Critical Incident Stress Management (C.I.S.M.) A Basic Introduction

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Critical Incident Stress Management (C.I.S.M.) A
Basic Introduction

• Montgomery County CISM Team

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Montgomery County Critical Incident
Stress Management

• Who takes care of the caregivers?

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Critical Incidents

• Events that have the potential to create
  significant human distress and can overwhelm
  ones usual coping mechanisms.

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What is a Critical Incident?

• Death or injury of a coworker
• Death or major injury to a child
• Situations involving extensive media coverage
• Prolonged situation with negative outcome
• Mistakes, real or imagined
• Victim previously known to person
• Natural Disasters

Unionville H.S.
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What is Critical Incident Stress?

• Emotional, mental, and/or physical response which
  interferes with behavior, or the ability to
  function either on scene or after the incident is
  over.
• As defined by Dr. Jeffrey T. Mitchell Ph.D.

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What DeterminesHow You Will React?

• The type of stress you experience is dependant on
  4 Ps
• Perception - How one views an event
• Planning - Training and preparation
• Preparedness - Ones expectations of the stimuli
• Past - The baggage you carry from previous
  experiences

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Coping Mechanisms

• Denial (Things just dont bother me)
• Titanic Syndrome (Im invincible and
  unsinkable)
• Image Armor (Admission of pain is seen as a
  sign of weakness)
• Anger
• Blame
• Dark Humor

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Exposure Control

• While working with a patient...
• You may have gotten exposed to an infection
• Would you seek treatment?

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Exposure Control

• After an exposure, a physician may prescribe some
  prophylactic medication
• CISM is the prescription following an exposure to
  stress

C I S M
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The Goals of CISM are

• Early Recognition
• Identifying a potentially stressful situation
• Activation
• Page the CISM Coordinator
• Suppression
• Set up an Intervention
• Prevent burnout
• Encourage the well being of personnel, careers,
  and families

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San Diego vs. Cerritos
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The Tale of Two Plane Crashes

• San Diego
• 125 killed-no survivors
• 16 homes destroyed
• 15 civilians killed on ground
• 300 EMS personnel
• gt 10,000 body parts

• Cerritos
• 82 killed-no survivors
• 16 homes destroyed
• 15 civilians killed on ground
• 300 EMS personnel
• gt 10,000 body parts

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Impact of CISM

• San Diego
• No CISM Services provided
• Lost police - 5 in one yr.
• Lost fire - 5 in one yr.
• Lost paramedics - 15 in one yr.
• Increase in mental health services - 31

• Cerritos
• 12 CISM Demobilizations
• Hotline Follow-up
• No loss of police or fire personnel
• 1 paramedic loss
• Increase in mental health services - 1

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What is Stress?

• Your reaction to stimuli
• Physical
• Mental/Cognitive
• Emotional
• Stress comes in two forms
• Eustress
• Distress

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What is Distress?

• A disruptive force that negatively impacts daily
  health -Mitchell Bray
• Physical- Change in eating patterns
• Mental/Cognitive- Inability to recall simple
  information
• Emotional- Hypersensitivity

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What is Eustress?

• The positive, motivating reactions to situations
• Driving force to do your best
• Physical - Exercise
• Mental - Academics
• Emotional - Optimism

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Psychological Crisis

• An acute response to a trauma, disaster, or other
  critical incident wherein
• 1) Psychological balance is disrupted
• 2) Ones usual coping mechanisms have failed
• 3) Evidence of significant distress, impairment,
  dysfunction

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Terrorism represents a form of psychological
warfareThe war will ultimately be won or lost
not on the battlefield, but in the mind
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Crisis Intervention was developed in response to
the acute mental health needs of those in crisis
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Crisis Assessments
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Acute Mental Status Assessment

• Orientation
• Long-term Memory
• Concentration
• Emotion

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What is cumulative stress?

• Chronic progressive culmination of small
  stressors
• May result in P.T.S.D., if not managed.
• Warning Contents under extreme pressure!

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Cumulative and Long-Term Effects of Stress

• Hindrance of performance
• Decreased ability to make decisions
• Memory problems
• Interpersonal Conflicts
• Morale problems
• Accident prone
• Absenteeism
• Depression
• Burnout and Attrition
• Suicide

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P.T.S.D. (Post -Traumatic Stress Disorder)

• This is a pathological reaction to an abnormal
  situation
• Symptoms inhibit the person from functioning at
  his/her job
• May have day or night terrors

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More P.T.S.D.

• Hypersensitivity
• May experience intrusive thoughts (flashbacks)
• Symptoms MUST last for over 30 days
• Early Recognition and intervention may prevent
  the domino effect

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Critical Incident Stress Management

• ...is a comprehensive, organized approach for
  the reaction, and control of harmful aspects of
  stress.
• Jeffrey T. Mitchell Ph.D.Forms of intervention

• Pre-incident Education
• On-Scene Support
• Demobilization
• Defusing
• Debriefing (CISD)

• Crisis Management Briefing (CMB)
• Family Support
• Assessment
• Follow-up/Referral
• Mutual Aid

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For Whom is C.I.S.M. Targeted?

• Normal people experiencing normal reactions to
  abnormal situations

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C.I.S.M. is not for CRAZY People!

• C.I.S.M. is not designed to be therapy or a
  replacement for therapy

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Critical Incident Stress Debriefing

• is a method for mitigating the harmful effects
  of work-related trauma, and ultimately preventing
  P.T.S.D.
• Jeffrey T. Mitchell Ph.D.

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What is a Defusing?

• A small group process which is initiated after
  any traumatic event that is powerful enough to
  overwhelm ones usual coping mechanisms
• Short version of a Debriefing

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What Does Defusing Mean?

• Means to render something harmless before it can
  do damage
• Overall objective is to reduce the potential for
  harm to those who were exposed to a critical
  incident

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Usual Effects of Defusings

• May possibly eliminate need for formal Debriefing
• It will enhance effectiveness of Debriefing
  process if one is needed

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Defusing Goals

• Achieve a rapid reduction in the intense
  reactions to a traumatic event
• Attempt to normalize the experience
• Attempt to re-establish the social helping
  network of the group
• Assess need for formal Debriefing process

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Additional Goals of Defusings

• Information transfer between members
• Re-focusing of thinking process getting your
  act together
• Education as to survival skills over next few
  days
• Identifying support resources/personnel

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Debriefing - What is It?

• A formal peer group discussion designed to help
  alleviate the effects of critical incident stress
  
• A prevention program for burn-out

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What Happens at a Debriefing?

• Team
• Location
• Phases
• Introduction
• Fact
• Thought
• Reaction
• Symptom/teaching
• Re-entry

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Introduction Phase

• Introduce members
• Establish ground rules
• Explain process

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Fact Phase

• Who are you and what was your job, or how were
  you involved in the incident?
• What happened from your point of view?

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Thought Phase

• What was your first or most prominent thought
  once you came off auto pilot?

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Symptom Phase

• The group is asked to describe
• Any cognitive, physical, emotional or behavioral
  symptoms they experienced at the scene
• Symptoms they experienced in the following days
• Symptoms they continue to experience

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Teaching Phase

• All team members teach about symptoms one may
  experience
• Find a positive outcome, or gift that may have
  come out of tragedy
• Utmost concern for group

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Re-entry Phase

• Clarify issues
• Answer questions
• Team members make summary comments

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Follow-up and Referral

• May return for another debriefing if group
  decides
• May have an individual who may ask for further
  help

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Signs and Symptoms

• Physical
• Chest Pain
• Elevated BP
• Headaches
• Muscle tremors
• Cognitive
• Confusion
• Poor attention
• Intrusive images
• Nightmares

Behavioral
Physical
Cognitive
nal
Emo
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Signs and Symptoms

• Emotional
• Guilt
• Anxiety
• Depression
• Behavior
• Withdraw
• Loss of or increase in appetite
• Changes in sleep patterns
• Increased alcohol consumption

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The Keys to Unlocking a Successful Career

• After a Critical Incident
• Helping a Peer
• Listen carefully
• Spend time with the traumatized person
• Help with everyday tasks
• Know your limitations as a peer supporter

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The Keys to Unlocking a Successful Career

• Helping yourself
• Eat well-balanced and regular meals
• Drink plenty of water
• Get plenty of rest
• Structure your time - Keep busy
• Allow yourself to be emotional
• Look to your peers and family for support

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Pre-Incident Strategies

• Eat Properly
• Exercise
• Rest
• Talk

Must practice/do/engage in regularly
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Post-Incident Strategies

• Eat Properly
• Exercise
• Rest
• Talk

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Montgomery County

• Critical Incident Stress Management Team
• Department of Public Safety
• Division of EMS
• and the
• Office of Mental Health

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History of the Montgomery County CISM Program

• Trained Emergency Services Peers
• Mental Health Professionals
• All Volunteers
• Services are free

C C - C I S M
C C - C I S M
M C - C I S M
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Main goals of CISM

• To jump start your natural support systems
• To help keep your baggage at a manageable level
• To get you back to work and functioning at an
  optimal level after a critical incident

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Team Make-up

• Mental Health Professionals
• EMS/ Medical Professionals Peers
• First Responders, EMTs, Paramedics, PHRNs,
  Nurses, Physicians
• Police Officers Peers
• Active, and retired
• Firefighters, Rescue, Water Rescue Peers
• Dispatcher Peers
• Clergy
• Community Service Peers

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The expanding role of CISM

• Services for families of Emergency Services
  Personnel
• Industrial First Responders
• Proactive Training Education
• Community Group Crisis

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Who Can Activate CISM?

• CISM may be activated by any member of any
  Emergency Service in Montgomery County
• It is advised that these requests go through a
  supervisor or an administrator
• CISM may be activated by other community service
  groups

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How to Access the Team

• CISM can be activated through
• Montgomery County Emergency Dispatch Service
• 911
• or
• 610-631-6541

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Special thanks to Marc Borish, NYC Regional EMS
CISM Coordinator (and formerly the Chester County
CISM Coordinator) for the preparation of the text
portion of this presentation
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