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CISM Course 2004Minus · PDF fileCritical Incident Stress Management (CISM) Mitchell & Everly, 2002 68 CISM: Critical Incident Stress Management is a comprehensive, systematic, and

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    Mitchell & Everly, 2002 1

    Critical Incident StressManagement

    By:The International Critical Incident Stress Foundation

    Mitchell & Everly, 2002 2

    Lt Col Sherry Jones, RN, EMTP, CAP

    Psych/English: AAS, AA, AGE, ADN; RN, EMTP10 years EMS, 7 years Level One Trauma Center ERCrisis Team Member IMT/Southfield, MIIntroduced/designed CISM program MIWG 97

    Introd CISM at CAP NB 1998/1st CAP Team Nationally CAP GLR CISM Team (ICISF Registered)

    Civil Air Patrol member since 1990 SQ PAO/SOA, CVC, Group Admin., MIWG PAO/PAOA, MIWG

    Medical Director/SOA, MIWG CISTC-A (ADY), GLR CISM Director (ADY), NHQ SANC-CISM

    DFI International (DHS/ODP)/National CISM Work Group

    Mitchell & Everly, 2002 3

    Course Overview Major TopicsKey Concepts in Psychological CrisisCrisis-Related SymptomsCrisis Assessments / Follow-up & ReferralCrisis Communication TechniquesCrisis Intervention

    Mitchell & Everly, 2002 4

    Major Topics:CISM Interventions

    Pre-Incident Preparation & EducationOne-on-One Crisis InterventionDemobilizationCrisis Management Briefing

    Mitchell & Everly, 2002 5

    Major Topics:DefusingCritical Incident Stress DebriefingFamily SupportOrganizational / Community Crisis ResponsePastoral Crisis Intervention

    ICISF CISM: A Standard of CareNorthwest Flight 255 crash CISM in CAP: CAPR 60-5

    Mitchell & Everly, 2002 6

    Critical Incident Stress

    DebriefingAn Operations Manual for CISD,

    Defusing and Other Group Crisis Intervention Services

    Third Edition

    Jeffrey T. Mitchell, Ph.D., CTSGeorge S. Everly, Jr., Ph.D., CTS

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    Mitchell & Everly, 2002 7

    Nature of Stress

    Mitchell & Everly, 2002 8

    StressWear and Tear

    (Selye, 1976)

    A State of Physical and Psychological Arousal in Response to a Stimulus

    Excessive Stress and Psychological Trauma Are Just As Potentially Disabling As Is Physical traumatization.

    (Mitchell/Everly 1993)Pg. 33Pg. 33--3838

    Mitchell & Everly, 2002 9

    Categories of StressGeneralCumulativeCritical incident (traumatic stress)Post traumatic stress disorder

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    Initially stress reactions are adaptive and helpful. As the stress reactions increase, however, there is a greater chance that they will be maladaptive and disruptive.

    Mitchell & Everly, 2002 11

    Signs and Symptoms of StressCognitive


    Pg. 52/137Pg. 52/137



    Mitchell & Everly, 2002 12

    Terrorism: A Unique Cause of Stress

    The explicit goal of this form of trauma / disaster is to create a condition of fear, uncertainty, demoralization, & helplessness as a coercive force.

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

    Mitchell & Everly, 2002 14

    Critical Incidents

    Mitchell & Everly, 2002 15

    Critical Incidents:

    Events that have the potential to create significant human distress and can overwhelm ones usual coping mechanisms.

    Mitchell & Everly, 2002 16

    The Terrible Ten (Emergency Services):Suicide of a colleagueLine of duty deathSerious line of duty injuryDisaster/multiple casualtyPolice shootings/accidental killing or wounding of innocent person(s)

    Pg. 6Pg. 6

    Mitchell & Everly, 2002 17

    The Terrible Ten (Emerg. Svcs.):Significant events involving childrenProlonged incidents, especially with a lossPersonally threatening situationsEvents with excessive media interestAny significant event capable of causing considerable emotional distress for those who are exposed to it

    Mitchell & Everly, 2002 18


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    Mitchell & Everly, 2002 19

    The psychological distress in response to critical incidents

    such as mass disasters, traumatic events, or

    terrorist attacks, is called a PSYCHOLOGICAL CRISIS.

    (Everly & Mitchell, 1999)

    Mitchell & Everly, 2002 20

    Psychological Crisis:An Acute Response to a Trauma, Disaster, or Other Critical Incident Wherein:1) Psychological Balance Is Disrupted2) Ones Usual Coping Mechanisms Have Failed3) Evidence of Significant Distress,

    Impairment, Dysfunction

    Mitchell & Everly, 2002 21

    Characteristics of CrisisMaturational Crisis

    Former coping skills arent workingTemporary disequilibrium: resolution can come through support systems

    Alcohol/drugs interrupt progression: skill development arrests at age when abuse began

    Situational CrisisCritical life problem arises from an external source

    Job change/loss, death of loved one, divorce

    Threatens self-concept and self-esteemMitchell & Everly, 2002 22

    The Need for Crisis Services:Over 80% US Citizens Exposed to TraumaAbout 30% of Those Exposed Will Develop PTSD40% US Children Exposed to Trauma14% Violent Crimes Occur at Work16% Viet Nam Veterans Develop PTSD

    Mitchell & Everly, 2002 23

    The Need for Crisis Services:31% Urban Firefighters Report Symptoms of PTSD10-15% Law Enforcement Personnel Develop PTSDPolice = 8.6x Greater Risk of Suicide than Accidental DeathNIOSH Recommends Workplace Crisis Intervention Systems

    Mitchell & Everly, 2002 24

    The Need for Crisis Services:Up to 35% disaster victims develop PTSDMass disasters and terrorism will create more psychological casualties than physical casualtiesOver 50% of disaster workers can be expected to develop significant posttraumatic distress (Wee & Myers, 2001)

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    Mitchell & Everly, 2002 25

    The Need for Crisis Services:Estimated 1.5 Million People In NYC May Need Counseling Post September 11th (U.S. Center for Mental Health Services)Random NYC Survey (Manhattan): 7.5% PTSD, 9.7% Depression, 20% PTSD In Close Proximity to WTC

    Mitchell & Everly, 2002 26

    Research has shown that human-made disasters are more psychologically pathogenic than are natural disasters. Terrorism may be the most pathogenic of all due to its UNPREDICTABLE and UNRESTRAINED nature.

    Mitchell & Everly, 2002 27

    5 Antidotes for Crisis:Structure for ChaosCognition for Excessive EmotionCatharsis and Disclosure for Psychological TensionUnderstanding for Loss of ControlAction for Helplessness

    Mitchell & Everly, 2002 28

    Crisis Work Believes in the Inherent STRENGTHS of the Person in Crisis and Builds on These,

    You Do Not Look for Pathology As You Might in a More Traditional Therapeutic Environment.

    Mitchell & Everly, 2002 29

    Crisis Related Symptoms:Anxiety, PanicAngerHelplessnessSuicidal Ideation


    Mitchell & Everly, 2002 30

    Crisis-Related Symptoms:PeritraumaticDissociationPsychophysiologicalDisorderSomatoform Conversion Disorder

    Post Traumatic Stress Disorder (PTSD)Brief Psychosis

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    Mitchell & Everly, 2002 31

    Major Depression:Depressed MoodAnhedonia, LethargyTerminal InsomniaPsychomotor RetardationExcessive Weight LossReduced Libido

    Mitchell & Everly, 2002 32

    Major Depression:GuiltDiminished Personal HygieneHopelessnessHelplessnessWorthlessnessSuicidal Ideation

    Mitchell & Everly, 2002 33

    Suicidal Risk Increases With:IsolationAgitationRigid CompulsivityProximity to Lethal MeansFinancial or Marital ProblemsPainful or Terminal Illness

    Mitchell & Everly, 2002 34

    Suicidal Risk Increases With:Adolescence and ElderlyHopelessnessPrevious Suicide AttemptsHistory in the FamilySevere GuiltDetailed Plan

    Mitchell & Everly, 2002 35

    Suicide Intervention:EmpowerContradict HopelessnessListen IntentlyValidate EmotionsAssist in Finding Alternatives

    Mitchell & Everly, 2002 36

    Common Forms of Self-medication:

    Stimulants (Caffeine, Amphetamine, Cocaine)Depressants (Alcohol, Nicotine)HallucinogensAntihistamines

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    Mitchell & Everly, 2002 37

    Acute Posttraumatic Stress (Critical Incident Stress) Is a Normal Reaction in Normal

    People to an Abnormal Event.

    Oh ****!Mitchell & Everly, 2002 38

    Mitchell & Everly, 2002 39

    Posttraumatic Stress Disorder (PTSD):

    First Named in 1980Anxiety DisorderStarts With The Same Traumatic Event That Initiates Critical Incident Stress

    Pg. 49, 53Pg. 49, 53

    Symptoms: Intrusive Memories, Avoidance, ArousalSymptoms Last 30 Days or MoreProduces Significant Disruption to Normal Life Pursuits

    Mitchell & Everly, 2002 40

    PTSD:General Population: 1-3%Urban Adolescents: 9%Viet Nam Veterans: 15-20% Emergency Services Personnel: 15-32%

    Mitchell & Everly, 2002 41

    Crisis Assessments

    Mitchell & Everly, 2002 42

    Acute Mental Status Assessment:IntoxicationHead InjuryPsychotic ProcessDelusionsHomicidal IdeationSuicidal Ideation

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    Mitchell & Everly, 2002 43

    Acute Mental Status Assessment:OrientationLong-term MemoryConcentrationEmotion

    Mitchell & Everly, 2002 44

    Follow-up & Referral:

    One of the most convincing reasons for instituting a crisis intervention program is to identify those who require or desire continued care, and to facilitate access to that care. (Triage)

    Mitchell & Everly, 2002 45

    When to Refer For Follow-up:Persistent SymptomsSuicidal / Homicidal IdeationDisabling SymptomsEvidence of Cognitive ImpairmentWhen in Doubt

    Mitchell & Everly, 2002 46

    Where to Refer:Medical / Legal ServicesFamily Support ProgramsFinancial Aid ServicesReligious / Spiritual ServicesPsychological ServicesPsychiatric Ser

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