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  • CISM:Does It Help or Not?Rev. KC Schuler, MDiv, BCCSupervising ChaplainThedaCare (and ICISF Trained Trainer)[email protected] slides borrowed from ICISF: Group Crisis Response Training

  • At the heart of any field of study or practice resides a basic vocabulary. Unfortunately, the field of crisis and disaster mental health intervention has been plagued by the lack of a standardized nomenclature. So, we will begin with a review of several key terms and concepts that will help clarifiy some of the issues and the materials later presented.

  • Critical Incident Stress (CIS) is also known as Post Traumatic Stress (PTS), which is not the same as Post Traumatic Stress Disorder (PTSD).

  • CIS/PTS is a normal response of normal people to an abnormal event.

    CIS/PTS reactions may look similar to some symptoms of PTSD.

    If the CIS/PTS does not get resolved, it may turn into the disorder (PTSD).

    Only a trained, Mental Health professional can diagnose PTSD.

  • DefinitionsCRITICAL INCIDENTS are unusually challenging events that have the potential to create significant human DISTRESS and can overwhelm ones usual coping mechanisms.In other words, and abnormal event that evokes a normal response (CIS/PTS) to that abnormal event

  • DefinitionsThe psychological DISTRESS in response to critical incidents such as emergencies, disasters, traumatic events, terrorism, or catastrophes is called a PSYCHOLOGICAL CRISIS(Everly & Mitchell, 1999)

  • Psychological CrisisAn acute RESPONSE to a trauma, disaster,or other critical incident wherein:Psychological homeostasis (balance) is disrupted (increased stress)Ones usual coping mechanisms have failedThere is evidence of significant distress, impairment, dysfunction (PTS/CIS)(adapted from Caplan, 1964, Preventive Psychiatry)

  • IMPORTANT!

    Crisis intervention targets the RESPONSE, not the EVENT, per se.

    Thus, crisis intervention and disaster mental health interventions must be predicated upon assessment of need.

  • Crisis Intervention (CI)An active, short-term, supportive, helping process.

    Acute intervention designed to mitigate the crisis response (CIS/PTS).

    NOT psychotherapy or a substitute for psychotherapy.

  • Crisis Intervention (CI)Goals:1. Stabilization2. Symptom reduction3. Return to adaptive functioning, or4. Facilitation of access to continued care

    (adapted from Caplan, 1964, Preventive Psychiatry)

  • Crisis Intervention (CI):Lessons Learned From The MilitarySalmon (1919, NY Med J) Nothing could be more striking than the comparison between the cases treated near the front and those treated far behind the linesAs soon as treatment near the front became possible, symptoms disappearedwith the result that sixty percent with a diagnosis of psychoneurosis were returned to duty from the field hospital (p. 994).

  • Principles of Crisis Intervention (CI): (Most Were Developed By The Military)ProximityImmediacyExpectancyInnovationBrevitySimplicityPragmatism

  • Crisis Intervention: Leadership CommunicationIntentional or unintentional communication:Compassion: Deep awareness of the suffering of another coupled with the wish to relieve itDisdain: To regard or treat with contempt; despiseIndifference: Having no particular interest or concern; apatheticThe American Heritage Dictionary of the English Language, Fourth Edition Copyright 2006 by Houghton Mifflin Company.

  • The Need in EMS?Incidence of Posttraumatic Stress with EMS in urban setting (NYC) (9.3%) met the strict DSM-III-R criteria for PTSD Another (10%) had the required number and combination of symptoms for PTSD, but these symptoms had not persisted for the 1 month required by the DSM-III-R criteria. Thus, a total of 19.3% of subjects who completed the survey were shown to be suffering from PTSD symptoms. Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers, Medscape Psychiatry & Mental Health eJournal 2(5), 1997. 1997 Medscape

  • The Need in EMS? (cont.)The interaction between age and several other factors, however, was significant, including:Study participants between the ages of 18 and 24 who graduated from a rural high school were nearly 3 times as likely to have PTSD as those from urban or suburban high schoolsThe prevalence of PTSD increased significantly with the total number of previous medical emergency work jobsDevelopment of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers, Medscape Psychiatry & Mental Health eJournal 2(5), 1997. 1997 Medscape

  • Review for Canadian Armed ForcesRitchie, P. (2002)Literature suggests value in debriefingCISD (debriefing) should only use group formatCISD should be offered as part of a larger integrated intervention system (CISM)Participation is Voluntary and involves informed consentCISD contraindicated if basic physiological, shelter, & safety needs not metPositive outcome may be other than prevention of PTSD (provides information, support, may increase cohesion, positively viewed)

  • Lessons Learned From Community Mental HealthEarly Psychological Intervention may reduce the need for more intensive psych services. (Langsley, Machotka, & Flomenhaft, 1971, Am J Psyc; Decker, & Stubblebine, 1972, Am J Psyc)

    Early Psychological Intervention may mitigate acute distress . (Bordow & Porritt, 1979, Soc Sci & Med; Bunn & Clarke, 1979, Br. J Med. Psychol; Campfield & Hills, 2001, JTS; Flannery & Everly, 2004, Aggression & Violent Beh.)

  • Lessons Learned From Community Mental HealthEarly psychological Intervention may reduce EtOH use. (Deahl, et al, 2000, Br J Med Psychol; Boscarino, et al., 2005)

  • Lessons Learned From Consultation Psychiatry (Stapleton, Medical Crisis Intervention, 2004)Early Psychological Intervention is improved by increased training in a standardized CI paradigmResults:trained d=.57 vs. untrained d=.29

  • Lessons Learned From Consultation Psychiatry (Stapleton, Medical Crisis Intervention, 2004)Early Psychological Intervention outcome is enhanced via multiple sessions (multiple contacts d=.60 vs. single contact d=.33) (plateau at 2-3 sessions, Boscarino, et al., 2005)

    Early Psychological Intervention is enhanced via the use of multiple interventions on PTS (multiple interventions d=.62 vs. single interventions d=.55)

  • Lessons Learned From The WorkplacePost disaster crisis intervention (CISM) was associated with reduced risk for:binge drinking (d=.74)alcohol dependence (d=.92) PTS symptoms (d=.56)

    (Boscarino, et al, IJEMH, 2005).

  • Lessons Learned From The WorkplacePost disaster crisis intervention (CISM) was associated with reduced risk for: major depression (d=.81) anxiety disorder (d=.98)global impairment (.66) compared with comparable individuals who did not receive this intervention (Boscarino, et al, IJEMH, 2005).

  • There is now emerging evidence that prompt delivery of brief, acute phase services in the first weeks after an event can lead to sustained reduction in morbidity years later, reducing the burden of secondary functional impairment, presumed daily average life years lost (DALYS), and costs to both the individual and the public (p. 15).

    Schreiber, M. (Summer, 2005). PsySTART rapid mental health triage and incident command system. The Dialogue: A Quarterly Technical Assistance Bulletin on Disaster Behavioral Health, 14-15.

  • Value Added of Crisis Intervention:Screening & Increasing Access To CareOnly 11% of victims of violent crime responded to institutional invitations to express attitudes regarding crime & punishmentLess than 7% of sexual assault victims chose to utilize free psychotherapy within walking distance of their home (Rose, et al., Psychological Medicine, 1999).

    Formal mental health utilization post 9/11 increased only ~3% in civilians and emergency personnel even though prevalence of PTSD estimated at 7-20% and depression at ~9% (see Johns Hopkins Center for Public Health Preparedness -- JHCPHP, 2005)

  • Value Added of Crisis Intervention:Screening & Increasing Access To Care

    First responders are often resistant to seeking Mental Health treatment, therefore crisis intervention may be their only access to mental health services (North, et al., 2002, J. T. Stress)

    While ~ 85% of military sampled who served in Iraq/Afghanistan recognized problems, only ~44% were willing to seek assistance (Hoge et al., NEJM, 2004)

    Less than 50% of civilian disaster workers, who screened + for mental health concerns sought treatment (Jayasinghe, et al, 2005, IJEMH)

  • Reasonable Evidence-based ConclusionsMore and better controlled research is still needed

    Care must be taken in setting up a support response

    Data reviewed support use of group debriefing with emergency services personnel (Arendt & Elklit, 2001)

    Data reviewed tend to support use of group debriefing subsequent to disasters, war, robbery (see NIMH, 2002, tables 2-3)

  • Reasonable Evidence-based ConclusionsThe research does not support single session, individualized interventions after medical, surgical distress with minimal training (nurses with 15 min training)The research does support multi-component intervention systemsNIMH (2002), Institute of Medicine (2003), NVOAD (2005) recommend acute phase psychological first aid

  • In all the controversy, criticism and research debate on the merits of debriefing [early intervention], certain constants are emerging. The most effective methods for mitigating the effects of exposure to trauma, those which will help keep our people healthy and in service, are those which use early in

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