CRISIS REACTIONS FOLLOWING TRAUMATIC INCIDENTS JUNE 18, 2009 NUI MAYNOOTH
Helping the traumatized.... through education, certification and deployment. www.greencross.org
Dr. Dan Casey, CT Director, UMTTI 11959 77 th St. Clear Lake, MN 55319 320-282-2436 320-743-4119 F firstname.lastname@example.org www.jec-counseling.com
ICISF & Green Cross Trained trainer – International- Basic, Advanced, Individual, School, College & Suicide trainings, Compassion Fatigue, Field Traumatology, ICS Green Cross & ICISF Board member Coordinator for three Crisis teams 25 years wild land fire fighter- incident commander 800+ fires 7 years University instructor/ counselor SJU, UMM, UMB Provide 100 interventions per year on average 22 years -2000 interventions- trained 10,000 Dr. Daniel Casey, CT
DEALING WITH Emergency Services Personnel ON SCENE SOON AFTER - a few days LATER - a few weeks
Traumatizing events Auto accident Abuse Robbery Injury death to ones child or a child Suicide Line of duty death homicide (s) Tornadoes Earthquake Hurricane Fires Flood Pollution Multiple injury/fatality Terrorism Community disasters
Katrina’s Coming!!!!! A Model Response… Katrina’s Coming!!!!! Phone call among Dr. Jeffrey Mitchell – ICISF, Director – American Red Cross, Dr. Charles Figley – Green Cross “Let’s Not Compete” ICISF – Serve First Responders Red Cross – Serve Victims/Evacuees Green Cross – Serve Volunteers and Non Traditional First Responders
WHAT IN THE WORLD IS HAPPENING ??? PSYCHOLOGICAL FIRST AID (PFA) COMPASSION FATIGUE (CF) CRITICAL INCIDENT STRESS MANAGEMENT
Psychological First Aid A set of skills that helps community residents care for their families, friends, neighbors, and themselves by providing basic psychological support in the aftermath of traumatic events…
Psychological First Aid A model that: –Integrates public health and community and individual psychology. –Includes preparedness for communities, work places, schools, faith communities, and families. –Does not rely on direct services by mental health professionals. –Uses skills you probably already have…
Psychological First Aid Skills Part I – Understanding common symptoms and responses associated with trauma Part II - Active Listening Improving a skill you already possess Part III – Resource Awareness
COMPASSION FATIGUE “There is a cost to caring. People who listen to others’ stories of fear, pain, and suffering may feel similar fear, pain and suffering because they care. Sometimes we feel we are losing our sense of self to … those we serve…” It is the cost of working with people. The better you are at your work, the more compassion is expended, and the more compassion fatigue is experienced.
COMPASSION FATIGUE Post-Traumatic Stress Disorder Exposure is core factor in risk Sympathy is the vehicle of transmission
COMPASSION FATIGUE A state of tension and preoccupation with traumatized individual(s) by Re-experiencing the traumatic events, Avoidance/numbing of reminders, and Persistent arousal (e.g., anxiety)
signs of COMPASSION FATIGUE Loss of sense of humor Difficulty separating work and personal life Lowered frustration tolerance Dread (of working with certain clients or of certain calls) Disruption of one’s frames of reference (sense of identity, world view, and spirituality) Ineffective or self-destructive self-soothing behaviors
CRITICAL INCIDENT STRESS MANAGEMENT (CISM) A comprehensive, integrated, systematic, and multi - component approach to crisis / disaster intervention.
Disasters and CISM Situations beyond the resources of the local community Produce a great deal of emotional response usually requiring CISM services Victims, survivors, rescuers and community members need a variety of types of assistance
Disasters are Different Know Crisis services before you work a disaster Requires a high level of skill Needs most highly experienced Tendency towards overreaction Timing is essential Group processes out of place initally
10 th World Congress on Stress, Trauma & Coping COST OF CARING How we know we are stressed CHEMICAL & PHYSIOLOGICAL STRESS REACTIONS
Chemistry of Survival Catecholamines Excites the system Triggers increased nervous system “flight or fight” response Corticosteroids Moderates and controls extremes of catecholamines Keep ‘flight or fight’ in check
Endogenous Opiods Creates heightened threshold of pain Causes dissociative reactions Causes blunting of emotions Causes feelings of euphoria with catecholamines, causes amnesiac reactions
PHYSIOLOGICAL REACTIONS Ch. 7 RER ADRENAL GLANS KICK IN Cortisone levels rise +-protects from reactions - Immune system depleted -Body goes into starvation mode Thyroid kicks in + everything is working at peak performance – burnout faster
Physiological reactions Endorphins + nature’s opium- no pain - little hurts become big
Physiological reactions Shutdown of digestive tract + Blood diverted to muscles and engine room - no lubrication Sex Drive is reduced + Survival mode - Menstrual cycles disrupted - Erectile disfunction
Physiological reactions Sugar + short distance energy – tough on diabetics Cholesterol + long distance energy –loads arteries
Physiological reactions Heart + pumps thickened blood beats harder and faster – bad heart/ blood pressure? Lungs + collecting more oxygen - tough on smokers
PHYSIOLOGICAL REACTIONS Skin + largest organ protects us - dry skin and scaly All six senses + more acute and focused – more prone to accident
COMPASSION “a feeling of deep sympathy and sorrow for another who is stricken by suffering or misfortune, accompanied by a strong desire to alleviate the pain or remove its cause.” - Webster-EUDEL
10 th World Congress on Stress, Trauma & Coping COMPASSION STRESS The cost of providing compassionate care. What we invest of ourselves to do our work
COMPASSION SATISFACTION What we gain by the work we do. What keeps us doing what we do. What defines how we are mentally, physically, emotionally, spiritually, and behaviorally
COMPASSION FATIGUE “There is a cost to caring. People who listen to (and witness) others’ stories of fear, pain, and suffering may feel similar fear, pain and suffering because they care. Sometimes we feel we are losing our sense of self to … those we serve…” Charles Figley
COMPASSION FATIGUE “ Those who have enormous capacity for feeling and expressing empathy tend to be more at risk of compassion fatigue.” (Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatized, Charles Figley, Editor, 1995)
COMPASSION FATIGUE Results Diminished sense of purpose/ enjoyment of career Reduced ego functioning (time, volition, identity, language, cognition) Lowered functioning in non- professional situations Diminished capacity for intimacy Loss of hope
More RESULTS Subtle manipulation to avoid painful/traumatic material Loss of confidence Diminished effectiveness Dread Victim Perpetrator Diminished capacity to listen and communicate
WHAT DOES IT MEAN? Not a reflection of the helper’s inadequacy, nor indicative of the toxicity or badness of the client Is a result of one’s strengths: empathy, involvement and helping Is an occupational hazard for trauma workers, regardless of their profession Is a form of PTSD, and can be repaired.
is a strategic intervention system. It possesses numerous tactical interventions CISM
All CISM Services Must Be: Timely Efficient Consistent Thorough
Never Interfere With On-going Operations Ability to function is more important than a display of emotions Low profile CISM services Do only what is necessary Do not “push” your support Go easy
Planning and Education Basic /Advanced CISM training Peer support / Family Training Psychotraumatology training Disaster response training Strategic planning Written plans Training and practice Carefully select staff Drill Critique Rewrite the plan Practice again Continue In-Service training
CISM protocols are likely to break down if they have not been preplanned and practiced
ACCOMPLISHED? NATIONAL INTERAGENCY INCIDENT MANAGEMENT SYSTEM [NIIMS] INCIDENT MANAGEMENT SYSTEM [ICS] IRELAND HEALTH SERVICES USES MIMS
Positive Redundancy Two separate groups working on identical information with the intention of developing a comprehensive plan of action Some overlap Some new ideas Clarification of potential problems
10 th World Congress on Stress, Trauma & Coping SCENARIO FIRE AMBULANCE GARDAI
CISM INTERVENTIONS DEMOBILIZATION CRISIS MANAGEMENT BRIEFINGS INDIVIDUAL INTERVENTIONS SMALL GROUP INTERVENTIONS FOLLOW UP –IMMEDIATELY- & AFTER
Demobilization Quick information and rest session 10 minutes of information 20 minutes of food and rest Applied at 1.) end of first shift or 2.) before teams are released from incident Provided to teams of workers Provided by CISM team members
10 th World Congress on Stress, Trauma & Coping Crisis Management Briefing This large group process is one of the most versatile tools to be used in disaster related CISM services. It lowers anxiety and guides people toward effective action
Crisis Management Briefing Keep groups as homogeneous as possible Representative of organization presents information Sometimes question / answer period is allowed CISM team member presents information Specific practical advice is presented to manage the stress associated with the situation
ATSM SAFER OBSERVE and identify CONNECT GROUND SUPPORT NORMALIZE PREPARE STABILIZE ACKNOWLEDGE FACILITATE ENCOURAGE RESTORE/REFER
SAFE-R model content goal STABILIZE mitigate effective escalation ACKNOWLEDGE ventilation, reduce arousal, build rapport, sense of safety FACILITATE view symptoms as normal ENCOURAGE improve imm. & short term coping, develop plan RESTORE/REFER okay/ need help?
DEFUSING SMALL GROUP DISCUSSION following critical event. TIMING: Typically provided within 8 hours of the event. STRUCTURE: 3 phases DURATION: less than 1 hour LOCATION: Best in secluded room adequate for the purpose GROUP: Homogeneous group only
DEFUSING GOALS Normalization / lower tension Set expectations, provide information Discuss coping methods Identify those who need additional support
DEFUSING: 3 PHASES INTRODUCTION – Introduce team; lay out the guidelines; lower anxiety about the process EXPLORATION – Allows a brief discussion of the experience. A brief “story” of the event INFORMATION – Provide information, normalize, teach, guidance, summarize key points
Critical Incident Stress Debriefing (CISD) A structured GROUP discussion concerning a critical incident. First described by Mitchell (1983) for use with small groups of emergency services personnel. Historical roots in military psychiatry (see HERD, S.L.A. Marshall) Requires a team approach
CISD GOALS Mitigate distress. Facilitate psychological normalization and psychological “closure” (reconstruction). Set appropriate expectations for psychological / behavioral reactions. Serve as a forum for stress management education. Identification of external coping resources. Serve as a platform for psychological triage and referral.
Phases of a CISD COGNITIVE AFFECTIVE INTRODUCTION FACT REACTION THOUGHTSYMPTOM TEACHING RE-ENTRY
INTRODUCTION Introduces team members Sets expectations Describes “ground rules.” Ground rules anticipate potential problems and attempts to address them in advance. Addresses confidentiality. Participation in discussion is VOLUNTARY. Preview questions.
FACT PHASE Possible prompt: “Tell who you are and what happened from your perspective.” May still be used when group exposed to multiple stressors, as in disaster out -processing, or culmination of a tour of duty
THOUGHT PHASE * “What was the first or most prominent thought that entered your mind regarding the incident?” Any unusual or disquieting thoughts?
REACTION PHASE “What was the worst part of this event for you?” What feelings go with that? OR Any aspects of the event that have caused you the most pain or distress? OR If you had the power to erase one single aspect what would you most want to eliminate from the total experience?
SYMPTOM PHASE “What physical or behavioral changes have you experienced since the event?” Or, “What has life been like for you since the event?” Or, “What signals of distress have you noticed in yourself since this happened?”
TEACHING PHASE Team members normalize reactions of group members, then provide anticipatory guidance, teach stress management, describe external resources available.
RE-ENTRY PHASE Reiterate normalization Q & A, if indicated” Develop a plan –group or individual Foster group cohesion, if indicated
10 th World Congress on Stress, Trauma & Coping FOLLOW UP 24 Hours 3 days 3 weeks 3-6 months 51 weeks