Critical Incident Stress Management

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Critical IncidentStress Management Command
Officer CourseLearning from the Past, . . .
Progressing into the Future Developed by Lt.
Col. Sam D. Bernard, Ph.D.CAP CISM National Team
Leader Partial content from Chevron Publishing
2
Welcome Thank you for attending this
session concerning CAP Command Officers
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Rationale

• To provide Command Staff Incident Commanders
  with basic knowledge to
• Recognize the need for CISM,
• Implament the CISM program,
• Understand basic CISM principles,
• Identify distressed personnel under their
  supervision,
• Access CISM services.

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Goals

• To provide the knowledge to
• Mitigate critical incident stress,
• Prepare for critical incident stress,
• Identify critical incident stress,
• Support interventions for active critical
  incident stress intervention,
• Recover from a critical incident while supporting
  members the organization
• in CAP members while performing CAP duties.

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Agenda

• Stress Types of Stress
• Management of Cumulative Stress
• Recognizing Critical Incident Stress (CIS)
• Preventing Critical Incident Stress (CIS)
• Mitigating Op Stress
• After Action Support
• Indicators of CIS vs. Disciplinary Problems or
  Character Disorders

• CISM Resources
• General Functions of CISM Teams
• Follow-Up Services
• P.A.S.S.
• CAPR 60-5 Updates
• Liability
• Charge
• Contact Information

Jeffrey T. Mitchell, Ph.D., CTS George S.
Everly, Jr., Ph.D., CTS
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CAP Personality Traits

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Stress
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Stress

• Stress is a state of
• Physical
• Cognitive
• Behavioral
• Emotional and
• Spiritual arousal.

Take Home Message
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Once physical, cognitive, emotional and spiritual
arousal occurs, behaviors change.
Chevron Publishing, 2002
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Primary Types of Stress

• General Stress
• Cumulative Stress
• Critical Incident Stress
• Stress Related Disorder

Take Home Message
Normal Pathological
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Having stress is not bad, in itself.What is bad
is experiencing excessive or prolonged stress.
Chevron Publishing, 2002
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Resistance If the stressor continues, the body
mobilizes to withstand the stress and return to
normal.
Exhaustion Ongoing, extreme stressors
eventually deplete the bodys resources so
we function at less than normal.
Alarm The body initially responds to a stressor
with changes that lower resistance.
Return to homeostasis
Homeostasis The body systems maintain a
stable and consistent (balanced) state.
Stressor The stressor may be threatening or
exhilarating.
Illness
Illness and Death The bodys resources are
not replenished and/or additional stressors
occur the body suffers breakdowns.
Death
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The brain becomes more alert.
Stress can contribute to headaches, anxiety, and
depression.
Sleep can be disrupted.
Stress hormones can damage the brains ability
to remember and cause neurons to atrophy and die.
Baseline anxiety level can increase.
Heart rate increases.
Persistently increased blood pressure and heart
rate can lead to potential for blood clotting and
increase the risk of stroke and heart attack.
Adrenal glands produce stress hormones.
Cortisol and other stress hormones can increase
appetite and thus body fat.
Stress can contribute to menstrual disorders in
women.
Stress can contribute to impotence and premature
ejaculation in men.
Red immediate response to stress
Muscles tense.
Blue effects of chronic of
prolonged stress
Muscular twitches or nervous tics can result.
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Mouth ulcers or cold sores can crop up.
Breathing quickens.
The lungs can become more susceptible to colds
and infections.
Immune system is suppressed.
Skin problems such as eczema and psoriasis can
appear.
Cortisol increases glucose production in the
liver, causing renal hypertension.
Digestive system slows down.
Stress can cause upset stomachs.
Red immediate response to stress
Blue effects of chronic of prolonged stress
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Stress Curve
Maximum adaptive arousal
Health Performance
Stress arousal
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Cumulative Stress

• Destructive pathway of stress
• Piled up, unresolved general stress
• Takes time
• Produces negative changes in
• Mental physical health
• Performance
• Relationships
• Personality

Chevron Publishing, 2002
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Cumulative Stress

• A chronic state of disturbing stress which can
  cause physical changes in personality over
  time.
• Takes months or years to develop.
• May be a combination of work or home life.
• Often referred to as burnout.
• Often needs professional help for recovery
  especially if in late stages. continued...

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Cumulative Stress - continued

• Develops in four stages
• Early Warning
• Mild Symptoms
• Entrenched
• Severe Symptoms
• Characterized by gradually declining performance,
  increasing problem in job. continued...

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Cumulative Stress - continued

• Early Symptoms
• Vague anxiety
• Boredom
• General fatigue
• Mild Symptoms
• All of the Early Symptoms
• Irritability
• Chronic tension
• Depression continued...

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Cumulative Stress - continued

• Mild Symptoms
• Frustration
• Frequent sighs
• Sleep disturbance
• Chronic worry
• Loss of interest in work
• More frequent colds
• Mild rashes
• Headaches
• Withdrawal from others
• etc..

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Entrenched Symptoms

• Chronic depression
• Loss of joy of life
• Chronic anger
• Increased drinking / drugging
• Thoughts of suicide
• Emotional outbursts
• Marital or relationship discord
• Conflict with fellow workers
• Conflict with supervisors
• Increasing discipline problems continued...

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• Entrenched symptoms - continued
• Increased self destructive behaviors (i.e.?)
• Withdrawal from loved ones Continued... Loss of
  trust in others
• Increasing paranoia
• Loss of ambition
• Tendency to blame others
• Inability to take responsibility for ones own
  actions
• Minor property destruction
• Acting out behaviors
• etc.. (?)

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• Severe Symptoms
• Rage reactions
• Homicidal thinking
• Suicidal thinking / acts
• Easily angered
• Verbally violent outbursts
• Acts of violence
• Threats to others
• Excessive drinking / drugging
• Severe depression
• Severe paranoia continued...

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• Severe Symptoms - continued
• Break up of relationships over minor issues
• Compulsive thinking about bothersome topics
• Easily frustrated
• Sense of hopelessness
• Sense of helplessness
• Seriously declining performance
• Most symptoms from previous levels
• etc..

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Burnout

• Changes attitudes
• Avoids work
• Or, becomes totally immersed
• Develops negative outlook

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Flame-out

• Exhaustion, hyperactivity
• Overwhelming negative emotions
• Denial of symptoms
• Loss of objectivity

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Stress Reactions
Physiological not Characteriological
Take Home Message
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Management of Cumulative Stress Reactions

• Stress management education
• Balance in life - work - home, etc..
• Recreation
• Vacation
• Limiting overtime
• Emphasis on home life
• Professional counseling when needed continu
  ed...

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Management - continued

• Exercise
• Proper food
• Clear job expectations
• Reduction of one worker performing two jobs
• Effective leadership
• Administrative support
• Stress reduction techniques
• Healthy living
• Effective training

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Critical Incident
An event that has the power to overwhelm the
coping abilities of an individual or group.
Take Home Message
Chevron Publishing, 2002
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The Terrible 10 for CAP
1. 6. 2. 7. 3. 8. 4. 9. 5.
10.
. . . not limited to missions!
Take Home Message
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Crisis
Noun vs Verb
Both
Take Home Message
An acute reaction to a critical incident. A name
of a particular critical incident.
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Crisis Characteristics

• The relative balance between thought processes
  and emotional processes is disturbed,
• The usual coping methods do not work effectively,
• There is evidence of mild to severe impairment in
  individuals or groups exposed to the critical
  incident,

Chevron Publishing, 2002
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Post CRISIS
Pre-CRISIS
FEELINGS
THOUGHTS
FEELINGS
THOUGHTS
CRISIS
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Assessing the Need forCrisis Intervention (CISM)

• Is this one of the CAP Terrible 10?
• Are coping mechanisms working effectively for
  EVERYONE?
• Is there evidence of mild to severe impairment in
  individuals or groups exposed to the critical
  incident?

Take Home Message
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Critical Incident Stress (CIS)

• Also called traumatic stress
• Not caused by general stress or cumulative
  stress, but produced by a specific terrible event
• All people are vulnerable
• Emergency personnel may be more vulnerable
  because of exposure to traumatic
  events continued...

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C I S - continued

• Some may react more strongly than others
• Usually resolves in a reasonable period of time
• May need some form of brief support service
• Can turn into a serious problem for a few people
  if it is not resolved
• Supervisors are able to recognize the
  problem continued...

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C I S - continued

• Some people have several Critical Incident Stress
  reactions during their careers
• Reactions can be reduced by early intervention
• Critical Incident Stress can be an opportunity
  for positive change and growth

Chevron Publishing, 2002
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Reactions to Stress

• Physical
• Cognitive
• Emotional
• Behavioral
• Spiritual

Chevron Publishing, 2002
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PhysicalSigns and Symptoms of Critical Incident
Stress

• Thirst
• Fatigue
• Nausea
• Twitches
• Vomiting
• Dizziness
• Elevated B/P
• Muscle tremors
• Grinding teeth

• Visual difficulties
• Profuse sweating
• Difficulty breathing
• Fainting / LoC
• Weakness/numbess
• Chest pain
• Headaches
• Rapid heart rate

Chevron Publishing, 2002
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CognitiveSigns and Symptoms of Critical Incident
Stress

• Confusion
• Nightmares
• Uncertainty
• Hypervigilence
• Suspiciousness
• Intrusive images
• Blaming someone
• Poor problem solving
• Poor abstract thinking
• Change in attention/decision

• Poor concentration or memory
• Disorientation
• Change in alertness
• Suicide/homicide
• Hallucinations/delusions
• Paranoid ideas
• Disabling guilt
• Hopelessness
• Helplessness

Chevron Publishing, 2002
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BehavioralSigns and Symptoms of Critical
Incident Stress

• Withdrawal
• Inability to rest
• Intensified pacing
• Erratic movements
• Changes in social activity
• Changes in speech
• Changes in appetite
• Hyper-alertness

• Changes in alcohol or drug consumption
• Antisocial acts
• Abuse of others
• Diminished personal hygiene
• Immobility
• Self medication
• Violence

Chevron Publishing, 2002
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EmotionalSigns and Symptoms of Critical Incident
Stress

• Guilt
• Grief
• Denial
• Anxiety
• Agitation
• Irritability
• Depression
• Anger
• Apprehension

• Emotional shock
• Emotional outburst
• Feeling overwhelmed
• Loss of emotional control
• Inappropriate emotional responses
• Infantile emotions
• Panic attacks

Chevron Publishing, 2002
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SpiritualSigns and Symptoms of Critical Incident
Stress

• Angry at God
• Asking why questions
• Cessation of practice of faith
• Faith rituals fail to have meaning
• Religious hallucinations or delusions

Chevron Publishing, 2002
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Cumulative CIS

• High frequency of activation
• Long duration of service
• High intensity of service provision

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Cumulative CIS

• Loss of purpose
• Loss of connection
• Loss of autonomy
• Loss of integrity
• Spiritual depletion
• Kendall Johnson,
  1993

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Factors Effecting Crisis Reactions

• Suddenness
• Intensity
• Duration
• Level of loss
• Age
• Injury or death to relatives or friends

• Availability of resources
• Level of education / training
• Availability of coping mechanisms

Chevron Publishing, 2002
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Crisis Intervention
An active and temporary entry into the life of an
individual or a group during a period of
significant distress.
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Crisis Intervention
Emotional first aid designed to assist the
person in a crisis state to return to adaptive
functioning.
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Objectives ofCrisis Intervention

• Stabilize situation
• Mitigate impact
• Mobilize resources
• Normalize reactions
• Restore to adaptive function

Take Home Message
Chevron Publishing, 2002
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Dose Response
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1/3 Rule - Theoretical
1
2
3
8
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Imprint of Horror

• Visual
• Auditory
• Olfactory
• Kinesthetic
• Gustatory
• Temporal

Psychological / Perceptual Contaminants
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CISM as Mitigation

• Efforts attempt to prevent hazards from
  developing into disasters altogether, or to
  reduce the effects of disasters when they occur.
• Differs from the other phases because it focuses
  on long-term measures for reducing or eliminating
  risk.
• Implementation of mitigation strategies can be
  considered a part of the recovery process if
  applied after a disaster occurs.

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CISM as Mitigation

• Structural or non-structural,
• Is the most cost-efficient method for reducing
  the impact of hazards.
• Does include providing regulations . . . and
  sanctions against those who refuse to obey the
  regulations . . . potential risks to the public
  fema.gov

A natural mesh with Public Affairs
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Mitigating C I S
Even with all the right programs, briefings,
teams, personnel, etc lined up available
there can still be CIS. We dont know our
membersbaggage. (Pre-existing
conditions) Pre-Exposure Training can helpID
potential psych/perceptualcontaminants
Take Home Message
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Mitigating Operational Stress (OpStress)

• Frequent information / feedback to staff
• Frequent rest breaks
• Cold or hot environments might require more
  frequent rest breaks
• Rest areas away from stimuli
• 12 hour limit for same scene stimuli
• Assure proper rehabilitation sector
• Provide lavatory facilities continued...

Take Home Message
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Mitigating OpStress - continued

• Provide hand washing facilities
• Provide medical support to staff
• Monitor hyper- or hypo-thermia
• Proper food
• Limit fat, sugar and salt
• Fluid replacement
• Provide drinking water
• Provide fruit juices
• Limit use of caffeine products
• CISM on scene support services continued...

Take Home Message
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Mitigating OpStress - continued

• Monitor signs of emotional distress
• Limit overall stimuli at incident
• Give clear orders to personnel
• Avoid conflicting orders to staff
• Delegate authority
• Frequent rest breaks for all
• Back up leaders
• Sectorization of the incident
• Delegation of authority
• Credit people for proper actions continued...

Take Home Message
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Mitigating OpStress - continued

• Limit criticism to absolute minimum
• Utilize a staging area for uninvolved personnel
• Limit exposure to event sights, sounds and smells
  (reminders)
• Announce time periodically
• Rotate crews to alternate duties
• Others ?

Take Home Message
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Peritraumatic Stress

• Dissociation
• Depersonalization, derealization, fugue states,
  amnesia
• Intrusive Re-Experiencing
• Flashbacks, terrifying memories or night mares,
  repetitive automatic re-enactments
• Avoidance
• Agoraphobic-like social withdrawal
• Hyperarousal
• Panic episodes, startle reactions, fighting or
  temper problems
• Anxiety
• Debilitating worry, nervousness, vulnerability or
  powerlessness
• Depression
• Anhedonia, worthlessness, loss of interest in
  most activities, awakening early, persistent
  fatigue, and lack of motivation
• Problematic Substance Use
• Abuse or dependency, self-medication
• Psychotic Symptoms
• Delusions, hallucinations, bizarre thoughts or
  images, catatonia

Disaster Mental Health Services-A guidebook for
Clinicians Administrators Dept of Veterans
Affairs, 1998
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Highest Risk forExtreme Peritraumatic Stress

• Life-Threatening danger, extreme violence, or
  sudden death of others
• Extreme loss or destruction of their homes,
  normal lives, and communities
• Intense emotional demands from distraught
  survivors (rescue workers, counselors,
  caregivers)
• Prior psychiatric or marital/family problems
• Prior significant loss (death of a loved one in
  the past year)
• Cardena Spiegel, 1993 Joseph et.al, 1994
  Kooperman, et.al., 19945 La Greca et.al.,1996
  Lonigan, et.al., 1994 Schwarz Kowalski, 1991
  Shalev, et.al., 1993

Disaster Mental Health Services-A guidebook for
Clinicians Administrators Dept of Veterans
Affairs, 1998
66
Effects of Hyper-Arousal

• Being more emotional
• Panicking
• Intensified alertness
• Reminders of the trauma leading to physical
  reactions
• Rapid heart beat
• Sweating
• etc
• Increased anxiety

• Trouble sleeping
• Difficulty concentrating
• Heightened vigilance
• Being easily startled
• Being wary
• Sudden crying
• Becoming suddenly angry

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Hyper-ArousalSleep Disturbances

• Longer to fall asleep
• Unable to fall asleep
• More sensitive to noise
• Awaken more often during the night
• Have dreams and/or nightmares about the trauma
• Repetitive trauma dreams may awaken and leave
  frightened and exhausted

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After Action Support

• Thank personnel for their work
• Consult with CISM team
• Provide demobilization services on large scale
  incident
• Utilize services of CISM teams
• Arrange defusing for unusual events
• Consider debriefing for personnel if it appears
  necessary continued...

Take Home Message
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After Action Support - continued

• Allow follow up services by CISM team members
• Critique incident operationally
• Teach new procedures from lessons learned
• Consider the need for family support
• Other ?

Take Home Message
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IndicatorsofCritical Incident
Stressvs.Disciplinary ProblemsorCharacter
Disorders
Take Home Message
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Critical Incident Stress

• Identifiable traumatic event
• Reactions begin with an event
• Reactions worsen after event
• Reactions follow expected patterns
• Sudden changes are common in CIS
• CIS reactions usually reduce with
• Peer assistance and,
• With the passage of time

Take Home Message
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Characteriological Disciplinary Problems -
continued

• Disciplinary problems have a long and diffuse
  history
• Problems may have preexisted entry into the CAP
  job
• Identifiable traumatic event(s) missing
• Problems may exist in several other important
  areas of the persons life.
• Problems do not easily resolve over time even
  with help.

Take Home Message
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Addressing C I S

• Acknowledge the existence of CIS
• Pre-incident education
• Planning
• Drills / practice
• Pre-deployment briefings
• Avoid avoidance of CIS

Take Home Message
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Critical IncidentStress Management
Comprehensive Integrated System utilizing a
Multi-Tactical Crisis Intervention Approach
to Managing Traumatic Stress
Take Home Message
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CISM Menu of Services

• Pre-Crisis Preparation
• Group Intervention
• Demobilization
• Crisis Management Briefing
• Defusing
• Critical Incident Stress Debriefing
• Individual Crisis Intervention
• Pastoral Crisis Intervention
• Family CISM
• Organizational Consultation
• Follow-up/ Referral

Tactics
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CISM TacticsMust be Available for

• Individuals
• Groups
• Organizations
• Families
• Significant others

Take Home Message
Chevron Publishing, 2002
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Core Competencies in CISM

• The ability to properly assess both the situation
  and the severity of impact on individuals and
  groups
• Ability to develop a strategic plan
• Individual crisis intervention skills
• Large group crisis intervention skills
• Small group crisis intervention skills
• Referral skills

Take Home Message
Chevron Publishing, 2002
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Treatment Referral Options

• Medical Care Professional
• MD / DO
• PA / NP
• Mental Health Care Professional
• Psychologist
• Counselor
• Social Worker
• Psychiatrist / NP / PA
• Spiritual Care Professional
• Faith Leader
• Chaplain

Take Home Message
CAP LegalTreat like a physical injury
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Essential CISM Courses(2 Days Each)

• Assisting Individuals in Crisis
• Basic Critical Incident Stress Management Group
  Crisis Interventions
• Suicide
• Grief Following Trauma
• Advanced Critical Incident Stress Management
  Group Crisis Interventions
• T.E.A.M.
• Emotional Spiritual Care in Disasters

Take Home Message
Chevron Publishing, 2002
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CISM ComponentsBefore an Incident

• Education (PEP)
• Team training
• Planning
• Administrative support
• Protocol development
• Guideline development
• Networking with other teams resources

Take Home Message
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CISM ComponentsDuring an Incident

• On-scene support services
• One-on-one crisis intervention
• Advice to supervisors/IC
• Support to primary victims (CAP)
• Provision of food, fluids, rest and other
  services to operations personnel
• Organizational Consultation (CC)

Take Home Message
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CISM ComponentsAfter an Incident

• One-on-one crisis intervention
• Demobilization (post-disaster, large group)
• Crisis Management Briefing (CMB, large group)
• Defusing (small group)
• Critical Incident Stress Debriefing (CISD, small
  group)
• Significant other support services
• . . . more . . .

Take Home Message
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CISM ComponentsAfter an Incidentcontinued

• Post-incident education
• Follow-up services
• Referrals according to needs

Take Home Message
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CISM

• Typically 3-5 contacts
• After that,
• Recovery is evident
• Referral is indicated

Take Home Message
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CISM

• Is not psychotherapy
• Is not a substitute for psychotherapy
• Is not a stand-alone
• Is not a cure for PTSD, Depression, Anxiety, etc

Take Home Message
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CISM has far more to do withgroup
supportandassessment (triage)than it does
withtreatment and cure.
Take Home Message
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Follow-Up

• Must be provided after every CISM service
• Assess impact of intervention
• Assess for uncovering prior issues
• Assess trajectory of reactions
• Decreasing
• Same
• Increasing
• Assess for possible referral
• Health Care Professional
• Mental Health Care Professional
• Spiritual Care Professional

Can be accomplished telephonically
Take Home Message
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P. A. S. S.Post Action Staff SupportDennis
Potter, LCSW
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Goals For PASS

• Increase longevity of CISM team members
• Increase learning from the experience
• Increase stress management skills
• Decrease the chance for personal reactions
• To take care of ourselves (too)
• Increase effectiveness of team members
• Monitor team for any adverse reactions

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Why Do It?

• To Prevent
• Vicarious Traumatization
• Cumulative Stress
• Critical Self Judgment
• To Teach
• To Practice What We Teach
• The same professionalism we provide to others,
  we deserve ourselves SDB

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Important Notice

• All CISM services should be provided only by
  people who have been properly trained in Critical
  Incident Stress Management courses,
• Having attained an advanced academic degree alone
  does NOT indicate knowledge of CISM or related
  protocols.

Take Home Message
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InternationalCritical Incident Stress
Foundation 3290 Pine Orchard LaneSuite
106Ellicott City, MD 21042(410) 750-9600Fax
[phone]Emergency (410)
313-2473www.icisf.org
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CAPR 60-5

• Administratively authorizes CISM,
• Provides background information and how to
  information,
• Mandates each Wing to name a CISM Officer,
• Please read and review 60-5

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CAP Personality Traits

• Need to rescue or be needed
• Strong intrinsic motivation
• Stimulation seeking/easily bored
• Need for immediate feedback
• Action oriented
• Desire to do a perfect job
• Need to be in control
• Strive for consistency
• Risk taker
• High dedication
• Likes uniforms

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CAP Personality Traits

• Those 10 traits make us very good at what we do
  our jobs in CAP,
• Those same 10 traits put us at high risk
• Cumulative Stress
• Critical Incident Stress
• Depression
• Anxiety
• Panic Attacks
• PTSD
• Substance Abuse
• Relationship Problems
• Antisocial traits (isolation, etc)

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Questions . . .

• Do CAP members have the potential for attaining
  physical injury?Yes
• What is done to address this potential?Safety
  briefings, Regulations, Checklists, Medical
  Officers, First Aid kits, Disciplinary actions,
  etc.
• Do CAP member have the potential for attaining
  psychological injury? Yes direct and indirect
• What is done to address this potential?CISM
  program, Regulation 60-5, PEP Talks, Briefings

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Deliberate Indifference

• U.S. Supreme Court concluded that inadequacy of
  police training may serve as a basis for
  municipal liability where failure to train
  amounts to deliberate indifference for the rights
  of persons with whom the police come into
  contact.
• The Court said that the City of Canton, Ohio was
  negligent in failing to train their police
  officers in first aid on a regular basis because
  the probability of needing to use first aid in
  police work was so high.
• Lt. Michael S. Woody, Ret. Akron Ohio Police
  Dept, Jan 6, 2003

Lets not put CAP at risk acknowledge and
support the CAP CISM program.
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Knowledge itself is powerSir Francis Bacon
Action is the proper fruit of knowledgeThomas
Fuller
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What Actions from here?

• Acknowledge the CAP CISM program
• Designate a CISM Officer or Coordinator
• Incorporate CISM into each mission
• Designate CISM specific taskings during evals
• Allow CISM to support your team and staff by
• Triaging mental health issues
• Helping them cope with their experiences,
• Getting them back into service
• Offer referrals if needed

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Feedback
Thoughts Comments Reactions
102
National Staff
Lt Col Sam D. Bernard, PhD National CISM Team
Leader [phone] sam_at_sambernard.info Maj
Chris Latocki Administrative Officer ( 813)
412-9231 clatocki_at_cism.cap.gov
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Region Staff
________Name____________ Region CISM
Officer Telephone / e-mail ________Name_________
___ Region Clinical Director Telephone / e-mail
104
Wing Staff
________Name____________ Wing CISM Officer /
Coordinator Telephone / e-mail ________Name_____
_______ Wing Clinical Director Telephone / e-mail
105

• Whos needs am I meeting,
• Just because you can, doesnt mean you should,
• Everything that is countable, doesnt always
  count everything is counts is not always
  countable,
• Do not confuse effort with results,
• Listen to the words for the underlying meaning,
• Have a good day, unless you have made other
  plans,
• Timing is all,
• Bring cognition to chaos,
• Its not about you,
• No one is immune,
• You will walk with a limp,
• Hear with your ears, see with your eyes, and
  think with your brain,
• Its bigger than you,

Sams Pearls of Wisdom
106
Critical Incident Stress Management
Lt. Col. Sam D. Bernard, Ph.D. National CAP CISM
Team Leader [phone]Cell sbernard_at_cism.cap.g
ov www.sambernard.info cism.cap.gov
107
. . .and just one more thing. . .
Thank You!
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Critical IncidentStress Management Command
Officer CourseLearning from the Past, . . .
Progressing into the Future Developed by Lt.
Col. Sam D. Bernard, Ph.D.CAP CISM National Team
Leader Partial content from Chevron Publishing