Critical Incident Response: Evolving Best Practices in the Workplace

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Critical Incident Response Evolving Best
Practices in the Workplace
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Do It Well

• It is the willingness and capacity to develop
  their skills that distinguishes leaders from
  followers.
• Warren Bennus and Bert Nanus

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Presentation Outline

• R2P CIR History and Mile-High View of Recent
  Changes
• CIR Workplace-Specific Objectives
• Questions and Discussion
• Paradigm Shift toward Psychological First Aid
• Questions and Discussion
• Leadership in Time of Crisis ACT

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History of Critical Incident Response

• American Revolutionary War (1770s) Rail Road
  Spine
• Civil War (1860s) Soldiers Heart
• WW I (Early 1900s) -- Shell Shocked
• WWII (1940s) -- Applying the Tools of Newly
  Emerging Field of Psychiatry Combat Fatigue
• Viet Nam (1960s) -- Dx of PTSD Comes to National
  Awareness
• First Responders (1980s) -- Recognition of Need,
  Development of Models
• Sept. 11, 2001 -- Widest Application of CIRS to
  General Population
• 2002 to Present -- Research, Evaluation,
  Validation of Best Practices

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Disaster Response

• Literature and the experience of experts
  advise a phase sensitive multi-component response
  for populations exposed to extreme stressors.
• World Health Organization, 2003

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Evolution in Critical Incident Response

• Evidence-informed best practices (R2P)
• Support for psychological first aid
• Continuum of care multi-component and
  phase-sensitive
• Selectively drawing from existent models and
  approaches
• Continued valuing of group interventions
• Minimizing risk of harm. Assessment of who
  benefits and who might be at risk. Provides
  additional safeguards against the possibility of
  doing harm by limiting likelihood of additional
  stripping of defenses in the intervention.
• Interventions specifically designed for the work
  setting

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Evolution in Critical Incident Response

• Positions the organizations leadership as
  competent and compassionate.
• Provider serves more as consultant and
  psycho-educator than counselor and the
  intervention as more educational than cathartic.
• Assumes recovery and defines that recovery in
  terms of return to work and function.
• Promotes a flexible approach that allows for
  unique response and taps into the strengths and
  resources of the individual to return to adaptive
  functioning.
• Normalizes symptoms to reduce anxiety regarding
  them without prescribing them.
• Provides strategies for self-care and re-entry to
  life and work.

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Business Continuity and Recovery

• There is no business recovery without people who
• Are healthy enough to return to work and be
  productive
• Are assured enough of their safety to not feel
  afraid to return to work
• Have had their trust in the leadership
  established so that they desire to return to work
• Have had their loyalty rewarded so they remain
  employees over the short haul and the long haul
• Marsh Crisis Academy 2003

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Understanding the Corporate Client

• Employers Concerns
• Communicating the employers compassion and
  support for employees
• Fulfilling duty to provide a safe workplace
• Protecting Assets
• Protecting Brand
• Assuring Public that they are safe
• Responding to Regulatory Agencies
• Resuming Operation ASAP
• Controlling Losses

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Corporate Impact Immediate Stressors

• Displaced employees
• Death of employees
• Destruction of property Unable to return to
  work until safe
• Communication barriers
• Increased media scrutiny of procedures
• Disruption in usual procedures
• Veteran's Administration National Center for
  PTSD

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Corporate Impact Ongoing Stressors

• Actual or perceived decreased safety.
• Pursuit of medical and psychiatric opinions.
• Employees coping with issues related to
  grief/loss, increased financial strain, traumatic
  stress, family concerns, physical needs.
• Harsh judgments if emergency decisions were
  handled poorly
• Tolerance among departments and personnel often
  decrease as stress, role conflict, and extreme
  fatigue set in.
• Difficulty concentrating at work/increased
  mistakes.
• Irritability with fellow workers and customers.
• Absenteeism and presenteeism.
• Decreased productivity.
• Ongoing corporate financial concerns.
• Adapted from Veteran's Administration National
  Center for PTSD

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CIR from the Corporate Perspective

• For us, this service is about having
  available immediately (KEY) the specialized,
  trained (KEY) care our associates need. Our
  robberies happen late at night and on weekends.
  The workers compensation system is not set up to
  address the associates needs in this situation.
  Untrained doctors and counselors think it is best
  to keep associates out of work whereas these
  Specialists know the best option for the
  associate in most cases is to continue working.
  Once an associate is put out of work by WC
  doctors, it takes months to years to get the
  claim resolved.
• Director of Risk Management
• Retailer

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Paradigm Shift in Healthcare (Ray, 2004)
Components of Health Care Models Past Future
Focus Fighting sickness Building health
Emphasis Environmental factors Behavioral factors
Cause of disease Pathogen Host-pathogen interaction
Patient role Passive recipient of tx Active in tx and health
Belief system of patient Irrelevant Critically important
Physician role Determiner of tx and healing process Collaborator in tx and healing process
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Paradigm shift Pathology to Resiliency

• Much attention in critical incident response has
  been focused on the avoidance of
• pathology, most specifically on the prevention
  of PTSD.
• In the days immediately following September 11,
  2001, many concerned voices
• proclaimed that psychiatric casualties might
  number in the millions. Experts estimated that
  as many as 1 in 4 New Yorkers would need
  treatment.
• Extensive sampling of Manhattan residents
  following the September 11th attacks found that
  only 7.5 showed probable PTSD 4 weeks after the
  event at 4-6 months, the level had declined to
  slightly more than one-half of one percent.
  (Galea, 2003)
• Research indicates that efforts should be
  directed towards fostering natural resiliency
  rather than abating symptoms associated with
  PTSD. (Bonnano, 2004)
• Effective critical incident response allows
  individuals to find their own levels of
• recovery and does not programmatically apply
  trauma remembrance and
• emotional processing in the early phases
  following critical incident. (NCCTS NCPTSD,
  2005)

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Psychosocial Impact of Disasters

• Sources Ursano, 2002 Institute of Medicine, 2003

Fear and Distress Response
Behavior Change
Psychiatric Illness
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Resiliency vs. Recovery

• Resiliency to loss and Trauma
• Refers to the ability to maintain relatively
  stable, healthy levels of psychological an
  physical functioning after exposure to an
  isolated and potentially highly disruptive event.
  
• Recovery
• Represents a trajectory in which normal
  functioning temporarily gives way to threshold or
  sub threshold of psychopathology.
• (Bonnano, 2004)

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Individual Stress Response

• Existing research on resiliency and recovery
  indicates that most everyone experiences some
  level of distress when a significant crisis
  strikes a community or workplace.
• The individual reactions and the course they take
  will turn out to be highly varied between persons
  and will represent a wide range.

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Facilitating Resiliency

• People are more resilient than they feel.
• Education can provide inoculation.
• Utilize strengths.
• Reduce likelihood of making it worse.

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Resiliency You tend to find what you look for!

• A powerful finding in resiliency research
  suggests that internally directed, self-motivated
  people thrive in conditions of constant change.
  (Siebert, 2005)
• Evidence suggests that resiliency is much more
  common than often believed. (Bonanno, 2004)

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Functional Denial

• Reported by Dr. Edna Foa as affective and
  cognitive avoidance previously looked at as
  dissociation.
• Rather than a sign of pathology, researchers are
  now looking at this reaction as one of
  self-preservation.
• Denial is an adaptive reaction that protects
  survivors from the full force of the tragedy.
  This coping mechanism is a gradual and graceful
  way to deal with the loss of a loved one,
  allowing families the time that they need to make
  the transition from shock and denial into the
  grieving process.
• Cummock, 1996

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Psychological First Aid (PFA) Overview

• Is an evidence-informed approach to providing
  immediate support after exposure to a traumatic
  event.
• Directs efforts toward enhancing natural
  resilience rather than preventing PTSD.
• Assists in reducing initial distress.
• Fosters short and long-term adaptive functioning.
  
• Is used by mental health specialists in diverse
  settings.
• Embraces a wide range of techniques and
  anticipates that methods will change as evidence
  develops.
• Still needs further research.

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Organizations Endorsing Use of PFA

• US Dept of Veteran's Affairs
• National Center for PTSD
• Substance Abuse and Mental Health Services and
  Administration
• International Society for Traumatic Stress
  Studies
• National Child Traumatic Stress Network
• Center for Disaster Medicine
• American Psychological Association
• John Hopkins Center for Public Health
  Preparedness
• American Psychiatric Association Disaster
  medicine

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Psychological First Aid Field Operations
Guide(National Child Traumatic Stress Network
and National Center for PTSD)

• Core Activities of PFA
• Contact and Engagement of those in need of
  assistance
• Comfort and Safety for those affected
• Stabilization of situations and reactions
• Information Gathering to assess impact
• Practical Assistance
• Connection with Social Supports
• Information about Coping
• Linkage with Collaborative Services
• (NCCTS National Center for Traumatic Stress,
  2005)
• www.NCTSN.org

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Crisis Leadership

• Vision (Understanding Corporate Needs)
• Action (Plan to Facilitate Resiliency)
• Leadership in Times of Crisis
• From Michael Useems,
• The Leadership Moment

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Leadership in Time of Crisis
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Leadership Vision Action

• Deprivation Basic resources
• Isolation Connectivity
• Chaos Structure
• Helplessness Efficacy
• Victim Survivor

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ACT Process

• A- Acknowledge and name the incident and its
  impact.
• C- Communicate pertinent information with
  competence and compassion.
• T- Transition to next steps adaptive
  functioning or an appropriate level of care.

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ACT Process

• Identify circles of impact and utilize the
  continuum of CIR services accordingly.
• Position corporate leadership favorably by
  coaching regarding an ACT process.
• Integrate the elements of PFA into an ACT
  process.

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ACT

• Acknowledge
• Acknowledge what has happened.
• Summarize what has happened using the real words.
• Present objective and credible information.
• Deliver information with sensitivity.
• Serves to control rumors, reduce anxiety, and
  return a sense of control to impacted
  individuals.

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ACT

• Communicate
• Communicate competence and compassion
  simultaneously.
• Visible leadership communicates care and concern
  for those involved.
• Transitions to specialist (if utilized).
• Provide information about common. reactions to
  critical incidents and what can be done to
  exercise resiliency.

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ACT

• Transition
• Information about Coping Emphasize resiliency.
• Triage back to adaptive functioning or to an
  appropriate level of care.
• Practical Assistance - determine basic and
  practical needs.
• Linkage with Collaborative Services - transition
  individual to appropriate level of support and
  provide information. (EAP, counseling center,
  community resources, written communications and
  web resources, telephonic support via a 1-800
  number, to continued personal assistance/
  intervention).

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References

• Bonanno, G.A. (2004). Loss, trauma, and human
  resilience. American Psychologist, 59, (1),
  20-28.
• Boscarino, J.A., Adams, R.E., and Figley, C.R.
  (2005) A Prospective Cohort Study of the
  Effectiveness of Employer-Sponsored Crisis
  Interventions after a Major Disaster.
  International Journal of Emergency Mental Health,
  Vol. 7, No. 1, pp. 9-22.
• Foa, E.B., et.al., (2005) Social, Psychological,
  and Psychiatric Interventions Following Terrorist
  Attacks Recommendations for Practice and
  Research. Neurospsychopharmacology 30, 1806-1817.
• Frankl, V.E. (2005). Mans search for meaning.
  Boston, MA Beacon Press.
• Maddi, S.R Khoshaba, D.M. (2005). Resilience
  at work. New York, NY AMACOM.
• National Child Traumatic Stress Network and
  National Center for PTSD, Psychological First Aid
  Field Operations Guide, September, 2005.
• National Institute of Mental Health (2002).
  Mental Health and Mass Violence Evidence-Based
  Early Psychological Intervention for
  Victims/Survivors of Mass Violence. A Workshop
  to Reach Consensus on Best Practices. NIH
  Publication No. 02-5138, Washington, D.C. U.S.
  Government Printing Office.
• Department of Veteran's Affairs. Disaster Mental
  Health Services A Guidebook for Clinicians and
  Administrators.
• Ray, O. (2004). How the mind hurts and heals
  the body. American Psychologist, 59, (1), 29-40.
  
• Siebert, A. (2005). The resiliency advantage.
  San Francisco, CA Berrett-Kohler Publishers,
  Inc.
• World Health Organization. Mental Health in
  Emergencies Mental and Social Aspects of Health
  of Populations Exposed to Extreme Stressors.,
  2003.

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