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

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

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

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

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.

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?

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

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

Exposure Control  After an exposure, a physician may prescribe some prophylactic medication  CISM is the prescription following an exposure to stress

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

San Diego vs. Cerritos

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

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%

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

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

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

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

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

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

Crisis Assessments

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

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!

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

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

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

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

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

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

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.

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

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

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

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

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

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”

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

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

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How to Access the Team n CISM can be activated through: n Montgomery County Emergency Dispatch Service 911or

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