Category: Crisis Intervention

Passed CA Assembly – Peer Support and Crisis Referral Services Act

California Assembly Bill 1116, formerly called the Critical incident Stress Management Services Act, has passed the state assembly and is on its way to the Senate. If it becomes law, the act would protect the confidentiality of public safety peer support team interactions except in the case of criminal proceedings. To be covered, team members would have to have completed a peer support training course to be developed by the Office of Emergency Services, the California Firefighter Joint Apprenticeship Committee or the Commission on Correctional Peace Officer Standards and Training.

This legislation would not give the level of protection that a therapist or ordained clergy has, but it will raise the bar considerably – unlike states that have passed similar laws, peer support and CISM teams in California currently have no protection against being subpoenaed. However, in the context of non-criminal proceedings, the legal “privilege” would be the same as between a psychotherapist and patient. The only exception would be “gross negligence or intentional misconduct.”

All of the components of a CISM program along with grief support and substance abuse are named as topics the law would cover.

The bill includes the phrase “toxic stress,” which I believe we should strike from our vocabulary. Stress can be toxic, but it doesn’t have to be, and the phrase “toxic stress” carries a strong connotation that all stress is toxic. That can be a self-fulfilling expectation – if you think stress is toxic, it probably will be.

This is a great step forward for California. I would have preferred that the state also recognize ICISF-approved training, rather than only requiring new courses, but “peer support” covers more than ICISF encompasses, so it is understandable.

If you’re in California, urge your senator to vote in favor. Let’s get the law in place, develop the classes and take the training.

CISM Protection Bill Introduced in California

California may join Michigan and other states that have made CISM activities “privileged” communications, meaning they could not be subpoenaed or otherwise demanded by a court. Michigan’s legislature unanimously passed the “First Responder Privileged Communications Act” a year ago.Subpoena protection for California CISM

California will consider AB 1116, the Critical Incident Stress Management Services Act.

Here is the key provision.

Except as otherwise provided in this section, a communication made by an emergency service provider to a CISM team member while the emergency service provider receives CISM services is confidential and shall not be disclosed in a civil, criminal, or administrative proceeding. A record kept by a CISM team member relating to the provision of CISM services to an emergency service provider by the CISM team or a CISM team member is confidential and is not subject to subpoena, discovery, or introduction into evidence in a civil, criminal, or administrative proceeding.

The exceptions are not problematic – they cover referrals, events where most of us are already mandated reporters, imminent threats and waivers.

The bill was introduced last month by Assemblyman Tim Grayson, former mayor of Concord, California, who is also a Concord Police Department “Critical Response Chaplain.” He undoubtedly knows a thing or two about this issue.

In my dozen years in CISM I’ve dealt with this through our team’s policy of never keeping written records and my own lousy memory for what other people say during interventions.

Paper: Psychological First Aid: Rapid proliferation and the search for evidence

Psychological First Aid (PFA) – there are many different protocols, great confusion about its relationship to Critical Incident Stress Management (PFA is part of it), and it is increasingly recommended by people and organizations who often don’t seem to recognize that PFA has multiple meanings, is limited in scope and hasn’t yet been confirmed as effective in field evaluations.

I’m not a PFA skeptic – I use it and teach it – but it needs more, careful investigation.

A recent report took a look at PFA’s popularity and lack of field evaluation. The authors are from  two academic centers focused on emergencies and mental health:

The authors give a nod to the down-to-earth nature of PFA guidelines, which are “evidence-informed,” meaning that they are based on related research:

[PFA is] documenting and operationalizing good common sense – those activities that sensible, caring human beings would do for each other anyway.

As the authors observe, the lack of proof that PFA works doesn’t mean it is ineffective. It means that PFA’s effectiveness hasn’t been demonstrated.

They identified forty-eight PFA courses and materials! Yet, oddly, they failed to include one that has been around for quite a while, the SAFER-R model developed by George Everly and incorporated in ICISF CISM training.

Now the bad news.

PFA’s popularity, promotion, and proliferation have not been matched with a commensurate pursuit of evidence demonstrating its effectiveness. Not only is there a dearth of data regarding the benefits of PFA, but there is limited demonstration of widespread commitment to generate such data.

However, like other kinds of crisis intervention, PFA is difficult to study. With nearly 50 different approaches, it is hard for researchers to know exactly what care is being given. There is no way to create control groups – they have to be observed, which is daunting.

The writers offer five recommendations.

  1. Evaluating PFA with first responders, rather than disaster survivors, “may be a good place to start.”
  2. Hospital emergency rooms or other controlled settings might be good places to begin to evaluate PFA for civilians.
  3. We need to figure out how to test its effectiveness for civilians in real disasters. “Predictable disasters” such as annual flooding might create opportunities.
  4. International coordination will make evaluation most effective – agreement on methods and techniques.
  5. PFA should be adapted as the field of trauma evolves. The authors are working on an approach that suggests that early intervention can be tailored to the nature of an incident.

A similar report, by an international group of researchers for the Belgian Red Cross-Flanders, reviewed literature the literature on PFA and came to essentially the same conclusion:

The scientific literature on psychological first aid available to date, does not provide any evidence about the effectiveness of PFA interventions. Currently it is impossible to make evidence-based guidelines about which practices in psychosocial support are most effective to help disaster and trauma victims.

Paper: Psychological First Aid training helps EMS workers

Star of LIfe

A dissertation , Community-based psychological first aid for emergency medical service providers: Mental health stigma, resilience, and social support, published at the University of South Dakota took a look at the effect of Psychological First Aid (PFA) training on EMS workers. Although the study did not confirm the researcher’s hypotheses about why there is stigma in EMS around asking for psychological help, there were two positive findings. Knowledge of PFA gave EMS workers a greater sense that they are supported and a decrease in the self-stigma of getting help.

Results are supportive of PFA as a practical and effective psychosocial support method for EMS providers. The present study contributes to the limited literature on psychological support for EMS providers and invites further research on the topic.

 

Election 2016: When reality and “rules” collided

(Trigger warning – this post contains the “F” word – “Feelings.” A lot.)

If you’re on social media, you’ve probably seen reports of colleges cancelling classes or postponing exams because of election grief. You’ve probably also seen the responses – those students should just suck it up and turn down their sensitivity. Some of the “advice” has turned into outright mockery.

First, a reminder that it is never helpful to tell another person – or yourself – how they “should” feel. It is tempting when emotions strike us as inappropriate, weak or wrong and we want to explain them away. It is a natural inclination. But especially now, we need to look deeper, listen harder. I know that I’ve caused myself a lot of suffering by insisting that something “should not” upset me, because…. whatever.

After getting requests to help lead post-election emotional support groups, I’ve been asking myself if the election really is a subject for crisis intervention as I know it. My answer is a qualified “yes.” It is yes, because people are having strong reactions. We never base our decision to intervene on what happened, we base it on reactions. But it is a qualified “yes” because we are in new territory. In all of the crisis intervention training I’ve had, nobody ever taught me how to respond to a political event that impacts everyone,  in which so many people have strong beliefs and feelings. We’re at an intersection of psychology and sociology where I doubt anyone really knows what’s best.

For those who are bringing people together for emotional support, I’ve compiled some guidelines.

Here’s what we do know about holding strong (often unconscious) beliefs – they can be the source of great emotional pain, frustration and anger when reality disagrees. Today, people who strongly believed that the United States could never, must never elect someone like Donald Trump (regardless of who or what they think he is), are having that kind of stress. The more certain they were that “someone like Trump” could not or must not win, the stronger their emotions probably are.  Notice that this is about “facts” they believe, not judgments. It is quite different to believe “Trump cannot, must not win” versus “Trump should not win.” The latter leaves room for acceptance and disappointment – perhaps deep, deep disappointment – rather than the confusion, anger, frustration, resentment and even violence that the first one can trigger.

An “unenforceable rule” is the name that psychologist Fred Luskin, author of “Forgive for Good”, calls this kind of belief.  We need rules to make sense of the world, but when we hold onto unenforceable rules in the face of conflicting reality, we’re stuck – painfully, often angrily stuck, often with no clear sense of why.

For those who had the unenforceable rule “Trump cannot, must not win,” and now believe that his election will cause pain to them or to people they care about or identify with, the feelings are amplified. When the effects are personal, pain, anger and frustration are stronger.

Well, say the critics in social media, those people just need to get in touch with reality! But that doesn’t work – logic doesn’t wipe out feelings. In fact, saying things like “You’re out of touch with reality” will probably make the feelings worse – broadening the divide – because it amounts to telling them how they should feel.

In a Star Trek episode, a senior officer yells, “Lieutenant Worf, I order you to calm down!” It doesn’t work. It never works. Not with Klingons. Not with humans.

A supportive response starts with nothing more than acknowledging the pain, frustration and anger that many people feel, quite naturally, now that world has refused to go along with how they think it’s supposed to be. If you believe that’s just catering to weak-minded wimps, hang on. Those people have a great challenge before them. They can hold a grudge, build resentments, perhaps even cross the line from political protest into criminal behavior. Or they can take a more difficult, positive path for which Luskin’s book can be one of the guides. His book can be especially meaningful to those who were already mired in resentments against their political opponents.

Resentments are like taking poison and waiting for the other person – or political party – to die.

If you were one of the “Trump cannot, must not win” people, your choice is between getting stuck there or aiming for connection and compassion. I would invite you to start with compassion for yourself – the world really did suddenly stop making sense – on a global scale! – and that truly is difficult. You will find that compassion for others is a great source of peace.

If you’re one of those who is tempted to issue orders – “It’s reality, deal with it” – you’ll find that compassion will go much farther.

At some point, healing and growth call us to take action. In my opinion, the most important action we can all take these days is the hard work of reconnecting with one another. We are so disconnected. Our American individualism has been an ally, but it has also meant we were always a less interdependent society. Technology – from highways and TVs to the Internet and smart phones – has prompted more disconnections than connections. The election outcome surprised us because we are so disconnected. Most of us had no idea of the depth of discontent and anger, in our nation.

Far fewer of us would have held the “Trump cannot, must not win” unenforceable rule if we knew each other better. Too many voices are unheard, too many faces unseen – and although Trump tapped into the politics of disconnection, this is far from merely a political problem. When we are disconnected and dispassionate about each other, we are weaker. The more isolated we are, the less stress we can handle.  Creativity and growth thrive on exposing ourselves to others’ ideas, even – perhaps especially – ideas that disturb us. “Love your neighbor as yourself” includes the neighbors you feel uncomfortable around.

We need creative solutions today and disturbing ideas are often fuel for creativity. One of the most creative people I have ever known, who often seemed to most people (including me for a long time) to be a narcissistic, egotistical prima donna, invited me back to his company, over and over, for years, to criticize his ideas. It was my job – I was an industry analyst. But I wondered why he encouraged me, even though I would often publicly challenge his cherished ideas and products. If he really was a narcissist, why expose himself to that? After he died, when I read his biography, I realized that he was in the habit of keeping people around him who disagreed, who would argue. In fact, if you agreed with him regularly, that would get you fired. I can’t say that I ever really liked him, but I respect the way he embraced the challenge of people who would tear apart his ideas. His name was Steve Jobs. One more thing about Steve that many people either don’t know or don’t appreciate – he practiced meditation. Nobody should try to imitate Steve, but I think we would all benefit by following both of those habits, especially these days.

 

Article: Middle School Suicides Reach All-Time High

NPR reports that the suicide rate for middle schoolers doubled from 2007 to 2014, reaching an all-time high. More of them now die by suicide than car crashes. The article describes six common myths about student suicides.

For those of us who do crisis intervention in schools in the aftermath of suicides, the statistic is all too real. Our Bay Area Critical Incident Stress Management Team helps schools with notifications, resources for the child’s family, students, the school staff and the community. Administrators are almost always focused on what they can do for teachers; the teachers are mostly focused on what they can do for the students. Nearly everyone is asking themselves what they could have done to change the outcome. It is a tough situation to walk into.

Eva Bee/Getty Images

Although schools know in theory that children sometimes kill themselves, when it actually happens, they know it in an entirely new way. We sometimes call this “crossing a line.” One you have crossed that line, you can never go back and “un-know” the reality. Although school has to go on, it’s not going to be the same again. You will never be the same again.

One of the most difficult parts of all suicides, but particularly painful for teachers and school staff, is to recognize the warning signs afterwards, when it is too late to intervene. There are almost always warnings when you know what to look for. Suicides are rarely impulsive and are preventable. (Nevertheless, we often tell friends and family afterwards that if someone is absolutely determined, they will probably succeed no matter what you do – and acknowledge how incredibly pain that helplessness is.)

Suicide is preventable because – and this might seem strange – it is a solution to life’s problems. The suicidal person unfortunately, mistakenly, comes to the conclusion that suicide is the only solution. It is absolutely possible to help them postpone their decision, giving them time and resources to recognize that there are other solutions. I have seen it happen – we regularly discover and intervene with other suicidal students in the aftermath.

Schools have to walk a fine line after a suicide – honoring and acknowledging the grief and suffering of the student who died, while avoiding activities that would send the message that suicide is an acceptable solution to life problems.

I’ve seen a pattern in many of the student suicides to which I’ve responded in recent years. There’s nothing scientific about this observation, but my instincts suggest it is not uncommon. The student who took their own life was often quite successful academically, involved in many activities, leading a very busy life. They become attracted to or involved romantically with another person, who rejects them. These are typical teenage experiences, except that these students seem to have become deeply, deeply invested in this one relationship, so that when it fails, they are left emotionally adrift. They are so busy with school and activities that they didn’t have time and space – and little encouragement – to develop a social support network with depth; instead, they “bet everything” on the one person. This pattern doesn’t always lead to suicide, but many teen and young adult suicides seem to fit it.

I believe that we will fail to truly address the problem if we only blame suicides on academic pressure, which often is the immediate reaction. Stress doesn’t have to be bad for you, but it certainly is when you are socially isolated. Disconnection is toxic for anyone who lets work or school become so important that they let go or fail to develop the kinds of relationships that we increasingly recognize are crucial to thriving under pressure.

We should not focus so hard on what is happening to these students; we have to remember to look for what is missing. To cope with stress effectively, we need strong connections to the people around us, to ourselves and nature, and to our spiritual values. When schools focus too much on academics and accomplishments, the stress-coping resources can easily lose priority.

Technology hasn’t helped – it has given us myriad new ways to connect with others in shallow ways, contributing to sedentary lives that disconnect us from our bodies and nature, disrupting traditional communities, and devaluing spirituality. In fact, spirituality has been so devalued and confused with religion that I feel as though any time I mention it, I also need to define it – spirituality (in the context of thriving under pressure) means having values and a sense of awe and wonder., bigger-than-self goals and purposes. Religion can be a source of spirituality, but schools can instill values, selflessness and care for others without crossing the line into religion.

Psychological First Aid and CISM – Clearing the Confusion

(For publication in the California Peer Support Association newsletter.)

Copying this article is permitted: Psychological First Aid – Clearing Confusion (PDF)

The name “psychological first aid” (PFA) has become a source of great confusion and controversy in emergency services. For 60 years, it has been a generic term for offering immediate support to people impacted by highly emotional events. Multiple PFA protocols have been developed, refined and studied for decades.

Confusion about PFA escalated 10 years ago, when the National Child Traumatic Stress Network (NCTSN) published a new PFA protocol, developed with the National Center for PTSD, and touted it as a “replacement” for Critical Incident Stress Management (CISM).

However, PFA has long been a component of CISM, so calling it a replacement is like saying a finger is a replacement for a hand, says Dr. George Everly, a Johns Hopkins psychologist and co-founder of the International Critical Incident Stress Foundation (ICISF), which establishes CISM standards. Everly has pioneered development and evaluation of both CISM and PFA protocols. He was a primary creator of the PFA protocol taught in CISM, the SAFER-R model.

Unfortunately, PFA confusion has led various organizations and agencies to recommend the NCTSN protocol as a “CISM replacement.” For example, a recent U.S. Department of Justice report, Preparing for the Unimaginable, which reviewed Sandy Hook and other mass casualty incidents, recommended NCTSN PFA as a “replacement” for CISM for law enforcement.

Concern over just one CISM component – debriefing – is at the root of the PFA muddle. The debriefing controversy began about 20 years ago when a small number of inconclusive studies of non-CISM debriefing techniques (none of which involved responders) were misinterpreted as suggesting that re-telling a traumatic story during debriefings could cause harm. However, over 35 years, no study has ever showed harm when ICISF protocols are used by trained people. Although much more research into the effectiveness of debriefings and other interventions is needed and welcome, the criticisms of CISM suggesting harm have been discredited.

Get trained, follow the ICISF protocols and rest assured that you are not going to do damage.

PFA’s Confusing Multiple Meanings

The existence of multiple PFA protocols has led to careless misrepresentation of support for the NCTSN protocol. For example, an Everly paper has been misquoted by multiple authors as saying NCTSN PFA is a “best practice” for first responders. However, the paper was actually about the Johns Hopkins RAPID-PFA protocol. (Everly et al., 2006). Reviewers should have noticed that the paper was written before NCTSN PFA was developed! In many other papers, the specific PFA protocol is not identified, casting doubt on whether NCTSN’s was used.

The NCTSN protocol was not developed with responders in mind. “[NCTSN] PFA is basic ‘grassroots’ psychological support provided for family, friends, neighbors and colleagues by members of the general population” (Barbanel and Sternberg, 2005). It was developed for children, schools and communities. The research literature reports that it has been used by faith communities to support their members in disasters, on school campuses, by community mental health, with disaster survivors, Syrian refugees, Greek refugees and domestic violence survivors. Applying it to responders has been an afterthought.

There has been one study of the NCTSN protocol in public safety. In Hong Kong, 900 responders were trained in the protocol in 2012. Early results were positive. (Chan, 2012,)

The NCTSN Protocol is for Individuals, Not Teams

The NCTSN PFA protocol only addresses interventions with individuals. There is no associated group process that would apply to responders, who have a strong sense of group cohesion and typically share trauma as a team. Applying it to a group is a round peg in a square hole.

The NCTSN Protocol’s Effectiveness Remains Unproven

The NCTSN protocol’s creators call it “evidence informed,” which means that it is based on research that identified potential, rather than actual benefits. Multiple expert reviewers say that there is almost no evidence for its effectiveness and further study is needed.

“The scientific literature on psychological first aid available to date, does not provide any evidence about the effectiveness of PFA interventions. Currently it is impossible to make evidence-based guidelines about which practices in psychosocial support are most effective to help disaster and trauma victims” (Dieltjens et al., 2014,).

“Despite popularity and promotion there remains a dearth of evidence for effectiveness and recent independent reviews of PFA have highlighted this important gap” (Shultz and Forbes, 2014).

“More evidenced-based research is still needed to prove the effectiveness of PFA.” (Zhang, Zhou, and Li, 2015).

The Red Cross, which has endorsed NCTSN PFA training for disaster workers, commissioned an independent review, which also found little evidence. “It was determined that adequate scientific evidence for psychological first aid is lacking but widely supported by expert opinion and rational conjecture. No controlled studies were found. There is insufficient evidence supporting a treatment standard or a treatment guideline” (Fox et al., 2012).

CISM is Helpful, not Harmful

The myth that researchers found that CISM is potentially harmful to responders was an odd conclusion of a review of several studies that gave “psychological debriefings” to victims of auto collisions, burns, dog bites and other accidents. In fact, the studies were inconclusive, but even if they actually had demonstrated potential harm, they are irrelevant to CISM and responders.

  • The interventions were inconsistent; ICISF CISM protocols were not followed.
  • No responders were involved – the care receivers were medical patients, victims of burns, accidents, etc.
  • All of the interventions were with individuals, rather than groups.

Another myth is that debriefings (which are just one component of a CISM system) are intended reduce or prevent Post-Traumatic Stress Disorder. Although debriefings may contribute to that goal, they really are intended to help a team “bounce back” from a difficult incident. Their explicit goals are:

  1. Mitigation of the impact of a traumatic event.
  2. Facilitation of the normal recovery processes and a restoration of adaptive functions in psychologically healthy people who are distressed by an unusually disturbing event.
  3. A [debriefing] functions as a screening opportunity to identify group members who might benefit from additional support services or a referral for professional care.

Evidence of many benefits of CISM are documented in the scientific literature. Stress-related symptoms drop, such as depression, anger and anxiety. Alcohol consumption is reduced. Self-esteem and emotional well-being are higher. Recipients are more cooperative with treatment and care. Suicide rates are lower.

None of the scientific evidence could be properly described as making a strong case for CISM, which is undoubtedly one of the reasons for the “controversy” around it. More research is needed.

Isolation is Toxic

Protocols matter, but resistance and resilience to stress – chronic or acute – correlates most strongly to an individual’s social support. Social isolation, like physical isolation, puts people at high risk. So in the end, no matter our approach, demonstrating that we care for each other – that no one has to be alone – is the most important “protocol” of all.

Bibliography

ABPP, Laura Barbanel, EdD, and Robert J. Sternberg PhD. Psychological Interventions in Times of Crisis. Springer Publishing Company, 2005.

Chan, Emily Y. Y. “Preliminary Results of Psychological First Aid Capacity Building Program on Coping Strategies and Mental Health Measures Among Emergency Responders in Disaster: Results of 6-Month Follow-up of a Randomized Controlled Trial.” World Federation of Public Health Associations, 2012. https://wfpha.confex.com/wfpha/2012/webprogram/Paper10006.html.

Dieltjens, Tessa, Inge Moonens, Koen Van Praet, Emmy De Buck, and Philippe Vandekerckhove. “A Systematic Literature Search on Psychological First Aid: Lack of Evidence to Develop Guidelines.” PloS One 9, no. 12 (2014): e114714. doi:10.1371/journal.pone.0114714.

Everly, George S., Suzanne B. Phillips, Dianne Kane, and Daryl Feldman. “Introduction to and Overview of Group Psychological First Aid.” Brief Treatment and Crisis Intervention 6, no. 2 (2006): 130–36. doi:10.1093/brief-treatment/mhj009.

Fox, Jeffrey H., Frederick M. Jr Burkle, Judith Bass, Francesco A. Pia, Jonathan L. Epstein, and David Markenson. “The Effectiveness of Psychological First Aid as a Disaster Intervention Tool: Research Analysis of Peer-Reviewed Literature From 1990-2010.” Disaster Medicine and Public Health Preparedness 6, no. 3 (October 2012): 247–252. doi:10.1001/dmp.2012.39.

Shultz, James M., and David Forbes. “Psychological First Aid.” Disaster Health 2, no. 1 (January 1, 2014): 3–12. doi:10.4161/dish.26006.

Usher, Laura, Stefanie Friedhoff, Sam Victor Cochran, and Anand A. Pandya. Preparing for the Unimaginable: How Chiefs Can Safeguard Officer Mental Health before and after Mass Casualty Events. Washington, DC : Arlington, VA: Office of Community Oriented Policing Services, U.S. Department of Justice ; National Alliance on Mental Illness, 2016.

Zhang, Li, Jiangsong Zhou, and Lingjiang Li. “Crisis Intervention in the Acute Stage after Trauma.” International Journal of Emergency Mental Health and Human Resilience 2015 (January 1, 1970). doi:10.4172/1522-4821.1000299.

Copyright © 2016 Nick Arnett, Stress, Spirit, Science (http://nickarnett.net)

Permission to copy unchanged is authorized.