2. Preparing for the Unthinkable Presented by: Tim P. Faulk, PhD, CTS Certified Trauma Specialist Clinical Director, Headland Police Department Clinical Director, Wiregrass Critical Incident Stress Management Team

3. Professional Background Board Certified Expert in Traumatic Stress Board Certified Expert in School Crisis Response Approved CISM Instructor: Individual Crisis Intervention & Peer Support - International Critical Incident Stress Foundation (ICISF) Approved CISM Instructor: Basic Group Crisis Intervention (ICISF) Clinical Fellow, American Association for Marriage and Family Therapy

4. Objectives Preparing for the Situation Define Critical Incident Stress Management (CISM) Define conflict and stress Define the different body responses to stress Understand the CISM Model

5. A Dale County School Bus Driver Murdered and A Kindergarten Student Taken Hostage

6. The Situation On January 29 th, 2013, an individual boarded a school bus then shot and killed the bus driver when his demand for two children wasn’t met. He then took a 5 year old boy to an underground bunker where he was held as a hostage.

7. What NOW? A Critical Incident Response plan became crucial in order to provide all related school employees with the coping skills to deal with the situation. Implement of the plan to include not only school personnel, but individuals affected by the school crisis.

8. The Pre-Plan In order to understand how the plan was developed, it is essential that you comprehend the process leading to the Plan. The model implemented was CISM (Critical Incident Stress Management) which was developed by the International Critical Incident Stress Foundation (ICISF).

9. What is CISM? Critical Incident Stress Management (CISM) is a comprehensive, integrated, systematic and multi-component crisis intervention program. It was developed to help manage traumatic experiences within organizations and communities.

10. Overview CISM is a “package” of crisis intervention tactics that are strategically woven together to: 1) mitigate the impact of a traumatic event; 2) facilitate normal recovery processes in normal people, who are having normal reactions to traumatic events;

11. 3) restore individuals, groups and organizations to adaptive function; and to, 4) identify people within an organization or a community who would benefit from additional support services or a referral for further evaluation and, possibly, psychological treatment.

12. CISM is neither a form of psychotherapy, nor is it a substitute for psychotherapy.

13. What CISM really is…. Instead, CISM is a broad collection of support services that can be selected and applied to assist people who are experiencing a strong reaction to a traumatic event. In other words, it is “psychological first aid” or “emotional first aid.”

14. Similar to a toolbox with many tools for different purposes, CISM contains many crisis intervention “tools.” Some of those tools are useful before a traumatic event occurs.

15. Others are useful while an event is ongoing. Still others are available for when the event is over.

16. Critical Incidents Critical Incidents are unusually challenging events that have the potential to create significant human distress and can overwhelm one’s usual coping mechanisms.

17. Psychological Crisis The psychological distress in response to critical incidents such as emergencies, disasters, traumatic events, terrorism, or catastrophes is called a psychological crisis. (Everly & Mitchell, 1999)

18. Four goals of crisis intervention 1.Mitigate the impact of the traumatic event (lower tension); 2.Facilitate normal recovery processes in normal people who are having normal reactions to abnormal events; 3.Restoration to adaptive function; 4.Facilitation of access to continued care.

19. History 1989 – ICISF formulated an international network of crisis response teams (standardized training), 1992 – American Red Cross began formalized training for establishing a nationwide disaster response capability,

20. History 1997 – ICISF gained United Nations affiliation. 2007 – The United Nations adopts an integrated, multi-component critical incident management approach as the overarching intervention system.

21. History Although not called CISM until the mid 1980s, critical incident stress management concepts were introduced into the emergency services field in 1974. They were first developed to assist emergency operations personnel, such as police officers, firefighters, emergency medical and military personnel.

22. History Over the last few decades CISM support services have extended well beyond their original intended target populations and now include school systems, the business sector, church groups and the industrial sector.

23. The impact of Stress When a traumatic events happens, there are a collection of bodily reactions that occur. In order to understand the CISM process, it is essential to understand these reactions and the impact they have following the traumatic event.

24. Understand the Stress Response Stress is an elevation in a person’s state of arousal or readiness, caused by some stimulus or demand. As stress arousal increases, health and performance actually improve.

25. Understanding Stress However, at some point stress arousal reaches maximum level, then the deterioration of health and performance begins. Some stress is a part of daily life and it affects everyone. Certain kinds of stress are actually helpful because they keep you on your toes.

26. What Stress Is Not! The confusion created when your mind overrides your body’s basic desire to choke the living mess out of some person who desperately needs it.

27. Common Stress Response Emotional: –Fear –Anxiety –Overwhelmed –Frustrated –Alone –Anger –Grief

28. Common Stress Response Physical: –Tired –Nausea –Sweating –Faintness –Shortness of breath –Easily startled –Headaches

29. Common Stress Response Social –Isolation –Blaming –Difficulty in giving or accepting support or help –Hypervigilant

30. Psychological Crisis An acute response to a trauma, disaster, or other critical incident wherein: 1.Psychological homeostasis (balance) is disrupted (increased stress). 2.One’s usual coping mechanisms have failed. 3.There is evidence of significant distress, impairment, and/or dysfunction. (adapted from Caplan, 1964, Preventive Psychiatry)

31. PRE-EVENT EVENT THOUGHTS FEELINGS THOUGHTS FEELINGS CRISIS Reactions Pre and Post Event

32. Traumatic Events A traumatic event is defined as any event that has sufficient impact to overwhelm the usually effective coping skills of either an individual or a group. These events are typically sudden, emotionally powerful, and outside the range of usual human experience.

33. Traumatic Events These events may have a strong emotional effect even on well-trained and experienced individuals. In a crisis, an individual’s sense of psychological balance is disrupted by an adverse event or stressor.

34. Coping?! Most importantly, the individual’s usual coping mechanisms become temporarily ineffective. This leaves the individual potentially feeling overwhelmed, vulnerable, and/or agitated.

35. Traumatic Responses There are five reactions to a traumatic event: –Emotional –Cognitive –Behavioral –Physiological –Spiritual

36. Emotional Responses Shock Highly anxious Stunned Emotionally numb “In a fog” Denial Dazed Panic/fear

37. Cognitive Responses Impaired concentration Confusion Self-blame Forgetfulness Thoughts of losing control Hypervigilance Recurring thoughts of the event Vulnerability

38. Behavioral Responses Withdrawal “Spacing out” Non-communication Impulsivity Pacing Exaggerated startle response Inability to sit still Erratic movements

39. Physiological Responses Rapid heart rate Elevated blood pressure Fatigue Anger Grinding of teeth Headaches Gastrointestinal upset Dizziness

40. Spiritual Responses Feeling distance from God Withdrawal from attending services Sudden turning to God Feeling that God is powerless God doesn’t care Questioning of one’s basic beliefs

41. Reactions Important to recognize that these reactions do not represent an unhealthy response. They may be viewed as a normal response to an abnormal event.

42. The Brain and Trauma The amygdala, is a part of the emotional center of the brain, begins the process of emotional memories. For a memory to be “filed” in the amygdala, the event must be logical in nature. If not, the memory lodges in the neurological system (5 senses).

43. The Question………. There must be something that will help alleviate the stress of a critical incident?

44. Now………. In most situations, an intervention is the standard of care approach. The intervention should be tailored to the situation and focus on the immediacy of the situation. Pre-incident planning is the ideal, but…..!

45. The Answer! Having spent more than forty years in the area of crisis intervention, and upon reviewed all available material regarding the best method of crisis intervention it was determined the best method of crisis intervention was the services provided through the International Critical Incident Stress Foundation (ICISF), specifically CISM.

46. A Comprehensive, Integrated Multi-Component Crisis Intervention System (adapted from: Martha Starr) Each “leaf” represents a specific tactical intervention.

47. The Beauty of CISM CISM is guided by peer’s and directed by the Clinical Director and Team Leader!

48. The Beauty of CISM “Ethos,” i.e. credibility, is one of the 3 core elements of interpersonal influence. Aristotle (ethos, pathos, logos) Peer support personnel have an “ethos” (credibility) that no academic training program can create!

49. Elements of CISM Pre-incident education and preparation –A form of psychological “immunization.” –The goal is to strengthen potential vulnerabilities and enhance psychological resiliency in individuals who may be at risk for psychological crisis and/or psychological traumatization. –Familiarization with common stressors, stress management, stress resistance training and crisis mitigation training.

50. Elements of CISM Assessment –ALL Crisis Intervention should be based upon the Assessment of NEED…and the further ASSESSMENT of the most appropriate intervention

51. Elements of CISM Strategic Planning –A strategic planning model can assist with this process. 1.Threat 2.Target 3.Type 4.Timing 5.Resources

52. Elements of CISM Large Group Crisis Intervention: –Demobilizations {Rest, Information, Transition sessions} One time large group informational meeting –Respite/Rehab Sectors Ongoing physical/psychological respite area –Crisis Management Briefings (CMB) Structured group (town meeting) format

53. Elements of CISM Small Group Crisis Intervention: –Defusings Small group (<20), structured Homogeneous group Within 12 hours of the event Can be repeated for ongoing events –Small group CMB Structured group (Town meeting) format

54. Elements of CISM Small Group Crisis Intervention (cont.): –Debriefing Structured 7-phase group discussion typically conducted with homogeneous groups (2-10 days; 3+ weeks mass disasters) post incident. Designed to mitigate distress, facilitate psychological closure, or facilitate access to continued care.

55. Elements of CISM One-on-one crisis intervention (PFA) –Most crisis intervention is done individually –Psychological first aid (PFA) is the most elemental form of this intervention

56. Elements of CISM Family Crisis Intervention –Traumatic stress can be )contagious –Family members are adversely affected by other family members who develop post traumatic stress –Families require support, especially when loved ones are seriously injured or killed.

57. Elements of CISM Organizational/Community intervention and consultation –Consist of risk assessment, pre and post incident strategic planning, tactical training and intervention, consultation with leadership and the development of a comprehensive crisis response plan.

58. Elements of CISM Pastoral crisis intervention –The functional integration of the principles and practices of psychological crisis intervention with the principles and practices of pastoral support.

59. Elements of CISM Follow-up and referral for continued care –ALL forms of crisis intervention should possess some form of follow-up. –Identification of those who may require or desire continued care –Facilitate access to mental health.

60. REMEMBER! These components of CISM are NOT substitutes for psychotherapy! Rather, they are elements within the emergency mental health system designed to precede and complement therapy. Part of the continuum of care

61. Team Composition CISM Team consist of: –Clinical Director –Team Leader –Trained Peer’s (Discipline specific) –Mental Health Professional All should be trained in the CISM Model and receive on-going training.

62. Please Remember! The tactics of CISM are not substitutes for psychotherapy. Rather, they are elements within the emergency mental health system designed to precede and complement psychotherapy, i.e., part of the full continuum of care.

63. CISM Goals Alleviate distress. Assist with psychological normalization and psychological “closure” (reconstruction). Set appropriate expectations for psychological/behavioral reactions.

64. CISM Goals Serve as a forum for stress management education. Identification of external coping resources. Serve as a platform for psychological triage and referral.

65. CISM Response Contact was made with Superintendent Bynum on Tuesday night (29 th ) regarding the availability of services; Met with Superintendent Bynum on Wednesday morning (30 th ) to develop a Crisis Response Plan.

66. The following were considered: Temporarily shut down the school’s website due to privacy issues involving the faculty/staff; Critical Incident Stress Management “Debriefing” for Administrators, School Counselors and Bus Drivers; Discussed possibilities of grief counselors, pastors, etc.;

67. The following were considered: Crisis Incident Stress Management (CISM) “Debriefing” for the students who were on the bus and their parents; When to re-open schools. Discussed safety measures related to parents, students and personnel.

68. CISM Response –Consideration was given to the fact that the crisis was on going and careful planning was needed; –Emphasized that the response would be in the form of an intervention and not therapeutic in nature; –Discussed the importance of specific homogeneous groups to prevent re- traumatization.

69. CISM Response Given incident dynamics and timeframes the following were developed for Thursday (31 st ) sessions: School officials and support staff Transportation personnel Family to include students on the bus (2 sessions) All groups were provided with specific details that would be covered during the meetings and all were provided with additional resources.

70. CISM Response School officials and staff were provided with the following information: Group intervention was conducted to assist with the goal of mitigating the emotional reactions to the crisis. The format was the modified CISM model for a Debriefing. Question and Answer period

71. CISM Response The following articles were provided to the Staff: –The School Personnel Guidelines for Crisis Response –The Critical Incident Stress Information Sheet

72. CISM Response Transportation staff was provided with the following : –Group intervention was conducted to assist with the goal of mitigating the emotional reactions to the crisis. –The format was the CISM model for a Debriefing. –Brief question and answer period.

73. CISM Response The following articles were provided to the Transportation Staff: The Critical Incident Stress Information Sheet.

74. CISM Response Parent’s and students were provided with the following : –Meet together for a brief overview of intervention. –Separated out with a parent group and a student group. –Parents remained in the same room to ensure parents had visual contact with the student.

75. CISM Response A specific format (parent/student) was used to ensure that everyone’s experience was positive. The format was the CISM model for Debriefing (family and students)

76. CISM Response Each parent was provided with the following informational sheets: Parenting Guidelines for Crisis Response Practical Suggestions for Parents Reactions to Trauma

77. CISM Response Teachers and related staff met on Monday (4 th ) morning to address issues relating to students return to school. Discussed Informational sheet. Question and answer time to assist with any on-going emotional reactions.

78. CISM Response Presented an informational sheet developed to assist with explaining, at that time, the on-going incident. –Return to School Outline

79. Evaluation of the Dale County Response

80. Strengths Responses were within the time guidelines; The school system provided a quality setting for the debriefings to include security measures;

81. Strengths Adequate resources were provided; Positive interaction between school personnel; The target groups were appropriate.

82. Improvement areas No established plan for responding; Several groups were to large and thereby facilitated tension; Unable to provide a follow-up with the groups.

83. Closing Thoughts “If you think you are too small to be effective, you have never been in the dark with a mosquito.” - Author Unknown

84. Prepared for the Unthinkable!

87. If you are interested in receiving CISM training and becoming a CISM team member contact: Alabama State Department of Education Prevention and Support Crisis Management

88. Contact Information www.thecrisisdoctor.com thecrisisdoctor@gmail.com (334) 701-9624 (cell) (334) 794-2113 (office)