1. Denton County CERT Team
Understanding CISM
Denton County CERT Team

2. What is CISM ?
Critical
Incident
Stress
Management

3. STRESS
RESPONSE to a stimulus characterized by increased psychological AROUSAL
Physical is the body’s response to some powerful stimulus. Psychological has two parts. One is the intellectual response (or level of arousal) and the other is the emotional level of arousal. In essence, a stress reaction is made up of physical, emotional and intellectual factors.

4. In SIMPLE terms Stress Is:
NORMAL reaction by a
NORMAL person to a
ABNORMAL situation.

5. Two Types of Stress
EUSTRESS = Positive, motivating stress (increases performance)
DISTRESS = Excessive, debilitating stress (decreases performance)
Not all stress is bad. Stress is bad when it is prolonged or intense.

6. Physiological Aspects of Stress

7. Responses To Stress Hormonal dump into the bloodstream
Increased heart rate & respiration
Increased blood flow to larger muscles
Tension of large muscles

8. Reasons For These Reactions
FIGHT !
FLIGHT !
What happens when we can’t fight or flee?

9. Common Symptoms of Stress (US Army Study, 1944)
Nausea
Feeling faint
Cold sweats
Loss of bowel control

10. Psychological Aspects of Stress

11. Ingredients For Distress
In order for an event to become stressful, it must be interpreted or appraised as being:
CHALLENGING, THREATENING, or ADVERSE, and
MEANINGFUL.

12. Critical Incident Stress (CIS) AKA: Post Traumatic Stress (PTS)
NORMAL reaction by a
NORMAL person to a
ABNORMAL situation.

13. Signs and Symptoms of Distress
I. Cognitive (Thinking)
II. Emotional
III. Behavioral
IV. Physical
V. Spiritual

14. I. COGNITIVE (Thinking) DISTRESS
Sensory distortion
Confusion (“dumbing down”)
Inability to concentrate
Difficulty in decision making
Guilt
Preoccupation (obsessions) with event
Inability to understand consequences of behavior
Suicidal/homicidal thoughts
Psychosis
Instructor, please do not get bogged down in going over the lists of symptoms. Your aim here is a quick overview. The students have the lists of symptoms in the student manual. It is recommended that you caution the students against memorizing lists of symptoms. Every person reacts somewhat differently. There are some common reactions as pointed out in these slides, but there will be some variation as well.

15. II. EMOTIONAL DISTRESS Anxiety Irritability ANGER !
Panic (often associated with self -medication)
Vegetative Depression
Fear, Phobia, Phobic Avoidance
Post-Traumatic Stress (PTS)
Grief (Mourning associated with loss)

16. III. BEHAVIORAL DISTRESS
Impulsiveness
Risk - taking
Excessive Eating
Alcohol/Drug Use
Hyper-startle
Violence
Sleep Disturbance
Withdrawal
Family Withdrawal
Crying Spells
yard Stare
Antisocial Behavior

17. IV. PHYSICAL DISTRESS Tachycardia, Bradycardia Headaches
Hyperventilation
Muscle Spasms
Psychogenic Sweating
tach·y·car·di·a - A rapid heart rate, especially one above 100 beats per minute in an adult.
brad·y·car·di·a - Slowness of the heart rate, usually fewer than 60 beats per minute in an adult human.

18. IV. PHYSICAL DISTRESS (Con’t.)
Fatigue/ Exhaustion
Indigestion, Nausea, Vomiting
Blood in stool, sputum, vomit, urine
Chest pain
Loss of Consciousness

19. V. SPIRITUAL DISTRESS Anger at God
Withdrawal from Faith-based Community
Loss of moral compass
Instructors, please note: It is a bad idea to get into long discussions about the spiritual reactions. State them and move on in the course. Type and intensity of symptoms will vary from person to person. Some may not suffer spiritual symptoms at all. Others will experience an increase in faith after a tragedy. All of these outcomes are possible.

20. What is Crisis Intervention ?
First Aid for emotional distress caused by a traumatic experience:
Allowing people to “vent” (explain) their thoughts about the incident
Helping people understand they are “OK”
Teaching them good coping skills
Assessing if additional care is needed

21. Crisis Intervention Characterized by: PROXIMITY – close to incident
IMMEDIACY – early intervention (“trauma membrane”)
EXPECTANCY – belief this can help
SIMPLICITY – simple, concrete strategies
BREVITY – interventions short, not long- term care
PRACTICALITY – easy to implement

22. (adapted from Caplan, 1964, Preventive Psychiatry)
Crisis Intervention
Goals:
STABILIZATION of symptoms
(keep things from getting worse)
REDUCTION of symptoms
(stress relief)
RESTORATION of independent function
(“back on the street”)
ACCESS to additional care
(if needed)
(adapted from Caplan, 1964, Preventive Psychiatry)

23. Crisis Intervention What crisis intervention is NOT: NOT Psychotherapy
NOT Counseling
NOT Psychotherapy
NOT Substitute for Counseling or Psychotherapy

24. Types of Stress Which is most likely to cause greatest harm?
Cumulative Stress
Unresolved everyday stressors (“Burnout”)
Critical Incident Stress
Result of a single, traumatic event
Which is most likely to cause greatest harm?
Cumulative – silent & slow

25. TWO TYPES OF STRESS Cumulative Stress (“Burnout”)
slow erosion of functioning
incomplete work
lateness
impulsive need for change
chronic physical illness
“Critical Incident” (Traumatic)
normal coping overwhelmed
adaptive functioning interrupted
symptoms of posttraumatic distress evident
Unresolved every day stressors produce cumulative stress. Critical Incident Stress (CIS), on the other hand, arises only as a result of a traumatic event.

26. Stress Response Syndromes Cumulative Stress
Normal Stress Path
General Stress
All
Normal
Eustress
Distress
Pathological Path
Cumulative Stress
Piles up
Takes time
“Burnout”
Destructive
Changes in health, performance, relationships, and personality
The four categories of stress listed on this slide and the next one are just an attempt to simplify and summarize the huge field of stress. There are two “normal” pathways of stress and there are two pathological pathways of stress. Each slide contains a normal pathway and a pathological pathway of unresolved stress.
Note: solid arrows in the both the slide above and in this one indicate the normal stress path for the vast majority of people (toward resolution and recovery). The broken or hashed arrows indicate the path of a much smaller percentage of people (toward pathology).
Recovery

27. Continuum of Care RESISTANCE – Ability to resist the effects of stress
RESILIENCE – Ability to bounce back from stress
RECOVERY – Ability to return to “normal” within reason

28. RESISTANCE
Psychological/behavioral immunity (“psychological body armor”) to distress and dysfunction.
(Pre-incident training/preparation may be best way to build resistance.)

29. RESILIENCE Refers to the ability to rapidly and effectively rebound from psychological and/or behavioral effects of stress.
Resilience does not mean that a person does not have stress. It only means that they can bounce back from that stress and then continue on with their lives.

30. RECOVERY The ability to literally recover the ability to adaptively function after stress.
Recovery implies that some shock or damage may have been caused by the stressful experience, but that the person or the group is able to overcome the damage and eventually recover their ability to function in an adaptive manner.

31. ELEMENTS (TOOLS) OF CISM
Pre-incident education, preparation
Assessment
Strategic Planning
Large Group Crisis Intervention:
Demobilizations (large groups of rescue/recovery)
Rehab Sectors
Crisis Management Briefings (CMB)

32. ELEMENTS (TOOLS) OF CISM
Small Group Crisis Intervention:
Defusings (small groups)
Small group CMB
Debriefing (CISD)
Individual, one-on-one intervention
Family CISM
Organizational/Community intervention, consultation
Pastoral crisis intervention
Follow-up and referral for continued care

33. Things To Do To Cope with Stress
Exercise
Spend quality time with others
Avoid alcohol
Eat a healthy diet
Get plenty of rest
Drink plenty of water
Most of all --- TALK !

34. How important are your health & relationships with others?
How important is CISM ?
How important are your health & relationships with others?

35. When to Call For CISM
Anytime you think you have a stressful event during your shift.
Anytime you notice problems within your shift after a stressful event or cumulative events.
Anytime you notice an individual that is having problems dealing with a stressful event.

36. How to call for CISM
Contact EMS Division Chief Todd Jamison at The Little Elm Fire Department.
Office #
Cell #
Brenda Gormley

37. Little Elm CISM Team EMS Division Chief Todd Jamison
Pastor Richard Stevens - Fire Dept. Chaplain
Dan Phleps - Little Elm Police
EMS Lieutenant Glen Phipps –Aubrey Fire Department.
Matt Moore – Little Elm Fire Department
Jeremy Fuller – Little Elm Fire Department