1. Critical Incident Stress Management (C.I.S.M.) A Basic Introduction
Montgomery County CISM Team

2. Montgomery County Critical Incident Stress Management
Who takes care of the caregivers?

3. Critical Incidents
Events that have the potential to create significant human distress and can overwhelm one’s usual coping mechanisms.

4. What is a “Critical Incident?”
Death or injury of a coworker
Death or major injury to a child
Situations involving extensive media coverage
Prolonged situation with negative outcome
Mistakes, real or imagined
Victim previously known to person
Natural Disasters
Unionville H.S.

6. What is Critical Incident Stress?
Emotional, mental, and/or physical response which interferes with behavior, or the ability to function either on scene or after the incident is over.
As defined by Dr. Jeffrey T. Mitchell Ph.D.

7. What Determines How You Will React?
The type of stress you experience is dependant on 4 “P”s
Perception - How one views an event
Planning - Training and preparation
Preparedness - One’s expectations of the stimuli
Past - The baggage you carry from previous experiences

8. Coping Mechanisms Denial (“Things just don’t bother me”)
“Titanic Syndrome” – (I’m invincible and unsinkable)
“Image Armor” –(Admission of pain is seen as a sign of weakness)
Anger
Blame
Dark Humor

9. Exposure Control While working with a patient...
You may have gotten exposed to an infection
Would you seek treatment?

10. Exposure Control
After an exposure, a physician may prescribe some prophylactic medication
CISM is the prescription following an exposure to stress
C I S M

11. The Goals of CISM are: Early Recognition
Identifying a potentially stressful situation
Activation
Page the CISM Coordinator
Suppression
Set up an Intervention
Prevent burnout
Encourage the well being of personnel, careers, and families

12. San Diego vs. Cerritos

13. The Tale of Two Plane Crashes
San Diego
125 killed-no survivors
16 homes destroyed
15 civilians killed on ground
300 EMS personnel
> 10,000 body parts
Cerritos
82 killed-no survivors
16 homes destroyed
15 civilians killed on ground
300 EMS personnel
> 10,000 body parts

14. Impact of CISM San Diego Cerritos No CISM Services provided
Lost police - 5 in one yr.
Lost fire - 5 in one yr.
Lost paramedics - 15 in one yr.
Increase in mental health services - 31%
Cerritos
12 CISM Demobilizations
Hotline Follow-up
No loss of police or fire personnel
1 paramedic loss
Increase in mental health services - 1%

15. What is Stress? Your reaction to stimuli Stress comes in two forms
Physical
Mental/Cognitive
Emotional
Stress comes in two forms
Eustress
Distress

16. What is Distress?
A disruptive force that negatively impacts daily health -Mitchell & Bray
Physical- Change in eating patterns
Mental/Cognitive- Inability to recall simple information
Emotional- Hypersensitivity

17. What is Eustress? The positive, motivating reactions to situations
Driving force to do your best
Physical - Exercise
Mental - Academics
Emotional - Optimism

18. Psychological Crisis
An acute response to a trauma, disaster, or other critical incident wherein:
1) Psychological balance is disrupted
2) One’s usual coping mechanisms have failed
3) Evidence of significant distress, impairment, dysfunction

19. Terrorism represents a form of psychological warfare The war will ultimately be won or lost not on the battlefield, but in the mind

21. Crisis Intervention was developed in response to the acute mental health needs of those in crisis

22. Crisis Assessments

23. Acute Mental Status Assessment
Orientation
Long-term Memory
Concentration
Emotion

24. What is cumulative stress?
Chronic progressive culmination of small stressors
May result in P.T.S.D., if not managed.
Warning: Contents under extreme pressure!

25. Cumulative and Long-Term Effects of Stress
Hindrance of performance
Decreased ability to make decisions
Memory problems
Interpersonal Conflicts
Morale problems
Accident prone
Absenteeism
Depression
Burnout and Attrition
Suicide

26. P.T.S.D. (Post -Traumatic Stress Disorder)
This is a pathological reaction to an abnormal situation
Symptoms inhibit the person from functioning at his/her job
May have day or night terrors

27. More P.T.S.D.
Hypersensitivity
May experience intrusive thoughts (flashbacks)
Symptoms MUST last for over 30 days
Early Recognition and intervention may prevent the domino effect

28. Critical Incident Stress Management
“...is a comprehensive, organized approach for the reaction, and control of harmful aspects of stress.”
Jeffrey T. Mitchell Ph.D.
Forms of intervention:
Pre-incident Education
Debriefing (C.I.S.D.)
Defusing
Crisis Management Briefing (CMB)
Demobilization
1:1

29. For Whom is C.I.S.M. Targeted?
Normal people experiencing normal reactions to abnormal situations

30. C.I.S.M. is not for CRAZY People!
C.I.S.M. is not designed to be therapy or a replacement for therapy

31. Critical Incident Stress Debriefing
“… is a method for mitigating the harmful effects of work-related trauma, and ultimately preventing P.T.S.D.”
Jeffrey T. Mitchell Ph.D.

32. What is a Defusing?
A small group process which is initiated after any traumatic event that is powerful enough to overwhelm one’s usual coping mechanisms
Short version of a Debriefing

33. What Does Defusing Mean?
Means to render something harmless before it can do damage
Overall objective is to reduce the potential for harm to those who were exposed to a critical incident

34. Usual Effects of Defusings
May possibly eliminate need for formal Debriefing
It will enhance effectiveness of Debriefing process if one is needed

35. Defusing Goals
Achieve a rapid reduction in the intense reactions to a traumatic event
Attempt to normalize the experience
Attempt to re-establish the social helping network of the group
Assess need for formal Debriefing process

36. Additional Goals of Defusings
Information transfer between members
Re-focusing of thinking process; “getting your act together”
Education as to survival skills over next few days
Identifying support resources/personnel

37. Debriefing - What is It?
A formal peer group discussion designed to help alleviate the effects of critical incident stress
A prevention program for “burn-out”

38. What Happens at a Debriefing?
Team
Location
Phases
Introduction
Fact
Thought
Reaction
Symptom/teaching
Re-entry

39. Introduction Phase Introduce members Establish ground rules
Explain process

40. Fact Phase
Who are you and what was your job, or how were you involved in the incident?
What happened from your point of view?

41. Thought Phase
What was your first or most prominent thought once you came off auto pilot?

42. Symptom Phase The group is asked to describe:
Any cognitive, physical, emotional or behavioral symptoms they experienced at the scene
Symptoms they experienced in the following days
Symptoms they continue to experience

43. Teaching Phase
All team members teach about symptoms one may experience
Find a positive outcome, or gift that may have come out of tragedy
Utmost concern for group

44. Re-entry Phase Clarify issues Answer questions
Team members make summary comments

45. Follow-up and Referral
May return for another debriefing if group decides
May have an individual who may ask for further help

46. Signs and Symptoms Physical Cognitive Chest Pain Elevated BP Headaches
Muscle tremors
Cognitive
Confusion
Poor attention
Intrusive images
Nightmares
Behavioral
Physical
Cognitive
nal
Emo

47. Signs and Symptoms Emotional Behavior Guilt Anxiety Depression
Withdraw
Loss of or increase in appetite
Changes in sleep patterns
Increased alcohol consumption

53. The Keys to Unlocking a Successful Career
After a Critical Incident:
Helping a Peer
Listen carefully
Spend time with the traumatized person
Help with everyday tasks
Know your limitations as a peer supporter

54. The Keys to Unlocking a Successful Career
Helping yourself
Eat well-balanced and regular meals
Drink plenty of water
Get plenty of rest
Structure your time - Keep busy
Allow yourself to be emotional
Look to your peers and family for support

55. Pre-Incident Strategies
Eat Properly
Exercise
Rest
Talk
Must practice/do/engage in regularly

56. Post-Incident Strategies
Eat Properly
Exercise
Rest
Talk

57. Montgomery County Critical Incident Stress Management Team
Department of Public Safety
Division of EMS
and the
Office of Mental Health

58. History of the Montgomery County CISM Program
Trained Emergency Services Peers
Mental Health Professionals
All Volunteers
Services are free
C C - C I S M
C C - C I S M
M C - C I S M

59. Main goals of CISM To “jump start” your natural support systems
To help keep your “baggage” at a manageable level
To get you back to work and functioning at an optimal level after a critical incident

60. Team Make-up Mental Health Professionals
EMS/ Medical Professionals Peers
First Responders, EMT’s, Paramedics, PHRN’s, Nurses, Physicians
Police Officers Peers
Active, and retired
Firefighters, Rescue, Water Rescue Peers
Dispatcher Peers
Clergy
Community Service Peers

61. The expanding role of CISM
Services for families of Emergency Services Personnel
Industrial First Responders
Proactive Training & Education
Community Group Crisis

62. Who Can Activate CISM?
CISM may be activated by any member of any Emergency Service in Montgomery County
It is advised that these requests go through a supervisor or an administrator
CISM may be activated by other community service groups

63. How to Access the Team 911 or 610-631-6541
CISM can be activated through:
Montgomery County Emergency Dispatch Service
911 or

64. STRESS IMPAIRS THE ABILITY TO CARE AND PERFORM

65. Special thanks to Marc Borish, NYC Regional EMS CISM Coordinator (and formerly the Chester County CISM Coordinator) for the preparation of the text portion of this presentation

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