CISM:CISM:Does It Help or Not?Does It Help or Not?

Rev. KC Schuler, MDiv, BCCRev. KC Schuler, MDiv, BCC

Supervising ChaplainSupervising Chaplain

ThedaCare ThedaCare (and ICISF Trained Trainer)(and ICISF Trained Trainer)

kc.schuler@thedacare.orgkc.schuler@thedacare.org

Most slides borrowed from ICISF: Group Crisis Response TrainingMost slides borrowed from ICISF: Group Crisis Response Training

At the heart of any field of study or practice At the heart of any field of study or practice resides a basic resides a basic vocabularyvocabulary. Unfortunately, the . Unfortunately, the

field of crisis and disaster mental health field of crisis and disaster mental health intervention has been plagued by the lack of a intervention has been plagued by the lack of a

standardized nomenclature. standardized nomenclature. So, we will begin with a review of several key So, we will begin with a review of several key

terms and concepts that will help clarifiy some of terms and concepts that will help clarifiy some of the issues and the materials later presented.the issues and the materials later presented.

Critical Incident Stress (Critical Incident Stress (CISCIS) ) is also known as is also known as

Post Traumatic StressPost Traumatic Stress ((PTSPTS)), , which is which is not the same as not the same as

Post Traumatic Stress Disorder (PTSD)Post Traumatic Stress Disorder (PTSD)..

CIS/PTSCIS/PTS is a is a normal responsenormal response of normal people to an of normal people to an abnormal eventabnormal event..

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

If the If the CIS/PTSCIS/PTS does not get resolved, does not get resolved, it it maymay turn into the disorder ( turn into the disorder (PTSDPTSD).).

Only a trained, Mental Health professional Only a trained, Mental Health professional can diagnose can diagnose PTSDPTSD..

DefinitionsDefinitions

CRITICAL INCIDENTSCRITICAL INCIDENTS are unusually are unusually challenging events that have the potential to challenging events that have the potential to create significant human create significant human DISTRESSDISTRESS and can and can overwhelm one’s usual coping mechanisms.overwhelm one’s usual coping mechanisms.

In other words, and abnormal event that In other words, and abnormal event that evokes a normal response (CIS/PTS) to that evokes a normal response (CIS/PTS) to that abnormal eventabnormal event

DefinitionsDefinitions

The psychological The psychological DISTRESSDISTRESS in response to in response to critical incidents such as emergencies, critical incidents such as emergencies, disasters, traumatic events, terrorism, or disasters, traumatic events, terrorism, or catastrophes is called a catastrophes is called a

PPSYCHOLOGICAL CRISISSYCHOLOGICAL CRISIS(Everly & Mitchell, 1999)(Everly & Mitchell, 1999)

Psychological CrisisPsychological Crisis

An acute An acute RESPONSERESPONSE to a trauma, disaster, to a trauma, disaster,or other critical incident wherein:or other critical incident wherein: Psychological homeostasis (balance) is Psychological homeostasis (balance) is

disrupted (increased stress)disrupted (increased stress) One’s usual coping mechanisms have failedOne’s usual coping mechanisms have failed There is evidence of significant distress, There is evidence of significant distress,

impairment, dysfunction impairment, dysfunction (PTS/CIS)(PTS/CIS)(adapted from Caplan, 1964, (adapted from Caplan, 1964, Preventive PsychiatryPreventive Psychiatry))

IMPORTANTIMPORTANT!!

Crisis intervention targets Crisis intervention targets the the RESPONSERESPONSE, ,

not the not the EVENTEVENT, per se., per se.

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

Crisis Intervention (CI)Crisis Intervention (CI)

An active, short-term, supportive, helping An active, short-term, supportive, helping process.process.

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

NOTNOT psychotherapy or a substitute for psychotherapy or a substitute for psychotherapy.psychotherapy.

Crisis Intervention (CI)Crisis Intervention (CI)

Goals:Goals:1. Stabilization1. Stabilization2. Symptom reduction2. Symptom reduction3. Return to adaptive functioning, or3. Return to adaptive functioning, or4. Facilitation of access to continued care4. Facilitation of access to continued care

(adapted from Caplan, 1964, (adapted from Caplan, 1964, Preventive PsychiatryPreventive Psychiatry))

Crisis Intervention (CI)Crisis Intervention (CI)::Lessons Learned From The MilitaryLessons Learned From The Military

Salmon (1919, NY Med J)Salmon (1919, NY Med J) “Nothing could be “Nothing could be more striking than the comparison between the cases more striking than the comparison between the cases treated near the front and those treated far behind the treated near the front and those treated far behind the lines…As soon as lines…As soon as treatment near the fronttreatment near the front became became possible, symptoms disappeared…possible, symptoms disappeared…with the result that with the result that sixty percent with a diagnosis of psychoneurosis were sixty percent with a diagnosis of psychoneurosis were returned to duty from the field hospitalreturned to duty from the field hospital” (p. 994). ” (p. 994).

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

ProximityProximity ImmediacyImmediacy ExpectancyExpectancy InnovationInnovation BrevityBrevity SimplicitySimplicity PragmatismPragmatism

Crisis Intervention: Crisis Intervention: Leadership CommunicationLeadership Communication

Intentional or unintentional communication:Intentional or unintentional communication: CompassionCompassion: Deep awareness of the suffering of : Deep awareness of the suffering of

another coupled with the wish to relieve itanother coupled with the wish to relieve it DisdainDisdain: To regard or treat with contempt; : To regard or treat with contempt;

despisedespise IndifferenceIndifference: Having no particular interest or : Having no particular interest or

concern; concern; apatheticapathetic

The American Heritage® Dictionary of the English The American Heritage® Dictionary of the English Language, Fourth EditionLanguage, Fourth EditionCopyright © 2006 by Houghton Mifflin Company.Copyright © 2006 by Houghton Mifflin Company.

The Need in EMS?The Need in EMS?

Incidence of Posttraumatic Stress with EMS in urban Incidence of Posttraumatic Stress with EMS in urban setting (NYC)setting (NYC)(9.3%) met the strict DSM-III-R criteria for PTSD (9.3%) met the strict DSM-III-R criteria for PTSD

Another (10%) had the required number and Another (10%) had the required number and combination of symptoms for PTSD, but these combination of symptoms for PTSD, but these symptoms had not persisted for the 1 month required symptoms had not persisted for the 1 month required by the DSM-III-R criteria. by the DSM-III-R criteria.

Thus, a total of 19.3% of subjects who completed the Thus, a total of 19.3% of subjects who completed the survey were shown to be suffering from PTSD survey were shown to be suffering from PTSD symptoms. symptoms.

Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service WorkersDevelopment of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers, , Medscape Psychiatry & Mental Health eJournal 2(5), 1997. © 1997 MedscapeMedscape Psychiatry & Mental Health eJournal 2(5), 1997. © 1997 Medscape

The Need in EMS? (cont.)The Need in EMS? (cont.)

The interaction between age and several other factors, The interaction between age and several other factors, however, was significant, including:however, was significant, including: Study participants between the ages of 18 and 24 Study participants between the ages of 18 and 24

who graduated from a rural high school were who graduated from a rural high school were nearly 3 times as likely to have PTSD as those nearly 3 times as likely to have PTSD as those from urban or suburban high schoolsfrom urban or suburban high schools

The prevalence of PTSD increased significantly The prevalence of PTSD increased significantly with the total number of previous medical with the total number of previous medical emergency work jobsemergency work jobs

Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service WorkersDevelopment of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers, , Medscape Psychiatry & Mental Health eJournal 2(5), 1997. © 1997 MedscapeMedscape Psychiatry & Mental Health eJournal 2(5), 1997. © 1997 Medscape

Review for Canadian Armed ForcesReview for Canadian Armed ForcesRitchie, P. (2002)Ritchie, P. (2002)

Literature suggests value in “debriefing”Literature suggests value in “debriefing” CISD (“debriefing”) should only use group formatCISD (“debriefing”) should only use group format CISD should be offered as part of a larger integrated CISD should be offered as part of a larger integrated

intervention system (CISM)intervention system (CISM) ParticipationParticipation is is VoluntaryVoluntary and involves and involves informed consentinformed consent CISD contraindicatedCISD contraindicated if basic physiological, shelter, & if basic physiological, shelter, &

safety needs not metsafety needs not met Positive outcome may be other than prevention of PTSD Positive outcome may be other than prevention of PTSD

(provides information, support, may increase cohesion, (provides information, support, may increase cohesion, positively viewed)positively viewed)

Lessons Learned From Lessons Learned From Community Mental HealthCommunity Mental Health

Early Psychological Intervention may reduce the need Early Psychological Intervention may reduce the need for more intensive psych services.for more intensive psych services. (Langsley, Machotka, & Flomenhaft, 1971, Am J Psyc; (Langsley, Machotka, & Flomenhaft, 1971, Am J Psyc; Decker, & Stubblebine, 1972, Am J Psyc)Decker, & Stubblebine, 1972, Am J Psyc)

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

Lessons Learned From Lessons Learned From Community Mental HealthCommunity Mental Health

Early psychological Intervention may reduce EtOH Early psychological Intervention may reduce EtOH use.use. (Deahl, et al, 2000, Br J Med Psychol; Boscarino, et al., 2005)(Deahl, et al, 2000, Br J Med Psychol; Boscarino, et al., 2005)

Lessons Learned From Lessons Learned From Consultation PsychiatryConsultation Psychiatry (Stapleton, Medical Crisis Intervention, 2004)(Stapleton, Medical Crisis Intervention, 2004)

Early Psychological Intervention is improved Early Psychological Intervention is improved by increased training in a standardized CI by increased training in a standardized CI paradigmparadigm

Results:Results: trained d=.57 vs. trained d=.57 vs. untrained d=.29untrained d=.29

Lessons Learned From Lessons Learned From Consultation PsychiatryConsultation Psychiatry (Stapleton, Medical Crisis Intervention, 2004)(Stapleton, Medical Crisis Intervention, 2004)

Early Psychological Intervention outcome is Early Psychological Intervention outcome is enhanced via multiple sessions enhanced via multiple sessions (multiple contacts d=.60 vs. single contact d=.33) (multiple contacts d=.60 vs. single contact d=.33) (plateau at 2-3 sessions, Boscarino, et al., 2005)(plateau at 2-3 sessions, Boscarino, et al., 2005)

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

Lessons Learned From The Workplace

Post 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).(Boscarino, et al, IJEMH, 2005).

Lessons Learned From The WorkplaceLessons Learned From The Workplace

Post disaster crisis intervention (CISM) was Post disaster crisis intervention (CISM) was associated with reduced risk for: associated with reduced risk for: major depression (d=.81) major depression (d=.81) anxiety disorder (d=.98)anxiety disorder (d=.98) global impairment (.66)global impairment (.66) compared with comparable individuals who did not receive compared with comparable individuals who did not receive

this interventionthis intervention (Boscarino, et al, IJEMH, 2005).(Boscarino, et al, IJEMH, 2005).

““There is now emerging evidence that There is now emerging evidence that prompt delivery of prompt delivery of brief, acute phase services in the first weeks after an brief, acute phase services in the first weeks after an

event can lead to sustained reduction in morbidity years event can lead to sustained reduction in morbidity years laterlater, reducing the burden of secondary functional , reducing the burden of secondary functional impairment, presumed daily average life years lost impairment, presumed daily average life years lost (DALYS), and costs to both the individual and the (DALYS), and costs to both the individual and the

public” (p. 15).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:Value Added of Crisis Intervention:Screening & Increasing Access To CareScreening & Increasing Access To Care

Only 11% of victims of violent crime responded to Only 11% of victims of violent crime responded to institutional invitations to express attitudes regarding crime & institutional invitations to express attitudes regarding crime & punishmentpunishment

Less than 7% of sexual assault victims chose to utilize free Less than 7% of sexual assault victims chose to utilize free psychotherapy within walking distance of their home psychotherapy within walking distance of their home (Rose, et al., Psychological Medicine, 1999).(Rose, et al., Psychological Medicine, 1999).

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

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

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

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

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

Reasonable Evidence-based ConclusionsReasonable Evidence-based Conclusions

More and better controlled research is still neededMore and better controlled research is still needed

Care must be taken in setting up a support responseCare must be taken in setting up a support response

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

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

Reasonable Evidence-based ConclusionsReasonable Evidence-based Conclusions

The research The research does not supportdoes not support single session, single session, individualized interventions after medical, surgical individualized interventions after medical, surgical distress distress withwith minimal training (nurses with 15 min minimal training (nurses with 15 min training)training)

The research does support multi-component The research does support multi-component intervention systemsintervention systems

NIMH (2002), Institute of Medicine (2003), NVOAD NIMH (2002), Institute of Medicine (2003), NVOAD (2005) recommend acute phase “psychological first (2005) recommend acute phase “psychological first aid”aid”

““In all the controversy, criticism and research debate on In all the controversy, criticism and research debate on the merits of debriefing [early intervention], certain the merits of debriefing [early intervention], certain

constants are emerging. The most effective methods for constants are emerging. The most effective methods for mitigating the effects of exposure to trauma…, those mitigating the effects of exposure to trauma…, those

which will help keep our people healthy and in service, which will help keep our people healthy and in service, are those which use early intervention, are multi-modal are those which use early intervention, are multi-modal and multi-component. That is, they use different ‘active and multi-component. That is, they use different ‘active ingredients’ …, and these components are used at the ingredients’ …, and these components are used at the

appropriate time with the right target group.”appropriate time with the right target group.”

Dr. Hayden DugganDr. Hayden DugganInternational Association of Fire Chiefs’ ICHIEFS International Association of Fire Chiefs’ ICHIEFS

on-line resource, Sept 1, 2002on-line resource, Sept 1, 2002

Acceptance of Psychological Debriefings (PD)Acceptance of Psychological Debriefings (PD)

“ “Since Since PDPD is fully accepted as standard practice for is fully accepted as standard practice for emergency services personnel and well-received by emergency services personnel and well-received by group members and organizations, it is hard to find group members and organizations, it is hard to find fault in its application in a mass disaster fault in its application in a mass disaster such as the terrorist attacks…on september 11, 2001.”such as the terrorist attacks…on september 11, 2001.”(Litz, et al., Clin. Psyc. 2002)(Litz, et al., Clin. Psyc. 2002)

Crisis Intervention (CI): Key PointsCrisis Intervention (CI): Key Points

Crisis Intervention is not intended to be the practice of Crisis Intervention is not intended to be the practice of psychiatry, psychology, social work, nor counseling, per se, it psychiatry, psychology, social work, nor counseling, per se, it is simply psychological/emotional first aidis simply psychological/emotional first aid

Consistent with NIMH guidelines and Federal “crisis Consistent with NIMH guidelines and Federal “crisis counseling” models, crisis intervention may be practiced by counseling” models, crisis intervention may be practiced by mental health clinicians, as well as, medical personnel, clergy, mental health clinicians, as well as, medical personnel, clergy, & community volunteers & community volunteers (although we believe mental health (although we believe mental health guidance, supervision, or oversight is essential)guidance, supervision, or oversight is essential)

AGAIN,AGAIN, Crisis intervention Crisis intervention does notdoes not appear to appear to “prevent”“prevent” PTSD PTSD in primary victims.in primary victims.

ResistanceResistance, Resilience, & Recovery, Resilience, & Recovery

In the present context, the term In the present context, the term Resistance Resistance refers to the ability of an individual, a group, refers to the ability of an individual, a group, an organization, or even an entire population, an organization, or even an entire population, to literally to literally resistresist manifestations of clinical manifestations of clinical distress, impairment, or dysfunction associated distress, impairment, or dysfunction associated with critical incidents, terrorism, and even with critical incidents, terrorism, and even mass disasters.mass disasters.

ResistanceResistance, Resilience, & Recovery, Resilience, & Recovery

ResistanceResistance may be thought of as a form of may be thought of as a form of psychological/ behavioral psychological/ behavioral immunityimmunity to distress to distress and dysfunction.and dysfunction.

Pre-incident training/preparationPre-incident training/preparation may be best may be best way to build resistanceway to build resistance

Resistance, Resistance, ResilienceResilience, & Recovery, & Recovery

In the present context, the term In the present context, the term ResilienceResilience refers to the ability of an individual, a group, refers to the ability of an individual, a group, an organization, or even an entire population, an organization, or even an entire population, to to rapidly and effectivelyrapidly and effectively reboundrebound from from psychological and/or behavioral perturbations psychological and/or behavioral perturbations associated with critical incidents, terrorism, associated with critical incidents, terrorism, and even mass disasters.and even mass disasters.

Resistance, Resistance, ResilienceResilience, & Recovery, & Recovery

■ ResilienceResilience is an is an ordinaryordinary, not extraordinary response , not extraordinary response associated with:associated with: Capacity to make and follow out realistic plansCapacity to make and follow out realistic plans Positive view of self, strength, and abilitiesPositive view of self, strength, and abilities Communication and problem solving skillsCommunication and problem solving skills Capacity to manage strong feelingsCapacity to manage strong feelings

Crisis and disaster mental health intervention may be Crisis and disaster mental health intervention may be the best way to enhance natural the best way to enhance natural ResiliencyResiliency, in , in addition to pre-incident preparation.addition to pre-incident preparation.

Resistance, Resilience, & Resistance, Resilience, & RecoveryRecovery

The term The term RecoveryRecovery refers to the ability of an refers to the ability of an individual, a group, an organization, or even an entire individual, a group, an organization, or even an entire population, to literally population, to literally recover the ability to recover the ability to adaptively function, adaptively function, both psychologically and both psychologically and behaviorally,behaviorally, in the wake of a significant clinical in the wake of a significant clinical distress, impairment, or dysfunction (PTS/CIS) distress, impairment, or dysfunction (PTS/CIS) subsequent to critical incidents, terrorism, and even subsequent to critical incidents, terrorism, and even mass disasters.mass disasters.

Crisis intervention, Treatment, and rehabilitation Crisis intervention, Treatment, and rehabilitation speeds speeds RecoveryRecovery..

An outcome-driven continuum of careAn outcome-driven continuum of care

Create Create ResistanceResistance Enhance Enhance ResiliencyResiliency Speed Speed RecoveryRecovery

Assessment Assessment AssessmentInterventionIntervention InterventionIntervention InterventionInterventionEvaluationEvaluation EvaluationEvaluation EvaluationEvaluation

[Kaminsky, et al, (2005) RESISTANCE, RESILIENCE, RECOVERY. In Everly & Parker, [Kaminsky, et al, (2005) RESISTANCE, RESILIENCE, RECOVERY. In Everly & Parker, Mental Health Aspects of Disaster: Public Health Preparedness and Response. Balto: Johns Mental Health Aspects of Disaster: Public Health Preparedness and Response. Balto: Johns Hopkins Center for Public Health Preparedness.]Hopkins Center for Public Health Preparedness.]

Goals of a Multi-Component Crisis Intervention System

CISM is a CISM is a strategic intervention strategic intervention system.system.

It possesses numerous It possesses numerous tactical interventions of which tactical interventions of which

CISD is one.CISD is one.

The challenge in crisis intervention is not only The challenge in crisis intervention is not only developing developing TACTICALTACTICAL skills in the “core skills in the “core

intervention competencies,” intervention competencies,” but is in knowing when to best but is in knowing when to best

STRATEGICALLY STRATEGICALLY employ the most employ the most appropriate intervention for the situation.appropriate intervention for the situation.

Core Competencies Of Comprehensive Core Competencies Of Comprehensive Crisis InterventionCrisis Intervention

Assessment/triageAssessment/triage benign vs. malignant symptoms benign vs. malignant symptoms Strategic planningStrategic planning and utilizing an integrated multi- and utilizing an integrated multi-

component crisis intervention system within an component crisis intervention system within an incident command systemincident command system

One-on-oneOne-on-one crisis intervention crisis intervention Small groupSmall group crisis intervention crisis intervention Large groupLarge group crisis intervention crisis intervention Follow-up and ReferralFollow-up and Referral

Can Intervention Be Harmful ?Can Intervention Be Harmful ?The Case of Psychotherapy...The Case of Psychotherapy...

Smith, Glass, & Miler (Benefits of Psychotherapy, Smith, Glass, & Miler (Benefits of Psychotherapy, 1980) meta-analytic review of 400 studies --> 9% 1980) meta-analytic review of 400 studies --> 9% negative outcomenegative outcome

Shapiro & Shapiro (Psychol. Bulletin, 1982) over Shapiro & Shapiro (Psychol. Bulletin, 1982) over 1800 “effects” --> 11% negative, 30% null effect1800 “effects” --> 11% negative, 30% null effect

Lambert (2003) estimated 5-10% of patients Lambert (2003) estimated 5-10% of patients deteriorate during treatmentdeteriorate during treatment

Can Crisis Intervention Be Harmful ?Can Crisis Intervention Be Harmful ?Theoretical Mechanisms/ IssuesTheoretical Mechanisms/ Issues

((see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003)see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003)

Excessive catharsis, disclosure, ruminationExcessive catharsis, disclosure, rumination

Pathologizing otherwise “normal” reactionsPathologizing otherwise “normal” reactions

Vicarious traumatization in groupsVicarious traumatization in groups

Coercive peer pressure in groupsCoercive peer pressure in groups

Scapegoating in groupsScapegoating in groups

Can Crisis Intervention Be Harmful ?Can Crisis Intervention Be Harmful ?Theoretical Mechanisms/ IssuesTheoretical Mechanisms/ Issues

((see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003)see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003)

Triggering of previous traumatic memoriesTriggering of previous traumatic memories

Intervention may be premature (inappropriate timing)Intervention may be premature (inappropriate timing)

May be inappropriate with highly aroused personsMay be inappropriate with highly aroused persons

May interfere with natural coping mechanismsMay interfere with natural coping mechanisms

May not be accompanied by adequate assessment or follow-upMay not be accompanied by adequate assessment or follow-up

7 Phases of a CISD7 Phases of a CISD

COGNITIVE

AFFECTIVE

INTRODUCTION

FACT

REACTION

THOUGHT SYMPTOMS

TEACHING

Re-entry

Reducing Risk of Adverse ReactionsReducing Risk of Adverse Reactions

Keep CISD within the multi-component Keep CISD within the multi-component context of CISMcontext of CISM: : CISD should never be a stand alone intervention. It CISD should never be a stand alone intervention. It

should only be used when it is part of a package of should only be used when it is part of a package of interventions which includes follow-up services.interventions which includes follow-up services.

Reducing Risk of Adverse ReactionsReducing Risk of Adverse Reactions

The group The group CISDCISD process should process should never be used never be used for individualsfor individuals since it was designed for since it was designed for groupsgroups

CISD should not be used to achieve CISD should not be used to achieve psychotherapeutic outcome: CISD is not psychotherapeutic outcome: CISD is not psychotherapy nor a substitute for psychotherapy nor a substitute for psychotherapypsychotherapy

Reviews which have been critical of small Reviews which have been critical of small group “debriefing” cite 3 primary concerns:group “debriefing” cite 3 primary concerns:

Traumatic story-telling may traumatize other participants Traumatic story-telling may traumatize other participants (Watson, et al., 2003, in Trauma & Disaster; Stokes, 2002, Cautions (Watson, et al., 2003, in Trauma & Disaster; Stokes, 2002, Cautions & Contraindications for Debriefings)& Contraindications for Debriefings)

Probing into affective domain with those who experience Probing into affective domain with those who experience numbing & avoidance may trigger pathognomonic re-numbing & avoidance may trigger pathognomonic re-traumatizationtraumatization(North, 2003, in Trauma & Disaster; Stokes, 2002)(North, 2003, in Trauma & Disaster; Stokes, 2002)

Inappropriate timing for hyper-aroused individuals Inappropriate timing for hyper-aroused individuals (NIMH, 2002)(NIMH, 2002)

To address concerns related to To address concerns related to group “debriefing”group “debriefing”

Maintain/facilitate an educational and story-telling format Maintain/facilitate an educational and story-telling format (Shalev, et al., 2003, Terrorism & Disaster)(Shalev, et al., 2003, Terrorism & Disaster)

Utilize homogeneous groups so as to prevent Utilize homogeneous groups so as to prevent traumatization from “new” information (similar levels of traumatization from “new” information (similar levels of exposure and function:exposure and function: do not include bystanders, etc. with professionalsdo not include bystanders, etc. with professionals Judgement call about mixing professions (Fire, EMS, Law Judgement call about mixing professions (Fire, EMS, Law

Enforcement) note: ICISF discourages mixingEnforcement) note: ICISF discourages mixing

Avoid delving into the affective aspects with groups that Avoid delving into the affective aspects with groups that are experiencing heightened arousal, avoidance, or are experiencing heightened arousal, avoidance, or numbing numbing (North, 2003; Stokes, 2002)(North, 2003; Stokes, 2002)

To address concerns related to To address concerns related to group “debriefing”group “debriefing”

Unless the magnitude of impairment is such that the Unless the magnitude of impairment is such that the individual represents a threat to self or others, crisis individual represents a threat to self or others, crisis intervention should be voluntary.intervention should be voluntary.

The interventionist must be careful not to interfere The interventionist must be careful not to interfere with natural recovery or adaptive compensatory with natural recovery or adaptive compensatory mechanisms.mechanisms.

The CISD has The CISD has notnot ended until the majority of the ended until the majority of the group has returned to the cognitive domain – and/or group has returned to the cognitive domain – and/or may require individual referrals to higher level of may require individual referrals to higher level of carecare

Summary Risks vs. Benefits of CISM

The risk of adverse outcome is associated with all human intervention and helping practices including medicine, surgery, and counseling.

Improper, inadequate training would appear the greatest risk factor associated with crisis intervention, as well as those practices just mentioned.

Thus, training and supervision may be the best way to reduce the risk of adverse outcome, rather than simply calling for an end to such helping practices.

Effectiveness Of Peer Support Personnel References

Peer Support Personnel are essential in the CISM processPeer Support Personnel are essential in the CISM process Authentic NormalizationAuthentic Normalization RapportRapport Clarification of protocol/processClarification of protocol/process Etc.Etc.

Truax & Carkhuff, 1967, Truax & Carkhuff, 1967, Toward Effective CounselingToward Effective Counseling

Durlak, 1979, Durlak, 1979, Psychological BulletinPsychological Bulletin

Hattie, Sharpley, Rogers, 1984, Hattie, Sharpley, Rogers, 1984, Psychological BulletinPsychological Bulletin

Important CISD Considerations & Ground Rules

Strict Confidentiality agreed upon by participants and teamStrict Confidentiality agreed upon by participants and team Timing is importantTiming is important Location and physical environment appropriateLocation and physical environment appropriate Closed circle formatClosed circle format Participation voluntaryParticipation voluntary No notes, recording devicesNo notes, recording devices No breaks (Try to limit breaks until after group is finished)No breaks (Try to limit breaks until after group is finished) Not operational critique, not investigationNot operational critique, not investigation Not a “blame” sessionNot a “blame” session Not therapy, nor substitute for treatmentNot therapy, nor substitute for treatment

Questi

ons?

Questi

ons?

Additional Information Additional Information and More Slidesand More Slides

• International Critical Incident Stress Foundationhttp://www.icisf.org/http://www.icisf.org/articles/

• Crisis Intervention and Critical Incident Stress Management: A Defense of the Field

http://www.icisf.org/articles/Acrobat%20Documents/CISM_Defense_of_Field.pdf

• National Organization for Victim Assistance NOVAhttp://www.trynova.org

THE NEEDTHE NEED

Over 80% Americans (general population) will be Over 80% Americans (general population) will be exposed to a traumatic event (Breslau) About 9% of exposed to a traumatic event (Breslau) About 9% of those exposed develop PTSD (40-70% in cases those exposed develop PTSD (40-70% in cases involving rape/torture) involving rape/torture) (Surgeon General, 1999, Report on Mental Illness)(Surgeon General, 1999, Report on Mental Illness)

Disasters may create significant impairment in Disasters may create significant impairment in 40-50% of those exposed 40-50% of those exposed (Norris, 2001, SAMHSA)(Norris, 2001, SAMHSA)

THE NEEDTHE NEED

About 50% of disaster workers likely to develop About 50% of disaster workers likely to develop significant distress significant distress (Myers & Wee, 2005, Dis. Men. Hlth)(Myers & Wee, 2005, Dis. Men. Hlth)

As many as 45% of those Directly Exposed to mass As many as 45% of those Directly Exposed to mass disasters may develop PTSD or Depressiondisasters may develop PTSD or Depression(North, et al., 1999, JAMA)(North, et al., 1999, JAMA)

Dose-response relationship with exposure is a key Dose-response relationship with exposure is a key factor in development of PTSfactor in development of PTSDD (DSM-IV R) (DSM-IV R)

THE NEEDTHE NEED

PTSD PREVALENCE: 10-15% OF LAW PTSD PREVALENCE: 10-15% OF LAW ENFORCEMENT PERSONNEL ENFORCEMENT PERSONNEL (see Everly & Mitchell, 1999)(see Everly & Mitchell, 1999)

PTSD PREVALENCE: 10-30% OF THOSE IN FIRE PTSD PREVALENCE: 10-30% OF THOSE IN FIRE SUPPRESSION SUPPRESSION (see Everly & Mitchell, 1999)(see Everly & Mitchell, 1999)

By comparison: PTSD PREVALENCE: VIETNAM By comparison: PTSD PREVALENCE: VIETNAM VETERANS 16% VETERANS 16% (National PTSD Study)(National PTSD Study)

THE NEEDTHE NEED

PTSD PREVALENCE: ~12%, Iraq – Desert Storm PTSD PREVALENCE: ~12%, Iraq – Desert Storm VETERANS (Hoge, et al., 2004, NEJM)VETERANS (Hoge, et al., 2004, NEJM)

PTSD PREVALENCE: unknown% with current Iraq/PTSD PREVALENCE: unknown% with current Iraq/Afghanistan War VeteransWar Veterans(VA system receiving public criticism for lack of support and (VA system receiving public criticism for lack of support and experts anticipating high numbers, May 2007 NYTimes)experts anticipating high numbers, May 2007 NYTimes)

By way of background…By way of background…The National Volunteer Organizations The National Volunteer Organizations

Active in Disaster (NVOAD)Active in Disaster (NVOAD)represents a consortium of represents a consortium of non-governmental agencies non-governmental agencies

providing disaster relief. providing disaster relief. NVOAD member organizations represent NVOAD member organizations represent

the largest group of non-governmental the largest group of non-governmental providers of disaster mental health services providers of disaster mental health services

in North America.in North America.

NVOAD Consensus Points NVOAD Consensus Points (2005)(2005)

Early Psychological Intervention (Early Psychological Intervention (EPIEPI) is ) is valuedvalued

EPI is a multi-component system to meet EPI is a multi-component system to meet the needs of those impactedthe needs of those impacted

Specialized training in early psychological Specialized training in early psychological intervention is necessaryintervention is necessary

NVOAD Consensus Points NVOAD Consensus Points (2005)(2005)

EPI is one point on a continuum of EPI is one point on a continuum of psychological care. This spectrum ranges psychological care. This spectrum ranges from pre-incident preparedness to post-from pre-incident preparedness to post-incident psychotherapy -- when neededincident psychotherapy -- when needed

Cooperation, communication, coordination Cooperation, communication, coordination and collaboration are essential to the and collaboration are essential to the delivery of EPIdelivery of EPI

NVOAD Interventions (2005)NVOAD Interventions (2005)

Pre-incident preparationPre-incident preparation Incident assessment and strategic planningIncident assessment and strategic planning Risk and crisis communicationRisk and crisis communication Acute psychological assessment and triageAcute psychological assessment and triage Crisis intervention with large groupsCrisis intervention with large groups Crisis intervention with small groupsCrisis intervention with small groups Crisis intervention with individuals, face-to-Crisis intervention with individuals, face-to-

face and hotlinesface and hotlines

NVOAD Interventions (2005)NVOAD Interventions (2005)

Crisis planning and intervention with Crisis planning and intervention with communitiescommunities

Crisis planning and intervention with Crisis planning and intervention with organizationsorganizations

Psychological first aid (PFA)Psychological first aid (PFA) Facilitating of access to appropriate levels of Facilitating of access to appropriate levels of

care when neededcare when needed

NVOAD Interventions (2005)NVOAD Interventions (2005)

Assisting special and diverse populations Assisting special and diverse populations Spiritual assessment and careSpiritual assessment and care

All NVOAD recognize need for spiritual careAll NVOAD recognize need for spiritual care

Self care and family care including safety and Self care and family care including safety and securitysecurity

Post incident evaluation and training based on Post incident evaluation and training based on lessons learnedlessons learned

Employee Assistance Professional’s AssociationEmployee Assistance Professional’s AssociationDisaster Response Task ForceDisaster Response Task Force

(EAPA, 2002)(EAPA, 2002)

EAPS should develop workplace disaster plansEAPS should develop workplace disaster plans Plans should consist of a continuum of Plans should consist of a continuum of

interventions, including:interventions, including: Pre-Incident Training/Coordination (early CISM Pre-Incident Training/Coordination (early CISM

intervention training, resiliency training, risk intervention training, resiliency training, risk assessment, policy development)assessment, policy development)

Acute response protocolsAcute response protocols

Employee Assistance Professional’s AssociationEmployee Assistance Professional’s AssociationDisaster Response Task ForceDisaster Response Task Force

(EAPA, 2002)(EAPA, 2002)

Plans should consist of a continuum of Plans should consist of a continuum of interventions including:interventions including: Post-Incident Response (defusing, CISD, crisis Post-Incident Response (defusing, CISD, crisis

management briefings, assessment/ referral, self-management briefings, assessment/ referral, self-care)care)

Follow-up (supervisory briefings, assessment, Follow-up (supervisory briefings, assessment, training)training)

Post-Incident Review and Plan ReformulationPost-Incident Review and Plan Reformulation