Psychological First Aid

Critical Incident Stress Management

By Ross Priebe: Consultant FH:CISM Program

2010

Introductions:

Name, place of work with FH. Number of years in current role. Experience with emotional support. Why are you taking this course? What are you hoping to take from this course?

Purpose of Session:

Gain some understanding: responses to a psychological crisis definitions How can you and I assist others? as peers/colleagues communication techniques
Purpose of session: Review intervention validation Recognition of symptoms & reactions Rehearse tools to assist

What is a Critical Incident?

Any sudden and unexpected, work related event which may cause staff to experience strong (but normal) reactions to an abnormal incident. These reactions have the potential to interfere with their ability to function effectively either at the time of the incident, a few hours later or within a few days.

PSYCHOLOGICAL CRISIS An acute RESPONSE to a trauma, disaster, or other critical incident wherein: 1. Psychological homeostasis (balance) is disrupted (increased stress) 2. One s usual coping mechanisms have failed 3. There is evidence of significant distress, impairment, dysfunction
(adapted from Caplan, 1964, Preventive Psychiatry)

Introductions:

Name, place of work with FH. Number of years in current role. Experience with emotional support. Why are you taking this course? What are you hoping to take from this course?

CISM is a highly valued people management tool in organizations, which suffer repeatedly from traumatic incidents. Studies have shown that it is appreciated by both the traumatized and their managers.
Journal of Mental Health

20 18 16 14 12 10 8 6 4 2 0

Ch illi w

Intervention Stats
[# of interventions]

CISM Intervention Report: April 1, 2008 to March 31, 2009

Bu rn ab ac k y G en er al Ea De l ta gl e Fr as Rid ge La er C ng an le yo y n M em or AR ia H M l iss & M io SA n M em Pe oria ac l Ri e dg Ar e ch Ro Me ya ado lC ws ol Su um r re bi y an M Su p p em o or t S rial er vic es

Types of Interventions - 2009

Group Individual Phone Support Manager Consult

Providers of Interventions - 2009

WorkSafe BC FH: CISM Consultant EFAP Other

Cat g

Respectful Wor place Suicide or Attempted Infant/Child: Death/Code Adult: Death/Code Needle Stick Staff: Injury/Illness/Death Grief Accumulative Aggressive Events Termination Follow-Up Sessions Outside Work Trauma Equipment Phone Fire Organ Harvesting

CISM Survey: January 2009 1058 surveys returned 68% aware of CISM Program Experienced a CI (53.5%) 38% attended a CII
80.5% indicated the intervention lessened the impact of the incident. Other Support
42.5% look to colleagues/supervisors

1.

2.

3.

Accessing the Services

24/7 phone triage

604.587.3707 or 1.866.584.7077

Webpage Resources:
http://fhaweb/HR+Online/Critical+Incident+Stress+Management/default.htm

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Con ac FH:CISM rogram 604.587.3707 or 1.866.584.7077 Acc bl 4/7 ( r age/request l ne pager) In te Sta : .e.; Lab/DI RNs/ CC/CRN/CNE MD/spec al sts Tr age/Un t Clerk Code Team CYS/SCN Soc al Work BCAS

Follow-up wit staff in t e days following. Let t em know if t ey ange t eir minds, an intervention an be set-up later.
O r EFA R ourc 6 4.87 .4 1.8 .505.4

Prepare room, remind staff ** relief elp

15

Preparation/Prevention Phase In-Services Cost of Caring: Seminar Construction Zone: Training PFA (Psychological First Aid Training) Individual Crisis Intervention & Peer Support Feb 2010 Grief Following Trauma April 2010

CRISIS INTERVENTION
Is a variation on the theme of physical first aid

Goals: 1. Stabilization 2. Symptom reduction 3. Return to adaptive functioning, or 4. Facilitation of access to next level of care
(adapted from Caplan, 1964, Preventive Psychiatry)

CISM As First Aid

Physical First Aid:

1. 2. 3. 4.

Stabilize: physiological functioning/physical need. Lessen/Reduce physiological dysfunction/distress (the pain). Return of normal physiological functioning. Refer to the next level of care as necessary.

Psychological First Aid:

1. 2. 3. 4.

Stabilizing of psychological functioning - meet basic needs first, then address basic psychological needs. Lessen/Reduce psychological dysfunction/distress. Return to normal psychological functioning. Refer to the next level of care as necessary.

THE NEED: for an intervention Intensity + Dose + Proximity= Impact

Human, health and emergency service professionals face high levels of risk for traumatic events.

Secondary Trauma/Vicarious Trauma: refers to the effects of hearing about traumatic events secondhand. This type of trauma is common among emergency services providers, hospital staff, social workers

What is this Secondary Trauma?

Predictors: Secondary Trauma

Individual Risk Factors:
Personal history Personality style Coping style Current life context Training & professional history Level of education about trauma

Secondary Trauma
Situational & Environmental Risk Factors:
Workload Nature of the work Nature of the clientele Cumulative exposure to traumatic events Relationship with co-workers Social and cultural context Supervision and consultation

Patricia Fisher, Ph.D. When Working Hurts Services.

Stress, Burnout & Trauma in Human, Emergency and Health

Look below the surface

CISM History:

7 Phases of CISD
1. 2. 3. 4. 5.

Introduction Fact Phase What happened? Thought Phase What were first thoughts? Reaction Phase What stands out? Symptom Phase How are you different since? Teaching Phase Normalize Re-Entry Cognitive Re-Framing

6. 7.

Defusing

Group Intervention (< 20) structured: 3-phase group discussion regarding a critical incident. Typically done with homogenous work groups within hours of the event.

Introduction: Why the intervention is important? Reactions: How are staff truly doing? Psycho-Ed: What are common/normal symptoms/expectations?

On-Site Support presence

Present and available Awkward but necessary Resources, handouts, brochures Offer of critical incident intervention Offer of EFAP

EUSTRESS vs. DISTRESS

Two intensity levels of stress: EUSTRESS & DISTRESS Eustress = Positive, motivating stress Distress = Excessive, debilitating stress

HOW WILL I KNOW IF I M SUFFERING FROM CIS?

There are a number of physical, emotional and cognitive symptoms of CIS. You may experience one or a combination of the following:

CIS Physical Reactions May Be

Sleep disturbance Fatigue Changes in eating habits Menstrual cycle changes Headaches Nausea

CIS Emotional Reactions May Be

Anxiety Irritability Depression Sense of loss Change in need for intimacy Feelings of isolation Guilt Flashbacks

CIS Behavioural Reactions

Isolation/withdrawal Irritability Over eating Under eating Losing or misplacing items Risky or self-destructive Easily startled Flashbacks

CIS Cognitive (Thinking) Reactions May Be

Confusion Difficulty making decisions Impaired thinking Difficulty problem-solving Memory loss Calculation difficulties Anomia (difficulty remembering names of things)

CIS Spiritual Reactions

Question meaning of it all Loss of sense of purpose Hopelessness Anger at God Anger at Spiritual Leaders Sense of life not being fair

REMEMBER!
Interventions of a CISM Program are not substitutes for psychotherapy, social work or counseling. Rather, they are elements within the emergency mental health system designed to precede and complement psychotherapy, i.e., part of the full continuum of care.

SIGNS AND SYMPTOMS OF DISTRESS

COGNITIVE (Thinking) EMOTIONAL BEHAVIORAL PHYSICAL SPIRITUAL

Symptoms: Critical Incident

Psycho-Social Reactions to Traumatic Events:

Lowered mood Loss of interest in activities Sleep disturbances Pessimistic views of the future Lack of trust Second guessing decisions Disturbed appetite Reduced energy levels

I. COGNITIVE DISTRESS

Sensory Distortion Inability to Concentrate Difficulty in Decision Making Guilt Preoccupation (obsessions) with Event Confusion Inability to Understand Consequences of Behaviour

I. SEVERE COGNITIVE DYSFUNCTION

Suicidal/ Homicidal Ideation Paranoid Ideation Disorientation Persistent Diminished Problemsolving Distressing Recurrent Dreams

Disabling Guilt Hallucinations Delusions Persistent Hopelessness/ Helplessness Psychogenic Amnesia Dissociation

II. EMOTIONAL DISTRESS Anxiety Irritability Anger Mood Swings Depression Fear, Phobia, Phobic Avoidance Posttraumatic Stress (PTS) Grief

II. SEVERE EMOTIONAL DYSFUNCTION

Panic Attacks Overwhelming Feelings Persistent Flat Affect Infantile Emotions in Adults Immobilizing Depression Posttraumatic Stress Disorder (PTSD)

III. BEHAVIORAL DISTRESS

Impulsiveness Risk-taking Excessive Eating Alcohol/ Drug Use Hyper startle Out of character or inappropriate sexual activity

Sleep Disturbance Withdrawal Family Discord Crying Spells Hyper vigilance 1000-yard Stare

III. SEVERE BEHAVIORAL DYSFUNCTION

Violence Antisocial Acts Abuse of Others Lasting Compulsive Acts Diminished Personal Hygiene Immobility Persistent Sleep Disturbance (e.g., nightmares) Self-medication

IV. PHYSICAL DISTRESS

Tachycardia or Bradycardia Headaches Hyperventilation Muscle Spasms Psychogenic Sweating Fatigue/Exhaustion Indigestion, Nausea, Vomiting

IV. SEVERE PHYSICAL DYSFUNCTION

Chest Pain Persistent Irregular Heartbeats Recurrent Dizziness Seizure Recurrent Headaches Blood in vomit, urine, stool, sputum Collapse / loss of consciousness Numbness / paralysis (especially of arm, leg, face) Inability to speak / understand speech

V. SPIRITUAL DISTRESS

Anger at God Withdrawal from Faith-based Community Crisis of Faith

V. SEVERE SPIRITUAL DYSFUNCTION

Cessation from Practice of Faith Religious Obsessions Religious Compulsions Religious Hallucinations or Delusions

Potential ymptoms and Impact of ritical Incidents (traumatic events)

Cogn tive Lowered oncentration Less SelfEsteem Apathy Rigidity Disorientation Perfectionism Preoccupation w/trauma Thoughts of self harm Thoughts of harm to others Emotional Powerless Guilt Anger/rage Survivor guilt Shutdown numbness Fear Helplessness Sadness Depression Mood swings Depleted energy Increased sensitivity Behavioural Impatient Withdrawn Moody Regression Sleep disturbance Nightmares Appetite changes Hyper-vigilance Elevated startle response Accident prone Easily loses things Spiritual Question: Meaning of life. Loss of Purpose Decreased self reflection Pervasive hopelessness Anger at God Question religious beliefs Loss of faith Increase in skepticism Loss of higher power ersonal Relationships Wit drawal Decreased interest (intimacy/sex) Physical Somatic Shock Sweating Rapid breathing Increased heart rate Breathing difficulty Joint/muscle pain Dizziness Disorientation Increase: medical issues Impaired immune system Other somatic complaint Increased: severity medical concerns Work Per ormance Low morale Low motivation Task avoidance Obsession about details Dichotomous thinking Apathy Negativity Lack of appreciation Detachment Poor work quality Staff conflict Absenteeism Withdrawal from colleagues

Isolation from others Overprotection as parent/spouse Projective anger or blame Intolerance Loneliness Increase: interpersonal conflicts

Mistrust

Symptoms: Critical Incident

Psycho-Social Reactions to Traumatic Events:

Lowered mood Loss of interest in activities Sleep disturbances Pessimistic views of the future Lack of trust Second guessing decisions Disturbed appetite Reduced energy levels

What labels do we usually attach to individuals experiencing some of the above symptoms?

How do we get someone to discuss how they are really doing?

A Simple check-in:
Available Permission Tentative Honour their natural coping

Stress Levels

Psycho-Social Reactions to Traumatic Events are not just based on the incident:

Stress Levels

Psycho-Social Reactions to Traumatic Events are not just based on the incident:

Look below the surface

Adding to Stress Levels:

Work at least ten hours a day and work as many holidays as possible. Assume the responsibility of solving the problem of all your friends, family and coworkers. Never delegate any responsibility never exercise.

Above all, get emotionally involved in everything you do. You must remember that everyone else comes first - your needs come last. Never waste time relaxing never say no

Bad Days in Health Care

Codes Infant deaths Unexpected patient outcomes Accidents/injury/death of co-workers Resuscitation by non-medical staff Blood and body fluid exposure Suicide attempts/completions Witness to critical incidents/traumatic events Threatening situations

The SAFER-Revised

Stabilize Acknowledge the crisis Facilitate understanding (normalization) Encourage effective coping Recovery or Referral (facilitate access to next level of care)

The SAFER-Revised Stabilize (introduction; meet basic needs; mitigate acute stressors) Acknowledge the crisis (event, reactions) Facilitate understanding (normalization) Encourage effective coping (mechanisms of action) Recovery or Referral (facilitate access to next level of care)

AN EXAMPLE
Introduce yourself Meet basic needs, stabilize, liaison Listen to the story (events, reactions) Reflect emotion Paraphrase content Normalize Attribute reactions to situation, not personal weakness Identify personal stress management tools to empower Identify external support/ coping resources Use problem-solving or cognitive reframing, if applicable Assess person s ability to safely function

Demonstration of Model

Scenario for demonstrating model:

SAFER

Planning An Intervention:

TARGET TYPE TIMING RESOURCES

(Who should receive services? ID target groups.) (What interventions should be used?) (When should the interventions be implemented, with what target groups?) (What intervention resources are available to be mobilized, for what target groups, when?)

CRISIS = RESPONSE The failure to understand that the event is not the crisis, can easily lead to over intervention, and the potential to interfere with natural recovery mechanisms!

Triaging for a Psychological Intervention: It is important for the interventionist to keep in mind the following points: 1. The majority of individuals exposed to a traumatic event will not need formal psychological intervention, beyond being provided relevant information. 2. The focus should be upon the individual more so than the event; assessment is essential. Assessment is an on-going dynamic process, rather than a discrete, static stage. 3. Normalization of the crisis response is to be encouraged, but should never lead one to dismiss serious crisis reactions.

4. Unless the magnitude of impairment is such that the individual represents a threat to self or others, crisis intervention should be voluntary. 5. The interventionist must be careful not to interfere with natural recovery or adaptive functioning. 6. The potential for vicarious trauma must be reduced. 7. Individuals should not be encouraged to talk about or relive the event, unless they are comfortable doing so. 8. When in doubt, seek assistance, supervision.

Caring Professionals
Several studies have demonstrated a relationship between job strain and onset of depressive symptoms in physicians. Similar findings have been obtained in studies of other healthcare workers, with indicators of job strain like increased levels of job demand, lack of social support in the workplace and lack of control related to depressive symptoms. A recent Canadian survey revealed that the impact of stress was heightened for healthcare workers because of the demands of rotating shifts and concerns about accidents or injuries.

Depression & Work Function: Bridging the Gap Between Mental Health Care & the Workplace

How do we take care of these symptoms?

1. 2.

3.

Use drugs and alcohol to cope. Isolate yourself go home and lock yourself in a dark den and veg-out on TV. Snack on junk food, double your caffeine intake and slob around.

Obviously, not the way of self-care post trauma.

Some Self-Care Ideas

1. 2. 3. 4. 5.

6. 7. 8. 9.

Do not use drugs or alcohol to cope. Do not isolate yourself. Eat well and maintain a physical outlet. Assess your work situation carefully. Watch fixation on the incident allow time to recover. Expect the incident to bother you. Learn about traumatic stress. Take time for fun. Get help if necessary.

Critical Incident Stress: Sources Reactions and Solutions, Easton-Snelgrove

SCENARIO - practice

Practice

Fraser Health

CISM Program

Debriefing

most common term.

Assists in: 1. Normalizing reactions and feelings to the event. 2. Enabling staff to return to functioning sooner. 3. Decreasing the impact of accumulative stressors. 4. Building stronger and resilient teams.

FH-CISM Program

Debriefing is one component Initial Phase

variety of responses CIR through WorkSafe BC

Additional Components

Health Care - Unique

Continuous operation Urgent/immediate Rotating shifts Days off

Additional Components/Phases

Three Phases: Preparation Response Follow-up

Preparation Phase

Immunization to CIS Vicarious Trauma Balance of Life Knowledge of the Symptoms It will happen Awareness & Sensitivity

Response Phase

Debriefing One-to-One interventions Defusing (urgent/immediate) Peer Support

Follow-up & Referral Phase

Resources available (printed) Assess the intervention Assess and evaluate the response of the program When necessary refer (EFAP)

Questions?