Resilience. K R Juzwin, PsyD/S. Blechschmidt, LCPC 21 September How to Mitigate Cumulative Stress

Transcription

1 Management Resources for First Responders Breakout Session 1A 10:30 am 11:45 am Kammie Juzwin, Psy. D. Susan Blechschmidt, LCPC Northern Illinois Critical Incident Management Team Consultant, Bartlett Police Department, Bartlett, Illinois Lake in the Hills Police Department, Lake in the Hills, Illinois This presentation will focus on recognizing and identifying cumulative career stress and stress management techniques for uniformed officers. It will also address resources for stress management, including debriefing services. Learning Objectives: 1. Identifying indicators of cumulative stress 2. Understanding the impact of cumulative stress on the body and functioning 3. Identifying ways to reduce and manage stress 2 No one who is a first responder is untouched by what they experience. How to Mitigate Cumulative Understand that it happens as a natural result of the job Understand what cumulative stress is Understand what critical stress involves Build resilience as part of your lifestyle and career Practice stress management techniques Recognize what it is when you experience it Anticipate it Insulate yourself from it 3 4 Resilience re sil ience noun \ri-ˈzil-yən(t)s\ 1 : the ability to become strong, healthy, or successful again after something bad happens 2 : the ability of something to return to its original shape after it has been pulled, stretched, pressed, bent, etc. Full Definition of RESILIENCE 1: the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress 2: an ability to recover from or adjust easily to misfortune or change Merriam-Webster Dictionary

2 or Is any event acting as a stimulus which places a demand upon a person, a group or an organization. The stressors first responders are exposed to and the environment and conditions they work in change a baseline and cause adaptation to survive. These stressors change biology, physiology, and psychology, and the way they experience the world. Eustress omotivating operformance-enhancement obonding and fellowship Distress oanxiety, fear, guardedness, apprehension ocumulative effect over time impacting body odepression & other biological functioning ocompassion Fatigue oburnout 7 8 Good or EUSTRESS NEGATIVE STRESS or DISTRESS Positive stress happens when the level of stress is high enough to move the individual into action to get things done. First responders are in a constant state of waiting for the go and generally don t like being bored or the down time. This has a physiological cost or the cost of preparedness. Negative stress happens when the level of stress is too high or too low AND there is a negative reaction to the stressors. Distress can lead to despondency, negativity, cynicism or hopelessness. Depression is seen in terms of apathy, chronic fatigue, emotional numbness, lack of ability to enjoy anything, problems sleeping and loss of appetite Research Demonstrates that Emotions Have Physical Connections in the Body Biogenic ors Stimulants which cause stress by virtue of the biochemical actions they exert on the body typically to keep the up Caffeine - Coffee, tea, soft drinks Nicotine- Cigarettes, Nicotine Gum Amphetamines Decongestants Sugar

3 Psychosocial ors Set the stage for stress responses to be initiated through interpersonal mechanisms. The current culture is creating more stress. They appear to be like beauty - they lie in the eye of the beholder. WHAT ONE PERSON SEES AS STRESSFUL, ANOTHER PERSON MAY NOT Psychological ors Those events that are interpreted or appraised as being challenging, threatening, or otherwise adverse can become stressors. Sometimes we don t know what is stressful until we face it, experience it, and survive it. If there is NO FRAME OF REFERENCE internally, it may be encoded as a stressor or critical memory Critical Incident Any event which is powerful enough to overwhelm the normal "coping mechanisms" used by emergency responders to cope with the effects of emergency response. Typically, we indicate that people are having a normal reaction to an abnormal event. For FIRST RESPONDERS, what they have defined as NORMAL is very different than the general population. Two Nervous Systems Sympathetic Nervous System: Turns system UP o Heart rate o Endocrine system dumps adrenaline, norepinephrine, cortisol Parasympathetic Nervous System: Turns system DOWN o Breathing o Increased blood flow The best way to intervene with the physical impact of stress is: PHYSICALLY spending the chemicals generated to manage the stress. PSYCHOLOGICALLY stress management, relaxation, meditation, relaxation, etc TWO TYPES OF STRESS REACTIONS ACUTE: Occurs during or shortly after an incident DELAYED: Can occur hours, days or years after an incident Three months, six months and one year are key markers after an event Olfactory, Visual, or Auditory Cues can contribute to intrusive memories and responses

4 The Realms of Personal Street Department ors inherent in your work: Prolonged exposure Physical environment challenges Physical challenges Multiple exposures Cumulative exposures The mundane Sensory overstimulation o Sight o Smell o Touch o Taste o Sound You adapt a great deal, but you still are a mammal physically. Katrina Volunteer feeding a stray Your Perspective is Different You see things others don t see You hear things others don t hear Your normal is different than others You are with people in their worst moments Your baseline and reference points are different than most peoples To be successful at your job you change and adapt to what you experience Possible long term effects of direct &vicarious exposure can impact any person. Psychologically Interpersonally in relationships Emotionally Physically Spiritually Socially AROUSAL Overstimulated Comfort Zone Understimulated

5 Selye s General Adaptation Syndrome Activation Limits Physical Adaptation & Long-term Costs Alarm Reaction Resistance Exhaustion AROUSAL Baseline (Recovery) Spectrum: Evolution Acute Distress Can become Chronic Traumatic Grief, Shock, Disbelief Cumulative Career Post- Traumatic Reaction Acute Symptoms lasting 2 days 4 weeks and cause a range of impairment Avoidance Anxiety, fear, apprehensive Hyperarousal Dissociation, disconnect, feel unreal Re-experiencing of event, preoccupation with event Physical Signs Of Reactions Physical Signs Of Reactions Tension Jumpiness Cold Sweats Pounding Heart Feeling out of breath Pre-occupation, reliving elements of the incident Anxiety Upset Stomach GERD/Heartburn Diarrhea/Constipation Fatigue Aches and pains "1000 mile stare Headache Vision issues

6 Emotional Signs Of Reactions Emotional Signs Of Reactions Major changes in typical behavior Trouble sleeping Anxiety Irritability Difficulty paying attention Concentration issues Numbness Hero syndrome Difficulty Thinking Difficulty Speaking Difficulty Communicating Grief and Anger Loss of confidence in self and agency Rapid mood changes Taking of unnecessary chances Excessive use of alcohol and/or drugs PTSD Trauma Responses Re-experiencing or intrusive thinking about the event Avoidance and withdrawal types of reactions Physical arousal reactions These THREE ARE NORMAL REACTIONS that can lead to PTSD over time ALL emergency response personnel experience some symptoms of Cumulative Critical Incident that includes post-traumatic stress, but is not necessarily PTSD You are trained to respond to the critical incidents of others which has impacted your own BASELINE of normalcy The "Constant State of Readiness on a daily basis and the exposure to urgent, risky, mundane and critical events has a price tag. This is specific to the culture of the service. The costs are measured in motional, psychological and physical reactions. Cumulative Career Accumulated stress over repeated exposure to events that are normal to responders, and make demands on coping mechanisms. Not every event is experienced the same by individuals at the same event. o This contributes both positively and negatively: (+) there are others who have similar experiences for support and mentorship (-) there can be a suck it up or it could be worse culture, where the individual doesn t have an opportunity to acculturate to the environment

7 Cumulative Career there is compelling logic that argues for the efforts to be directed toward prevention of occupational stress and post-trauma syndromes, especially among high risk professions. Dr. George Everly (1989). A Clinical Guide to the Treatment of the Human Response Reality Check: Canine responders are treated with more care than officers often treat themselves How do we know when enough is enough? Psychological Crisis is an acute response seen as: 1. Disruption of psychological homeostasis 2. Usual coping mechanisms have failed in solving the problem or to re-establish homeostasis; and, 3. The level of distress has impacted functioning negatively (Everly, 1999). How do we know when enough is enough? And.remember UFR already have an altered baseline homeostasis. You ve changed the mammalian foundation for: Sleep/Wake Cycles Tolerance for stress, off/on activation Over-ridden instinctual pulls to avoid certain situations Over-ridden instinctual reactions for selfcare or self-preservation

8 What are we trying to avoid? related injury and illness Burnout o Cynicism, withdrawal, negativity o Lack of sensitivity Retired on the job Career suicide Decreased productivity or ability on the job Physical effects of chronic stress (GERD, headaches, diabetes, COPD, BP) Depression, anxiety, and PTSD Isolation, withdrawal, social disconnection Psychological disability Substance abuse or dependency, self-medicating Loss of purpose, loss of faith, loss of believe in humanity Suicide CISM The Mitchell Model The first model to deal with RESPONDER STRESS Has empirical foundation Continuum of interventions & services What Are Critical Incidents? Line of duty death or major injury of and emergency services worker on the job. Death or a major injury to a child. Prolonged search and rescue effort with a negative outcome. Operations involving extensive media coverage. Incidents that are very close to home emotionally. Cumulative stressor and events. Prolonged personal contact with a victim with a negative outcome. What makes an incident a Critical Incident? Victims known to emergency responders. Similarities between victims and family members. Mistakes - whether real or imagined. Our need to do everything perfect every time. A current incident which provokes memories from previous situations which may have been traumatic. Cumulative major calls. A very young & inexperienced crew. Any event out of the ordinary that just can not get processed or put away What can make an otherwise routine incident a Critical Incident? Perception Physical status (exhaustion, fatigue, anger, fear) Cumulative stress Deviation from the norm Novel experiences Personal connection or identification Child involvement Colleague, coworker Prolonged exposure Real or perceived threat to safety Critical Incident Critical Incident occurs when the First Responders coping mechanisms during or following an incident become overwhelmed. Critical incident stress response is a NORMAL reaction to an ABNORMAL event. It is like almost every other type of injury if attended to appropriately, it will heal on its own, in time

9 Critical Incident Management or The Mitchell Model Mitchell proposed that the major goal of CISD/CISM was to alleviate overwhelming emotional feelings and potentially dangerous physical symptoms associated with emergency work (NAEMT, 2003). Much of the CISM research has been done with the general public, not following the model and using other formats, not the model as proposed, so there has been negative press based on review of faulty or inaccurate applications of the model. 49 Meta-Analysis Everly, G. S., Flannery, R. B., & Mitchell, J. T. (2000). Critical Incident Management (CISM): A review of the literature. Aggression and Violent Behavior, 5 (1), Everly, G. S., Flannery, R. B., & Evler, V. A. (2002). Critical Incident Management (CISM): A statistical review of the literature. Psychiatric Quarterly, 73 (3), Mitchell, A. M., Sakraida, T. J., & Karneg, K. (2003). Critical Incident Debriefing: Implications for best practice. Disaster Management Response, 1, Flannery, R. B. & Everly, G. S. (2004). Critical Incident Management (CISM): updated review of findings, Aggression and Violent Behavior, 9, Roberts, A. R. & Everly, G. S. (2006). A meta-analysis of 36 crisis intervention studies. Brief Treatment and Crisis Intervention, 6, CISM Description The culture of first responders warrants specific framework for interventions; and this becomes even more relevant in specific situations. The goal is to: Mitigate possible cumulative and traumatic stress in responders during response situations, and Prevent later post trauma symptomology These might impair health and functioning by using specific evidence-informed approaches of CISM and understanding first responder culture to enhance resilience and long-term career survival. Critical Incident Management The Mitchell Model Only individuals directly related to the incident should attend the session. No rank in the room, they are all team members, sometimes necessary to remove ranked individuals to their own session. NOT AN INCIDENT CRITIQUE. Sometimes it is necessary to refer people for additional support following a Debriefing. It is not necessary for all to speak during a session to be beneficial. The goal is to have everyone at least be present and to listen to their peers Critical Incident Management or The Mitchell Model CRITICAL INCIDENT STRESS MANAGEMENT is a continuum of services. CISD is one structured psychological debriefing process which utilizes a direct action oriented crisis intervention program designed to prevent or mitigate traumatic stress and its associated effects. The International Critical Incident Foundation, CISM goals are to minimize: related injury and illness Burnout Retired on the job Psychological disability Suicide Diminished life quality PTSD Self-destructiveness

10 CISM is considered a Psychological Trauma Immunization & Prevention Continuum of Services Critical Briefing (CSM) Defusing Debriefing (CISD) Education& Training Family Intervention Follow-up services Referral Options International Critical Incident Foundation CISD-CISM CISD is a structured psychological intervention debriefing process which uses a direct action oriented crisis intervention program designed to prevent or mitigate traumatic stress and its associated effects. It is not therapy Critical Incident Management The Mitchell Model The structure provides supportive factors to responding: Knowing the culture of your population Understanding the meaning, one s part in the whole, and one s experience of the event Imposing structure and containment Offering a potential for cognitive organization, meaning and reframing Defusing tension, fear, terror, shock, etc. Tolerance for affect Normalizing reactions Providing education A context for what next The CISM Model It is NOT Psychotherapy. It is NOT FITNESS FOR DUTY or RETURN TO DUTY. A meeting/discussion designed to help alleviate the effects of Critical Incident, usually as a group. It is a TEAM effort. NOT a CRITIQUE of an incident or department. Not a time to relive intense memories or discuss graphic details. Goal is to avoid vicarious traumatization Structure of the Model requires: Knowing the culture of the population o Being a responder but being outside of that particular group of responders Understanding the meaning, one s part in the whole, and one s experience of the event Understanding the demands of the job, culture, etc. Imposing structure and containment Offering a potential for cognitive organization, meaning and reframing Structure of the Model Defusing tension, fear, terror, shock, etc. Tolerance for affect Normalizing reactions Providing education A context for what next Educating on symptoms of stress

11 Demobilization and CMB The goal is to match the needs of the group in relationship to the event and time out from the event. Large Groups Shift disengagement vs. anytime post-crisis Inform and consult Allow psychological decompression Education and information about next step Defusing Are performed on the day of the incident up to 12 hours post-incident. The quicker the better! Duration is less than an hour Offer the opportunity for people involved in a horrible event to talk briefly about the experience before they have time to rethink the experience and possibly misinterpret its true meaning(s). Supportive Educational and preventive Defusing Goals Achieve a rapid reduction in the intense reactions to the traumatic event. Attempt to "normalize" the experience. Information transfer between members of the crew/shift. Attempt to reestablish the social helping network of the group. Assess need for a more formal process, debriefing or education. Education about reactions or responses; and how to address them Defusing Process: Introduction Phase o Introduce Team o Describe process o Summarize guidelines Exploration Phase o Combination of Facts, Thoughts and Reactions. o Ask about Symptoms experienced by group. Information Phase o Summarize information provided by the group. o Normalize the experiences and reactions of the group. o Teach Survival skills. o Organize Debriefing if one is needed. o Make summary comments, seek input from group. Formal Debriefing Process The core focus is the relief of stress in normal, emotionally healthy people who have experienced traumatic event(s). Generally hours post-incident. Structured team guided discussion for group of involved personnel Typically held approximately 24-hours to l week after incident Generally about 90-minutes

12 Formal Debriefing Process Introduction Fact Thought Reaction Symptom Teaching Re-entry Who should be present at a debriefing? ONLY emergency personnel directly involved in the incident Encourage all responders who were involved: LE, EMS, Dispatch/Telecomm, etc. NONE of the following: Curious but not involved personnel Supervisors not involved in incident Bystanders (even if involved) or media Family members or friends, spouses Victims Example of Symptoms from Delayed or Cumulative Physical Frequent and severe headaches Sleeping disorders Sexual dysfunction Substance abuse Loss of energy Increase use of sick time Cognitive Intrusive mental images Poor concentration Nightmares or flashbacks of event Emotional Marital or family problems Fear of event repetition Constant depression Apathy and cynicism toward job Defensiveness about problems CISM in SOP s We advocate adding language to Standard Operating Procedures (SOP) for automatic triggering of CISM consideration, perhaps even part of any NIMS pre-plans you may have. And allowing for any responding officer or supervisor to be able to arrange for CISM services. We also advocate for discussion as to whether or not to make it mandatory, timing, place, etc REMEMBER ALL emergency response personnel experience some symptoms of Critical Incident and cumulative career stress Normal reactions to abnormal events Not every one experiences the events in the same way Not every event is experienced as a critical event However, CISM services can help mitigate cumulative stress Employee Assistance Programs Employee-sponsored service designed for personal or family problems and short-term therapy. Verify if their personnel are certified by ICISF. Designed to assist employees & keep them on the job effectively. Sometimes part of substance abuse problems. Sometimes part of the disciplinary process. Expanded to incorporate health, wellness and work/life types of concerns. May include prevention, training, consultation, organizational development and CRISIS RESPONSE SERVICES. May or may not understand the culture of the responder. May or may not have documentation that is discoverable

13 Other Suggested Interventions Healthy lifestyle practices as a general practice Exercise after shift to burn off the stress chemicals Have a solid social support network Create something meaningful outside of work Practice some of the mind-body practices such as: o Yoga o Tai Chi o Running o Meditation o Breathing Exercises o EFT, acupressure, Capacitar exercises Example Breathing o Exhale stretch out o Hold o Inhale collapse in o Hold Tension Relaxation (Ice Puddle) o Inhale Create tension, pull in o Hold o Exhale Let go of the tension o Hold 2 May Specific Resources One Hour of Breathing 10-minutes of breathing The Brain hmtv_nm_mfj5sksxartbicwb Tapping EFT Responding to stress Fight or Flight Specific Resources - Relaxation One Hour of Breathing 10-minutes of breathing Tapping EFT Capacitar o Emergency kits o Q Mindfulness Based Resilience Training: Introduction to Mindfulness 2 May May Specific Resources - Education Northern Illinois Critical Incident Management Team The Brain PLHth24hLYhmTv_NM_mfJ5sKSxaRtBIcWB Responding to stress Fight or Flight Comprised of trained volunteers: Police officers Firefighters Paramedics Dispatchers Mental health professionals ER nurses/hospital healthcare professionals Chaplains The unique collaboration between skilled peers, chaplaincy, and mental health professionals is the foundation of the organization and produces a high level of integrity and acceptance within the emergency service community. 2 May

14 Types of Services offered by NICISM Demobilization Defusing Debriefing One-on-One Session Education Seminars Pre-event services planning Resources on the website NICISM Team History 30 years old this year! 39 th formal Team in the US through the International Critical Incident Foundation, and one of the only still active Teams from the initial charters. Roots began after the line of duty death of Lt. Frank Mercer Waukegan FD in 1984 followed by another line of duty death of Carmella Kohl, RN & EMT-P Spring Grove FPD in 1985 First callout was to Lake Forest FD (death of a child) First disaster was the Laurie Dann incident in Winnetka (1988) First natural disaster was the Will County Tornado (1990) Disaster mutual-aid: o United Crash Sioux City (1989) o Oklahoma City Bombing (1995) o 9/11 o Hurricane Katrina (2005) Dedicated to providing immediate comprehensive crisis response interventions and pre-incident stress management education for emergency service personnel throughout the Chicagoland area. Service includes the counties of: Cook Lake Kane McHenry Kendall DuPage Will Grundy Kankakee The main purpose of the Team and process is to help mitigate the impact of a horrible event and to help accelerate normal recovery for first responders. How to Access the NICISM Team Call (800) o All Counties Statewide o Have available your County, Agency/Department, name & phone number of contact person(s) The team is available 24-hours a day, 7-days a week, every day of the year There are no costs associated with the team every emergency response agency is eligible to receive service Team Requirements Successful completion of a 2-day Group Crisis Intervention CISM training course Application with letters of support Support of employer Interview Culture immersion - Ride-along experiences Meeting attendance (2x year) Responding to call-out notifications Most importantly Call-out participation! Questions? Northern Illinois CISM Team CISD

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