CISM:
Crisis Intervention Training For Disaster Responders
Critical Incident Stress Management

by George W. Doherty, M.S., LPC

This course meets the qualifications for 12 hours of continuing education

APA, BRN, CA BBS, FL, NAADAC, NBCC, TX SBEPC, TXBSWE

The purpose of this course is to provide training for mental health professionals who work with victims of disaster related stress and trauma. This course prepares the disaster mental health professional to relate with disaster victims and co-workers. The warning signs and symptoms in both disaster victims and workers are explored together with stages, strategies and interventions for recovery.

This course will introduce you to disasters, the community response, the role of first responders, and the role of Disaster Mental Health Services and Critical Incident Stress management responders and teams. It will provide a brief overview of Disaster Mental Health Services and Critical Incident Stress Management and their roles in responding to the needs of both victims and disaster workers. The role of critical incident stress management will be presented and discussed both for disasters and for critical incidents. This includes discussion about war, terrorism and the follow-up responses by mental health professionals. This course is designed to help participants identify appropriate methods for activating Disaster Mental Health Crisis Intervention Teams (CIT) for disaster mental health services for victims, co-workers, and self.

The content of this course includes general theory and models of Disaster Mental Health, Critical Incident Stress Management, crisis intervention techniques commonly used in these situations, supportive research, and practice of approaches used in responding to the victims, workers and communities affected by disasters, critical incidents and terrorism threats.

 

LEARNING OBJECTIVES

After taking this course, participants will be able to:

• Describe a variety of disasters and how they affect people and their communities differently.

• Identify the skills and abilities necessary to participate with Disaster Services and Critical Incident Stress Management as a team member.

• Define 'crisis intervention" as it relates to disaster situations and critical incidents and identify the stages of disaster recovery and problems associated with each stage.

• Identify the signs and symptoms of disaster induced stress and emotional trauma.

• Discuss and be able to recognize disaster's and critical incident's effects and impacts on victims and workers, including acute and posttraumatic stress.

• Identify common strategies for coping with disaster and critical incident related stress and demonstrate basic disaster mental health professional responses to disaster related crisis situations/scenarios


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Texas State Board of Examiners of Professional Counselors (#1761)
The Texas Board of Social Work Examiners (#6246)

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CISM: CRISIS INTERVENTION TRAINING FOR DISASTER RESPONDERS

TABLE OF CONTENTS

COURSE OBJECTIVES

INTRODUCTION

DEFINITIONS

FUNDAMENTALS OF VICTIMS' RESPONSES TO DISASTERS

STAGES OF GRIEF

Returning to Equilibrium

STAGES OF DISASTER RECOVERY

Heroic

Honeymoon

Disillusionment

Reconstruction

SYMPTOMS OF PSYCHOLOGICAL TRAUMA

BASIC ID

Children's Reactions

Preschool Children

Ages 6-12

Fears and Anxieties

Sleep Disturbances

School Avoidance and School Phobias

Loss, Death and Mourning

Suicidal Ideation

Confusion

Antisocial Behavior

CHILDREN WITH SPECIAL NEEDS

The Exceptional Children

The Injured or Ill Children

Adolescents

PROVIDING HELP FOR CHILDREN AND FAMILIES FOLLOWING DISASTERS

General Steps In The Helping Process

The Use of Play

Individual Counseling

Group Sessions

Telephone Crisis Service

Role of The Family

OTHER SPECIAL RISK GROUPS IN DISASTERS

Common Needs and Reactions

Middle Age

Elderly

Older Adults

Socioeconomic Classes

Cultural and Racial Differences

Institutionalized Persons

People In Emotional Crises

People Requiring Emergency Medical Care

Human Service And Disaster Relief Workers

Cultural And Ethnic Minorities

SOME EXAMPLES OF DISASTER RELATED EMOTIONAL PROBLEMS

Depression

Grief

Anger

Guilt

Apathy

Fears

The "Burn-out" Syndrome

Bizarre Behavior

Suicide

INTERVENTION STRATEGIES

Basic Guidelines

Interventions

PSYCHOLOGICAL IMPLICATIONS FOR DISASTER WORKERS

Factors Affecting Responders

Effects of Long Exposure to Stressors by Disaster Workers

STRESS MANAGEMENT

Stress Responses

Coping With Stress - Guidelines for Workers

INTERVENTIONS DURING A DISASTER

Team Managers

Workers

INTERVENTIONS FOLLOWING A DISASTER

Team Leaders

Survivors

Debriefings

Incident Debriefing

Information Sessions

Verbalization Sessions

Follow-up, Referral to Mental Health Resources/Counseling

Post-disaster Counseling for Individuals or Groups

Short Term Intervention

Medium and Long Term Intervention

Collaborative Relationship Between Emergency and Mental Health Services

SELECTED REFERENCES

WEB SITES WITH INFORMATION AND LINKS ABOUT DISASTER MENTAL HEALTH, TRAUMA, PTSD, AND DEBRIEFING

SCENARIO

ASSESSMENT QUESTIONNAIRE OF THE DISASTER VICTIMS' NEEDS



Bonus!

This course includes a scenario; if you like, answers may be written out and submitted to George W. Doherty, M.S., LPC, President and CEO of the Rocky Mountain Region Disaster Mental Health Institute. Mr. Doherty will review and personally comment on your responses!

To preview the scenario, please click here.

Excerpts from the course:

 

INTRODUCTION

 

Working with survivors following the loss of loved ones, homes, property or community is the role of disaster mental health professionals. Besides meeting their basic physical needs, clients will need to understand the grieving process, which may extend for a prolonged period of time.

Throughout this course, you will learn why Crisis Intervention, Defusing, and Debriefing have important roles in alleviating disaster induced stress and in preventing further psychological complications.

FUNDAMENTALS OF VICTIMS' RESPONSES TO DISASTERS

In order to fully understand the necessity for and functions of a Crisis Intervention Team, it is important to have a basic understanding of the psychological factors which influence the emotional responses of disaster victims. This section presents and discusses the basics of those factors and the resulting commonly observed responses of survivors.

Loss, Mourning, and Grief

All survivors of disaster suffer loss. They suffer loss of safety and security, loss of property, loss of community, loss of status, loss of beauty, loss of health, or loss of a loved one. Following a disaster, all individuals begin a natural and normal recovery process through mourning and grief.

In our western culture, we put the emphasis on life and youth. We often refuse to think about death. It is normal to be upset by a major loss - and then to suffer because of it. Bereavement is always deeply painful when the connection that has been broken is of any importance. The loss which is the reason for our mourning most often involves a person close to us. However, it can also be a familiar animal, an object to which we are very attached, or a value we have held dear. In mourning, the connection with what we have lost is more important than the nature of the lost object itself.

Grief is the process of working through all the thoughts, memories and emotions associated with that loss, until an acceptance is reached which allows the person to place the event in proper perspective. Theories of stages of grief resolution provide general guidelines about possible sequential steps a person MAY go through prior to reaching acceptance of the event. These stages include: Denial, Anger, Bargaining, Depression, and Acceptance. Whereas these theories provide general guidelines, each person must grieve according to his or her own values and time line. However, some persons will have trouble recovering emotionally and may not begin the process of mourning effectively.

This may result in troubling and painful emotional side effects. Sometimes these side effects may not appear immediately. They may remain beneath the surface until another crisis brings the emotions out into the open. Hence, many individuals may be surprised by an increase in emotionality around the third month, sixth month, and one year anniversaries of the event. Crisis intervention can assist victims and facilitate their progress in proceeding through the predictable phases of mourning, thus avoiding surprise reactions or emotional paralysis later.

 

STAGES OF GRIEVING

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance

 

LOSS, MOURNING AND GRIEF

Grief is the process of working through:

All the thoughts, memories, and emotions

associated with a loss, until an acceptance

is reached that allows the person to place

the event into the proper perspective.

 

Some typical reactions might include:

  • People who say they are drained of energy, purpose and faith. They feel like they are dead.
  • Victims who insist they do not have time to work through the grief with "all the other things that have to be done", and ignore their grief
  • People who insist they have "recovered" in only a few weeks after the disaster, and who are probably mistaking denial for recovery.
  • Victims who focus only on the loss and are unable to take any action toward their own recovery.
  • Each of these extreme emotional states is very common, very counterproductive, and requires active crisis intervention.

Denial - At the news of a misfortune, tragedy or disaster, our first reaction is not to accept it, but to refuse it ("No, it's not true! No! It's not possible!"). The opposite would be abnormal. This is a sign that it is essential for our psychological organization to avoid pain without ignoring reality. This refusal is, at the same time, the beginning of an awareness of the horrible reality and is aimed at protecting us from the violence of the shock.

Anger - A feeling of anger is experienced at the fact of our powerlessness in the face of something imposed on us arbitrarily. This anger is inevitable and it must be permitted. It allows the expression of our helplessness at the situation. Therefore, it isn't surprising that survivors take out their anger on the people around them (government and municipal officials, rescue personnel, insurance companies, their families and friends, etc.). Hence, there is the need to be able to verbalize and vent this anger in post-traumatic sessions with a counselor.

Depression - The path toward the acceptance of bereavement passes through the stage of depression. At the beginning of mourning, and for a long time after during this stage of depression, the lost being is omnipresent. Of course, he or she is lost to us in reality we agree and we are trying to accept it. However, inside, we reinforce our connection to him or her, because we no longer have it in objective reality. This process of intense reappropriation allows us, at the same time, both to lessen our pain and to console ourself in a way by means of the temporary survival of the loved being within us. At the same time, this movement enables the work of detachment to be carried out little by little.

Generally, little by little, these movements of detachment become less frequent, the pain subsides, the sadness lessens, the lost being seems less present and his or her importance tends to decrease. The end of mourning is approaching.

Acceptance - This stage is neither happy nor unhappy. Mourning leaves a scar as does any wound. But the self once again becomes free to live, love and create. One is surprised to find oneself looking toward the future, making plans. It is the end of mourning

The normal process of mourning takes place over a period of several months.

 

Returning To Equilibrium

Mental health is described by Antoine Parot as "a psychic ability to function in a harmonious, agreeable, effective manner when circumstances allow, to cope flexibly with difficult situations and to reestablish one’s dynamic equilibrium after a test."

Every time a stressful event happens, there are certain recognized compensating factors which can help promote a return to equilibrium. These include:

  • perception of the event by the individual
  • the situational reports which are available
  • mechanisms of adaptation

 

The presence or absence of such factors will make all the difference in one’s return to a state of equilibrium. The strength or weakness of one or more of these factors may be directly related to the initiation or resolution of a crisis.

When stress originates externally, internal changes occur. This is why certain events can cause a strong emotional reaction in one person and leave another indifferent.

Why do some people reach a state of crisis while others do not?

Perception of the event:

  • When the event is perceived realistically:

There is an awareness of the relationship between the event and the sensations of stress, which in itself will reduce the tension. It is likely that the state of stress will be resolved effectively.

  • When the perception of the event is distorted:

There is no awareness of the connection between the event and the feeling of stress. Any attempt to resolve the problem will be affected accordingly.

  • Hypotheses to verify concerning the individual’s perception of the event:

What meaning does the event have in the person’s eyes?

  • How will it affect his/her future?
  • Is he/she able to look at it realistically? Or does he/she misinterpret its meaning?

Support by the natural network:

Support by the natural network means the support given by people in the individual’s immediate circle who are accessible and who can be relied on to help at that time.

In a stressful situation, the lack or inadequacy of resources can leave an individual in a vulnerable position conducive to a state of disequilibrium or crisis.

Mechanisms of adaptation:

These mechanisms reduce the tension and help promote adaptation to stressful situations. They can be activated consciously or unconsciously.

Throughout life, individuals learn to use various methods to adapt to anxiety and reduce tension. These mechanisms aim at maintaining and protecting their equilibrium.

When an event happens which causes stress, and the learned mechanisms of adaptation are not effective, the discomfort is experienced at a conscious level.

STAGES OF DISASTER

Just as there are stages of individual grieving, there are also stages of disaster in communities. The emotional responses of a community can be very closely tied together with emotional responses of individuals.

Heroic Stage

The Heroic Stage lasts from impact or pre-impact to approximately one week post impact. People respond to the demands of the situation by performing heroic acts to save lives and property. There is a sense of sharing with others who have been through the same experience. There is almost a feeling of "family", even with strangers. There is immediate support from family members both in and out of the area and by agency and governmental disaster personnel promising assistance. Feelings of euphoria are common. There is strong media support for the plight of the victims and the needs of the community. Activity levels are high. However, efficiency levels are low. Pain and loss, including physical pain, may not be recognized.

The most important resources during the Heroic Stage are family, neighbors, and emergency service workers.

During the immediate post-impact phases, workers react and respond with high levels of energy, and seek information and facts. They develop and coordinate plans, equipment and staff resources. Following the impact, adrenaline levels are high. Workers continue to push themselves through and past the stress signals and warnings.

Honeymoon Stage

The Honeymoon Stage follows the Heroic Stage and may last for several weeks following the disaster. In the early parts of this stage, many survivors, even those who have sustained major losses, are feeling a sense of well-being for having survived. Shelters may at first be seen as central meeting places to talk about shared experiences. It is also seen as being a safe place to stay until they can return to their homes. Supported and encouraged by the promises of assistance by disaster relief personnel from voluntary and federal agencies, survivors clear the dirt and debris from their homes in anticipation of the help they believe will restore their lives.

The community as a whole pulls together in initial clean-up and distribution of supplies. Church and civic groups become active in meeting the various needs of the community. "Super Volunteers" who are not ready to deal with their own losses work from dawn until after dark helping their friends and neighbors get back on their feet. In the early parts of this stage, the community's expectations of the various volunteer and governmental agencies are extremely high. Their faith in those organizations' ability to help them recover is frequently unrealistic.

Some of the common emotional reactions during this stage include: adrenaline rush, anxiety, anger and frustration, survival guilt, restlessness, workaholism, risk-taking behaviors and hyperactivity.

Disaster mental health professionals can assist during this stage by educating about common stress reactions and coping techniques, working with distressed clients, advocating for breaks and time off, defusing workers, team building, etc.

© 2001 George W. Doherty and Rocky Mountain Region Disaster Mental Health Institute.

public

All material included in this course is either in the public domain, or used with express permission.

APA Ethics

We do adhere to the American Psychological Association's Ethical Principles of Psychologists. Our courses are carefully screened by the Planning Committee to adhere to APA standards. We also require authors who compose Internet courses specifically for us follow APA ethical standards.

Many of our courses contain case material, and may use the methods of qualitative research and analysis, in-depth interviews and ethnographic studies. The psychotherapeutic techniques depicted may include play therapy, sandplay therapy, dream analysis, drawing analysis, client and therapist self-report, etc. The materials presented may be considered non-traditional and may be controversial, and may not have widespread endorsement within the profession. www.psychceu.com maintains responsibility for the program and its content.

Cost of the 12 unit course is $150

George W. Doherty, M.S., LPC has held positions as counselor/therapist, Masters Level psychologist, consultant, educator, and disaster mental health specialist and is a former U.S. Air Force Officer. Currently, he serves as President of O`Dochartaigh Associates, a position he has held since 1985. He is also President and CEO of the Rocky Mountain Region Disaster Mental Health Institute. He has served as an Adjunct Faculty member of the University of Wyoming, a Psychologist for Rural Clinics Community Counseling Center (State of Nevada) in Ely, NV, and an Adjunct Instructor for Northern Nevada Community College, and is currently an Adjunct Faculty member of Kennedy-Western University. He has been an Associate Member of American Psychological Association and is a Life Member of the Air Force Association and a Life Member of the Penn State Alumni Association.

He has authored numerous publications, including: "Crisis Intervention Training for Disaster Workers," Graduate Course Materials, Counselor Education Department, University of Wyoming, 2001; "The Trauma of Cultural Diversity" (publication pending, Australia), 2003; "A Review of: American Hazardscapes", Population and Environmental Psychology Bulletin, (Winter) 2003; "A Review of: Problems and Issues of Diversity in the United States," Population and Environmental Psychology Bulletin, 2001; "Cross-Cultural Counseling in Disaster Settings," Australasian Journal of Disaster and Trauma Studies, 1999; "Towards the Next Millennium: Disaster Mental Health- Learning from the Past and Planning for the Future," Traumatology-e, 1999. He has also been honored by the following professional societies: Arnold Air Society, 1962; John Henry Cardinal Newman National Honor Society, 1964; Psi Chi, 1971; Commemorative Medal of Honor 1985, 1993 (ABI). He has also served as a Research Advisor and Research Fellow at the American Biographical Institute.

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