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Group Crisis Intervention 5th Edition Slides Authored by Jeffrey T. Mitchell, Ph.D. 5th Edition Categories Important Information - Must know information Critical Information – Essential for CISM applications Enrichment Information – Expands CISM knowledge base Objectives: Define key crisis terms and concepts Define key stress terms List components of CISM system Explain informational vs. and concepts interactive groups Explain CISM Role-play practice Understand Resistance, Explain risks if providers resilience and recovery List elements of CISM strategic planning formula are not trained or if they violate standards of practice 6 Core Elements of CISM Surveillance, Assessment and Triage Listening skills, SAFER-R, Individual Crisis intervention Strategic assessment and planning Informational group processes Interactive group processes Personal and Community resilience: resistance, resilience, and recovery- (defined page 17) for further reading see appendix 1, page 133 Section One Pages 17-34 Key Terms and Concepts: Crisis and Crisis Intervention Key Terms and Concepts of Crisis and Crisis Intervention Critical Incidents Powerful traumatic events that initiate the crisis response Without critical incidents there would be no crisis reactions and no need for crisis intervention. The “Terrible Ten” A sample of Critical Incidents Line-of-duty death Suicide of colleague Serious line-of-duty injury Disaster / multi-casualty incident Killing or wounding an innocent person “The Terrible Ten” Significant events involving children Prolonged incidents especially with loss of life Personally threatening situations Events with excessive media interest Any highly distressing event Simply stated…. Crisis is state of heightened emotional arousal …a state of emotional turmoil Crisis A crisis is an acute emotional reaction to some powerful stimulus or a demand CRISIS PRE-CRISIS FEELINGS THOUGHTS FEELINGS THOUGHTS Types of Crises Maturational Crises (plural of crisis) – Associated with changes in various stages of life: adulthood, midlife, aging, retirement. Situational (associated with events such as accidents, deaths, disaster, violence, loss, illness, threats.) Characteristics of a Crisis Disruption to a person’s state of psychological balance Usual coping mechanisms fail Distress, impairment, or dysfunction (Gerald Caplan, MD, 1964) STAGES OF CRISIS post-crisis 3. improved 1.function crisis pre-crisis * 2. stuck Angle of disorganization Point of impact disorganization Trial and error High anxiety Denial Anger Remorse Grief Reconciliation * Crisis event Crisis and Stress Crisis and stress are related. When a person has an emotional crisis, there is also a state of Mental and Physical arousal (stress) that goes along with the state of emotional turmoil Stress Without Crisis We live in stress throughout our existence (24 hours x’s 7days a week – always) Balancing between eustress and distress Stress is a state of arousal from mild to extreme. Helps us to stay healthy You have stress even when you have no crisis. But you can’t have a crisis without stress. Critical Incident Stress An acute emotional, cognitive, and physical reaction that results from an exposure to a powerful, horrible, awful, terrifying, threatening or grotesque stimulus or to an overwhelming demand or circumstance page 18 Critical Incident Stress A state of heightened cognitive, physical, emotional and behavioral arousal that accompanies the crisis (more to be said in Section Two) Crisis Intervention Crisis intervention is a temporary, active, and supportive entry into the life situation of an individual or of a group during a period of extreme distress. Groups are not treated as individuals and individuals are not treated as groups! Different intervention procedures are used for individuals than those that are used for groups. History of Crisis Intervention …these milestones are amplified on pages 22-28 The beginnings of people helping others is lost in antiquity. First organized approach to Crisis Intervention – Franco Prussian War (18701871) Simple procedures: reduction of war stimuli, food, rest, fluids, opportunity to speak with medical personnel History of Crisis Intervention World War I –First the French and then the Americans used a similar approach Crisis intervention helped 65% of psychologically traumatized soldiers to return to front in 3-4 days. Without crisis intervention, only 40% were able to return to combat and that took 3-4 weeks. (Thomas Salmon, 1919) History of Crisis Intervention Crisis Intervention has often been called “Psychological First Aid.” That term was first used about 1933. It certainly was applied in WWII. Crisis Intervention formalized by the work of Gerald Caplan and Eric Lindermann in the Coconut Grove fire in 1942. History of Crisis Intervention In the early 1970’s the foundations of CISM were set In the 1980’s Dr. Jeffrey Mitchell developed the CISM program through his work at the University of Maryland Baltimore County. 2007 United Nations adopted CISM program for its employees world-wide. Providers of Crisis Intervention Police Community volunteers Firefighters School personnel Medical staff Disaster workers Pre-hospital EMS Mental health professionals Military Clergy / chaplains Federal agencies others Communications personnel Goals of Crisis Intervention Reduce emotional tension Stabilize the person Mobilize personal resources Mitigate the impact of the traumatic event Goals of Crisis Intervention Normalize reactions and facilitate normal recovery processes. Restore individuals to adaptive functions Enhance unit cohesion and unit performance in homogeneous groups Identify individuals who may need professional assistance and refer as necessary Simplicity Brevity Innovative Pragmatism Proximity Immediacy Expectancy Principles of Crisis Intervention Steps in Crisis Intervention 8 steps of CI, Albert Roberts, Ph.D. Introduction Assess the situation and the impact on the people involved Mentally list all the options Choose the best option Implement the option immediately read more on pgs. 28 - 32 Steps in Crisis Intervention Reassess the people involved Maintain, change, or abandon the option Closure of the intervention Note: if the person is suicidal, a referral to the next level of care is required. (8 steps of CI, Albert Roberts, Ph.D.) Critical Incident Stress Management A way to remember: Title and Description C - Critical C - Comprehensive I - Incident I - Integrative S - Stress S - Systematic M - Management M – Multi-component Pgs.33 & 34 Critical Incident Stress Management An organized approach to Crisis intervention A “package” of crisis intervention techniques CISM is a subset of Crisis Intervention and shares directly in the history, theory, principles, practices, goals and techniques of Crisis Intervention Pages 32 and 33 Critical Incident Stress Debriefing One tactic among many in the CISM system Not the same as CISM For homogeneous groups only Interactive group crisis intervention 7 step model Covered thoroughly in Section Seven Section Two Stress: Psychological and Behavioral Reactions to Stressors pages 37-46 Stressor A stressor is a stimulus that causes or initiates the stress response Stressor vs. Stress Response there is a difference Stressor is the stimulus Stress is arousal in response to a stimulus. It is a nonspecific response of the body to any demand Stressor vs. Stress Response there’s a difference Stress consists of a combination of neurologic, neuroendocrine, and endocrine arousal response mechanisms that can alter every organ and function in the human body. Stress can accelerate the aging process. Stress equals arousal. General Adaptation Syndrome Alarm equals arousal (cognitive, physical, emotional) Resistance equals behaviors to cope with the arousal Exhaustion equals the period when energy to maintain resistance is depleted Concept developed by Dr. Hans Selye General Adaptation Syndrome Stimulus Resistance Exhaustion baseline Recovery Main Types of Stress Eustress- positive Distress- negative Page 38 Eustress vs. Distress Maximum positive effect Stress Arousal Stress is Usually Not Dangerous Unless… It Prolonged or Intense Cumulative Stress “Burnout” is an out-of-date term that is occasionally brought up Cumulative stress is unmitigated stress arousal that builds over time Cumulative stress: Three identifiable phases a) Stress arousal b) Energy conservation c) Exhaustion Page 37 Target Organ The part of the body, or mind, that is a target of the stress and which develops signs and symptoms of over-arousal Stressor Stress Response Target Organ Target Organ Identification An Example….. Traffic jam Increased Adrenalin Increased Feelings of anxiety, Heart rate increases, and blood pressure rises, etc. Trauma A horrific event outside of the realm of usual human experience. The person experiencing it finds it markedly distressing and feels fear, helplessness and horror Page 38 Traumatic Stress Most intense form of distress A broad range of cognitive, physical, emotional, spiritual, or behavioral reactions Page 39 Post Traumatic Stress Also known as Critical Incident Stress Normal response of normal, healthy, people to a terribly abnormal event. Often overwhelms coping mechanisms Critical Incident Stress* is Normal After Trauma It becomes dangerous to health when it is not resolved *AKA Post Traumatic Stress Post Traumatic Stress Disorder If Critical Incident Stress is not managed properly and if it remains unresolved, it may turn into one or more psychological conditions that can interfere with normal life functions. One of the worst conditions is Posttraumatic Stress Disorder (PTSD) Page 39 Overview of Criteria for PTSD A. Exposure to actual or threatened death, serious injury or sexual violence B. Symptoms of intrusion associated with the traumatic event C. Persistent avoidance of stimuli associated with the traumatic event D. Negative alterations in thinking and mood Associated with the traumatic event Overview of Criteria for PTSD E. Marked alterations in arousal and reactivity associated with the traumatic event. F. Duration of the disturbance(B.C.D.E) is at least 30 days G. The disturbance causes clinically significant distress or impairment in social, occupational and other important areas of function. Overview of Criteria for PTSD The disturbance is not attributable to physiologic effects of a substance (e.g. medication or alcohol) or other medical condition. Other Conditions Resulting From Trauma Substance abuse Panic disorder Withdrawal Changes in personality Depression Loss of self confidence Brief Psychotic Reaction Increased anxiety Panic attacks Increased irritability Trauma Membrane After trauma, people begin to form a membrane around themselves that insulates them from additional trauma. Over time it may block out appropriate help as well. Early intervention is highly recommended. Symptoms of Traumatic Stress Cognitive Physical Emotional Behavioral Spiritual see, read and remember pages 41-43 Psycho-traumatology A study of psychological traumatization Section Three Strategic Planning in Crisis Intervention & Critical Incident Stress Management Pages 46-58 Effective Staff Support Programs Comprehensive Not therapy, but support Integrative Systematic Full support package Multi-tactic Effective Staff Support Programs Linkage to wide range of resources Run and staffed by Peer Support Personnel Contains the Six Core Elements Six Core Elements of CISM Surveillance, Assessment of the event and the impact on the personnel Strategic Planning Listening, Individual support, and Crisis Intervention Informational groups Interactive groups Follow-up and referral services Assessment Circumstances Nature and Magnitude of event Impact on people exposed Characteristics of a Crisis Strategy Full assessment Development of goals and objectives Select the right people to provide the services Develop a strategic plan of action Select the right crisis tactics Tactical Components of CISM Pre-event preparation, education, training, planning and policy development Assessment procedures (nature and magnitude of event, impact on people) Strategic Planning procedures (5 T’s) Individual crisis intervention support actions Tactical Components of CISM On scene support services Informational groups for operations personnel (RITS) Informational groups for citizens (CMB) Interactive groups: Defusing Interactive groups: CISD Tactical Components of CISM Significant other support services Follow-up services Referral services for those who need more than what CISM can provide See pages 52-54 See chart on Pages 55-56 Strategic Planning Formula Theme Target(s) Types Timing Team Theme What are the issues, concerns, questions, threats, circumstances, and special situations that need to be considered? Pages 50-51 Targets Who needs assistance and who does not need assistance? Types What types of help will be most beneficial? Timing When will the assistance be most useful to those who need it? Team Who is being sent in to provide the assistance and do they have the personality, background, and skills to provide the necessary support See pages 50-52 Introduction to Strategic Crisis Planning Exercise Your instructor will conduct a brief Strategic crisis planning exercise at this time. Section Four Informational Group Crisis Interventions Informational Groups 1. Rest, Information, Transition Services (RITS) 2. Crisis Management Briefing (CMB) A change in terminology RITS was formerly known as “Demobilization” The name change brings about clarity of function and eliminates confusion with military communities. The need, function and process remains unchanged Rest Information Transition Services Informational session for staff, not for use with populations outside of Emergency Services or the military. Provided once at end of a unit’s first exposure to a major prolonged critical incident (disaster, military operation). Some form of follow-up is usually required. Pages 59 -64 Rest Information Transition Services Primary purpose: to provide support and information to operations personnel at large scale, complex and prolonged incidents. Consists of two main segments 1) brief information presentation (10 minutes maximum) 2) rest, food, refreshments (20mins.) Command then informs personnel of the next steps or tasks (reassignment, rest, etc.) Rest Information Transition Services Only one provider necessary No efforts to have a discussion No one asked to speak Provide information, instructions, guidance only Have peers available for individual support Rest Information Transition Services Logistical Considerations Assemble team members Establish a schedule for arriving workers Establish liaison with Incident Management Establish location within reasonable proximity of the incident that has adequate space for crews Goals-assessment, mitigate impact Page 61 Rest, Information, Transition Services Exercise Crisis Management Briefing Versatile informational group process Works well with heterogeneous groups Works with any event that has an powerful impact on the community. Has been used in schools, businesses, organizations, clubs, hospitals and government agencies. Crisis Management Briefing Can be repeated to accommodate huge numbers of people Can be provided multiple times as long as new information is added each time. May be done via television or radio if necessary May be provided at regular intervals during a disaster Crisis Management Briefing May be applied to military and emergency services personnel Generally 20 to 45 minutes Primary purpose is information, instructions, and guidance only Crisis Management Briefing Goals 1. Provide Information 2. Rumor Control 3. Reduce Chaos 4. Share effective coping 5. Provide avenues for follow-up care / Referral information 6. Engender Community Morale / Enhance Morale 7. Restore to adaptive function Crisis Management Briefing Process Step 1 Assemble participants (Team and Victims) Step 2 Provide accurate information about the incident Step 3 Anticipate, discuss and normalize current and potential stress reaction Step 4 Teach stress management specific to the groups needs Crisis Management Briefing Exercise Section Five Interactive Group Crisis Intervention Defusing Pages 69-83 Yalom’s Eleven Most Therapeutic Factors for Effective Groups Impart information Use socializing techniques Instill hope Initiate behaviors Altruism Interpersonal learning Universal concepts Group cohesiveness Corrective recapitulation Catharsis Guidance, nurturing, support, assistance Homogeneous Groups Best served by interactive group processes The interactive group processes are 1. Defusing and 2. CISD Understanding and resolving the traumatic experience can best be accomplished in a brief group discussion Group members learn from each other Types of Groups Primary groups – very homogeneous Secondary Groups – some familiarity but most heterogeneous Random groups – extremely heterogeneous NOTE: Defusing and CISD were designed only for homogeneous groups never to be used for heterogeneous groups Therapeutic Factors in Group Impart information Instill hope Altruistic Universal concepts Corrective recapitulation Therapeutic Factors in Groups Use socializing techniques Initiate behaviors Interpersonal learning Group cohesiveness Catharsis (Irvin D. Yalom (2005) Defusing An interactive group process Same day (up to 8 hours after incident ends) Has little effect or no effect after 12 hours Group must be homogeneous If opportunity is missed, provide one-on-one support followed later by CISD Defusing Advantage in defusing is group members emotional guards are down and needs are high. Groups in crisis are more open to right kind of help Focus on unit cohesion and unit performance Defusing In a few cases a defusing may be all the group needs. In other cases a CISD should follow If reactions are intense or suppressed and if there appears to be unfinished business, then a CISD is indicated a few days later. Defusing When a CISD is necessary, it is generally made stronger by having had the defusing first. In a line of duty death situation a 5-phase CISD is provided instead of the defusing 5-phase CISD is taught in the advanced group course. In a disaster, RITS is provided instead of a defusing Criteria for Homogeneous Group Group members have a relationship with each other before the traumatic event They have a shared history They have spent considerable time together prior to the event They have experienced the same traumatic event. Warning! If the Group is Heterogeneous Provide informational group services like the RITS (for staff in large scale events) or, more likely, the CMB Goals of Defusing Stabilization of the traumatized group Restore unit cohesion Restore unit performance Assessment tool to determine if group members need something else in addition to the defusing Defusing Don’ts go beyond 30 minutes go into detail try to turn the defusing into a therapy session. have deep discussions of emotions Defusing Do’s Brief group discussion Brief situation overview Opportunity for a quick assessment of group needs Run by two trained peers Rarely a stand alone. It needs follow-up Defusing All providers of defusing must be properly trained in CISM! “…peer interactions tap into many therapeutic factors.” (Paturel, 2012) “groups provide social support, they improve social networks and they can reduce stigma, isolation and feelings of alienation among members.” (Paturel, 2012) Defusing “…hearing from peers may be more helpful than receiving guidance from a therapist since peers can identify with one another.” (David Yalom, MD, 2005. Theory and Practice of Group Psychotherapy” as reported in Paturel, 2012) DEFUSING: 3 PHASES INTRODUCTION – Introduce team; lay out the guidelines; lower anxiety about the process EXPLORATION – Allows a brief discussion of the experience. A brief “story” of the event INFORMATION – Provide information, normalize, teach, guidance, summarize key points Introduction Phase Introduce team members State purpose / describe process Motivate participants Set ground rules Stress confidentiality Not investigative No one forced to speak All viewpoints are important INTRODUCTORY EXERCISE take a look at pages 86-81 Exploration Phase Ask for brief description of event Ask clarifying questions Group members share experiences of the event only as much as they wish Look for themes / concerns Assess need for more help Reassure as necessary Information Phase Acknowledge / summarize the exploration provided by the group members Normalize 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 Section Six Practice Exercises for Defusing Section Seven INTERACTIVE GROUP CRISIS INTERVENTION CRITICAL INCIDENT STRESS DEBRIEFING Pages 91-125 Critical Incident Stress Debriefing (CISD) A structured GROUP discussion concerning a critical incident First described by Mitchell (1983) for use with homogeneous groups of emergency services personnel Historical roots in military psychiatry (see HERD, S.L.A. Marshall) Requires a team approach CISD GOALS Mitigate distress Facilitate psychological normalization and psychological “closure” (reconstruction) Set appropriate expectations for psychological / behavioral reactions Serve as a forum for stress management education Identification of external coping resources Serve as a platform for psychological triage and referral CISD Team Resources Minimum: Two CISM trained team members At least one mental health clinician Other team member(s) may be “peer support personnel,” spiritual leader, another mental health, or physical health professional ALL TEAM MEMBERS MUST BE TRAINED IN the interactive group process - CISD PLANNING THE CISD SIZE: group (2-20) DURATION: 1-3 hours TIMING: 1-10 days for most incidents (1-3 days for most acute public safety incidents; 3-4 weeks for disasters). note: Implement when “psychological closure” possible, i.e., disengagement. Timing has more to do with PSYCHOLOGICAL READINESS than the passage of time LOCATION: Room with chairs placed in a circle or around a table, isolated away from incident site and distractions CISD Considerations Convenient time All involved operations personnel invited Personnel relieved of duties Ideal group size is 2 - 20 Homogeneous groups (homogenize with regard to traumatic exposure/ psychological toxicity) Ideally, one team member for every 5 or 6 participants minimum of 2 Follow up planning as necessary Important CISD Considerations Strict Confidentiality No breaks Timing is important Location and physical environment Closed circle format COMMON GROUND RULES Participation voluntary No notes, recording devices Try to limit break until after group is finished Not operational critique, not investigation Not a “blame” session Not therapy, nor substitute for treatment Address issue of confidentiality vs. privilege PHYSICAL FORMAT Door Peer MHP Door Peer MHP Peer Peer Door Peer MHP Peer Peer Door MHP Peer Peer Door Peer Peer Avoid tables, distractions, dispatch speakers, equipment, And CPR training dummies. Try to avoid snacks till after. They are impediments to communications! Peer MHP!!!! CISD STRUCTURED 7 PHASES INTRODUCTION FACT PHASE THOUGHT PHASE REACTION PHASE SYMPTOM PHASE TEACHING PHASE RE - ENTRY PHASE Phase Progression of a CISD COGNITIVE RE-ENTRY INTRODUCTION FACT TEACHING THOUGHT SYMPTOM REACTION AFFECTIVE Clarified Phase Progression of a CISD COGNITIVE Introduction Summary Brief Situation Review Stress Management and Recovery Process First Impressions of the Incident Signals of Distress Aspect causing most personal distress AFFECTIVE INTRODUCTION Introduces team members Sets expectations Describes “ground rules” Ground rules anticipate potential problems and attempts to address them in advance Addresses confidentiality Participation in discussion is VOLUNTARY Preview questions INTRODUCTORY EXERCISE Take a look at Pages 110-113 FACT PHASE* Prompt “Tell who you are and what happened from your perspective.” *May still be used when group exposed to multiple stressors, as in disaster out-processing, or culmination of a tour of duty. “Tell us about your experiences.” Alternative Fact Phase: Used when larger than expected group shows up at CISD Used when the administrator places the CISD team members under an arbitrary time restriction Who arrived first; what happened Who came in next; what happened, etc. THOUGHT PHASE Prompt “What was the first or most prominent thought that entered your mind regarding the incident?” Any unusual or disquieting thoughts? REACTION PHASE Prompts “What was the worst part of this event for you?” Any aspects of the event that have caused you the most pain or distress? If you had the power to erase one single aspect what would you most want to eliminate from the total experience? SYMPTOM PHASE Prompt “What physical or behavioral changes have you experienced since the event?” Or, “What has life been like for you since the event?” Or, “What signals of distress have you noticed in yourself since this happened?” TEACHING PHASE Team members normalize reactions, provide anticipatory guidance, teach stress management, describe external resources available. Teach to what has been expressed Encourage participants to continue the recovery process The group should be used as a resource to identify coping techniques that have been useful in the past. RE-ENTRY PHASE Prompts Reiterate normalization Q & A, if indicated Summarize key points, “lessons learned” Offer cognitive reframe if useful to facilitate closure, reconstruction Foster group cohesion, if indicated Section Eight CISD Practice Session End of Slide Program
