Bk071 - CRITICAL INCIDENT STRESS DEBRIEFING.pdf

CISD Training Manual Section Index Section Title Index Number Index 1 Stress Management Program Description 2 Stress 3 Informal Definition of Term...

CISD Training Manual Section Index Section Title Index Number Index 1 Stress Management Program Description 2 Stress 3 Informal Definition of Terms Three Stages in Reacting t o Stress Physiological Reactions t o Stress Stress on the Body Some Occasional Physical Effects Some Occasional Psychological Reactions List of Symptoms Trauma Stress Management Long-Term Stress Management Inventory Instruments Life Changes and Physical Ailments Personal Event Inventory Signs of Stress Job Stress Index: Are You Hassled? Symptom Frequency Chart CISD Traumatic Event Critical Incident Identification Crisis General Profile After the Crisis Crisis Intervention Section Title Index Number Psychological Aftershocks 7 "Post-Traumatic Stress Disorder (From DSM-Ill)" Post-Traumatic Stress Disorder and the Firefighter" b y Francis X. Holt Facts About Effects of Stress on Disaster Workers Disaster Response Interventions During the Disaster Let D o w n Phase Intervention After the Disaster Survivors Guidelines Protocol Role of Debriefers at an Incident Disaster CognitiveIThinking Level Common Themes in DefusingsIDebriefings Psychotherapy vs CISD Paper on "Critical Incident Stress Debriefing" b y Michael Kwiatkowski Post-Traumatic Event Handouts After It Happens...What's Next A Family Guide t o Surviving Critical Incident Stress Specific Skills Recommended for Counselors "Ten Basic Traits of an Effective Counselor" b y Robert Carkhuff Communication H o w t o Communicate Effectively Listening The Helping Process The Personal Problem Interview and Exercises Section Title Index Number Support and Disasters H o w Is Your Support Level? "Your Support Group" by Tom Ferguson, M.D. International CISD A n Example from Alberta, Canada Supplemental Reading "Development and Functions of a Critical Incident Stress Debriefing Team" b y Jeffrey T. Mitchell, Ph.D. " A Perspective of Need, A Study of Feasibility" b y Joanne Fish Hildebrand "Post-Traumatic Stress Disorder" b y Ellen McDaniel, M.D., and Paul McCIelland, M.D. "Pronouncing Death in the Field: Toward Developing an Understanding of its Impact on Emergency Service Personnel" b y Michael Kwiatkowski Dispatching Resource Supplement "Quake Stress" b y Marianne McManus, Ph.D. "Earthquake: The First 7 2 Hours" b y Sam Brunstein and Margaret Kilpatrick, L.C.S.W.  LOS ANGELES j DEPARTMENT & t DONALD 0 MANNING CHIEF ENGINEER A N D GENERAL MANAGER February 8 , 1988 TO : A l l Members SUBJECT: STRESS MANAGEMENT PROGRAM Introduction S t r e s s Management e n c o u r a g e s p e o p l e t o be a w a r e of a s e t of complex f a c t o r s i n t h e i r l i v e s i n o r d e r t o remedy t h o s e f a c t o r s which p r o d u c e e x c e s s i v e c o n f l i c t. T h i s b o o k l e t i n t r o d u c e s t h e S t r e s s Management Program of t h e D e p a r t m e n t t o a l l members. T h i s Program c a p i t a l i z e s on t h e s t r e n g t h s of two c o m p l e m e n t a r y - a p p r o a c h e s and e x p a n d s t h e D e p a r t m e n t ' s a b i l i t y t o p r o v i d e f o r t h e h e a l t h and s a f e t y of i t s members. A l l p e r s o n n e l a r e e n c o u r a g e d t o become f a m i l i a r w i t h t h i s m a t e r i a l. C r i t i c a l I n c i d e n t S t r e s s D e b r i e f i n g Program Members of t h e Los A n g e l e s C i t y F i r e D e p a r t m e n t a r e r o u t i n e l y c a l l e d upon t o p e r f o r m h a z a r d o u s and s t r e s s f u l d u t y. However, a s p a r t of t h e i r s e r v i c e t o t h e p u b l i c , members may r e s p o n d t o i n c i d e n t s of e x t r a o r d i n a r y magnitude p o s s i b l y i n t r o d u c i n g e x c e p t i o n a l p h y s i c a l and e m o t i o n a l t u r m o i l - a "critical incident." To a s s i s t a member i n c o p i n g w i t h t h i s t r a u m a t i c s i t u a t i o n , t h e Department i s implementing a C r i t i c a l I n c i d e n t S t r e s s D e b r i e f i n g Program b e g i n n i n g March 1, 1988. H i s t o r i c a l l y ,. m e m b e r s s o u g h t t h e s u p p o r t of f e l l o w members d u r i n g times of d u r e s s. The D e p a r t m e n t r e c o g n i z e s and e n c o u r a g e s t h e c o m f o r t of p e e r s - "They were t h e r e ; t h e y know." O f f i c e r s e f f e c t i v e l y use t h i s experience i n day-to-day operations, helping t h e i r personnel t o handle t h e traumatic distress.. i e T m c r i t i c a l i n c i d e n t g o e s bevond t h i s i n i t i a l l e v e l o f h e l p. The c r i tical i n c i d e n t i m p o s e s h e i g h t e n e d s t r e s s o r s from 7 a j o r ~ ~. - t s r e c Jie,d t n o t a D e p a r t m e n t member, m o r b i d i t y o r m o r t ~ i i CÈ a t a. c i v i l i a n o c c u r r i n g d u r i n g D e p a r t m e n t o p e r a t i o n s , a n d ~ 3 ~ ~ o t p r o t o u n d e m o t i o n a l i m p a c t oE e x t r e m e d a n g e r t o o u r personnel. The C r i t i c a l I n c i J e n t S t r e s s D e b r i e f i n g C C I 5 D ) Te.i'"i will provide timely consultation a f t e r the incident to s u b s t a n t i a l l y r e d u c e t n e i m p a c t of c r i t i c a l i n c i d e n t s on o u r members. The P r o g r a m ' s g o a l i s t h e r e s t o r d t i o n of members who a r e e x p e r i e n c i n g r e a c t i o n s and symptoms of d i s t r e s s a f t e r b e i n a exposed t o a h i g h l y unusual e v e n t. CISD u t i l i z e s t h e r e s p o n s e s t r u c t u r e of t h e I n c i d e n t Command S y s t e m a n d i n c o r p o r a t e s a u t o m a t i c O p e r a t i o n s C o n t r o l D i s p a t c h S e c t i o n (OCD) notifications. P e e r S u p p o r t Program S i n c e 1 9 8 4 , a P e e r S u p p o r t Program h a s been a v a i l a b l e t o D e p a r t m e n t members t h r o u g h t h e U n i t e d P a r a m e d i c s of Los A n g e l e s. T h i s Program i s a n o u t g r o w t h o f a s i m i l a r p e e r s y s t e m t h a t Eound r e m a r k a b l e s u c c e s s w i t h i n t h e Los A n g e l e s P o l i c e Department. P e e r S u p p o r t i s a n i n t e g r a l p a r t of t h e S t r e s s Management P r o g r a m. The p u r p o s e of P e e r S u p p o r t i s t o o f f e r h e l p f o r e m p l o y e e s and t h e i r E a m i l i e s d u r i n g t i m e s of c r i s e s. I t p r o v i d e s a way t o c o n f i d e n t i a l l y " t a l k o u t " p e r s o n a l and p r o f e s s i o n a l p r o b l e m s with s p e c i a l l y t r a i n e d coworkers. P e e r S u p p o r t Members a r e v o l u n t e e r s from a l l r a n k s w i t h i n t h e D e p a r t m e n t , b o t h sworn and c i v i l i a n. P e e r S u p p o r t Members h a v e t r a i n i n g i n l i s t e n i n g and assessment s k i l l s , problem s o l v i n g , c r i s i s i d e n t i f i c a t i o n , s u b s t a n c e abuse r e f e r r a l s , and o t h e r r e l a t e d s k i l l s. I t i s i m p e r a t i v e t h a t t h i s Program i n c l u d e t r u s t , a p p r o p r i a t e a n o n y m i t y , a n d a p r e s e r v a t i o n o f c o n f i d e n t i a l i t y f o r members engaged i n p e e r c o n s u l t a t i o n. Communication between a Peer S u p p o r t v o l u n t e e r a n d a c l i e n t i s c o n s i d e r e d p r i v i l e g e d by t h e D e p a r t m e n t , e x c e p t f o r m a t t e r s w h i c h i n v o l v e v i o l a t i o n of t h e law o r s e r i o u s m i s c o n d u c t. \i[ :.ie"ibe r 5 February 8 , 1988 Page 3 & t P e r sonne 1 T h e D L r e c t o r o f t h e S t r e s s Management Program i s t h e Deparc.-nenc ? s v c h o l o g ~ s t ,R u s s e l l B o x l e y , P h. 9. Dr. Boxley i s i n s c r u n e n r ~ i i n e s t a b l i s h i n g and Leading c h i s P r o g r a m. The C o o r d i n a t o r o f m e Proaram i s P a r a m e d i c I 1 1 M i c h a e l K w i a t k o w s k i. Parane.lic Kwiackowski h a s t h e e d u c a t i o n and p e r s o n a l q u a l i f i c a t i o n s 1. 3 manage t h e P r o g r a m. Working w i t h them a r e CISD and P e e r S u p p o r t Members - D e p a r t m e n t p e r s o n n e l from a l l r a n k s. Program Members nave s p e c i a l i z e d t r a i n i n g i n s t r e s s management and c r i s i s intervent ion. Members d e s i r i n g f u r t h e r i n f o r m a t i o n c o n c e r n i n g b o t h p r o g r a m s , i. e. , p e r s o n a l i n v o l v e m e n t , o r g a n i z a t i o n a l f u n c t i o n , member a p p l i c a t i o n , e t c. , s h o u l d d i r e c t l y c o n t a c t t h e Program C o o r d i n a t o r , Paramedic Michael Kwiatkowski, a t ( 2 1 5 ) 4 8 3 - 4 4 7 1. I e n c o u r a g e v o u r s u p p o r t and p a r t i c i p a t i o n i n t h e S t r e s s Management P r o g r a m. Attachment  Los Angeles City Fire Department STRESS MANAGEMENT PROGRAM CRITICAL INCIDENT STRESS DEBRIEFING Introduction: Members of the Los Angeles Fire Department (LAFD) are routinely called upon t o perform hazardous duty. As part of their service t o the public, members may respond t o incidents of such magnitude that extraordinary physical and emotional turmoil may occur- a "critical incident." This incident is charged with exceptional emotion and produces extraordinary reactions from trained emergency personnel. Most of these reactions disappear within three t o four weeks, but a f e w may continue. Timely psychological consultations have a great potential to:substantially reduce or eliminate long-term psychological and physical symptoms. The purpose of the Critical Incident Stress Debriefing (CISD) Program is t o reduce the impact of such events experienced by LAFD personnel in the line of duty. Creation of a CISD Program enables the Department t o deliver assistance in the restoration of normal job and personal function t o people who are experiencing reactions or symptoms of distress after being exposed t o a sianificant emotional event....................................................DiWiot - A licensed mental health professional in charge of the 1.......................... Department's Stress Management Program, including the CISD Team and Peer Support Program. *...................................................................... -oordinatot - A member of the Department who coordinates the CISD :............................................................................................................................. Program and maintains records of activity. The Coordinator maintains liaison with Operations, provides for the location and physical logistics of intervention, and assists in the Program's educational program. Team Me.................................................................................................................. :.z;:. mbers - Personnel who have received specialized training in.............................................................................................................................. stress identification and management, crisis intervention, listening, and related skills (included are in-service programs t o maintain skills). Team Members include trained mental health professionals. Incident - The following ,.,rfi&...................................................................................... are examples of incidents which may :..................................................................................................... qualify for CISD Program intervention: - Major disaster, e.g., airline crash, earthquake. a - Multiple fatalities, i.e., more than three deaths due t o traffic accident, fire, etc.  - Serious injury, death, or suicide of a Department member. - Serious injury or death of a civilian occurring during Department operations. - Death or serious injury of a child resulting from: a. Neglect b. Violence c. Conditions so extreme as t o have a lasting effect on Department personnel. - Loss of life of a victim following extraordinary and prolonged expenditure of physical and emotional energy during rescue efforts b y Department personnel. - Incident where members are exposed t o toxic or unknown chemicals or communicable disease exposure(s) which are likely t o have lasting physical or emotional side effects.........................................................................:.................:.:.: 5. Str&$s,R@ctiim.......................................... - During and following a critical incident, personnel......:.:.:.:.;.;.:.....;..=>............... ::::::::.. may feel the effects of traumatic stress. Because no t w o people will react t o disaster in the same way, there are several patterns of behavior or symptoms t o watch for. The feelings involved after a critical incident usually consists of seven basic reactions, namely: - Emotional,Numbing......... and EMS personnel............................................................;.................................................................................. : :::......:.:.:.>:,:.:,>>:.:.>:.:.:.:.:.:.:.,... - When Firefighters distance themselves from the incident and make an effort not t o feel anything, they almost deny having an emotional component and, therefore, give the appearance that they are in a state of shock. They usually say, however, that they are in control and are having no problems dealing with the situation. -................................................. :.:.......................... - Experiencing the feeling of being alone and that no one bolation...................... else knows what they are going through. They may experience irritability and agitation, and may again deny that anything is wrong. - Intrusive ThoughtsiFlashbacks - Mentally reliving the event over and over. If it continues, they begin t o wonder or question whether they have complete control of their thoughts.  ^ , , -.............. eep Disturbances - Disturbances which can result from a trauma...................... :.:..,.......................................................... :.....................>....:.:.: incident include inability t o sleep, nightmares, and waking in a cold sweat. In the nightmares, the theme is fear or guilt. Guilt is common in 95% of trauma incidents t o varying degrees. This guilt can be translated into anger or depression................................................................... - The fear ; - Afixi&''y............. ::;..................... ::;;;:::::: ::::;:: most common~yfeltisthat of returning......and. ,.,¥Ñ>> :  ¥;  ¥: <. ;. :Â¥:. :.;. :.:. :.:. :.:. :.;. ;.:  ¥~Â¥> t o the exact job duties as before, e.g., administering medical aid or fighting another fire....................................... returning t o it. Mundane activities suddenly become boring. - value system, goals, - Reevaluation of each person's and status is often the final step which determines the person's abilities t o cope and h o w that person will continue future activities. Some consider giving u p their current careers. They may also reevaluate their marital situation; some make a stronger commitment and others get divorced. The Critical Incident Stress Debriefing (CISD) Program is multifaceted. Implementation occurs at various phases ranging from proactive educational opportunities t o direct and poignant intervention. Phase I- Proactive Education Stress inoculation training begins with pre-incident education and continues t o strengthen as the member acquires and reinforces additional coping skills. Members are trained in developing and learning effective coping strategies. This training process suggests that adaptive coping responses need t o be available t o effectively deal with demands that either tax or exceed the coping resources of the person; it trains people t o utilize appropriate problem-solving techniques. Education will include multilevel exposure and training based on the finding that, the more a person knows about stress prior t o a stressor occurring, the better the chances of reducing its impact. Education will be accomplished by (but not limited to) the following: - Station visitations by the CISD Director and Team Members - Recruit training. - In-Service training programs. - Supervisor training programs. - Programs for family members. Phase II - Assessment and Contact When a critical incident may have occurred, involved members are encouraged t o immediately notify their Company CommanderIParamedic Supervisor. The Company CommanderIParamedic Supervisor shall notify the Battalion Commander. The Battalion Commander conducts the initial assessment of the impact of the incident on involved members. In addition t o incidents which could warrant Battalion Commander assessment, Department members may notify supervisors of Stress Reaction Symptoms. Following the assessment of the incident and concerned members, the Battalion Commander may determine that intervention will cease at this level of inquiry. The situation does not need further intervention; the issue has been resolved with these resources. Should the incident have the potential of being critical, the Battalion Commander will apprise the Division Commander of the assessment. The Division Commander originates approval for CISD notification. Members seeking initial information about the effects of a critical incident may contact the CISD Coordinator during normal business hours at (213) 485-4471. During nonbusiness hours, members seeking information on a critical incident may contact the CISD DirectorICoordinator through OCD. However, members are encouraged t o discuss the occurrence or effects of a. critical incident with their supervisors. OCD With Division Commander approval, the Battalion Commander will landline OCD requesting a CISD response, and Medical Liaison notification of the incident. OCD will contact the CISD DirectorICoordinator, apprising them of the situation. In addition t o specific requests for CISD response, OCD will automatically notify the CISD DirectorICoordinator in the following circumstances: Major emergencies requiring more than 15 companies. Unusual EMS incidents when the Division Commander is responding t o the incident. Fire Department member killed or seriously injured. Hazardous material incident, CISD notification made after the Division Commander is dispatched. CISD DirectorICoordinator The Battalion Commander and the CISD DirectorICoordinator will determine the appropriate means t o rectify the critical situation. If continued intervention is deemed necessary, the Battalion Commander and the CISD ~irector1Coordinatorwill formulate a plan of action. The Division Commander shall be kept informed b y the Battalion Commander. Critical Incident Stress Debriefing is an organized approach t o the management of stress responses in emergency services. It entails either an individual or small group meeting between the emergency personnel and the CISD Team Members who are able t o help members talk about their reactions t o the critical incident. Basically, CISD has three parts. The first part allows for an initial ventilation of feelings b y the members and an assessment by the CISD Team Members of the stress response in the personnel. Part t w o of CISD entails a more detailed discussion of the signs and symptoms of the stress response and provides for support and reassurance from the Team Members. The third part of CISD is the closure stage where resources are mobilized; information is provided; a plan of further action may be designed; and referrals, if necessary, are made. Phase Ill - Defusing Inf*:fma,Defuxfng............... is brief on-scene or near-scene intervention. The initial.............................................................................................................................................................................................. defusing may be conducted by an Officer who has undergone training in recognizing early warning signs of emotional and behavioral distress. It includes all of the members involved in the incident on a voluntary basis, and begins as soon as possible after the incident. Informal Defusing continues with the arrival of the CISD DirectorICoordinator. The CISD DirectorICoordinator, in consultation with the Battalion Commander, assesses the nature and severity of the reactions of the personnel assigned t o the incident. This is principally accomplished b y the following: 1. Provide a conducive listening environment. 2. Ask if the member had acute reactions during or immediately after the event. 3. Stimulate and encourage some ventilation of feelings and reactions t o the incident b y the member. 4. Analyze member's response t o see if there is a need for more Formal Defusing or professional intervention. Informal Defusing may be quite spontaneous, as those who have been involved in the critical incident gather around after cleaning equipment and preparing for the next response. Central t o this process is instilling an atmosphere that is positive, supportive, confidential, and based on care and concern for the members. In some situations, intervention may cease at this level; the situation is resolved. Conclusions drawn by the Battalion Commander and the CISD. DirectorICoordinator, concerning the nature and severity of the critical incident distress obtained through Informal Defusing, become the impetus for possible Formal Defusing. pormalDefusing is a voluntary......... hall,, type of event, group..:.$:::::.:.;.:.>:.;.;.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.>;.:.:.:.:.:.:..::.:.:.~:.>> formatted, confidential, and held normally at the members' quarters after returning from a critical incident. Conducted by Team Members, it should last no longer than one hour, but varies due t o the number of employees. Formal Defusing accomplishes the same objectives as Informal Defusing with the addition of: 1. Provides acknowledgment and support that the member's exposure t o this incident is recognized as a significant and extraordinary event. 2. Informs the member that there are normal reactions t o traumatic stressors which can be expected t o possibly manifest after the incident. 3. Assures the member that stress reactions are both normal and transitory. 4. Establishes an avenue for further post-traumatic stress information, follow up, and possible incident-related brief counseling. To implement Formal Defusing, the Battalion Commander informs the Division Commander of the conclusions, formed in consultation with the CISD DirectorICoordinator. The Division Commander originates approval for the Formal Defusing sequence. Following approval, Team Members and meeting locations are assigned b y the CISD DirectorICoordinator in consultation with the Battalion Commander. The supervisor of the affected members determines the conditions of availability for involved units. Since Formal Defusing is brief and immediate, it is suggested that this intervention process be uninterrupted. The Battalion Commander, with the approval of OCD, may make companies unavailable in order t o complete the defusing phase. In most cases, defusing is all that is necessary. Intervention may cease at this level. Any necessary follow up of defused members may be done in four t o six weeks by the DirectorICoordinator, or assigned Team Members. The specific focus of this follow up is t o monitor the post-incident reactions of all concerned. Phase I V - Formal Debriefing Sometimes following defusing is the more structured and educational intervention phase - Formal Debriefing. It is independent of the incident critique and convened optimally 24 t o 72 hours after the occurrence. Debriefing both facilitates and acceleratesthe natural psychological recovery of members who have experienced abnormal events, in an environment free from distractions. This intervention is expected t o significantly reduce stress reaction and, in most cases, prevent the development of both acute and chronic post-traumatic disorders. When deemed necessary, all involved personnel shall be debriefed. Guidelines for this process are explained at the outset. These include absolute confidentiality, no media, no note taking, and no recording. The optimal effectiveness of this intervention is with a group of 15 t o 20 in size, but comparable success is achieved when conducted for smaller or larger groups. Critical incidents of magnitude may require debriefing with members of other agencies that were also involved. It is facilitated by a mental health professional and trained peers, according t o prescribed phases. One main rule is adhered t o - To implement Formal Debriefing, the Battalion Commander informs the division Commander of the conclusions formed in consultation with the Department Psychologist. These conclusions are established following the defusing sequence. The Division Commander requests debriefing approval from the Deputy Department Commander. Following approval, Team Members and meeting locations are assigned by the CISD DirectorICoordinator in consultation with the Battalion Commander. Company availability status, possible sources of "V" staffing funds, degree of mandatory attendance, facility usage, and implementation will be determined once the sizeand severity of the critical incident have been assessed. Any necessary follow up of debriefed members may be done in four t o six weeks b y the DirectorICoordinator or assigned Team Members. The specific focus of this follow up is t o monitor the post-incident reactions of all concerned. Phase V - Critical Incident Stress-Related Counselinq After either a defusing or debriefing, it may be appropriate for a member t o request or t o be referred t o participate in voluntary brief counseling. It is anticipated that these counseling sessions are critical incident-specific and few in number. Its main purpose is t o resolve some issue or problem that came up as a result of the critical incident and is still present. More than one session may be necessary t o achieve the goals of relieving Department members from a set of painful or confusing psychological and physical reactions. CISD-related counseling will fall under the domain of the Department Psychologist. If the affected member is unable t o cope with the event, through-channels referral will be initiated by the Department Psychologist for evaluation by the Workers' Compensation psychologist or physician. Conclusion Critical incidents commonly result from situations in which there is imminent threat t o life, either for the member or for the people they serve. Typically, this would be a natural or technologic disaster, multicasualty incident, explosion, or massive exposure t o toxic substances. Implementation of the CISD Program will expand the Los Angeles Fire Department's ability t o provide for the safety and health of its members. Properly applied implementation of the CISD Program will significantly contribute t o the prevention of psychological disability accelerated by work-related critical incidents.  B. YOUR FOUR RESPONSES TO STRESSORS Ufe Event 'È Resolved  POTENTIAL CRITICAL TRAUMATIC EVENTS The following are examples of incidents which may qualify for CISD Program intervention: - Major disaster, e.g., airline crash, earthquake. - Multiple fatalities, i.e., more than three deaths due t o traffic accident, fire, etc. - Serious injury, death, or suicide of a Department member. - Serious injury or death of a civilian occurring during Department operations. - Death or serious injury of a child resulting from: neglect, violence, or conditions having a lasting effect on personnel. - Loss of life of victim after prolonged rescue efforts b y personnel. - Toxic/biologic exposures likely t o have lasting side effects. - Personnel are placed in extreme danger, e.g., hostage, assaults. OCD will automatically notify CISD administrators in the following circumstances: - Major emergencies requiring more than 15 companies. - Unusual EMS incidents when the Division Commander is responding t o the incident. - Department member killed or seriously injured. - "HazIMat" incident, notification made after the Division Commander is dispatched. Members seeking initial information about the effects of a critical incident................................................................... may contact the CISD Coordinator during business hours at 82I3@485$447%.................................................................................................................................................. ,.,..! During nonbusiness hours, members seeking information may contact the CISD DirectorICoordinator through OCD.  - CISD Action Plan An Overview The following charts depicts the actions and responsibilities of - members during a potential critical incident. Company CommanderIParamedic Supervisor notifies Battalion Commander........................................................................................................................... Performs initial asstssment. NO ACTION TAKEN........:.:.:.:.,.:...:.,.:.:...:.:.:..:.:.....>:...........:.:...........:. Does not need intervention 1. Battalion Commander apprises Division Commander of potential traumatic event. 2. Division Commander originates CISD notification approval. Battalion Commander requests CISD response, and notification of Medical Liaison through OCD 1. Assesses impact of incident. 2. Develops plan of action in consultation with Battalion Commander. Communication between CISD Director1 1. Requires Division Commander's approval Coordinator and involved members 2. In consultation with Battalion Commander. CISD Coordinator designates team assignments and location. 1. Department ~ s ~ c h o l o ~and ist Battalion Commander consult with Division Commander. 2. Division Commander requests debriefing approval from Deputy Department Commander. 3. In consultation with Battalion Commander, CISD DirectorICoordinator designates team assignments and location.  Los Angeles City Fire Department STRESS MANAGEMENT PROGRAM PEER SUPPORT  Introduction: Historically, peer support programs began in public safety organizations in Chicago, Illinois, in 1955 as an approach in dealing with employees with alcohol problems. Through the years, other successful programs have been developed and implemented in New York City, Boston, San Francisco, Long Beach, and Quantico, Virginia. The Peer Support Program has been functional in the Los Angeles Fire Department for over three years. It is the Department-supported, volunteer-staffed Program within a fire service organization in the United States. The Peer Support Program is programmatic strategy supported by the Department t o deal with job and life stressors. The Program fills a need in providing a service t o aid in increasing employee well-being, productivity, and retention. Peer Support provides a way for employees and members of their families t o confidentially "talk out" personal and professional problems - with specially trained coworkers, who understand and want t o help. There is no limit as t o the types of "life problems" which can be discussed with Peer Support Members. Many problems will resolve themselves when those involved are given a chance t o be heard. Some problems encountered include bereavement, substance abuse, career concerns, stress-related issues, relationships with children, retirement concerns, disciplinary issues, suicide, religiouslspiritual guidance, medical problems, problems with coworkers, financial concerns, supervisor/subordinate issues, relationships with step-children, and off-duty disability issues. The Peer Support Program is strictly voluntary. Peer Support Members are selected from all ranks and positions in the Department - sworn and civilian, active and retired. Peer Support Members attend an initial three-day training program under the direct supervision of the Department Psychologist. Further training is conducted periodically. Peer Support Members provide both short-term crisis intervention and necessary referral services. This Program provides an alternative for Department members seeking assistance and is not meant t o replace professional help. Terminoloav:............................................ Psychologis$ - A licensed mental health professional in charge of the 1.......................................................................... Department's Stress Management Program, including the CISD Team and the Peer Support Program; directly responsible for training, consultation, and supervision of all Peer Support Members; is on call 24 hours a day; attends Advisory Board Meetings.......................................... - A Peer Support Member selected by the Deputy Chief of 2. Coordinaso#.............................................................................. Operations and the Department Psychologist t o directly manage the Program and personnel; acts as liaison between Peer Support Members and Operations; maintains records of activity; provides for the logistics of intervention; assists in the Program's educational program; and distributes a periodic newsletter which contains items of information pertinent t o the Program. 3. P&e$Support Advisory Board - Volunteer Support Members from each...................................................................................................................................................................................................................................................................................................... rank w h o m e e t once a month and act as advisors and monitors for the Program. Advisory Board Members aid in the recruitment of applicants, and provide a network through which the Program Members can have input into this support system...........................................~~.~~>...................................*>> Â¥.Â¥................ Pee@Support 4. :...:.;.: Member.....: :..: ;...;.:.:.:.......:...................................................................................................... ,,.;.......... - Volunteer, sworn or nonsworn, employee who has undergone a three-day seminar in effective communications, crisis intervention, and helping skills t o aid and advise personnel in overcoming and dealing with problems. Purpose: One of the Department's priorities is the health and well-being of its members. There has been an increasing awareness and research into the damaging effects of stress. Although personal and professional life are thought t o be separate, the stressors of one affect the other. If stressors are not dealt with, the result can impact the member, hislher family, and the Department in a myriad of ways. The Fire Department's Peer Support Program (formerly Peer Counseling) is a volunteer program which has been established t o provide trained, volunteer Peer Support personnel who are available t o offer confidential help and guidance t o Department members experiencing a personal or professional crisis. The objective of the Program is t o assist members, during their time of need, by offering the following: A diverse network of volunteer Peer Support, available on a 24-hour basis t o render confidential support services t o members of the sworn and civilian fire and paramedic profession and their immediate families. A Program which promotes trust, respects the need for anonymity and preserves confidentiality, while developing in counselees the ability t o minimize conflicts by utilizing any of a variety of avenues for self-help. A n ongoing training program which ensures that Peer Support personnel are providing the most effective and competent service possible. The Peer Support Member's primary function is t o LISTEN, ASSESS and, whenever necessary, REFER t o professional counselors. They should NEVER be used as a replacement for required professional care. Confidentiality: The Department's Peer Support Program offers confidential help and guidance b y trained volunteer Peer Support Members t o all Department members and their families experiencing a personal or professional crisis. One of the most important responsibilities of a Peer Support Member is the promotion f trust, anonymity and confidentiality for employees who seek the assistance of the Peer Support Program. Therefore, communication between a Peer Support Member and a counselee is considered privileged b y the Department except for matters which involve violations of the law, a life threat, childlelder abuse, or serious misconduct. A copy of the Peer Commitment Agreement is included at the end of this report. It may occur that a Peer Support Member is providing support services t o an individual who is currently or becomes the subject of a disciplinary investigation. A Peer Support Member may not hamper or impede the actual investigation nor may they attempt t o shelter the individual from the Department. The Peer Support Member's role in disciplinary situations should be of one surmort in helping individuals through the problems they may face in the disciplinary process. If concerns arise, Peer Support Members should contact the Department Psychologist or the Program Coordinator. If a Peer Support member viol e confidentiality of an employee,' he/she will be removed from the Prog Fire Department personnel are encouraged t o seek assistance, from licensed professional counselors, or from fellow employees associated with the Peer Support Program, before a situation escalates into a severe personal problem or violation of the law. Anyone employed by the Los Angeles Fire Department or their family members may utilize the services of the Peer Support Program. An individual's decision t o seek Peer Support services shall be voluntary. Although supervisors may suggest, out of concern for the individual, that helshe may want t o see a Peer Support Member, referral shall not be made under duress or promise of reward. The above in no way alters a supervisor's responsibility t o supervise. Peer Support Members' names will appear on a list titled "Volunteer Peer Support Members" that will be updated, as needed. This list will be available at all work locations. Members interested in securing the help of a Support Member may self-select from this list; ask for aid in selection from another member familiar with the Program; or ask for a referral b y telephoning the Program Psychologist/Coordinator at ( 2 13)485-4471. Proaram Costs: There is no charae made t o someone using the Peer Support Program. This free service is sponsored through the mutual support of employee organizations and the Department. The Peer Support Program is sanctioned by the Department. Funds may be approved (when available) t o publish periodic newsletters and for other miscellaneous administrative expenses. Support members are not reimbursed for mileage nor for the use of private telephones for Program business. They may use City vehicles and telephones with the approval of Operations. Because Support Members are compensated employees of the Department and are covered for injuries sustained during Program business by Workers' Compensation, they are required t o "log" in and out with OCD whenever responding, off duty, t o a support session. Peer Support Members attend training sessions on their own time or as detailed. Support sessions are conducted on the Peer Support Member's own time. Case Log: To ensure that the Program is meeting the needs of the clients, a brief log is maintained by Support Members. This information monitors only the hours and the topics, not the client, in an attempt t o render quality care. This also provides valuable information for constructing classes that are pertinent t o the needs of the Support Members. Names and specifics about support sessions are n o t submitted. A copy of the log sheet is included at the end of this report. The Peer S u o ~ o r Member t Profile: Backaround - Peer Support Members are selected, on a volunteer basis, from all ranks and positions within the Department. They may be sworn or civilian, active or retired. An individual must have expressed a desire t o be a Peer Support Member, have no work restrictions involving psychological stress, not the object of a major investigation, or suffering from a serious personal problem. Peer Support Members tend t o possess the following qualities: - A sincere appreciation of people and their differences. - Satisfaction in being with, listening to, and in trying t o understand people and society. - Keeps personal opinions and beliefs from interfering with the ability t o help a person. - Gives empathy while maintaining emotional stability. - Is nonjudgmental. - Respects multi-ethnic and gender values and taboos. Training - The initial Peer Support training is conducted over a three-day period under the direct supervision of the Department Psychologist. It is intended t o provide a basic understanding of techniques in problem identification, listening, assessment, intervention, and referral. After completing the three-day training seminar, Peer Support Members will attend periodic follow-up training. Follow-up training consists of a series of periodic support training programs, approximately four hours in length, which are conducted with the assistance of specialists in the following areas: - Problem-solving Workshops - Referral Workshops - Advanced Skills Workshops - Counselor Workshops - Alcohol and Substance Abuse Workshops Res~onsibilities- The primary function of a Peer Support Member is t o provide short-term crisis intervention, lay assessment and referral services t o fellow employees in time of need. There are certain obligations and responsibilities a Peer Support Member must make t o the Program. They include: - Attend the Peer Support Program Training Seminar and follow-up training as required. - Offer all services on a voluntary basis. - Agree t o be contacted and, if practical, respond at any hour. - Attempt t o develop a sincere rapport with the individual employee and maintain confidentiality. Each person's situation is bound t o be unique. The Peer Support Member will help individuals identify their o w n concerns and assist these individuals in helping themselves. - Maintain a reasonable attempt t o remain available t o the individual and offer additional support, if necessary. - Recognize the propriety of referrals and follow up. Assistance should not extend t o prolonged periods of time which might amount t o formal counseling or psychotherapy role. In most cases, Peer Support should take the form of meetings of relatively short duration. The Peer Support Member must be responsible not t o take on more cases than he or she can handle. Those experiencing problems which require long-term or professional guidance shall be given the opportunity t o choose a professional resource.  1 Conclusion: The Peer Support Program provides both an intervention and prevention vehicle t o help Department personnel. This is accomplished by providing a method t o resolve "life stressors" before they become a significant problem impacting one's personal and professional life. Peer Support exists solely for the benefit of Department members and their families in time of need. I -1s. ADMISISTBATIVX ANALYSIS/ I I -17. STRESS MAHAGEMEHT PROGRAM PRODUCTIVITY I I I I I.O1 GENERAL: The Senior Management.O1 GENERAL: The Paramedic III Analyst I assigned to this position (Coordinator) assigned to this position 1 reports directly to the Operations reports directly to the Operations I I Deputy Chief, and maintains regular Deputy Chief, and maintains regular business hours. The duties include: business hours. A part-time clinical I psychologist is assigned on a I I A. Analyzes, makes recommendations, contractual basis and serves as I Director of the program. I prepares reports, and monitors I items relating to the Department's I I Productivity Program. - 2 0 RESPONSIBILITIES: The Director l is responsible for providing psycho- B. Coordinates, provides financial logical services pertaining to stress analysis, and procures Hazardous recognition training; critical incident Materials equipment for the Depart- debriefings; Peer Support Program, and ment's Hazardous Materials Program. short-term counseling for members with job-related problems. The duties in- C. Analyzes and recommends policy and clude : procedural changes of Department operations to ensure efficiency and A. Responding, as needed, to conduct cost effectiveness. Performs informal and formal defusings fol- Internal ,. audits of Department lowing memberse exposure to a cri- operations. tical incident. I I I D. Performs miscellaneous administra- I B. Providing in-service training to tive functions for the Operations ! - Department members who serve as I I I office including budget preparation 1 Critical Incident Team members and I.^ad analysis. I Peer Support members. I I I 1 C. Conducting fire station site visits I to inform members of the Stress I I Management Program and provide I stress recognition training. 1 The Coordinator is responsible for coordinating the Critical Incident S.-&-ess Debriefing Program and maintains records of activity. The duties in- -1de: &" I. I A. Provides for the location and phy- I sical logistics of informal and I I formal Critical Incident Debrief- I I ings. I I I B. Assists in the in-service edu'ca- I I tional program for Critical Inci- I dent Debriefing and Peer Support. I Page 3A  An Informal Definition of Terms Psvcholoaical Eauilibrium - an equal balance between our internal and external pressures. A person is in a state of equilibrium when hislher external demands are consistent with histher internal desires. If you want t o mow the lawn and the lawn needs mowing, you are in a state of psychological equilibrium. Homeostasis - a person's natural tendency t o maintain his environment within normal limits. For example, people automatically turn up a radio when it is too soft, and turn it down when it is too loud. Most people like a little variety in their environment occasionally, but only within controlled limits. Stress - is anything that disturbs our homeostatic world, whether it be pleasant or unpleasant. Stress is usually due t o one of t w o factors. 1. Stress is created when a person must suddenly deal with too many external demands (overwhelming) or too few (boring). 2. Stress is created whenever external demands are inconsistent with internal desires. This can happen in one of t w o ways. a) A person may be highly desirous of doing something (e.g., eating), while the external demand is for self- restraint (e.g., the doctor says he must lose weight). b) The external demand may require a difficult act (e.g., stop the bleeding of a would), while the internal desire urges an opposing action (e.g., flee from the sight of blood). People differ in a way they can react to stress. This is because: 1. The number and strength of internal desires vary from one person t o another. 2. An individual's desires change over time. 3. People vary in their ability t o withstand stress. 4. People can adapt t o some stress situations if they have the opportunity t o get used t o such situations gradually.  A Partial Description of the Physiological Reactions to Stress Autonomic Nervous System Evidence suggests that each individual has a characteristic autonomic response pattern. Sympathetic System Parasvmoathetic Svstem (Preparation for fight or flight) Gastrointestinal Effects Salivation is slowed or stopped. Increased salivation. Dry mouth. Inhibition of gastric secretions. Uncontrolled defecation. Inhibition of stomach and intestinal contractions. Inhibition of bladder. Uncontrolled urination. Circulatory Effects Increased heartbeat, blood Dramatic drop in hearbeat, pressure. blood pressure. Blood restricted t o G.I. track. Blood increased in muscles. Heart may stop. Rise in blood sugar. Miscellaneous Effects Sweating. "Goose pimples". Hyperventilation. Shortness of breath. Pupil dilation. Pupil contraction.  STRESS ON THE BODY Effects O f Stress On The Body Dent t e !cc ec "ro linking that stress and its effects on us are just states of mind T:ev TC: c.-!'.' nave real measurable physical consequences but scientists.?a,,? zeen aole !o identify the specific biological and chemical reactions :he', caLise in our bodies. Rememcer :r,e :hree s;ages of stress? Here is what goes on in your body during stages I ana 11. STAGE I: Alarm STAGE 11: Resistance The oooy metaoohzes for The baly tries to return to action normal. ^ ' k drain directs nyootnaia- L Salivation increases. mus. M. Brain mus. directs hypothala- 0, Thyroid produces normone tnat steps up energy oro- aucnon. N. Lungs slow back to normal. C. Hyoothalamus triggers 0. Hypothalamus triggers all- alarm system. clear system. 0. Lungs cause harder. faster P. Facial muscles relax. orearning 0. Spinal cord carries all- E. Fac'af muscles contract. clear signals directly to n u o ~ l s.nostrils. throat organs. expand R. Heart Dumps less blood. F. Ganglia (nerve clusters) act as "switching stations" S Blood sugar level is mat spread the alarm mes- lowered. sage "om lne Soinal cord to me organs T. Stomach. intestines. blad- der swing back into action; G. Heart Dumos more Diood digestion speeds uD. H. Biooa sugar level 1s ele- U. A d r e n a l g l a n d s l o p s va tee secreting hormone that regulates liver, pancreas. I Stomacn. intestines. Wad- spleen, kidneys, large der relax. digestion stows bloodvssels. to crawl. V. Sweating is retarded. J. Adrenal gland secretes normone which lle@~ liver. pancreas. kidnçyssoleen and large blood vessels take on extra workload. K. Sweating increases Of course, i f a person does not return to normal and instead moves on to stage I l l. all of the alarm reactions return and these lead to physical illness.  Some Occasional Physical Effects of Prolonged Stress There is evidence t o indicate that the symptoms an individual exhibits may be determined by an inherited organic predisposition. Gastrointestinal Ulcers Constipation Indigestion Colitis Hemorrhoids Diarrhea Circulatory Hypertension (All patients tend t o suppress rage. Can also be caused by prolonged fear.) Dysrhythmia Arteriosclerosis Cardiovascular Disease - Skin Allergies Neurodermatitis Hives Respiratory Allergies Asthma (may be a "learned" response in some cases) Muscular Paralysis Sexual Impotence Premature Ejaculation Frigidity  Some Occasional Psychological Reactions to Stress Verv Common and Potentially Dangerous Loss of sympathy, affection, humor, concern Hyperactivity Apathy Irritability, Argumentativeness Insomnia, Restlessness Hypersensitivity, Over-reaction Rigidity of thought Depression Withdrawal from social contacts Overdependency Diminished capacity for problem-solving Diminished tolerance for any unpleasantness Reasonablv Common and Danaerous "Unexplainable" fear, apprehension, dread Avoidance of responsibilities Excessive drinking, drug use Ritualistic behavior 0bsessive thoughts "Acting out" - e.g., gambling, speeding, overspending, illegal behavior, boisterous and obnoxious behavior, immature behavior, philandering, recklessness. Uncommon and Dangerous Bizarre perceptions and reactions Loss of contact with reality Hysterical blindness, deafness, paralysis  STRESS RESPONSE INVOLVES: d Breathing d Muscles d Heartbeat Â¥ Perspiration Â¥ Blood Pressure d Temperature PHYSICAL PROBLEMS CAUSED OR WORSENED BY STRESS High Blood Pressure Arthritis Atherosclerosis Facial Pail Angina Pectoris Ulcers Palpitations Heart Attacks Stroke Colds Insomnia Cold SoresIFever Blisters Spastic Colon Teeth Grinding Constipation Clenched Jaws Diarrhea Hair Loss Migraine Headaches Skin Problems Tension Headaches Refusal t o EatILoss of Appetite (Severe) Backaches Hay Fever Asthma For Women: Irregular Menstruation Cramps Vaginal Infections Difficulty or Pain in Intercourse  Long-Term Stress Management Goal 1: Reduce the Causes of Stress Goal 2: Increase Personal Stress Resources Goal 3: Constructive Release Talk it o u t Vigorous physical activity Relaxation exercises Goal 4: Stress Prevention Exercise aerobically Relaxation Nutrition Sleep  LIFE CHANGES AND PHYSICAL AILMENTS* After studying the recent histories o f people w i t h medical problems, Homes and Holmes ( 19 7 0 ) have concluded that any number o f illnesses, and not just the commonly recognized psycyhophysiological disorders, can be precipitated b y the stress accompanying changes in one's life. To measure the impact o f different kinds o f changes, Holmes and Rahe ( 1 9 6 7 ) have developed the Social Readjustment Rating Scale, which rates each kind o f potentially stressful event i n terms o f "life change units" (LCUs). Life Event LCUs Your LCUs Death o f Spouse 100 Divorce 73 Marital Separation 65 Jail Term 63 Death o f a close family member 63 Personal injury or illness 53 Marriage 50 / - - Fired at w o r k 47 Marital reconciliation 45 Retirement 45 Change i n health o f family member 44 Pregnancy 40 Sex difficulties 39 Gain o f n e w family member 39 Business readjustment 39 Change i n financial state 38 Death o f a close friend 37 Change t o a different line o f w o r k 36 Change in number o f arguments w i t h spouse 35 Mortgage over $10,000 31 Foreclosure o f mortgage or loan 30 Changes in responsibilities at w o r k 29 Son or daughter leaving home 29  Life Event LCUs Your LCUs Trouble w i t h in-laws 29 Outstanding personal achievement 28 Wife begins or stops work 26 Begin or end school 26 Change in living conditions 25 Revision of personal habits 24 Trouble w i t h boss 23 Change in work hours or conditions 20 Change in residence 20 Change in schools 20 Change in recreation 19 Change in church activities 19 Change in social activities 18 Mortgage or loan less than $10,000 17 Change in sleeping habits 16 Change in number of family get-togethers 15 Change in eating habits 15 Vacation 13 Christmas 12 Minor violations of the l a w 11 TOTAL LCUs What vour score mav mean. If you had over 150 LCUs within the last year, you have a 30-50% chance of developing an illness. A score of over 300 LCUs gives you about an 80% chance of developing an illness. Notice that "positive events" can also cause "negative" stress. *For demonstration purposes only; not considered suitable for research. Write the name of this event Please indicate which of the following you did in connection with this event: YES YES YES Once or Some- Fairly NO Twice times often 1. Tried to find out more about the situation 2. Talked with spouse or other relative about the problem 3. Talked with a friend about the problem 4. Talked with professional person (e.g., doctor, lawyer, Clergy, etc.) 5. Prayed for guidance and/or strength 6. Prepared for the worst 7. Didn't worry about it. Figured everything would probably work out 8. Took it out on other people when I felt angry or depressed 9. Tried to see the positive side of the situation 10. Got busy with other things to keep my mind off the problem 11. Made a plan of action and followed it 12. Considered several alternatives for handling the problem 13. Drew on my past experience; I was in a similar situation before 14. Kept my feelings to myself 15. Took things a day at a time, one step at a time 16. Tried to step back from the situation and be more objective 17. Went over the situation in my mind to try to understand it 18. Tried not to act too hastily or follow my first hunch 19. Told myself things that helped me feel better 20. Got away from things for awhile 21. 1 knew what had to be done and tried harder to make things work  YES YES YES Once or Some- Fairly Twice times often 22. Avoided being with people in general 23. Made a promise to myself that things would be different next time 24. Refused to believe that it happened 25. Accepted it; nothing could be done 26. Let my feelings out somehow 27. Sought help from persons or groups with similar experiences 28. Bargained or compromised to get something positive from the situation 29. Tried to reduce tension by: (Check all that apply) drinking more eating more smoking more exercising more taking more tranquilizing drugs  1. Pervasive feeling of anxiety. 2. Chronic fatigue. 3. Constant preoccupation with one's health. 4. Frequent spells of depression. 5. Nervous tension and panic feelings. 6. Physical tremors - "the shakes". 7. Fear of being alone. 8. Inability t o sleep well. 9. Occasional thoughts of suicide 10. Fear of an emotional breakdown. 11. Lack of self-confidence. 12. Wide mood swings. 13. Excessive irritability accompanied by emotional outbursts. 14. Feelings of hopelessness and despair. 15. Negative thinking as a dominant pattern. 16. A sense of unreality - out of touch. 17. Unreasonable complaining. 18. Excessive worrying. 19. Inability t o work or perform everyday chores adequately. 20. Continuous unhappiness. 21. Paralysis in decision making. 22. ~xcessivefear of making amistake. 23. Dread of supervisory personnel 24. Inordinate desire t o please others. 25. Chronic pains, especially, head and abdomen. 26. Poor health in general. 27. Early aging signs. 28. Extravagant spending. 29. - - Fear of the unknown future. 30. Excessive susoicion and/or fear of others.  JOB STRESS INDEX: ARE YOU HASSLED? Directions: This survey lists 10 job-related events that have been identified as stressful by employees working in different settings. Please read each item and circle the number that indicates the approximate number of times during the past month that you have been upset or bothered by each event. Number of Occurrences During Past Month 1. I have been bothered by fellow workers not doing their job..... 2. I've had inadequate support from my supervisor..... 0 1 2 3+ 3. I've had problems getting along w i t h coworkers..... 0 1 2 3+ 4. I've had trouble getting along w i t h my supervisor.....0 1 2 3+ 5. I've felt pressed t o make critical on-the-spot decisions..... 0 1 2 3 + 6. I've been bothered by the fact that there aren't enough people t o handle the job..... 0 1 2 3 + 7. I've felt a lack of participation in policy decisions..... 8. I've been concerned about m y inadequate salary..... 0 1 2 3+ 9. I've been troubled b y a lack of recognition for. good work.... 0 1 2 3 + 10. I've been frustrated by excessive paperwork..,.. 0 1 2 3 + TOTAL POINTS Score Yourself: To determine h o w your stress compares w i t h other workers, add up the points that you circled for each item (0-3). Your score will be between 1 and 30. Persons w h o score between 5 and 7 are about average in h o w often they experience job-related stress. I f you score higher than 9, you may have cause for concern. A t 4 or lower, you have a relatively non-stressful job.  0 1 2 3 4 Headaches Stomach-acheltension Backaches Palpitations (pounding in chest) Stiffness of neck/shoulders Chest Pain Elevated Blood Pressure Unexpected Sweats Diarrhea Fatigue Crying Forgetfulness Yelling Blaming -. Bossiness Constipation Compulsive gum-chewing Compulsive Antiacid Taking Compulsive Eating Insomnia Loss of Appetite Confusion Agitation Worrying Depression Impatience Anger Frustration  7- 4 never rarely often 1 always 1 tSS'i "Can't get it out of your mind" Problem Trouble Breathing Thoughts of fear of failure Powerlessness Inflexibility Compulsive smoking 1 Teeth grinding 1 1 Worry about being sick 1 1  CISD TRAUMATIC EVENT Major disaster, e.g., airline crash, earthquake. Multiple fatalities, i.e., more than tree deaths due t o traffic accidents, etc. Serious injury, death, or suicide of a Department member. Serious injury or death of a civilian occurring during Department operations. Death or serious injury of a child resulting from: a. Neglect b. Violence c. Conditions so extreme as t o have a lasting effect on Department personnel. Loss of life of a victim following extraordinary and prolonged expenditure of physical and emotional energy during rescue efforts by Department personnel. Cases with unusually heavy media attention. Incident where members are exposed t o toxic or unknown chemicals or communicable disease exposure(s) which are likely t o have lasting physical or emotional side effects. Incident where personnel are placed in extreme danger due t o firearms, hostage situation, or threats of, or actual, physical harm, e.g. assaults.  CRITICAL INCIDENT IDENTIFICATION Following are examples of critical incidents that normally would qualify for defusings (and debriefings): Mass casualty incidents. Serious injury or death of Fire Department member. Serious injury or death of non-Fire Department emergency personnel working at a Fire Department involved incident. Serious injury of death of a civilian caused by Fire Department operations (i.e., auto accident, etc.) Suicide of a crew member. Violent death of a child. Loss of life of a patient following extraordinary and/or prolonged expenditure of physical and emotional energy during rescue efforts by Fire Department personnel. Incidents that attract extremely unusual or derogatory news media coverage. Any shooting or other serious threat t o life of Department members. Any incident in which the circumstances are so unusual or the sights and sounds so distressing as t o produce a high level of immediate or delayed emotional reaction. I. GENERAL PROFILE OF CRISIS: A. Sense of Bewilderment (I never felt this way before) B. Sense of Danger I felt so nervous and scared -- something terrible is going t o happen) C. Sense of Confusion (I can't think clearly, m y mind isn't working right) D. Sense of Impasse (I feel stuck, nothing I do seems t o help) E. Sense of Desperation (I've got t o do something -- don't seem t o know what though) F. Sense of Apathy (Nothing can help me, I'm in a hopeless situation) G. Sense of Helplessness ( I can't manage this myself, I need help) H. Sense of Urgency ( I need help now) I. Sense of Discomfort ( I feel miserable, so restless and unsettled) I. PROBLEM SOLVING EXPLANATION A. Occurs when person's rational, usual method of solving problems fails. B. Person continues t o try this method. C. When method repeatedly fails, person may try an emergency method. D. When this fails, the result is agitation, anxiety, panic -- person is in crisis. II. AREAS AFFECTED BY CRISIS A. Thinking - typical reactions: 1. Overinclusive - can't identify problem - disorganized, chaotic. Can't sort out significant from insignificant problems. 2. Overly narrow - obsessed about irrelevant details. Fails t o look at reasonable alternatives - becomes preoccupied. 3. In general, the person seems unable t o exercise appropriate judgment and t o utilize reality testing, problem solving strategies. B. Emotions - will exhibit some of these: 1. Panicky, scared 2. Anxious, agitated 3. Depressed 4. Hopeless 5. Overwhelmed C. Behavior - See behavior that is out of the ordinary for the individual: 1. Acting out: excesses  2. Temper tantrums 3. Paralyzed -- withdrawn -- doesn't carry out normal routines. I. RECAP: A. Crisis occurs when the habitual backup methods of solving problems fail. The result is a breakdown in the judgment, control of affect and ability of person t o act appropriately t o the crisis. IV. WHEN DO CRISES OCCUR? A. Situational - examples: 1. Loss of relationship 2. Job difficulties B. Developmental - examples: 1. 30's crisis; re-evaluation of goals and values -- stuck in place 2. Middle age 40's; decline of power, loss of youth 3. Retirement -- can't stand nothing t o do -- self-image V. AS IN ANY COMMUNICATION, IT IS IMPORTANT TO: A. Establish rapport and trust. B. Allow for ventilation and validation of feelings. C. Show empathy, respect, genuineness, caring, and sincerity. D. Summarize t o client's satisfaction. E. Assessment for: 1. In or out of control F. Problem solving 1. Prefer non-directive or cooperative.  2. Directive if client is out of control. VI. KEY CONCEPTS IN CRISIS THEORY A. Immediacy - open door policy B. Deal with particular problem C. Time limited approach D. New situations are potential hazards and can cause crisis E. Maximum amount of change with minimum amount of work. There are both danger and opportunity in crisis situations. F. Most people in crisis go blank when attempting t o consider alternative - they say they've tried everything VII. STEPS FOR WORKING WITH PEOPLE IN CRISIS A. Understand present situation the person finds himself in. Meet on his ground. B. Understand importance t o individual. C. Try t o determine precipitating event - straw that broke the camel's back. D. Examine coping attempted - has it happened before? 1. Why isn't it working now? 2. What is different about this situation? E. Explore alternatives - person decides if at all possible - structure and detail situation if needed. Example: SUICIDE 1. The actual steps one follows in working w i t h people in crisis can be presented in the following way: A. Explore the current situation in order t o identify the precipitating event. What is new in the person's ongoing situation? B. What is the impasse brought about by the n e w element, i.e., why can the person not handle the present problem by previously used mechanisms. (What were those mechanisms?) C. Try t o define problem in ways hetshe can understand and agree with. D. If this last intervention has been successful, there will soon show a marked decrease of tension and an increase in ability t o deal w i t h the problem (re-establishment of equilibrium). Lend appropriate support t o the new person's efforts at solving the n o w defined problem (Problem-solving stage). Explore alternative w a y s o f handling the problem, and ways of viewing it in a different light. E. Do not get involved in prolonged discussions of chronic problems at any time. F. Be prepared t o find that in many instances the person does not desire or require further help after equilibrium is restored. For this group, brief problem-oriented type of help represents the treatment of choice. 11. A GUIDE FOR SHORT-TERM INTERVENTION A. Rank order the complaints and symptoms that the person considers most upsetting t o him and that he would like t o resolve. Verbalize h o w the person must feel about these t o communicate concern and understanding. B. Identify any important immediate problems that were associated with and perhaps continue t o be related t o the person's present complaint.  C. Explore what the person has done about his complaints and symptoms. Why has he been unable t o solve his present difficulty by himself? D. Inquire into previous upsets that were similar t o the present one, and see if a relationship between symptoms and precipitating events can be established. Is there a similarity t o the present crisis? E. Inquire into othercomplaints and symptoms, including what measures have been taken t o alleviate these. Were any tranquilizing or energizing drugs used. Ask about sleep and eating patterns. Weight loss? F. Avoid too involved probings into the past. G. Explore the person's ideas of how he can handle his problem. H. Clarify the person's problem, and attempt to get him t o think matters through and t o do things for himself. Ill. MODEL PLAN TO REDUCE STRESS A. State the problem. 1. "What do I want t o do about this stress situation?" B. List the alternatives open t o you. 1. "How can I deal with this situation? What options do I have?" C. Note the results you think will occur if you carry out each option.. 1 "What would happen if..... 7" D. Choose the alternative that has the best results for you in all dimensions. E. Develop a plan t o carry it out. F. Carry out your plan. G. Evaluate your results.  1. "Has my plan solved the problem of the stressor?" H. Make any change or modification that will give you improved success ft in carrying out your plan. IV. PRIORITIZING A. In all planning -- short range, middle range, long range -- you 1. Make a list 2. Set priorities a. setting priorities is a simple A B C process. B. Items on your list that have the highest value in terms of your time RIGHT NOW, results RIGHT NOW, are labeled with an A. Those that have least value are labeled with a C. C. Planning is done t o GAIN CONTROL t o free up time for you t o concentrate high priority items. D. By failing t o plan: 1. you do not free up time 2. you do not make wise choices 3. you almost certainly will not discriminate among the A's, B's, and C's E. There will always be more C's on a list than A's. F. Without planning and prioritizing, we very likely end up doing mostly the C's and not enough time is left for the A's. 1. A's should always be done first, then B1st and -- if there's enough time -- C's. G. C's can usually be delegated t o someone else of they haven't already resolved themselves. Following any event of profound emotional impact, normal, and unpreventable human responses occur. These chanaes in one's physical body, emotional feelings, and/or thinking-reasoning abilities, are svmptoms of stress reaction. There's no way of knowing whether a specific person will have anv, one, or multiple symptoms; nor is there any way of knowing when they'll appear. Usually they onset "soon" after the event, and last no more than a few weeks. Severity of symptoms can be diminished, and recovery can be accelerated by the "productive steps" listed below. However, if you find that your life has become significantly disrupted, it's advisable to seek professional assistance. Scientific studies show a direct relationship between "mismanagement" (i.e., non-treatment) of stress and physical illness - from colds, t o long term, serious problems. PHYSICAL SYMPTOMS: Nausea; Stomach/Digestive problems; Fatigue; Loss of appetite; Shock; Sweating; Chills; Tremors; Dizziness; Lack of coordination; Increased heart rate; Elevated blood pressure; Chest pains; Hyperventilation; Insomnia; Headaches; and Muscle soreness. COGNITIVE SYMPTOMS: Impaired thinking and decision making; Poor concentration; Confusion; Difficulty performing calculations; Loss of memory; Flashbacks; Short attention span; Recurring images; Insomnia; Nightmares; and an Inability to differentiate between trivial and important matters. EMOTIONAL SYMPTOMS: Short temper; Anxiety; Fear of repetition o f the event; Grief; Depression; Feeling abandoned and lost; Withdrawal from others; Reduced tolerance; Numbness; Shock; Overwhelmed; Angry; Resentful; Hopeless; Irritable; and Identification with victims. DESTRUCTIVE BEHAVIOR: Sometimes occurs in persons exposed t o traumatic incidents. Some people will overindulge in alcohol or other mind-altering substances; overeat; neglect their health care and grooming; become accident prone; and/or withdraw from social interaction. PRODUCTIVE STEPS: You can take to diminish negative effects and accelerate recovery include: daily or twice daily strenuous exercise; proper nutrition; regular rest; and expressing your feelings to someone you trust. Remember, psychological trauma is just as real, and just as significant, as a physical injury. With the current "state of the are" in preventing both acute, and long term stress disorder, there is no reason to endure unnecessary suffering.  POST-TRAUMATIC STRESS DISORDER (FROM DSM-111) A. Existence of a recognizable stressor that would evoke significant symptoms of distress in almost everyone. B. Reexperiencing the trauma, by at least one of the following: (1) recurrent and intrusive recollections of the event (2) recurrent dreams of the event (3) sudden acting or feeling as if the traumatic event were reoccurring, because of an association with an environmental or ideational stimulus C. Numbering of responsiveness t o or reduced involvement with the external world, beginning some time after the trauma, as shown by at least one of the following: ( 1)markedly diminished interest in one or more significant activities (2) feeling of detachment or estrangement from others (3) constricted affect. D. A t least t w o of the following symptoms that were not present before the trauma: ( 1)hyperalertness or exaggerated startle response (2) sleep disturbance (3) guilt about surviving when others have not, r about behavior required for survival (4) memory impairment or trouble concentrating (5) avoidance of activities that arouses recollection of the traumatic event (6) intensification of symptoms by exposure t o events that symbolize or resemble the traumatic event. 10. Incident with a profound emotional impact that could overwhelm the normal coping mechanisms of involved members, e.g., serious threats or harm to close relatives and friends, sudden destructions of one's home, or witnessing a person being seriously injured or killed as a result of an accident or physical violence. a. Neglect b. Violence c. Conditions so extreme as t o have a lasting effect on Department personnel 6. Loss of life of a victim following extraordinary and prolonged expenditure of physical and emotional energy during rescue efforts by Department personnel. 7. Cases with unusually heavy media attention. 8. Incident where members are exposed t o toxic or unknown chemicals or communicable disease exposure(s) which are likely t o have lasting physical or emotional side effects. 9. Incident where personnel are placed in extreme danger due t o firearms, hostage situation, or threats of, or actual, physical harm, e.g., assaults. 10. Incident with a profound emotional impact that could overwhelm the normal coping mechanisms of involved members, e.g., serious threats or harm t o close relatives and friends, sudden destructions of one's home, or witnessing a person being seriously injured or killed as a result of an accident or physical violence.  THE COUNSELING TEAM 696 NORTH "D" STREET 5tJlTr ? SAN RERNARDINO CALIFORNIA q2401 714/8U4-0133 PosFTraumatic Stress Disorder and the Firefighter BY FRANCIS X. HOLT cies and materials also helps to re- Recurrent d r e a m s of the P ost-Traumatic Stress Disorder (PTSD) was o n l y r e c e n t l y place stress with confidence. In event, More than recollections (1980) recognized by the medi- addition, exercises involving thc ~ n dintrusive memories, dreams cal profession as a bona fide diag- repetition known only to the fire- are often a terrifying replay of a nosis. This was acknowledged fighter also prepares him to func- traumatic experience. Sometimes when large numbers of Viet Nam tion well in circumstances that they are exaggerated i n their focus ' combat veterans began to display would elicit panic from the aver- on one detail in a pattern of events, common symptoms indicative of age person. or they contain a distortion of time the disorder. Veterans from pre- Despite all this training and ex- or other circumstances surround- vious wars who displayed these perience, the firefighter is likely to ing the trauda. An engineman symptoms were treated only for encounter some emergency inci- recounts hid dreams of going shell shock or traumatic war neu- dent for which nothing can pre- through a hole in the third floor of rosis. pare him psvchologically. Read- a vacant bt~ildingfour years ago: One of the criter~afor diagnos- ing about collapses, studying the ''I'\l be going into tlie room with ing PTSD is the presence of stress- physics and chemistry of back- the knob. I can remember think- o n that would evoke symptoms of drafts, talking to men who have ing 'We got it now' because the - distress in almost anyone. It is un- lost co-workers, is not the same as main body of fire was in a hall just derstandable, therefore, that Viet the experience. And the experi- beyond this room. Then the bot- Nam veterans would suffer from ence can be a life-changing ordeal. tom went out and 1 wound up this disorder because of extremely straddling a beam 011 the second Reliving the trauma floor. They say they got me out in stressful combat conditions. In addition to the presence of less than five minutcs, but in the PTSD AND THE FIRE SERVICE stressors, another criteria for de- dream I just hang there calling for termining if an individual is suf- help. fering from PTSD is if he relives "There's a lot of fire below the This kind of "combat'' stress, that the trauma. This can take any of beam, which there wasn't in the could conceivably lead to PTSD,is three forms: actual fire-the only fire was on common in the daily working lives Repeated and intrusive the third floor-and I'mf like, on a of fire service members. Training memories of the event. A.fire- spit. Nobody comes to get me. reduces much of the physical and fighter in a busy truck company Nobody comes to extinguish the psychological stress associated remembers a close call that hap- fire. There's nobody there but me, with firefighting. Smokehouses pened six years ago: and I'm scared. I wake up soaked and training towers' for instance, "S~metimes I'll be sitting on with sweat." can alter the firefighter's expecta- house watch at two in the morn- Suddenly acting o r feeling as tions and actions in extreme situa- ing,-just looking a! an old movie i f t h e trauma was h a p p