Crisis Response: What Do We Do Now? - insafetyconf.com · Crisis Response: What Do We Do Now? Pam Ruster, LCSW, ... • Yalom, 1970. Supportive Systems, ... summarize key points

Supportive Systems, LLC

EAP and Corporate Development 1

Crisis Response: What Do We Do Now?

Pam Ruster, LCSW, CEAPSupportive Systems, LLC

Indianapolis, INwww.supportivesystems.com

Objectives• Explore the history, physiology and psychology of critical

incident response • Familiarize participants regarding the implications of use for

crisis response• Identify opportunities for application in the workplace and

application of skills



Discussion of CISM

• What is CISM?• When do you do a CISM activity?• What is Psychological First Aid?• When do you apply that model?• What are the differences and what

came before?

Prevalence• 80% of Americans will be exposed to a traumatic

event (1)• 9% will develop PTSD (2)• 40-70% in rape or torture (2)• Disasters may create significant impairment in

40%-50% of those exposed (3)

• 1. Breslau 2. Surgeon General 1999 3. Norris 2001 SAMHSA



Prevalence• 10-15% of law enforcement personnel• 10-13% of those in fire suppression• 16% of Vietnam Veterans• 12% of Iraq War Veterans• 40% of those exposed to Mass disasters

1909 Cherry Hill, IL Mining Fire

• Early Crisis Intervention as Emotional First Aid–Not a Cure…–Not psychotherapy



Crisis Intervention

• Targets the Response, not the Event• An active, short-term supportive helping

process• Acute intervention designed to mitigate the

crisis response• Not psychotherapy or a substitute for

psychotherapy

Definition: Critical Incidents• Unusually challenging events that have the

potential to create significant human distress and can overwhelm one’s usual coping mechanisms.



Definitions: Psychological Crisis

• The psychological distress in response to critical incidents as in an acute response to a trauma, disaster, or other critical event where:

– Psychological balance is disrupted– One’s usual coping mechanism’s have

failed– There is evidence of significant distress,

impairment, dysfunction

Psychiatric Casualties

• Civil War 3.3/1000 29 Soldiers Heart• WWI 4/1000 28 Shell shock• WWII 4.4/1000 26 War Neurosis

Combat Fatigue• Korean 4.6/1000 23 Combat Fatigue• Vietnam 5/1000 19 PTSD/PTAN• Iraq 12/100 23 PTSD



The Stats

• 50-70 % of US adults experience Trauma• 30% of those will suffer from PTSD (20% women/8% men)• 5% of Americans are diagnosed with PTSD at any given time• 8% of Americans will have a diagnosis of PTSD at some time in

their lifetime• Those with PTSD 8x more likely to attempt suicide• If have PTSD and Depression, number becomes 16x more

likely

Resistance-Resilience-Recovery

• An outcome driven continuum of careCreate resistance Enhance Resiliency Speed RecoveryAssessment Assessment AssessmentIntervention Intervention interventionEvaluation Evaluation Evaluation

Kaminsky, et.al. (2005) Resistance, Resiliency, Recovery. In Everly & Parker, Mental Health Aspects of Disaster, Public Health Preparedness and Response. Balto; Johns Hoskins Center for Public Health Preparedness



Resistance may be

• Thought of as a form of psychological/behavioral immunity to distress and dysfunction.

• Pre-incident training /preparation is thought to be the best way to build resistance.

Resilience refers to the ability

• to rapidly and effectively rebound from psychological and or behavioral interruptions associated with critical incidents, terrorism and even mass disasters.



Hope• Left frontal lobe of brain is activated when praying,

meditating • Instilling hope

• Physiologically impossible to experience hope and fear at the same time

• The impact of the event depends on the clients degree of hope, resilience and their capacity to transcend the event.

• Transcendence: I believe I can rise above this.

Recovery refers to

• the ability to adaptively function, both psychologically and behaviorally in the wake of a significant clinical distress, impairment, or dysfunction subsequent to critical incidents, terrorism and even mass disasters.



Lessons learned from Community Mental Health

• Early psychological intervention may reduce need for further intensive services. Langsley, Makota & Flomenhaft, 1971, Am J Psyc; Decker & Stubblebine, 1972, Am J Psyc.

• Early psychological intervention may mitigate acute distress Flannery & Everly, 2004, Aggression & Violent Beh

• Early Psychological intervention may reduce ETOH (alcohol use) (Deahl et al, 2000, Br. J Med Psychology; Boscarino, et. Al. 2005

Let’s Start at the Beginning



Stressors• ANY environmental

event that produces an…ANSR

• Autonomic• Nervous• System• Response

Typical Symptoms of Stress• What is your Body Talk?

• Headaches• Gastrointestinal

disturbance• Change in eating/sleeping• Overwhelmed• Anger/Irritability• Vertigo• Muscle Spasms



Two Types of Stress• Eustress

– Positive motivating stress

• Distress– Negative excessive

debilitating stress events

Two Types of DistressCumulative (burnout)

• Slow erosion of functioning

• Cynicism• Incomplete work• Lateness• Impulsive need for

change• Chronic physical illness

Critical Incident (traumatic)

• Normal coping overwhelmed

• Adaptive functioning interrupted

• Symptoms of post traumatic stress evident



Flight. Fight. Freeze.• Normal Survival

Reactions

• What do animals do when frightened?

Typical Stress Response

• Increased heart rate• Elevated blood pressure• Increased muscle tone• Dilated pupils• Increased perspiration



Stress Response• Secretion of

Epinephrine and other hormones

• Increase in oxygen uptake

• Mobilization of Glucose and Fatty Acids

Cumulative Stress Reaction• A problem born of good intentions,• Unrealistic expectations



Cumulative Stress

• Derogatory labels

• Intellectualization

• Psychological distancing• Drugs/alcohol

• Mismanagement of resources

• Patient/Client abuse

• Unappreciated

• Detached

• Self-separated

• Paranoid

• Cynicism

• Denial

• Jargon

Behavioral Aspects• Anger• Irritability• Constant talking• Crying • Fear• Laughter• Avoidance• Changes in

concentration

• Loss– If loss has occurred it is

not possible to begin the grief process until the immediate effects of the crisis have been mitigated



Cumulative Stress Reactions• Unrealistic expectations• Health complications• Changes in concentration• Ineffective coping techniques• BUT THIS IS NOT WHAT WE ARE TALKING ABOUT

A Critical Incident: Definition

• Any event which has a significant emotional power sufficient enough to overwhelm a person’s or groups ability to cope and causes impairment in work or personal activity.

• Officially recognized definition by the United Nations



Examples of Critical Incidents

• Suicide of a colleague• Line of Duty Death • Serious on the job injury• Disaster or a multi-casualty incident• Police shooting• Killing or wounding of any person in a routine

operation• Any event with significant threat to those involved

Examples of Critical Incidents

• Events involving children• Relative of a known victim• Prolonged incidents especially with a loss• Events with excessive media interest• Any significant event



Intensity of the Impact Determinants

• Personal relevance• Duration• Sense of loss• Previous history• Social support & coping skills• Guilt• Hopelessness/helplessness

Characteristics of the Crisis• Characteristics provide the layer of perception

thru which the crisis is experienced. These perceptions then provide the context from which individuals respond to the crisis and associated loss.– Warning/None – Time of day – Duration – Natural vs Man-made



Characteristics of the Crisis

– Intentionality– Scope of impact– Post-crisis environment– Preventability of the event– Did anyone suffer

High Risk Determinants

• Severity and duration of the event• History of childhood abuse• Personal and/or family history of psychiatric illness• Poor or negative social support• Substance abuse• Previous exposure to trauma• Inability/difficulty attaching to others



Emotional Trauma

• Blow to the Psyche that breaks through one’s defenses suddenly, with such force that one cannot respond effectively.

Trauma looks like… A Normal reaction

in Normal people

to an Abnormal event



Purpose of PTS

Post Traumatic Stress is a Survival Mechanism

PTSD results from Violation

• Expectations• Deeply Held

Beliefs–(world views)



Core Beliefs/World Views• Belief in a just and fair world• Our need to trust others• Self-esteem, Self efficacy• Need for a predictable and SAFE world• Spirituality, belief in an order and congruence in

life and the universe• Morality is in place

Purpose

• The memory of the event is set as a light switch to “ON”

• Designed to help you remember so it won’t happen again.



Goals

• Acute Stabilization• Mitigating critical incident stress• Mitigating escalation of distress• Provide opportunity to assess and

potentially follow-up and/or refer

Types of Interventions• Pre-incident Education• On scene support services• Defusing• Demobilization• Formal CISD• Psychological First Aid• Significant Other support



Objectives of CISM• Education• Ventilation• Reassurance• Confront fallacy of uniqueness• Confront fallacy of abnormality• Increase group cohesion• Restore self confidence

Structure of a CISD Meeting

• Peers• Mental Health Provider• Neutral setting• Disruption free (as possible)• Establish confidentiality• Separate participants according to

involvement



Stages of a Debriefing• Introduction• Fact• Thought• Reaction• Symptoms• Teaching• Re-entry

Be Mindful

• Must taste your words before you speak them.

– old eskimo saying



When debriefings fail

• Team not trained• No mental health practitioner present• Not held confidentially• Discussed other debriefings• Insensitivity to participants

Reactions• Common concerns

– Rational versus irrational safety concerns

– Flashbacks visual/auditory– Sleep disturbance– Meal disruption– Concentration– Physical ailments



Reactions

• Returning to work–Fears–Questions–Non-involved persons reactions–Accommodations

Reactions

• Taking care of each other• Guilt• Relief• Fear of retribution• Fear of discipline



Cautions• Sugar• Caffeine• Alcohol

Follow-up

• Crucial to follow up with anyone for whom you have concerns

• Reassure they will continue to improve over a period of time.



Defusing• Small group

• More informal

• More common

What makes groups unique?

• Learning from others• Catharsis• Group cohesion• Personal insight• World View awareness• Universality• Instillation of hope

• Yalom, 1970



Defusing

Small Group discussion• Timing: Usually

between 8-10 hours of event

• Structure: 3 phases• Duration: less than 1 hr. • Location: secluded

room• Group: Homogeneous

Goals:– Normalization – Reduce tension– Set expectations– Discuss coping

methods– Identify those who

require additional support

Defusing: 3 Phases

• Introductions of team; layout, what to expect• Exploration: A brief story of the event• Provide information , normalize, teach,

guidance, summarize key points



Introduction Phase• Introduce team • State purpose/describe process• Motivate participants• Set ground rules• Stress confidentiality• Not investigative• Non one forced to speak• All viewpoints are important

Exploration Phase

• Ask for brief description of event

• Ask clarifying questions• Group members share

experiences on the event if they choose

• Look for themes/concerns

• Assess need for help• Reassure as necessary



Information Phase• Acknowledge/ summarize the exploration

provided by the group• Normalize key experiences and or reactions• Teach key stress survival skills• Emphasize taking care of self• Rest/family life/stress management• Offer additional help such as one on ones

Defusing not indicated when• Overwhelming emotions• Affective lability• Dysfunctional arousal• Group cohesion fragile

• Option: Consider small group information session• Assemble group• Presentation of facts• Typical symptoms persons may experience• Suggestions for coping, stress reduction



Critical incident response is main stream

• The more prepared we are, the more routine the responses will be.

• Preparation is key.

CISM Summary• Requests for CISM may include response to:

– Robbery– Suicide– Employee death– Family member death– Fatal automobile accidents involving employee

or family – Workplace accidental death



Types of Interventions• Pre-incident Education• On scene support services• Defusing• Demobilization• Formal CISD• Psychological First Aid• Significant Other support

How to Apply this information• Next Steps….How to implement

• Will you have a team on site?

• Who else knows this stuff?



Contact Information• Pam Ruster, LCSW, CEAP• President & CEO• Supportive Systems, LLC• 25 Beachway Drive, Suite C• Indianapolis, IN 46224• www.supportivesystems.com• 317-788-4111• 800-660-6645

• Women Business Enterprise certified by State of Indiana and City of Indianapolis

Documents

Crisis Response: What Do We Do Now? - insafetyconf.com · Crisis Response: What Do We Do Now? Pam Ruster, LCSW, ... • Yalom, 1970. Supportive Systems, ... summarize key points