and how does it work? Assist people to deal with their trauma one incident at a timeAllows conversation about the incident when it happens without judgment or criticismCISM is peer driven and those providing CISD may be from all walks of lifeAll interventions are strictly confidentialCaveat: If person is deemed to be a danger to themselves or othersEmphasis: Keeping people safe and returning them to more normal levels of functioning as quickly as possibleWHAT IS “NORMAL”? “Normal” is different for everyone, and it is difficult to quantify. Any critical incident causes a dramatic raise in stress levels in a short amount of time. Although “normal” may vary between individuals trauma establishes a new normal that is always higher than the previous level.PURPOSE: The purpose of the CISM intervention process is to establish or set the new normal stress levels as low as possible.TYPES OF INTERVENTION: It depends upon the situation, the numberof people involved and their proximity to the event. The optimumis a three-step approach that addresses the trauma at variousstages of progression: defusing, debriefing, and follow-up.CONFIDENTIALITYCISM is designed to help people deal with their trauma one incident at a time, by allowing them to talk about the incident when it happens without judgment or criticism. The program is peer-driven and the people giving the treatment may come from all walks of life, but most are first responders or work in the mental health field. All interventions are strictly confidential, the only caveat to this is if the person doing the intervention determines that the person being helped is a danger to themself or to others. The emphasis is always on keeping people safe and returning them quickly to more normal levels of functioning.Normal is different for everyone, and it is not easy to quantify. Critical incidents raise stress levels dramatically in a short period of time and after treatment a new normal is established, however, it is always higher than the old level. The purpose of the intervention process is to establish or set the new normal stress levels as low as possible.
16SYMPTOMSA person has been exposed to a catastrophic event involving actual or perceived death or injury. This event is characterized by intense fear.The duration of the PTSD symptoms last at least a month but may last a lifetime.The person experiences significant occupational, social or other distresses.The person starts to avoid anything that will cause them to re-experience the event. He/she also experiences a numbing effect that interferes with his/her personal relationships.The person tends to be in a state of hyper arousal that results in being startled very easily and a heightened vigilance to the point of paranoia.The traumatic event persists as a dominating psychological experience, typically causing a person to experience flashbacks of the event from other stimuli.
17RECOGNITION & TREATMENT Many hospitals, corporations, law enforcement and EMS have recognized the importance of CISM. In many cases they have incorporated training and a response team within their organization. If not, they know the LOCAL resources that are available.Left untreated, traumatic stress will culminate into far greater mental health issues such as PTSD. However, we have come a long way, especially in the Military! We now recognize symptoms of Combat Stress and a focus on its treatment before it evolves into PTSD.Throughout the years there have been many names for it to include:Battle Fatigue or Gross Stress Reaction for soldiers who came down with PTSD after World War IICombat Fatigue or Shell Shock for soldiers who experienced PTSD symptoms after World War ISoldier's Heart for soldiers who developed the symptoms of PTSD after the Civil War.Worst of all, it was often mistakably considered to be COWARDICE…Click Hereto watch shorttake from“Patton”
18Kyle Housmann-Stokes: ”Now, After” The producer, Kyle Housmann-Stokes, was an OIF Veteran who was preceded in militaryservice by his grandfather who is a Lieutenant Colonel serving two tours in Viet Nam and one in Iraq. This film depicts the plight of stress and trauma that many returning service men and women suffer. It’s poignant and it’s direct… Please be aware that there are some parts which are graphic representations but allows you a better understanding, if you are not military or a Vet, of what is war means to those returning.Regardless of the era, conflict or war, the technologies may changebut the carnage and after effects remain much the same, as does thecamaraderie among Veterans, young and old. You can see from thisfilm how Veterans are not strangers and regardless of era rally to his side.Let’s watch the film… (or via Internet: Watch Film)For Kyle’s latest filmography you can go to:For a background on Kyle and how this came about you can log on to the following:
19Kyle Housmann-Stokes: ”Now, After” Personal observations about the film:Pride in his military service and accomplishmentsHe possesses hyper-vigilanceFlashbacks (both good & bad, human carnage and the Iraqi people)Indications of Obsessive Compulsive Disorder (O.C.D.) (preparing for his schoolday as if it were for a patrol)AnxietySweatingApprehensive about leaving the safety of his homeInability to “disconnect” himself from the MilitaryHyper-vigilance and flashbacks while driving (speeding up and driving themiddle of the road to avoid possible “IED’s”)Avoiding others, lonerUncontrolled outburst of anger, anger management issuesOnce at the VA:Reverence when at the VA parking garageRealization that he’s not alone…
20GUIDELINES FOR STRESS MANAGEMENT Diet Mind what you eat…Focus on the following:High Protein, raw fruits, vegetablesStay away from:Carbohydrates, low sugar, low fat and low saltWhy?Cortisone levels rise when you are stressedImmune system depletesBrain tells our body that it’s starving to death
21GUIDELINES FOR STRESS MANAGEMENT Exercise Sweat out the chemicals!132 chemicals mix together when your body goes into the stress responseSweat is the only way to remove these quicklyRecommend physical therapy massage to ease the pains in the bodyChemistry of survival:CatecholamineExcites the SystemTriggers increased nervous system“Flight or Fight” responseCortico-SteroidsModerates and controls extremes of catecholamineKeeps “Flight or Fight” response in checkEndogenous OpioidsCreates Heightened threshold of painCauses dissociative reactionsCauses blunting of emotions with catecholamine’s, causes amnesiac reactionsCauses feelings o f euphoria
22GUIDELINES FOR STRESS MANAGEMENT Let It Run Your unconscious has to find a “fit”Your mind must find a “fit” for the event in your memory so your memory can accept itIt will “run” at your request or when it feels it is necessaryLet it run when YOU control itIf it is overwhelming now, “set it up” to run at another day or time
23GUIDELINES FOR STRESS MANAGEMENT Breathing Deep BreathingGenerally you only use 1/3 of your lung capacityDeep Breathing, using more than 2/3 of your lung capacity:Increases oxygen flow to your brainDumps the Carbon Monoxide in our lungsThis allows us to breath betterAllows us to think with more clarityDeep Breathing also increases the serotonin levels in our bodyPractice deep breathing techniquesOxygenate!Oxygenseven just isn’t enough…
24CISM: Timeline Defusing – Immediately On-siteGroup or One-on-OneDebriefing – Within 72 hours of the incidentFormal setting for groupFormal/informal setting for one-on-oneFollow-up – Within approximately 30 daysComfortable settingPreferably in person
25CISM: DefusingWHO: Individuals who were directly involved in the incidentHOW: These are generally informal and often performed at the sceneSteps used in this process are:Introduction; Exploration; InformationWHEN: The day of the event before the person gets to sleepInitial Defusing: Initial informal defusing sessions should be held within 8-12 hours after the incident. A defusing session is a brief, spontaneous, non-evaluative discussion coordinated and conducted by a minimum of two peer supporters and held immediately following a critical incident. The defusing may be considered an emotional “triage”, in which a person can begin to talk about and explore their thoughts concerning the incident - a chance to “vent” feelings - in an informal, positive and supportive atmosphere.It is NOT to serve as a critique of the situationWHAT: Designed to assure those involved that their feelings are normal:It’s a process of “talking it out “Explanation of what symptoms to watch for over the short termOffering a lifeline (phone number where they can reach someone withwhom they can talk)
26CISM: Group Debriefing WHO: Those who were directly affected by the incident and often the first for those not directly involvedHOW: Formal, in a group setting“Seven Step Process” is generally used in this settingIntroduction; Facts; Thoughts; Reactions; Symptoms; Teaching; Re-EntryNo notes taken or paper/pen allowedFacilitator and intervenor are the only two in the room besides those participatingWHEN: Within 72 hours of the incidentA chance to “vent” feelings - in an informal, positive and supportive atmosphere.It is NOT to serve as a critique of the situationWHAT: Structured to allow participants to “talk it out” and “reflect” on the event(s) to help them identify with how one another reacts to an abnormal event, everyone’s normal reactions are differentGroup debriefing provides the group the opportunity to talk about their experience, how it has affected them, brainstorm coping mechanisms, identify individuals at riskIt also serves to inform the group about services available to them in their communityProvides an explanation of what symptoms to watch for over the short termThe “intervenor” is always on watch for individuals who are not copingwell and additional assistance is offered at the conclusion of the process
27CISM: One-on-One Debriefing WHO: An individual who was directly, or possibly indirectly, affected by the incidentHOW: In a quiet & comfortable setting“Seven Step Process” is generally used in this settingIntroduction; Facts; Thoughts; Reactions; Symptoms; Teaching; Re-EntryNo notes taken or paper/pen allowedFacilitator and intervenor are the only two in the room besides the participantWHEN: Within 72 hours of the incidentA chance to “vent” feelings - in an informal, positive and supportive atmosphere.It is NOT to serve as a critique of the situationWHAT: Structured to allow participants to “talk it out” and “reflect” on the event(s) to help them identify with how one another reacts to an abnormal event, everyone’s normal reactions are differentGroup debriefing provides the group the opportunity to talk about their experience, how it has affected them, brainstorm coping mechanisms, identify individuals at riskIt also serves to inform the group about services available to them in their communityProvides an explanation of what symptoms to watch for over the short termThe “intervenor” is always on watch for individuals who are not copingwell and additional assistance is offered at the conclusion of the process
28CISM: Follow-upFollow-up is the most important final step to the processFollow-up is generally done within the week (or up to 30 days) following the debriefingFollow-up is for participants as well as CISM team members as a check-in to make sure they are OK tooDuring a follow-up additional intervention or a referral may be provided to the original participant. It may also be provided for the caregiver(s) to ensure theCaregiver(s) does not demonstrate the symptoms of Compassion Fatigue.
29CISM: Referral There are many links in the chain of concern Referrals are recommended any time that it is obvious that one or more persons needs are beyond the scope of the CISM program. The referral action is considered an essential component of CISM that supports and enhances the care provided for these people.There are many links in the chain of concernthat are dedicated to assist you…
30Compassion Fatigue Compassion Fatigue is the cost of caring… You must care for yourself and allow others to help you care for yourselfUse your Compassion Fatigue TherapistIt is care for the caregiver…Compassion fatigue plagues caregivers worldwide. When providing care to otherswithout incorporating authentic, sustainable self-care practices into our daily lives,destructive symptoms surface. Isolation, emotional outbursts, substance abuse andreoccurring nightmares are just a few of the symptoms that can distress the life of acaregiver. With awareness and knowledge, compassion fatigue can berecognized and managed.For more information about Compassion Fatigue please visit:
33CONFIDENTIALITY CISD’s are like visiting Las Vegas… What is said, what is heard & what is seen during a CISD will remain at the CISD! Everything is CONFIDENTIAL.Don’t “monkey around” with another person’s life…
34Critical Incident Stress Management (CISM): Group Crisis Intervention (4th Edition) Jeffery T. Mitchell, Ph.D., C.T.S. International Critical Incident Stress Foundation,JEC Counseling, Dr. Dan Casey, Traumatologist“Green Cross Academy of Traumatology”, Charles R. Figley, Ph.D.,Green Cross Academy of Traumatology,International Red Cross,
35Thank You. SPREAD THE WORD… THE WORD IS “FAC” Thank You! SPREAD THE WORD… THE WORD IS “FAC”! (FAC = “Family Assistance Center”)Your Presenter: Jeff GayMinnesota Military Family Assistance Center500 Timmerman DriveMarshall, MNOffice or CellularYou make the call;We’ll make the difference!8 Locations! To locate your nearest FAC go to:
36IN REVIEW Question, Comments, Observations, Conversation, Constructive Criticism, Blasphemous Commentsabout the Presenter, Praise, Adoration, Accolades…To locate your local CISM team, contact your localLaw Enforcement Center or EMSDo You wish to become a CISM Volunteer?If you wish to become involved in volunteering in the area of CISMlocally or, becoming Green Cross certified and travel to disasterareas worldwide, please contact Dr. Dan Casey ator on-line at for upcoming classes inyour area.It feels good to help and the best feeling you can haveis knowing that you “made a difference” in someone’s life…Catch that feeling! Become a peer volunteer!