Critical Incident
Stress Management
Command Officer
Course
Learning 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
Thank you for attending this session
concerning CAP Command Officers
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.
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.
Agenda
•
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Stress & Types of Stress
• CISM Resources
Management of
• General Functions of
Cumulative Stress
CISM Teams
Recognizing Critical
• Follow-Up Services
Incident Stress (CIS)
• P.A.S.S.
Preventing Critical Incident • CAPR 60-5 &
Stress (CIS)
Updates
Jeffrey T. Mitchell, Ph.D.,
CTS
Mitigating Op Stress
& • Liability
After Action Support
George S. Everly, Jr.,• Ph.D.,
CTS
Charge
Indicators of CIS vs.
• Contact Information
Disciplinary Problems
or Character Disorders
CAP Personality Traits
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Stress
Take Home Message
Stress
Stress is a state of:
• Physical
• Cognitive
• Behavioral
• Emotional and
• Spiritual arousal.
Once physical, cognitive,
emotional and spiritual
arousal occurs, behaviors
change.
Chevron Publishing, 2002
Take Home Message
Primary Types of Stress
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General Stress
Cumulative Stress
Critical Incident Stress
Stress Related Disorder
Normal
Pathological
Having stress is not bad, in itself.
What is bad is experiencing
excessive or prolonged stress.
Chevron Publishing, 2002
Resistance
If the stressor continues,
the body mobilizes to
withstand the stress and
return to normal.
Alarm
The body initially
responds to a
stressor with
changes that lower
resistance.
Exhaustion
Ongoing, extreme
stressors eventually
deplete the body’s
resources so we
function at less
than normal.
Return to
homeostasis
Stressor
The stressor
may be threatening
or exhilarating.
Homeostasis
The body systems
maintain a stable
and consistent
(balanced) state.
Illness and Death
The body’s resources are not
replenished and/or additional
stressors occur; the body
suffers breakdowns.
Illness
Death
The brain becomes more alert.
Stress can contribute to headaches, anxiety,
and depression.
Sleep can be disrupted.
Stress hormones can damage the brain’s 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.
Red = immediate response
to stress
Blue = effects of chronic
of prolonged stress
Stress can contribute to impotence and
premature ejaculation in men.
Muscles tense.
Muscular twitches or “nervous tics” can
result.
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
Health & Performance
Stress Curve
Maximum adaptive arousal
Stress arousal
Cumulative Stress
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Destructive pathway of stress
Piled up, unresolved general stress
Takes time
Produces negative changes in:
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Mental & physical health
Performance
Relationships
Personality
Chevron Publishing, 2002
Cumulative Stress
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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...
Cumulative Stress - continued
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Develops in four stages:
Early Warning
 Mild Symptoms
 Entrenched
 Severe Symptoms
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Characterized by gradually declining
performance, increasing problem in job.
continued...
Cumulative Stress - continued
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Early Symptoms:
Vague anxiety
 Boredom
 General fatigue
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Mild Symptoms:
All of the Early Symptoms
 Irritability
 Chronic tension
 Depression
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continued...
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..

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
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continued...
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 one’s 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
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continued...
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
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Changes attitudes
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Avoids work
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Or, becomes totally immersed
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Develops negative outlook
Flame-out
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Exhaustion, hyperactivity
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Overwhelming negative
emotions
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Denial of symptoms
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Loss of objectivity
Take Home Message
Stress Reactions
Physiological
not
Characteriological
Management of Cumulative
Stress Reactions
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Stress management education
Balance in life - work - home, etc..
Recreation
Vacation
Limiting overtime
Emphasis on home life
Professional counseling when needed
continued...
Management - continued
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Exercise
Proper food
Clear job expectations
Reduction of one worker performing two jobs
Effective leadership
Administrative support
Stress reduction techniques
Healthy living
Effective training
Take Home Message
Critical Incident
An event
that has the power to
overwhelm the coping abilities
of an individual or group.
Chevron Publishing, 2002
Take Home Message
The Terrible 10 for CAP
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
Take Home Message
Crisis
Noun
vs
Verb
An acute reaction to a critical incident.
A name of a particular critical incident.
Crisis Characteristics
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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
Post CRISIS
Pre-CRISIS
FEELINGS
THOUGHTS
FEELINGS
THOUGHTS
CRISIS
Take Home Message
Assessing the Need for
Crisis Intervention (CISM)
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Is this one of the CAP “Terrible 10”?
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Are coping mechanisms working
effectively for EVERYONE?
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Is there evidence of mild to severe
impairment in individuals or groups
exposed to the critical incident?
Critical Incident Stress (CIS)
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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...
C I S - continued
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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...
C I S - continued
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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
Reactions to Stress
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Physical
Cognitive
Emotional
Behavioral
Spiritual
Chevron Publishing, 2002
Physical
Signs and Symptoms of Critical
Incident Stress
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Thirst
Fatigue
Nausea
Twitches
Vomiting
Dizziness
Elevated B/P
Muscle tremors
Grinding teeth
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Visual difficulties
Profuse sweating
Difficulty breathing
Fainting / LoC
Weakness/numbess
Chest pain
Headaches
Rapid heart rate
Chevron Publishing, 2002
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Cognitive
Signs and Symptoms of Critical
Incident
Stress
Confusion
Nightmares
Uncertainty
Hypervigilence
Suspiciousness
Intrusive images
Blaming someone
Poor problem solving
Poor abstract thinking
Change in
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Poor concentration or
memory
Disorientation
Change in alertness
Suicide/homicide
Hallucinations/delusions
Paranoid ideas
Disabling guilt
Hopelessness
Helplessness Chevron Publishing, 2002
Behavioral
Signs and Symptoms of Critical
Incident Stress
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Withdrawal
Inability to rest
Intensified pacing
Erratic movements
Changes in social
activity
Changes in speech
Changes in appetite
Hyper-alertness
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Chevron Publishing, 2002
Changes in alcohol or
drug consumption
Antisocial acts
Abuse of others
Diminished personal
hygiene
Immobility
Self medication
Violence
Emotional
Signs and Symptoms of Critical
Incident Stress
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Guilt
Grief
Denial
Anxiety
Agitation
Irritability
Depression
Anger
Apprehension
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Emotional shock
Emotional outburst
Feeling overwhelmed
Loss of emotional
control
Inappropriate
emotional responses
Infantile emotions
Panic attacks
Chevron Publishing, 2002
Spiritual
Signs and Symptoms of Critical
Incident Stress
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Angry at “God”
Asking “why” questions
Cessation of practice of faith
Faith rituals fail to have meaning
Religious hallucinations or delusions
Chevron Publishing, 2002
Cumulative CIS
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High frequency of activation
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Long duration of service
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High intensity of service provision
Cumulative CIS
Loss of purpose
 Loss of connection
 Loss of autonomy
 Loss of integrity
 Spiritual depletion
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Kendall Johnson, 1993
Factors Effecting Crisis
Reactions
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Suddenness
Intensity
Duration
Level of loss
Age
Injury or death to
relatives or friends
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Availability of
resources
Level of education /
training
Availability of coping
mechanisms
Chevron Publishing, 2002
Crisis Intervention
An active and temporary entry
into the life of an individual or a
group during a period of
significant distress.
Crisis Intervention
Emotional “first aid” designed
to assist the person in a crisis
state to return to adaptive
functioning.
Take Home Message
Objectives of
Crisis Intervention
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Stabilize situation
Mitigate impact
Mobilize resources
Normalize reactions
Restore to adaptive function
Chevron Publishing, 2002
Dose Response
“1/3 Rule” - Theoretical
1
2
3
8%
Imprint of Horror
Visual
 Auditory
 Olfactory
 Kinesthetic
 Gustatory
 Temporal
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Psychological / Perceptual
Contaminants
CISM as Mitigation
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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.
CISM as Mitigation
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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
Take Home Message
Mitigating C I S
Even with all the right programs,
briefings, teams, personnel, etc lined
up & available – there can still be
CIS.
We don’t know our member’s
baggage.
(Pre-existing conditions)
Pre-Exposure Training can help
ID potential psych/perceptual
contaminants
Take Home Message
Mitigating Operational
Stress (OpStress)
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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
Mitigating OpStress - continued
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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...
Mitigating OpStress - continued
Take Home Message
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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
Mitigating OpStress - continued
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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 ?
Peritraumatic Stress
Dissociation
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Intrusive Re-Experiencing
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Anhedonia, worthlessness, loss of interest in most activities,
awakening early, persistent fatigue, and lack of motivation
Problematic Substance Use
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Debilitating worry, nervousness, vulnerability or powerlessness
Depression
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Panic episodes, startle reactions, fighting or temper problems
Anxiety
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Agoraphobic-like social withdrawal
Hyperarousal
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Flashbacks, terrifying memories or night mares, repetitive
automatic re-enactments
Avoidance
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Depersonalization, derealization, fugue states, amnesia
Abuse or dependency, self-medication
Psychotic Symptoms
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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 for
Extreme Peritraumatic Stress
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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., 1994&5;
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
Effects of Hyper-Arousal
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Trouble sleeping
Difficulty
concentrating
Heightened vigilance
Being easily startled
Being wary
Sudden crying
Becoming suddenly
angry
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Being more emotional
Panicking
Intensified alertness
Reminders of the
trauma leading to
physical reactions
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Rapid heart beat
Sweating
etc
Increased anxiety
Hyper-Arousal
Sleep Disturbances
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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
Take Home Message
After Action Support
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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
After Action Support - continued
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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
Indicators
of
Critical Incident Stress
vs.
Disciplinary Problems
or
Character Disorders
Take Home Message
Critical Incident Stress
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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
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Take Home Message
Characteriological &
Disciplinary Problems - continued
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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 person’s life.
Problems do not easily resolve over time
even with help.
Take Home Message
Addressing C I S
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Acknowledge the existence of CIS
Pre-incident education
Planning
Drills / practice
Pre-deployment briefings
Avoid avoidance of CIS
Take Home Message
Critical Incident
Stress Management
Comprehensive
Integrated
System utilizing a
Multi-Tactical
Crisis Intervention Approach
to Managing Traumatic Stress
CISM: Menu of Services
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Pre-Crisis Preparation
Group Intervention
Demobilization
 Crisis Management Briefing
 Defusing
 Critical Incident Stress Debriefing
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Individual Crisis Intervention
Pastoral Crisis Intervention
Family CISM
Organizational Consultation
Follow-up/ Referral
Take Home Message
CISM Tactics
Must be Available for:
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Individuals
Groups
Organizations
Families
Significant others
Chevron Publishing, 2002
Take Home Message
Core Competencies in CISM
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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
Chevron Publishing, 2002
Treatment Referral Options
Take Home Message
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Medical Care Professional
MD / DO
 PA / NP
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Mental Health Care Professional
Psychologist
 Counselor
 Social Worker
 Psychiatrist / NP / PA
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Spiritual Care Professional
Faith Leader
 “Chaplain”
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Essential CISM Courses
Take Home Message
(2 Days Each)
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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
Chevron Publishing, 2002
Take Home Message
CISM Components
Before an Incident
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Education (PEP)
Team training
Planning
Administrative support
Protocol development
Guideline development
Networking with other teams
& resources
Take Home Message
CISM Components
During an Incident
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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
CISM Components
After an Incident
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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
CISM Components
After an Incident
continued
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Post-incident education
Follow-up services
Referrals according to needs
Take Home Message
CISM
Typically: 3-5 contacts
 After that,
 Recovery is evident
 Referral is indicated
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Take Home Message
CISM
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Is not psychotherapy
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Is not a substitute for psychotherapy
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Is not a stand-alone
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Is not a cure for PTSD, Depression,
Anxiety, etc
Take Home Message
CISM has far more to do with
group support
and
assessment (triage)
than it does with
treatment and cure.
Take Home Message
Follow-Up
Must be provided after every CISM service:
 Assess impact of intervention
 Assess for uncovering prior issues
 Assess trajectory of reactions
•
•
•
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Decreasing
Same
Increasing
Assess for possible referral:
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Health Care Professional
Mental Health Care Professional
Spiritual Care Professional
P. A. S. S.
Post Action Staff Support
Dennis Potter, LCSW
Goals For PASS
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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
Why Do It?
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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
Take Home Message
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.
International
Critical Incident Stress
Foundation
3290 Pine Orchard Lane
Suite 106
Ellicott City, MD 21042
(410) 750-9600
Fax: (410) 750-9601
Emergency: (410) 313-2473
www.icisf.org
CAPR 60-5
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Administratively authorizes CISM,
Provides background information and
“how to” information,
Mandates each Wing to name a CISM
Officer,
Please read and review 60-5
CAP Personality Traits
Need to rescue or be needed
2. Strong intrinsic motivation
3. Stimulation seeking/easily bored
4. Need for immediate feedback
5. Action oriented
6. Desire to do a perfect job
7. Need to be in control
8. Strive for consistency
9. Risk taker
10. High dedication
11. Likes uniforms
1.
CAP Personality Traits
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Those 10 traits make us very good at
what we do – our jobs in CAP,
Those same 10 traits put us at high risk:
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Cumulative Stress
Critical Incident Stress
Depression
Anxiety
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Panic Attacks
PTSD
Substance Abuse
Relationship Problems
Antisocial traits (isolation, etc)
Questions . . .
1.
Do CAP members have the potential for
attaining physical injury?
Yes
2.
What is done to address this potential?
Safety briefings, Regulations, Checklists, Medical Officers, First
Aid kits, Disciplinary actions, etc.
3.
Do CAP member have the potential for
attaining psychological injury?
Yes – direct and indirect
4.
What is done to address this potential?
CISM program, Regulation 60-5, PEP Talks, Briefings
“Deliberate Indifference”
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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
Let’s not put CAP at risk – acknowledge and support the CAP CISM program.
“Knowledge itself is power”
Sir Francis Bacon
“Action is the proper fruit
of knowledge”
Thomas Fuller
What “Actions” from here?
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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
National Staff
Lt Col Sam D. Bernard, PhD
National CISM Team Leader
(423) 322-3297 sam@sambernard.info
Maj Chris Latocki
Administrative Officer
( 813) 412-9231 clatocki@cism.cap.gov
Region Staff
________Name____________
Region CISM Officer
Telephone / e-mail
________Name____________
Region Clinical Director
Telephone / e-mail
Wing Staff
________Name____________
Wing CISM Officer / Coordinator
Telephone / e-mail
________Name____________
Wing Clinical Director
Telephone / e-mail
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Sam’s Pearls of Wisdom
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Who’s needs am I meeting,
Just because you can, doesn’t mean you should,
Everything that is countable, doesn’t 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,
It’s 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,
It’s bigger than you,
Critical Incident Stress
Management
Lt. Col. Sam D. Bernard, Ph.D.
National CAP CISM Team Leader
(423) 322-3297Cell
sbernard@cism.cap.gov
www.sambernard.info
cism.cap.gov
. . .and just one more thing. . .
Thank You!
Critical Incident
Stress Management
Command Officer
Course
Learning 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