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

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

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

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

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

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

9. Exposure Control n While working with a patient... –You may have gotten exposed to an infection n 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

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

12. San Diego vs. Cerritos

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

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

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

16. What is Distress? n 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? n 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

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

21. Crisis Assessments

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

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

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

25. P.T.S.D. (Post -Traumatic Stress Disorder) n 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

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

27. Critical Incident Stress Management n “...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 On-Scene Support Demobilization Defusing Debriefing (CISD) Crisis Management Briefing (CMB) Family Support Assessment Follow-up/Referral Mutual Aid

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

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

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

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

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

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

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

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

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

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

38. Introduction Phase n Introduce members n Establish ground rules n Explain process

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

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

41. Symptom Phase n 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

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

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

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

45. Signs and Symptoms n Physical –Chest Pain –Elevated BP –Headaches –Muscle tremors n Cognitive –Confusion –Poor attention –Intrusive images –Nightmares

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

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

48. 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

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

50. Post-Incident Strategies n Eat Properly n Exercise n Rest n Talk

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

52. History of the Montgomery County CISM Program n Trained Emergency Services Peers n Mental Health Professionals n All Volunteers n Services are free

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

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

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

56. Who Can Activate CISM? n 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 n CISM may be activated by other community service groups

57. How to Access the Team n CISM can be activated through: n Montgomery County Emergency Dispatch Service 911or610-631-6541

58. 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