POLICIES AND OPERATIONAL GUIDELINES
(Revised January 2011)
I. Introduction 3
II. Mission Statement 5
III. DRCISST Values 5
IV. DRCISST Goals 6
V. Community Relations Objectives 6
VI. Service Areas 7
VII Team Structure 8
Executive Team Chairperson Membership Coordinator Secretary/Treasurer Clinical Directors Team Coordinators Therapy Dog Coordinator Special Projects Chairperson Other Committees
VIII. Operations 13
Guidelines for DRCISST Coordinators
IX. Team Membership 21
Standards of Reactive Membership
Team Member Duties and Responsibilities
Special Member/Therapy Dog Training
Revocation / Suspension of Membership
X. Services Provided 27
Crisis Management Briefing
XI. Group Protocol 29
Crisis Management Briefing
Defuse / Debrief Considerations
XII. Appendix 39
Applicant Interview Questions
Telephone Reference Check
Memo of Understanding
Pre-Incident Education Agenda
In-service Request Form
Debrief Cheat Card
Diffuse Cheat Card
Pre and Post Debrief Checklist
Post Event Contacts
CISM Attendance letter
I. INTRODUCTION STATEMENT
Emergency services personnel are increasingly aware of the toll that their unique occupational stressors take on the quality of their personal lives. The nature of emergency services jobs exposes these individuals (routinely or periodically) to stressful events, which they may or may not be able to work through satisfactorily on their own.
Factors that cause stress to one individual may be non-stressful for another, but research has shown that only a very small percentage of emergency service workers are not affected by occupational stress. Approximately one-half of those who demonstrate reactions related to stress could resolve their stress reactions on their own; the other one-half continue to be affected.
Responses to stress may be immediate and incident specific; they may be delayed for a period of time after the incident; or they may be cumulative, building up over long periods and many incidents or they may be organizational responses. Multiple personal and external factors affect an individual’s response to stress including the individual’s personal qualities, past experiences and the (internal and external) resources available to him or her.
It has been demonstrated that certain events, such as the death of a child, the death of co-worker, high-rise fires and multiple casualty incidents are particularly stressful for emergency workers. Any of these events, plus a host of others, may cause or contribute to a critical incident (trauma) for an emergency worker or group of workers.
A critical incident (trauma) has been defined by Jeffery T. Mitchell as, “Any situation faced by emergency service personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later”.
“The incident, regardless of type, generates unusually strong feelings in the emergency workers.” (1) A critical incident (trauma) has also been described as any event which overwhelms the capabilities of a person to psychologically cope with the incident. (1)Mitchell, Jeffery T.: When Disaster Strikes … The Critical Incident Stress Debriefing Process: JEMS; January, 1983; pp 36-39.
The following are examples of incidents that may have significant emotional impact and are appropriate for CISM intervention(s):
- Serious injury or death of an emergency service worker (law enforcement, firefighter, paramedic or other emergency personnel in the line of duty, including during the incident, en route to or returning from a scene, or during a training exercise)
- Mass casualty incidents
- Suicide of a crewmember or other unexpected death
- Serious injury or death of a civilian resulting from emergency services operations
- Events that seriously threaten the lives of responders
- Death of a child or violence to a child
- Loss of life of a patient following extraordinary and prolonged expenditure of physical and emotional energy during rescue efforts by emergency services personnel
- Incidents that attract excessive media coverage
- Personal identification with the victim or the circumstances
- Events where the victims are relatives or friends of emergency personnel
- Any incident that is charged with profound emotion
- Any incident, in which the circumstances were so unusual, or the sights and sounds so distressing…as to produce a high level of immediate or delayed emotional reaction
Emergency services workers benefit from specialized stress management programs and peer supports designed for their personality profiles and to address issues specific to their vocations. Normal therapeutic remedies performed by person(s) “outside” or unaware of emergency service operations are generally not effectual. Emergency service personnel respond favorably to support services where the emphasis is on learning and education. Cross training of mental health professionals and the incorporation of peer support personnel into CISM process has proven through scientific research to be most successful.
The solution to the critical incident stress (post trauma stress) problem is a multi-dimensional crisis intervention/ psychological first aid program that includes proactive education, peer support, reactive support and referral components.
II. MISISON STATEMENT
The Durham Region Critical Incident Stress Support Team (DRCISST) was developed in 1991 to provide proactive education and reactive interventions for emergency service personnel and agencies requesting such assistance. The primary purpose of the team is to provide education regarding critical incident stress (CIS) to emergency service workers within the Durham Region. The secondary purpose is to minimize the harmful effects of job stress, particularly in crisis or emergency situations. Using the critical incident stress management (CISM) process, the team provides emergency personnel with beginning tools or psychological first aid to alleviate potential stress related reactions before they become symptoms. It is not the function of the team to provide on-going professional counseling, but a range of early education and then immediate crisis intervention services.
The services provided by the Durham Regional Critical Incident Stress Support Team are not psychotherapy. The “team” does not provided group therapy or stand-alone clinical services. Participation during any team reactive service is voluntary and participation does not establish a relationship with the team.
III. DRCISST VALUES
We believe that emergency services workers deserve and require a defined, structured and confidential crisis intervention/ psychological first aid support system.
This confidential support system/ range of Critical Incident Stress Support Management services assist each individual and group to cope with stress reactions related to his/her work.
We value and respect each individual’s unique thoughts and feelings.
We operate exclusively within the standardized protocols and procedures and as a voluntary charitable organization.
IV. DRCISST GOALS
- Provide a standardized protocol and operational procedures for all team operations and functions
- Determine standardized training for team members (for crisis intervention/ psychological first aid, individual and group process, communications, stress management, disaster psychology for emergency responder peers and volunteering MHP’s)
- Provide a quality assurance mechanism for the CISM model
- Collect non-identifying statistical data on the CISM processes with due consideration to maintaining maximum confidentiality
- Provide continuing education for team members
- Serve as a resource for other CISM teams in developmental stages
- Evaluate and share information on the evolution of crisis intervention processes
V. COMMUNITY RELATIONS OBJECTIVES
- Train a minimum of (5) five peers per agency and (2) two mental health professionals to function as members of the Team
- Work in partnership with St. John’s Ambulance Therapy Dog program to train several therapy dog teams to function as support with our team
- Deliver awareness training to emergency service agencies in the Team’s service area regularly
- Contact the educational institutions and departments that serve emergency service agencies/ workers located in the service area and provide them with information regarding the Team’s function
- Contact identified community support/crisis agencies (Canadian Mental Health Association, Durham Mental Health Services, and EMO) located in the service area, to provide the agencies with an awareness of the Team’s function and develop a link for operations
- Occasionally assist civilian groups with CISM education and/ or psychological first aid group services when there are no referral services available AND when the primary target (emergency services) population does not have immediate needs AND when DRCISST resources permit
- Connect and work with adjacent regional, national and international emergency services when we are able
VI. SERVICE AREA
The service area of the Durham Regional Critical Incident Stress Support Team will include the geographical areas contained within the Regional Municipalities of Durham. This includes:
- City of Pickering
- Town of Ajax
- Town of Whitby
- City of Oshawa
- Municipality of Clarington
- Township of Scugog
- Township of Uxbridge
- Township of Brock
All emergency service agencies including, but not necessarily limited to paramedic services, fire services, police services, water rescue services, hospital emergency staff, situated within the defined service area will receive services upon request. Services will be delivered to these agencies at no cost.
Requests originating from persons and agencies outside the service area will be reviewed on an individual basis by the team coordinator in consultation with DRCISST executive members. When services are approved and delivered to emergency services personnel outside of our catchment area, the co-coordinator will inform the requesting service that our team is a voluntary and charitable organization, and would be pleased to accept a donation from their service or group.
VII TEAM STRUCTURE
The Durham Region CISS Team is an independent charitable organization that consists of voluntary members – peers drawn from emergency services and mental health professionals from the community. This is an alliance of interested individuals that operate under these procedures and protocols without a supervisor/ worker or employer/ employee relationship.
Team structure consists of the following:
a) The Executive
The Executive Committee of DRCISST includes one representative from each emergency service (service representatives), chairperson, co-chairperson, past chair(s), clinical director(s), therapy dog team chairperson, secretary-treasurer, chairperson of special projects, membership chairperson and all co-ordinators. The Executive:
- Establishes, reviews and makes decisions and recommendations to the full reactive team regarding operational procedures, goals and objectives as necessary. Policy/ procedure recommendations are presented to a business meeting by emailing proposed changes 1 week in advance and voted on by reactive team members.
- Selects a review board when necessary.
- Selects auditors to annually review all team financial records.
- Selects the co-coordinators in consultation with the Clinical Director(s).
The team chair and co-chairpersons are elected by the membership every two years on alternate years. Our goal is that each of the leadership roles represents different services.
Emergency services representatives are elected by the voting peer membership every 2 years.
The Membership Chairperson, Secretary-treasurer and Chairperson of Special Projects are elected by the voting membership on alternate years from the service representatives.
The Therapy Dog Team Chairperson is appointed by the Executive and becomes part of the Executive.
The Clinical Director(s) are appointed by the Executive in alternate years to the service representatives.
All peer and executive members have one vote.
All executive Members are elected for a two-year term and may be re-elected.
It is an on-going goal to have an energetic, stable and representative (of all emergency services) executive, working with continuity. Half of the executive team stand for election each year at the November team business meeting.
The Executive appoints a Nominating Committee of at least 2 executive members to prepare a slate for each November’s meeting. The slate is circulated for consideration to all reactive members at the October meeting. The Nominating Committee administers the voting procedure at the November meeting.
b) Team Chair duties include:
- chair meetings;
- establish meeting agenda;
- initiate and follows review board procedures when necessary;
- may appoint an alternate as necessary
A co-chair may assist and works with the chairperson – bringing the perspective of their service and increasing the representative and communication of their joint roles.
Alongside the chair and in the absence of the chair – the co-chair assumes the leadership.
c) Membership Coordinator:
- may form an ad hoc group and function, or work as an individual;
- is a member of the Executive Committee;
- solicits and manages membership applications;
- schedules the panel and chairs the conduct of interviews of applicants;
- uses the Membership Interview Questions and oversees DRCISST Reference Check documentation;
- makes confidential recommendations to the executive regarding acceptance or non-acceptance of applicants and is responsible for ensuring feedback communication (formal letter for non-acceptance signed by the Chair) or telephone call for acceptance.
- New members are offered peer and group crisis interventions courses around their 6th month of attendance and participation in DRCISST. We encourage their services to assist in the costs of this education. DRCISST will assume the costs of education, accommodation and 1 meal/day.
d) Team Secretary/Treasurer duties include:
- maintains documentation and administrative support;
- secretarial support;
- administrative/ office location;
- prints/photocopies hand-out materials;
- prepares and distributes minutes, newsletters, etc.;
- maintains current team roster mailing lists;
- attends Executive Committee meetings;
- maintains financial records and accounts for team;
- liaises with the CGA to ensure tax filing and charitable org. status documentation
- maintains team files including attendance records, correspondence, etc.
e) Clinical Director(s):
The Clinical Director(s) is/are appointed by the Executive Committee. The appointment is reviewed every two years and duties include:
- insuring that quality clinical service is provided by the Team
- providing informal or formal debriefings with DRCISST peers as needed
- providing clinical expertise and consultation to the team members
- providing referral sources as needed
The Clinical Director(s) shall be a licensed mental health professional and is a voting member of the DRCISS Team. The Clinical Director(s) have been trained and participated in CISM process and are aware of the dynamics and needs of emergency service workers and team members.
We recommend that our MHP’s experience ride-alongs with each of the active emergency services that our team represents.
a) Administrative Functions:
- establishes co-ordinator rotation, connects with switchboard and expedites smooth on-call coverage and work
- links with administrative emergency service personnel as an advocate and representative when required
- links with ICISF as required – including hotline updates
- serves as clinical backup for peer and group interventions
- provides clinical resources internally and externally
- maintains records of certification for all team members
- links collaboratively with the other clinical director
b) Clinical Functions:
- develops and presents regular training to meet individual and team needs at training meetings
- serves as clinical backup for peer and group interventions
- provides clinical resources internally and externally
- links collaboratively with the other clinical director
f) Team Coordinators:
- carry the DRCISST pagers (property of Lakeridge Health Corporation) or an identified cell phone or blackberry and back each other up regarding call-outs, scheduling and managing an incident-response
- are on-call Friday to Friday as primary and back-up coordinator
- receive, screen and act as an ambassador during calls for support or assistance
- assess the needs, priorities and specialty approaches with each call and encourage the caller to share details (as timely and appropriate) of the event in order to promote successful matching and an informed response
- contact DRCISST members regarding the request and the event; arrange and schedule timely responses by DRCISST
- receive requests for education, in-service and information; offer information to the callers and inform DRCISST executive to promote broader awareness, discussion, continuity and and/or additional follow-up in consult with the clinical director or MHP
g) Therapy Dog Co-ordinator
- appointed by the Executive and fills an Executive role in planning, implementation and the promotion of the vision, mission and goals of DRCISST
- links the Executive with the Therapy Dog members and their role with DRCISST
- along with The Special Projects Chairperson is responsible for up-to-date documentation, affidavits and education of Therapy Dog personnel
The Therapy Dogs teams are expected to have 1 year or more of experience with St.
John Ambulance Therapy Dog Program. The dogs’ vaccinations are certified up-to-
date. An affidavit is signed by the Therapy Dog personnel that their Canadian Police
Check has been obtained, filed with SJA and reveals no criminal behaviour and these
records are kept up-to-date. This Co-ordinator also notes unique characteristics of the dog-teams – such as those dogs that are hypoallergenic.
Each therapy dog team receives DRCISST education after they have been committed
to DRCISST for 6 months
h) Special Projects Chairperson duties include:
- reviews current developments r/t psychological first aid and crisis intervention for emergency responders
- assists development of approved projects for DRCISST
- ensures that the vision, mission and goals of DRCISST are consistently applied in new project development and implementation
i) Other Committees:
Resource Committee, Peer Service Committee roles and duties can be assigned to a group or individuals by the Executive Committee.
Ad hoc committees and/or individual assignments are appointed by the executive. The roles and duties will adapt to the needs of emergency services members and DRCISST. The following descriptions will assist the executive and the membership to determine and review needs and assignments.
i) An Education Committee:
- determines the educational and training needs of team members in consultation with the Clinical Director(s)
- provides input for training meetings
- is alert for new information, research and identifies special training opportunities
- co-ordinates training for new members
ii) Resource Committee:
- actively solicits donations
- co-ordinates fund raising directions and momentum
- reviews adjunctive resources such as meeting places, community places to hold interventions, community leaders to expedite problem-solving and stocks practical necessities for interventions such as the travel box with water, juices, tissues
iii) Peer Service Committee:
- works with emergency services organizations to establish clear understanding/ education opportunities/ relevant utilization of CISM by DRCISST
- emphasizes the importance and pivotal role of subtle, quiet, individual peer support and teaches how to contact and access peer resources
- ensures the Peer Supporter DRCISST list is up-to-date and available on the website and by all emergency personnel in Durham Region
iv) Team Legal Advisor may be appointed by the Executive Committee and duties include:
- reviewing organizational structure, by-laws and other written documents that govern the structure and activities of the team
- providing advice and information concerning liability and negligence for the benefit of the team
1. Guidelines for DRCISST Coordinators:
A. Written guidelines to switchboard are:
- information/ education-request calls during day are paged out;
- hold information calls during night to 0800 next a.m.
- urgent/emergency ‘help calls”, page out right away; page second on- call if no response in twenty minutes
- paging to follow prearranged rotation roster
B. When called:
- Who is asking for help? Who was on scene?
- Obtain shift or platoon identification
- What form of help are they asking for / is this most beneficial?
- If defuse is requested…and most appropriate – get the quiet space lined up at time of the first call
- If on-scene is requested… find out who are the commanding officers, where is the rest area?
- What are crew shifts / how many units, personnel anticipated?
- Can they be taken out of service for defuse / debrief/ (varying times)?
- Were other emergency personnel involved in the incident?
- Teach the requester that we are a tri-service team and it would sometimes be beneficial for them to extend the invitation to other service colleagues
- The coordinator assesses if the initial requesting service has time and inclination to invite the other services to a defuse. We assume the responsibility of scheduling and inviting personnel to a debrief. If yes – ask them to tell the other services that they are requesting a defuse following …….. incident (date / time). All responding emergency personnel are being invited to attend at the appointed place.
The coordinator’s invitation is generally most effective. THE ONLY TIME THAT IT IS UNHELPFUL TO ENCOURAGE THE MULTAGENCY RESPONSE ARE LINE-OF-DUTY DEATH; ON-DUTY DEATH; SUICIDE OF AN EMERGENCY RESPONDER; SIU INVOLVEMENT. When this is an SIU follow-up CISM response the request is coming from DRPS and they need to be regarded as unique – with peer police support for the designated subject and witness officers responding rapidly to the division that is now housing those officers.
C. Contact Information
It may be most effective to invite the duty crew through the crew rooms at the responding station. They will then contact the duty crew members from the incident. Dispatch is called at their own location. It may also be useful to connect Durham Region Emergency Medical Service (DREMS) via their designate at ___________________
- Durham Regional Police
It most effective to call the Duty Inspector through 579-1520 or the supervisor who is most involved in this event. The Comm supervisor (@6600) will direct us to the most appropriate supervisor – for accurate information, planning and teamwork. It is important for all services to move to the involved supervisor to plan our involvement – not do this only through communications.
- Fire Departments:
It is most effective to call the large departments through their alarm rooms and the smaller services through their main numbers. Information, planning and teamwork usually works best through the Platoon Chief or Captain.
- All General Hospitals:
It is most effective to call the hospital emergency department through their Clinical Leader. They will identify the involved multi-disciplinary personnel and with them, the co-ordinator will decide how best to expedite invitations to the intervention.
- If DRCISST is NOT doing the invitations – it is essential to inform the service’s lead supervisor that intervention start time is firm. There is absolutely no admittance to the group process from 5 minutes after it is scheduled
- Consider nights/ W.E./ summer take longer to mobilize our team/ average three calls to get one DRCISS team member, but it may also be awkward to plan rapid interventions because the agency may take longer to get staff covered and pull them off duty. ALLOW YOURSELF ENOUGH TIME WHILE ATTEMPTING TO MEET THE IDENTIFIED NEEDS.
- Give requestor a time / date / place if appropriate for defuse or on-scene. Try to do this at the time of the first call as response needs to be immediate.
- Call back with planning information when you are working on setting up a debrief.
D. Developing a co-coordinating plan:
- Slow down, and take several deep breaths!
- Operate a radio of 1:5 to put together a full team. This allows for increasing numbers, door person and rabbit.
- Start with primary service who is requesting CISM. Aim to include at least one of their service peers.
- Start call-outs: tell team regarding “incident call” – provide factual information about the incident and the plan. Request their participation. “Can you go at this time?”
Be thinking where they can meet, who will be the Team Leader, can they travel together, tell them time, place, who called, nature of the intervention, booklets (1.5 x initial numbers anticipated). There is a stocked kit at DRPS. The kit should contain five tissue boxes, juice and CISM booklets.
Sometimes it is faster to purchase supplies on the way and save the bill.
- REMIND TEAM ABOUT THE NECESSITY to get a list of participants to plan FOLLOW-UP calls at 1 week, 1 month and 1 year minimum – unless the participant states “no more calls please”.
- Tell team who is their team leader and remind the team leader to complete the Individual Service Form.
- Remind team leader to report to the Clinical Director within 24 hours, sooner if concerned or in trouble.
- Ask for direct feedback if you as the co-ordinator – would like.
- Remind about “Do Not Disturb” sign on door or door person for group or relevant 1:1’s who are late.
- Inform switchboard generically about the “help-plan”. This completes the feedback loop and allows them some closure.
- RELAX – they’ll be great!
E. DRCISST Coordinator Strategies/Tools and Tips
- The 2 person on-call system is designed to promote response to our customers in 20 minutes and to provide teamwork in a unique call or when consultation is required. At times, switching coverage responsibilities occurs. It is essential to notify the Admin. Clinical Director of call changes once the rotation has been posted. This person will then notify switchboard.
- All coordinators use (LHO donated) pagers or their own cell phone/ blackberry.
- Page-outs from LH-O switchboard are most often actual calls for an intervention, but sometimes represent a request for information or education. The latter call may go to the pager rather than more appropriately waiting till the next morning. We continue to work with switchboard, fine-tuning and problem-solving.
- LH-O switchboard staff sees itself as DRCISST’s adoptive parent in some ways. They become quite anxious when it takes us 20 minutes to response to a page-out (as is protocol) and will often repage before calling the 2nd person.
- It is helpful (and policy) to check – in with switchboard Friday morning at changeover 08:00 and to follow-up a call request, by eventually telling switchboard staff (almost generically) that we are going to do an intervention.
- *When a service or individual calls, they often need to be coached through the process. Some of the data that is important to glean is: who is the caller, what role does the caller play in this incident; what is the incident; when, how long, how many and who are the on-scene and communications personnel, what was the outcome; what other emergency services were on-scene – from where; what reactions are being exhibited; what is the caller asking for – when does the caller think this will work the best. Listen to the phrases for uniqueness/ abnormalcy – in providing feedback you will begin to sort out what is needed. You may begin to decide, by chatting about options.
- Pay attentions to shift endings, rotations – when are they finished this rotation and when are they back to work. It is more difficult for some services to get out of the service, pull trucks, and have mutual aid coverage’.
- If they are asking for individual support – think group if 3 or more were on-scene. We do not provide surprise or coercive intervention. Folks need to know we’ve been called and are coming.
- On-scene intervention is unique and most often peer supports.
- Demobilization takes intensive pre-preparation and this is still a work in process. There is more planning for a demobilization than any other intervention. There is always a 2 room set-up and the plan is to tell our people when you dispatch them – rest/ feed/ teach – no defuse/ no debrief/ no digging.
- Individual support and intervention vis-à-vis a SIU call is unique and tailored, but designed to move fast, provide peer ADL support, relevant assistance including transportation to home/ nutrition/ hydration/ CISM education/training/guidance – using verbal police-peer support, written information, follow-up.
- Make a conscious decision about where is the best place to meet. Is the home base of the service most appropriate or should there be a neutral space? We have gotten away from looking for neutral space and it is an important consideration. If this is a multi-service intervention or there has been an extrication in the facility or you are aware of organizational tension afoot – think more about neutral space.
- When more than one service calls about one incident, always aim to plan a debrief 48-72 hours when possible.
- When there is more than 1 service on-scene the coordinator encourages invitation of the other emergency services. If we call the other services, we state … ‘a diffuse or debrief… is planned… regarding’ …. We are inviting your responding personnel …This usually works best through the shift supervisor or the incident commander.
- In almost all interventions it is helpful to call back to the requestor of our service. Inform them of finalizing arrangement: and who is our team leader,
- It does not work to have supervisors email invitations to emergency personnel. If we (DRCISST) are not doing the invites, encourage whoever is inviting their personnel to do this directly by phone. Supervisors continue to need coaching to NOT base an invitation on “how are you”, but to encourage participants to attend for themselves and for their colleagues.
- When you get the first call sorted out – give yourself 10 minutes to sit down and sort out what is going on here and what is really needed as a DRCISST response. Diffuse ratios are 1:4(ish) and no mental health needed unless there is responder death or the call is somehow unique, cumbersome or even weird. Debrief ratios’ are 1:5(ish) – don’t count the new team members going in as observers roles.
- Aim to include some matching of …at least the primary services – let our team members know when you call, WHEN YOU NEED THEM and a brief capsule of the incident. Remember some incidents trigger our people and they may not or may… want to respond. Ask straight-up – are you wanting and able to do this …?
- Once availability is clarified, review that you’ll call our people back once the team is built and pre-meeting plans are clear. Find out their availability so that you can minimize your calls – 3 average calls or e-mails are not unusual for a complex crisis intervention.
- Co-coordinators really try hard NOT to attend their own set-up but it’s OK to ask for feedback when the team returns.
- The Crisis Management Briefing is a newer strategy – kind of like a town hall information meeting – usually for large/ complex/ multi–layers and levels and it’s not over. We’ll talk more about this later.
- Always feel free to call for teamwork and back up. Remind the responding team-leader that they need to check in with a Clinical Director within 24 hours post-intervention.
F. Co-ordinator Checklist
- Contact name:
- Contact Phone:
- Contact Organization: Gather information about the incident
- What is the nature of the incident
- When did the incident occur? How much time has passed?
- Is there a death involved? How many? Were any responders required to handle bodies or body parts?
- How many responders were directly involved and how long were they at the scene?
- Were responders directly involved in the incident? (i.e., civilian death from the operation of an emergency vehicle? Police shooting? Will the SIU be involved?)
- Did responders perceive their lives to be in danger?
- Did anything go wrong? (This may only be found by talking to responders present.)
- Children involved? Do any of the responders have children of the same age?
- Did any of the responders spend an inordinate amount of time with the deceased? (i.e. talking to a victim during extrication)
- Do any of the responders know any victims personally?
- Have any of the responders been involved in a similar incident? If so, try to find out the particulars of the other incident(s).
- Have any of the responders suffered any significant loss in the last year? (i.e., marriage? child? parent?)
- To what degree might this incident impact the responder’s spouses/families? Note: in rural volunteer fire services – many families are listening to the scanner.
- Were there any supervisory/management persons involved? Is this complicating the event… then consider contacting a supervisor/ manager peer. Otherwise – all involved scene personnel are invited to a group intervention.
- Are they looking for a debrief/defuse?
- Do we need to contact other emergency services?
G. Co-ordinating Housekeeping
- The rotation is based on a first and second call assignment.
- It is anticipated that the first call person will be paged-out from LH-O switchboard. Switchboard anticipates a response within 20 minutes – after that interval, they page-out the second person.
- We work as a team to help each other out. When an individual is unavailable for their rotation, he/she will endeavour to switch weeks with a colleague. It works best to do this in advance when possible. These changes are then communicated to the Admin.Clinical Director.
- Pager AAA batteries are best changed regularly (every 8 weeks appears to be useful at present).
- Pagers are the property of LH-O (and a gift to us). When there is a malfunction (usually the display), LH-O communications will replace the pager unit rapidly with another that is programmed to the same number. Switchboard has been helpful in transporting the new pager to “Patient Info” in the main lobby for our convenient pick-up.
- During group interventions we also turn our pagers off. If you are the on-call coordinator participating in a group intervention, let your alternate person know you are ‘out of service’ – if both 1st and 2nd are in the debrief, let switchboard know that you are both out of services/holding calls until you check in with them after the group crisis intervention is over.
H. Co-ordinating and responding team responsibilities
- LH-O switchboard staff has developed a sense of partnership with DRCISST – many times they are aware of the unfolding event and its medical/ personal implications as they are paging us. Often when the caller into switchboard is also anxious or there is a particularly distressing event – switchboard demonstrates their own concern by paging the coordinator frequently.
- When our on-call personnel are indeed ‘working or unavailable’ it is useful if this coordinator can let their own colleague-coordinator know of their own need for backup. When this is not possible and you are paged, let them know that you need help…’ please page my backup’.
- Upon returning the call, the coordinator will determine the caller’s role in the event and the basis of their request. This begins the discussion of: what happened/ when/what are they seeing in their personnel/
do the involved personnel know that DRCISST is being requested?
- This will help you decide WHAT you are planning to organize: do they need a site response – on-scene support (or rarely and only with substantial preparation and planning, a demobilization), a fairly-soon-response back at the station/hall/base – to do a group defuse or a 1:1 peer support and/ OR may you also need to look towards organizing a debrief within 24-72 hours when possible OR when it’s a big community event, also consider a Crisis Management Briefing.
- Try not to be the responder yourself – this takes you out of commission and makes your rotation week longer.
- In your discussion with the caller, try to get a sense of the numbers of personnel and emergency services involved. When you are moving towards a debrief – it becomes your challenge to find the central persons in each service so that you can determine shifts/ rotations/ mobilize invitations to all relevant persons.
- Often this is your first contact with the caller. When you have a little more time to plan, you are still likely to call back to this person with details such as place/ precise times. Cultivate a positive relationship here because you’re going to need this person to be committed to this process. It is crucial that services do not use email as a primary contact means with the involved personnel – personal calls are much more effective in recruiting attendees and diminishing rumour. Emails by supervisors have proven to be unsuccessful and ineffective communication.
- Now that you have a sense of what happened and what is the best intervention, you can take a couple of minutes to sort out what and whom you need next.
- Look at your list and see if you have the luxury of remembering who has been most active and who is chomping to do some work. With this in mind, view the needs of the people at hand and try to match DRCISST personnel services and strengths with the needs at hand.
- If you are planning a defuse, use 2 or 3 same service peers (when possible) for up to 8 participants.
- If you are managing an intervention r/t on-duty injury, line-of-duty death or suicide of an emergency responder, use more than less same services peers and always pull in a MHP as well for a group interventions.
- When you call DRICISST personnel, briefly highlight the event and request/ remember…our folks may be overloaded with past similar events and be sensitive to their choice – offer the opportunity of declining.
- Have a sense, as you are undertaking the call-out… who might be your team-leader and where you will direct people to meet to do their prep and planning. Remember to delegate someone to get the kit or get supplies at the store on their way in.
I. Special Considerations – SIU interventions
- DRPS has mandated that DRCISST is activated when the SIU invokes their mandate. It is crucial to approach these peer supports with awareness and sensitivity. Once of the most frequent comments from a subject officer is their perspective of isolation. When the situation requires, one peer support DRCISST officer is rapidly dispatched to the relevant division and assigned to the subject officer for the duration of the investigations. Additional peer supporter(s) hopefully are sent for the designated witness officers. This is a time of teaching/ teaching/ teaching.
- In the past, we have approached any group crisis interventions with great care – indeed separating witness and subject officer. Although this debate continues, it remains worthy of serious and case-by-case evaluation of the strategy that is most appropriate in each instance.
- It has recently proven successful (after all of the SIU interviews are completed, to put a seasoned DRCISS team together and then undertake a ‘full group debrief’ – not separating the involved officers. During such debriefs, the DRCISST team needs to carefully translate ‘the rules’ with special emphasis on the meanings of:
- Confidentiality: not only a unanimous agreement of not sharing information discussed, but also clarifying that this is also an agreement to not operationally use the debrief information;
- Reviewing the ‘no rank in the room’: to ensure commitment to and comfort with the concept of the confidentiality agreement is reiterated as above.
- We are trained to clarify that CISM is a crisis intervention/ crisis education process. We also know that telling and re-telling the story of the event is part of the healing perspective. These are important aspects for our team to prep for and to clarify their own decisions and intentional plans in order to do the debrief theme work, in a deliberate, successful and careful manner.
IX TEAM MEMBERSHIP
The following process applies to team membership:
Team Membership is composed of three groups: General Membership, Reactive Services Membership and Special Membership (to date the St. John Therapy Dogs and their handlers.)
- Team members serve for a minimum of one year.
- Any member wishing to withdraw from the team for any reason should discuss the matter with the team chair and submit their resignation in writing to the team chairperson.
- Current reactive and Therapy Dog team members must sign a Memorandum of Understanding for each one-year period.
- It is expected that Membership means attendance of 75% of training meetings and 66.6% of business meetings
- Vacancies created will be discussed by the team and recommendations made to the Executive Committee regarding replacing members on the basis of: number of vacancies, type of emergency service or agency previously represented by any vacancy, current membership, time interval to end of vacant term, availability of training funds/opportunities.
- New members will be solicited, screened and interviewed according to established criteria.
- Team members are provided with an identification tag, DRCISST bag to be utilized when conducting DRCISST representation. Hats and golf shirts are available for purchase by team members.
A. GENERAL MEMBERSHIP CRITERIA
General Membership is available (by application) to agencies and individuals interested in or providing emergency services to the Durham Region.
B. REACTIVE SERVICES MEMBERSHIP CRITERIA
The Reactive Services Membership is available through application and the Membership Committee approval to emergency responders and mental health professionals. These individuals participate directly in the DRCISST Crisis Intervention/ Psychological First-Aid Services.
The following criteria are considered in screening new applications for membership in the Durham Region CISS Team Reactive Services:
- Completed the application form
- Emergency services experience and background at least 6 months at work
- Training in areas of stress/psychology and willingness to do CISM basis and peer education at start
- Evaluation of reasons for wanting to be on team
- Accessibility to meet team responsibilities
- Respect and trust of peers
- Ability to keep confidences
- Ability to express self
- Sensitivity to others
- Ability to work within an established framework
- Self identified assets/deficits
- Type of service represented (i.e., fire, law enforcement, mental health professional, dispatch)
- Geographic location of candidate
- At least 12 months away from a major and impactful event of their own – prepared to discuss this with the interview panel.
Mental health professionals should be employed in one of the following areas:
- Social services
- Psychiatric nursing
- Crisis intervention services
- Mental health/pastoral counseling
- Psychiatry or general practice medicine
Mental health professionals should have specific training in the following:
- Crisis intervention, psychological first aid
- Stress response and stress management
- Group process
- Directive intervention
- Communication skills
- Post traumatic stress disorder
- Cross training in emergency services, cultural sensitivity and be willing to obtain this experience
- Mental Health Professionals must have current professional licenses and liability insurance where applicable.
C. SPECIAL MEMBERS
Special DRCISST members are presently St. John Ambulance therapy dog handlers and their dogs. Special members are assigned a DRCISST mentor member during their tenure on DRCISST. During an intervention a special team is always buddied with a peer member.
D) STANDARDS OF REACTIVE SERVICES
DRCISST expects reactive and special members to adhere to our Standards of Reactive Service. These include:
- Adherence to membership and attendance criteria;
- Participation in group and peer support crisis Intervention training as requested.
- Participation in business and training meetings and education/ outreach opportunities.
These are essential components of teamwork and appropriate, successful interventions.
E) TEAM MEMBER DUTIES AND RESPONSIBILITIES
DRCISS Team members are emergency services workers or mental health professionals with an interest in crisis intervention who have made a commitment to volunteer their time, energy and resources to the Durham Region Critical Incident Stress Support Team.
All member duties and responsibilities include the following:
- Serve as team member for interventions as assigned by the team coordinator or peer support when requested by a colleague.
- Complete required Service Form and submit to executive.
- Provide crisis intervention and support during disaster situations for rescue workers and victims within training and protocol guidelines.
- Participate in regular continuing education sessions.
- Present educational programs on CISM to agencies and groups requesting this service, when requested to by DRCISST.
- Submit a record of education/in-service programs presented to the executive.
- Serve on team committees and positions, as requested.
- Serve as a member of a Peer Review Board, as requested.
- Develop and submit, as appropriate, materials for handouts and educational materials.
- Remain informed of team operational policies sand procedures.
- Be a team member ethically and operationally.
F) TEAM TRAINING
- All new reactive team members and MHP members must complete the new basic team member training (approximately 16 hours – individual and group crisis intervention training) before undertaking interventions.
- Mental health professionals benefit from cultural training and ride-alongs with all emergency service agencies within the first three months of membership
- Reactive DRCISST peer and MHP members are encouraged to continue their CISM and group/ individual crisis intervention/ psychological first aid training and practicum experiences. .
- Special members are expected to attend 1 identified DRCISST training night per year.
G) TRAINING for SPECIAL MEMBERS AND THERAPY DOGS
Special member (St. John handler and dog teams) complete The Special Member 6hour Training and Selection process developed by the team and attend a specific team training meeting annually. The initial selection/ training is completed within 3 weeks. The handler and dog will have been a working member of the St. John program for a minimum 12 months.
On the first evening of training interested St. John members/ dog handlers attend.
- One DRCISST member is assigned to take notes during the 3 training nights.
- DRCISST members and St. John members introduce themselves, tell a little about themselves.
- The team video “I am a Rock” is introduced and presented;
- DRCISST peer members of various services carefully describe a variety of first responder scenarios that the team has been invited to assist in 1:1 work, defuses, debriefs and national/ international incidents.
- DRCISST Special Projects Director describes some of the scenarios and mission that we visualize for expanded teamwork with St. John special members and their dogs;
- DRCISST MHP describes useful communication skills, entrance lines, active listening r/t this new teamwork;
- DRCISST members describe why this work is important to them – and ask St. John’s members to reintroduce themselves and state why they are interested in joining this team. St. John members who are still interested are given their DRCISST modified application form.
- Successful St. John members will have completed their acceptance process with St. John’s Ambulance, will have been actively visiting with St. John’s for at least one year (actively) and will successfully complete the DRCISST special member interviews, training and police check.
On the second evening of training
- St. John members return their completed application form and attend with their dogs.
- DRCISST members present 2 scenarios:
- Scenario 1 is the rest area of the emergency responder disaster response teams. There has been an aircraft disaster – a large airbus has crashed in Durham Region. The initial CISM response is demobilization and attendance in the rest/ food area. Individual responders come through this area for shift-break. Some of the first responders are very distressed by their mission. These people are approached by the DRCISST and other CISM members for 1:1 support and assistance in reaction management, designed to help them get back to work. The therapy dogs have a positive role in 1:1 support leading to this assistance and education. One St. John’s handler and dog work with one DRCISST member who is role-playing as an impacted emergency worker
- Scenario 2 is an urban firehall – the trucks are coming back slowly after a disastrous fire where 3 children have apparently died and been removed by firefighters to the paramedics. The firefighters have had long on-scene time and are tired, irritable and distressed. The DRCISST members will be doing teaching and reaction-management intervention in 1:1 and small group work. The therapy dogs have a positive role in 1:1 support leading up to education and individual/ group intervention.
DRCISST members will interview St. John members (in groups of 3) and make notes regarding their individual and group dynamics.
On the third evening of training
- This is a large group event. The purpose of this evening is to assess the larger group skills and conflict adaptation of individual St. John handlers. The group scenario is a discussion about this innovative and specialty role of therapy dogs and their handlers. DRCISST members present opposing ideas regarding their acceptance of the roles of therapy dogs. The DRCISST and St. John group facilitators offer the group as a whole, but uniquely to the St.John members… an opportunity to interact and discuss their experiences and beliefs in this (participatory conflict management) new program.
- Ideally 4 DRCISST members are participating as the training and selection team alongside the St. John Coordinator for this process.
- A predetermined number of new special members are then selected and informed by phone. Those members that are not successful are informed in writing.
- These special members are asked to sign a modified Memo of Understanding and are assigned to a DRCISST buddy.
Modified Application form and
Modified Memorandum of Understanding are in the Appendices.
H) REVOCATION / SUSPENSION OF MEMBERSHIP
Team membership is revocable at the discretion of the team chair on the recommendation of a Peer Review Board. The team chair shall discuss all recommendations for suspension with the team executive and clinical director(s). The following guidelines represent some criteria for membership review:
- Organizing or in any way attempting to organize a formal debriefing, or any other CISM activity, without the team coordinator prior knowledge and approval.
- Failure to be present at an assigned debriefing; formal or informal; or at a scheduled educational or in-service presentation, when the member has made a commitment to do so.
- Any misrepresentation of the Durham Region CISS Team, including responses to incidents without the team coordinator’s approval.
- Continued absenteeism at regular meetings (over 50% of meetings in a calendar year)
- Acting against the expressed direction of the team coordinator, clinical director or chair.
- Violation of confidentiality of confidential team interventions or educational reviews;
- Failure to follow protocols, directives or operational procedures regarding team activity.
Peer Review Board Procedures:
A Peer Review Board of three members shall be selected by the team chair to evaluate any reports or cause for membership revocation or suspension. The board will consist of a mental health professional and two other active members of the team, if the matter involves a clinical matter. For non-clinical problems, any three-team members may be selected.
For clinical issues the following procedures apply:
- The Peer Review Board shall meet or discuss the problem with the member within seventy-two (72) hours of notification.
- The Peer Review Board shall file a written report and recommendations within forty-eight (48) hours of the meeting to the team chair.
- The team chair will review and initiate any disciplinary action recommended by the Peer Review Board.
For non-clinical issues the following procedures apply:
- The Peer Review Board shall meet or discuss the problem with the member within one (1) week of notification.
- The Peer Review Board shall file a written report with recommendations within one (1) week of the meeting to the team chair.
X. SERVICES PROVIDED
All services of the Durham Region CISS Team shall be approved by policy and/or the Clinical Director. Several types of service may be delivered depending upon the circumstances of the incident. They may be conducted on an individual one-to-one basis or groups. The following types of services, singularly or in combination, are most commonly utilized.
Pre-incident education regarding stress, stress recognition and stress reduction strategies is an essential part of the CISM process. Educational programs for front line and command staff include information on critical incident stress interventions, how to contact the team, on-scene considerations, etc. Programs for spouses and significant others and may also include stress recognition and management.
Three types of services may be provided:
- one-on-one intervention with rescuers who show obvious signs of distress
- assistance to victims of incident
- consultation to the scene commander or commander officers
Therapy dog teams augment peer supports and always work with a buddy on-scene.
Crisis Management Briefing (CMB)
An expanded concept for a group informational briefing – a crisis intervention strategy following community violence, acts of terrorism and significant disasters.
It is a large group crisis intervention (up to 300) which lasts 45-75minutes.It resembles a town hall meeting for crisis intervention.
The CMB is best conducted by an intervention team:
- a mental health professional who has technical credibility to teach phases 3 and 4
- additional MHP’s and senior peers in the audience to assess and triage
- alongside CISM members are credible management/ administrative leaders, audio-video and sometimes press resources
A mini-intervention for a small working group (i.e., a police tactical squad, a pumper crew, etc.) conducted at their station shortly after the incident, usually within 3-4 hours, no later than 8 hours after the incident. Generally, this process lasts 20-45 minutes. A defuse provides information about the incident and general information and advice on stress reactions. In some circumstances, it may involve a more in-depth discussion of participants’ reactions – with teaching-to-the-reactions. Defuses may be performed by a minimum of 2 experienced peer debriefers. A defusing may eliminate the need for a formal debriefing.
(Note Introduction – Education – Information = I.E.I.)
A formal debriefing s ideally conducted within 24-72 hours of the incident. A debrief is a confidential non-evaluative structured discussion of the involvement facts, thoughts and feelings resulting from the incident. A debrief provides structured discussion and emphasizes education regarding post trauma stress reactions and strategies to minimize them.
One-to-one or group interaction or observations reveal individual difficulties that may be event-related, cumulative and/ or deeply personal. DRCISST does crisis intervention work using a range of services.
Some participants will require follow-up referral to assess and treat their mental, physical health. Peers consult with the participating MHP or clinical director regarding referral directions or direct response by DRCISST’s MHP. Rarely …it may be an essential measure to directly take a participant to a follow-up resource.
This is an informal discussion of the event by individual crews following a return to quarters. Initial discussion occurs spontaneously in many groups and is not structured. It may be facilitated by a team peer member who is present. The focus of discussion should be education regarding reactions and a potential formal request to DRCISST to initiate crisis intervention services.
Follow-up services are ideally conducted at one (1) one month, (6) six months or (1) one year of event being defused or debriefed.
Within DRCISST there is a special member team of St. John Ambulance handlers and their therapy dogs. This team is buddied long-term with a DRCISST peer or MHP and perhaps short-term, during an intervention with another team peer. Therapy dogs represent safety, non-verbal support, physical regrouping and unconditional acceptance in varying CISM settings.
Civilian specialty services are defined as providing crisis intervention/ psychological first aid for groups not directly involved in emergency services or otherwise outside the realm of the CISM/CISD team, and include significant others.
Our services may be requested if parallel services are not available in the mental health community. Approval will be the responsibility of the team coordinator in consultation with the team clinical director.
Demobilizations are only used when they have been structurally planned for/ and there are appropriate facilities at-hand. Demobilizations are only used when planning has been undertaken with senior personnel and a protocol has been established. A mental health professional may take up to 20 minutes to provide information on the signs and symptoms of stress reactions that may occur. Special handler and dog teams’ circulation can be a helpful part of demobilization DRCISST services. Unit may be released from duty or returned to their station in service. Incident commander may require that all personnel go through CISM demobilization session before they are released from the scene. Note: not yet developed by DRCISST.
XI. GROUP C.I. PROTOCOL
Emergency services personnel, command officers, and medical control authorities are responsible for identifying and recognizing significant incidents that may require crisis intervention. When an occurrence is identified as a “critical incident” a request for CISM Services should be made, as soon as possible.
The team is activated by a call to switchboard at Lakeridge Health Corporation. Appropriate call information is obtained and related to the team coordinator. The team coordinator also refers requests for educational / in-service presentations to the Executive.
DRCISST has developed an attendance letter for attendees of any DRCISST intervention. The letter may be of use for future WSIB claims, and this needs to be explained to attendees. The letters are to be made available to all attendees for their use; DRCISST does not keep a copy of them.
Pre-incident education is presented by a team of peers, mental health professionals and special members when possible. There is a standard agenda and power point presentation. Please see appendix.
Crisis Management Briefing (CMB)
It is a large group crisis intervention (up to 300) which lasts 45-75minutes.It resembles a town hall meeting for crisis intervention. The CMB is best conducted by an intervention team including mental health professionals, senior peers and CISM members. Audio video and press resources sometimes used.
There are 4 phases in this intervention:
- Assembly: there are identified target groups – as in every CISM intervention we are identifying similar group-experiences.
- Information: anxiety and rumours are educated by a factual presentation by the most senior, informed person. Depending upon the group this may be the premier, the mayor, the principal, the hospital administrator or senior trauma physician.
- Reactions: credible MHP normalizes and describes behavioural and psychological reactions.
- Coping Strategies and Resources: MHP and senior peers provide stress management techniques, personal and community resources and handouts.
Triaging individuals who demonstrate some ongoing difficulties and challenges – will result in follow-ups, referrals and potentially identifying the value of debriefing groups.
The Defusing Process (I.E.I.)
There are 3 main segments, which are linked to each other in a free flowing conversation about the event:
- Introduction: The DRCISST team introduces itself and the guidelines. The tone and expectation in this phase describe the shorter nature of this process (generally not more than 45 minutes) and simultaneously use all of the framework guidelines.
- Exploration: Participants are asked to discuss the factual experience they have just had. This process unfolds conversationally. DRCISST makes gentle and subtle efforts to get participants to talk a little. There is not a sense of pressure, but we convey concern for all members of the group. We attempt to clarify what happened and their roles – ask about details and interactions on scene once someone opens a door. As the group relaxes a little, they tend to talk more about the traumatic experience. When there is a lag – it usually indicates that DRCISST will head towards ‘information phase’.
- Information: Combines the teaching and re-entry phases of the debrief. DRCISST will provide as much useful information as possible to help participants manage their stress.
- Accept and summarize the information by the participants
- Normalize the experience and reactions
- Teach practical survival skills
- Open the door for questions – provide answers
- Introduce the potential for debrief and note willingness
- Make summary comments: offer handouts for participants and their families
- Stay around for a while and chat with individuals and the group over juice.
The Debriefing Process
There are 7 main segments and this is the most complex of all CISM crisis intervention strategies. This group process is a meeting/ discussion targeted to the beginning mitigation/ resolution of stressors associated with this traumatic event and then education regarding individual and collegial stress management.
DRCISST uses a peer driven process supported by MHP’s (offering guidance and clinical supervision). Thus, if this event is primary to one emergency service, DRCISST’s intervention-team leader and ‘starter’ is our member of that same service. This is a structured and formal discussion.
Essential considerations for a CIS Debrief are 3 main points:
- The group to be debriefed is homogeneous
- The mission is completed
- The traumatization is roughly equal
- Introduction: Is crucial and detailed. It sets the stage for the entire debrief, provides the framework and guidelines and may remove/ sort out the participants. The team shows itself to be confident, committed and concerned with the participants. The team reminds itself quietly to watch each other, use predetermined codes and work in all ways as TEAM.
- Fact: Is the easiest segment as the descriptor of the facts of the event; the facts are a collection of items outside oneself and are impersonal. The stage answers the questions: who are you, what was your job/role during the incident, a brief description of what happened from your point of view. Although participants may begin to express their emotion, we do not probe.
- Thought: This phase is the transition between cognitive to affective domains of the responders. It begins when the DRCISST peer member asks participants to state their first most prominent thought once they were not operating on autopilot. This stage requires alertness of DRCISST members as participants are becoming more involved.
- Emotional Reaction: usually if we have set the stage well, this is like a series of rolling waves. Do not speak unless it is truly necessary.
- What was the worst thing about this situation for you personally?
- Or…what part of this event bothers you the most?
- Or… If you could change one thing without changing the outcome – what would you change?
- Or…what aspect of this event causes you the most pain?
- Or…what do you think will stick with you the most?
- General Reactions: This stage moves away from the round-circle input and moves the group back from emotionally-charged towards a greater sense of safety as they think about their total reactions. Often they have already talked about their distressed-general reactions (such as impaired concentration, insomnia, restlessness, irritability, fatigue etc) DRCISST members will use what they have talked about, in framing the ‘normalcy of general reactions’. The DRCISS Team members will talk to the reactions that have occurred and those that may occur. In some places, this is called the symptoms phase, but we believe that general reactions are related to the biochemical and neuropsychological stressors, which are totally normal and last 14-16 days. Thus, we do not use the symptoms-language! This stage opens the door for good teaching and re-entry, identifies the normalcy of Critical Incident Stress for persons and reactions and that this process of crisis intervention offers a beginning series of tools.
- Teaching/teaching/teaching: Never underutilize this great stage!
- It easily follows the descriptions of general reactions and is very thought (cognitive) based. Make sure that as a team, we cover tools for nutrition, exercise, social, work, personal self-assessment rehabilitation. Sometimes at the end of the teaching process and as a bridge to re-entry there may be an opportunity to review positive additional occurrences:
- Was there something small that happened during or as a result of this event that lessens the chaos or pain just a little;
- Is there something valuable that you have learned about yourself form this experience?
- These opportunities should be thought out, assessed and used carefully.
- Re-entry: Clarifies issues, answers questions, summarizes and returns the group to their normal functions: DRCISST members will:
- Answer questions identified. Reassure and inform as needed – including about follow-up plans;
- Be very careful in the re-entry – it is tempting to tell a similar or reassuring story that may have happened to you. This is almost always less then helpful. It may be useful individually over a snack afterwards, to let the person know – you have walked in their shoes… then let them ask you about your story, if they want clarification or specific support.
- Provide summary comments are usually respectful, appreciative, encouraging and a little … directive.
- Re-entry is the opportunity for team members to identify and sort out whom they are going to approach first and where are the individuals who may be more at risk. The seeds of potential referral to the MHP in the room or the identification of future follow-up needs are thought-through and action plans are beginning, which will be implemented as folks socialize and chat post-debrief.
- A post-debrief meeting always occurs. We review important tasks:
- What was done during the CISD and what did we learn;
- Follow-up and referral specifics are clarified;
- DRCISST members debrief each other spontaneously and openly.
Defuse/ debrief process considerations include:
- The location selected should be free of distractions and represent a neutral environment (i.e., school, church or other meeting facility). Crew quarters or station may also be utilized, if appropriate to the circumstances.
- All emergency personnel involved in the incident should be invited and encouraged to attend. Supervisors are encouraged not to assess participants by asking how are you in advance.
- A time should be selected that is most convenient for as many responders as possible and for the team members.
- Agency management or command officers should be encouraged to relieve personnel from duty during the debriefing. The environment should be free of interruptions, telephone calls, radios and pagers.
- Team members should coordinate a time and location to meet prior, to discuss the incident, any available resources information and the approach to be used. Rarely, they may wish to visit the incident site. One team member is requested to obtain up to date factual, current status reports
- Seventeen concise rules or guidelines:
- Look around the room
- Confidentiality agreement
- Right to speak for oneself
- Right to refuse to speak
- Asked not to leave to room … (rabbit)
- No notes
- CISM = organized discussion of a traumatic event/ by trained personnel of peers and MH
- No rank in whole room – be a person
- Turn off pagers and distractions.
- Here for you now – here after plus want to plan follow-up contact with you before we go …
- Structured process starts by our introductions, then yours… at the beginning will be asking you to introduce yourself your role and what happened from your perspective
- Participation helps the whole group
- Not an operational critique
- CISM rationale is recovery – acknowledging the trauma, finding the tools; information taught towards the end
- No reporting back
- No breaks …. described BR locale/requesting returns
- Remind confidentiality
Peer support is a one to one intervention starting from the needs of individual emergency response personnel. It utilizes the strategies in both the diffuse and the debrief processes. Peer support can be a stand alone intervention (one time or continuing) or an outcome of a group intervention. Peers are reminded to check in with the clinical director within 48 hours of a peer to peer intervention initialization.
Demobilization services, also known as de-escalation or decompression, are reserved for large-scale disasters. An accepted definition criteria is that 40% or more, of the emergency service resources respond to a single incident for a period that is longer than the average shift. The objectives of demobilization are to:
- Provide a place for disengaging units (not returning to the incident) to rest; get something to eat and drink, away from the scene and in a comfortable atmosphere before returning to quarters or to home.
- Provide information and education on possible stress related affects, and initial ventilation, if necessary.
- Provide opportunity for selective circulation of therapy handlers and dogs with their assigned buddy to provide any necessary follow-up or 1:1 peer support.
- Provide command officers with an opportunity to give updates or closing remarks.
Consider the following guidelines when recommending a demobilization to command:
- Command will determine if demobilization will occur and the site.
- Demobilization site should be large enough to accommodate the anticipated numbers of personnel in two distinct areas: demobilization and nutrition.
- Demobilization services may be handled, unit-by-unit, by team MHP’s, off-duty peers, or an unrelated peer for each group of up to 8 emergency service workers.
- Prepare a handout and copy it. Include signs and symptoms, diet information, exercise recommendations, etc.
- A team member will greet each arriving unit, record names for tracking and follow-up, and escort them as a unit to the demobilization area.
- A team member will take 10-15 minutes maximum to discuss stress and recovery information. Suggested format:
- Recognition of workers efforts and their fatigue.
- State your objectives; a desire to give workers a chance to rest, ‘unwind’ and eat before returning to quarters or home.
- If a formal debriefing is possible or scheduled, provide the appropriate information.
- Inform the workers that: some of them may have no reactions to the incident and that is normal; some may have a delayed reaction and that too is normal; some may already be reacting to the incident and that too is normal; provide a brief sampling of typical reactions to critical incidents; give each of them the prepare handout and refer to it; if anyone wants to stick around and ask questions or talk, we’ll be here, or call us later at the numbers on the handout; send them to eat.
- Nutrition after demobilization, 20 minutes minimum.
- Only emergency service supervisors or officers will report on the illness, injury or death of any co-workers and the progress of the incident. TEAM MEMBERS DO NOT OFFER THIS INFORMATION, BUT WILL PROVIDE SUPPORT. DRCISST members are not members of the workers units or family and it is not our place to inform them about any such news.
On-Scene Support Services
Support services and interventions may be provided during an emergency incident. These may occur at or near the scene of operations. In most cases, peer team members will provide these services, although mental health professional members may be requested or required, if the situation warrants. On-scene support may consist of the following elements:
- One-on-one support to emergency service workers showing obvious signs of distress.
- One to one support at rest area by peer members and special team members (handlers and therapy dogs).
- Advice and assistance to incident commanders regarding stress management by the team leader.
- Assist when directed by team leader from incident command… to victims, survivors and families victimized by the incident.
a) PEER MEMBER ENGAGED AT THE SCENE
Any peer member who is dispatched to an incident as a member of an emergency services organization is primarily responsible for operating with that agency. For example, firefighters accompanying their units to the scene will serve in the capacity designed by fire command. The same holds true for all other emergency service personnel responding/involved in an incident.
While performing assigned duties, it may be possible for the peer member to observe the incident scene for situations that may increase the potential for a stressful impact. It may also be possible, while performing assigned duties, to observe personnel for signs of obvious distress. While these are not the primary functions of these persons at this time, appropriate disclosures of their observations may provide insight to command officers. If the need to make recommendations to command becomes obvious or if the peer member suspects that the potential for the development of affect is unusually high, the peer may suggest to command that they consider contacting the CISS team. If command should designate the peer member as CISS on scene support, the peer shall request additional assistance from the CISS team. The rationale for this requirement is:
- To keep the team coordinators informed of the activity.
- Is inappropriate for the peer member to provide services to their own units.
- Is too ‘draining’, physically, mentally or emotionally, for the peer member who is has been engaged in service to carry out the functions of on scene support services.
b) PEER MEMBER DISPATCHED TO THE INCIDENT
Reactive team members dispatched by a coordinator shall travel together in a minimum number of vehicles, mileage maybe claimed for personal vehicles used to and from the response site. Attempts will be made to have the team members escorted to the scene by an emergency service agency to expedite access to the scene.
c) ON-SCENE CISS TEAM-LEADERSHIP
The team leader is clearly designated by the co-ordinator and shall act as team leader and will report to the incident commander. This member will advise the incident commander of the number of CISS Team personnel, team location, possible team activities, and request direction from the officer. The team leader is the liaison between command and the team, for the duration of on-scene support services. Any recommendations or observations of any team member are to be made to the team leader. The team leader should establish reporting times with commander.
d) ONE-ON-ONE INTERVENTIONS on-scene
One-one-one interventions will be provided only to those workers displaying signs of distress and who are receptive to assistance. Signs of obvious distress include:
- Shock like state (i.e., ‘thousand mile stare’)
- Unusual behaviour
- Acting out behaviour
- The interventions will normally take place during a break from active service, and will last 5 to 15 minutes’
- Interventions with therapy dogs are supportive, safe, minimum verbal interactions and buddied with a peer.
- Interventions should take place in a neutral environment away from the sensory elements (sights, sounds, smells, etc.) of the incident. This is support, not therapy.
- Interventions focus on the immediate (here and now), use the following as a guide:
- ASK: What is happening with the individual at that moment?
- LISTEN AND REASSURE: Display good attending skills, offer supportive comments. Reactions are normal (not abnormal), dispel the ‘myth of uniqueness’.
- STATE: Inform the emergency service worker that the main objective is to help them regroup and be ready to return to work. Set goals and objectives early in your contact with the worker.
- REINFORCE: Reinforce positive activities and remind worker of skills and strengths. Give minimal advice. Distressed individuals should show signs of improvement within 15 minutes of the intervention process.
- NOTE: Interventions are successful if the actions are genuine; sincere and team members offer assistance in a confident manner. When in doubt as to what to say or how to say it, consider asking yourself. ‘If I were in that person’s position right now, what could be said to me that would be most helpful?
- No ‘Group’ intervention in the field AND no feeling focus in the field!!! Everyone is at different emotional levels.
- It is our procedure to recommend to the incident commander that all persons receiving one-on-one interventions are given an additional 15 to 30 minutes rests after the intervention is completed (15 minutes increments to a maximum of 45 minutes). During the rest period, team members will allow the emergency service worker to ‘rest’ and will not remain actively involved with the worker, but will move away to provide some ‘breathing room’. Therapy dogs and their handlers can be very useful to bridge the 1: 1 contact coming in or leaving with an emergency worker.
- When leaving the emergency service worker to rest, the team member should advise the worker that they will be back in 15 to 20 minutes to check on them and that the worker is to remain there until that time. An assessment of the worker can then be made after the rest and a return to duty or an alternative action can be recommended to command.
- Restoring an emergency service worker to duty will depend on how they are functioning and/or feeling after the intervention and rest.
- If there is a return of the distressed state or no reduction in the distress, the choice should be removal from the scene.
- Removal from the scene is a last resort; removal to home is a very last/last resort. Removal from the scene should be carefully planned to avoid having distressed emergency service workers left alone.
- Distressed individuals should have a vital signs assessment by a medical staff at the scene. Injured emergency service personnel should be removed for medical attention.
- If the emergency service worker is displaying psychotic behaviour, immediate removal from the scene is indicated.
e) ADDITIONAL FIELD SERVICE PROTOCOLS
- All CISS team members acting on behalf of the team shall wear team ID at all times while at the scene.
- Team members should be appropriately dressed. Protective clothing to be on site, proper shoes/boots, head protection, cold/wet weather protection, etc.
- Yellow golf shirts and hats should be worn when appropriate for additional identification.
- No team member will go inside an internal perimeter unless requested to do so by DRCISST Team Leader on behalf of the commanding officer.
- The team leader is accountable for the location of team members throughout the incident.
- Except in extreme circumstances, the team leader will be the only liaison with command.
- The team leader will assign tasks to other team members.
- Team members will attempt to maintain a ‘low profile’.
f) ADVICE AND ASSISTANCE TO COMMAND (via the DRCISST Team Leader)
Team members may offer advice and assistance to command only through the DRCISS team leader. All decisions are the responsibility of the commander officers. The team leader will act as the liaison between the incident commander and other team members whenever possible.
Some considerations for minimizing stress and maximizing performance include:
- Rotation of staff, all staff, including command. Two hours of duty, followed by a 15 to 30 minute rest period will decrease the possibility of injury, decrease fatigue, and decrease intense emotional drain. Circumstances may dictate shorter work cycles. If crew is within 10 to 15 minutes of completing a significant activity, let them complete the task before a change in duty assignment. Do not listen to ‘I’m OK’; rotate the workers.
- Provide rest and relaxation sites away from the noise, sights, sounds, etc. (all senses) of the scene.
- Brief new personnel prior to scene entry. Avoid surprises, use video, Polaroid pictures, etc. Advise emergency service workers if they will be doing additional damage to mitigate incident (i.e., washing away body parts, cutting through bodies to remove others, etc.) No freelancing, no rubbernecks. Assign and execute.
- When rotating crews, it is suggested that part of an old crew be replaced with part of a new crew, for the first few minutes. This will permit the new workers to learn the new task. Once this is accomplished, the rest of the new crew will replace the remaining members of the old crew. As far as possible, engage crews together and disengage crews together.
- If it is not possible to give workers a rest period, rotate them to lighter duty. Crews should go from intense duty to medium duty to light duty. Those at light duty should work their way up to intense duty.
- Four hours of duty without a break will cause extreme emotional and physical fatigue.
- Maximum scene time for emergency service workers should be 12 to 14 hours, regardless of the rest/rotation sequences. This is vital if the same personnel may have to resume duties at the scene on their next shift.
- Command may need to alter normal routine during extended operations. For example, volunteer firefighters may be required to man station 24 hours a day; extended operations of several hours or days may require emergency workers to sleep at or near the scene during rest periods.
- Never commit 100% of your staff.
- Advise all personnel when strategic operations switch from rescue to recovery.
- Keep emergency service workers away from the media. Command should appoint a public information officer as part of the emergency management staff.
- Watch workers nutrition. Fresh or dried fruits, granola and carbohydrates are good. Clear fruit drinks and cool water are ideal. Foods with high fat and sugar should be avoided. No caffeine (coffee, tea, cola drinks, etc.). No alcohol at the scene or for as long as 24 to 48 hours after the incident. Avoid ‘Gatorade’, too much sugar, or dilute at least 50% with water. No ‘Squint’, ‘Recharge’, etc. – as they disrupt electrolyte balance.
- Team members may have a better opportunity at long scene-incidents for all overall observation. Watch for the following and bring it to the attention of the team leader:
- Inappropriately dressed emergency service workers (weather, safety, etc.)
- Need for food or water
- Need for rest breaks or toilet facilities
- Need for demobilization
- Need to establish victim/survivor staging area, and contact victim support organizations
- Need to return worker to alternate or lighter duty
- Need to remove worker from scene, and the need to send someone with the worker
- Any reason where command is unaware of a potentially harmful situation
g) ASSISTING VICTIMS, SURVIVORS AND FAMILIES – on-scene
Assisting victims, survivors and families is not the function of the CISS team. However, from time-to-time it may be necessary to provide interim support to these individuals so that emergency service crews may perform their duties unimpeded. Consider establishing a staging area for these people.
The team maintains a listing of various resources that members can utilize when required. Solicit the approval of command before activating these agencies. Once on the scene, management of these people must be turned over to the appropriate victim support agency.