Debriefing Models

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Debriefing Models

• Goals of Critical Incident Stress Management
• CISM - Mitchell Model
• NOVA Model

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Critical Incident Stress Managment (CISM)
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Purpose of CISM

• Triage
• Educate
• Social Support
• Constructive Therapeutic Action

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Goals

• To
• Save lives
• Reduce trauma and injury
• Facilitate psychological well-being
• Enable schools to resume normal activities

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Goal of Crisis Response

• Defuse emotional memory
• Organize cognitive processes
• Integrate events into life story
• Create meaning

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Special School Issues

• Works with groups or individuals
• Emphasizes the survivor
• Support school faculty
• Connect
• Understand
• Participate as caregivers

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Special School Issues (Continued)

• Provides structure
• Format for intervention
• Provides a schedule
• Time frame of 1 hr over 3 days
• Establishes roles
• Facilitator, scribe, caregiver
• Minimizes interruptions in routine

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Who?

• The crisis team
• Training
• Roles
• Mental health professionals
• Counselors, psychologists, teachers
• Crisis response workers
• Volunteers

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What?

• What do they do? (they do not takeover)
• Plan with community leaders
• Support local caregivers
• Train local caregivers
• Do group crisis intervention (GCI)
• Provide service - information, outreach
• Identify high risk groups

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How?

• Walk and talk through the experience
• Get orientation and information
• Listen to the story
• What happened?
• How are you?
• What is next?
• Help survivors put incident in perspective

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Debriefing Models

• CISM - Mitchell Model
• First responders
• NOVA Model
• Civilian audience
• Red Cross Model
• Victims of a natural disaster

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Essential Components of CISM

• This is NOT therapy
• Used as a band-aide during or shortly after a
  critical incident
• Used to validate normal reactions to an abnormal
  event
• Way to teach stress coping techniques
• Timing is key - not too early, or too late

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Essential Components - cont.

• Needs to be a part of larger Critical Incident
  Stress Management system
• Pre-incident stress relief techniques and
  education very important
• Refreshments AFTER intervention important

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Mitchell Model of CISM
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Types of CISM - Mitchell Model

• Defusing
• Shorter version of debriefing
• Services provided within 8 hours of incident
• Debriefing
• Longer, more structured (1 1/2 to 2 hours)
• Conducted after event, usually 24 to 48 hours
• Demobilization
• Intervention for large-scale disaster

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Defusing

• Shortly after traumatic event
• Shorter in length than debriefing
• Three stages
• More flexible than debriefing

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Defusing Stages

• Introduction
• Opening remarks
• Confidentiality
• Exploration
• Ask participants to describe what happened
• Experiences and reactions
• Information
• Stress relief techniques

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Debriefing Components

• Longer than defusing
• Group composition important
• Deeper emotional level reached
• Peer driven, with mental health consultation
• Participants sit in circle, with team members
  spread-out around room
• Safe, secure location essential

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More Components

• No breaks given
• Not a critique of policy or procedures
• Conducted 24-72 after the incident for best
  results
• Conducted up to 7 days after the incident o.k.
  (Mitchell, 1999)

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Still More Components

• Door Person
• Crowd Control
• NO NOTES TAKEN IN DEBRIEFING!!!

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Seven Stages of CISM Debriefings

• Introduction
• Fact Phase
• Thought Phase
• Reaction
• Symptom
• Teaching
• Re-entry

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Introduction

• Introduce self and team
• Confidentiality
• Identify non-members
• Speak for yourself
• Set expectations

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Fact Phase

• Everyone asked to speak
• Who are you?
• What was your role in the event?

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Thought Phase

• Ask each person to talk (last formal time)
• When did you start to think about the scene?
• What were your thoughts of the event?

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Reaction Phase

• Identify most traumatic part of event
• If you could erase one part of this incident,
  what would you erase?
• What is the worst part for you?
• If this were a movie, what part would you want
  to edit out?

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Symptom Phase

• What normal reactions are being experienced by
  the group?
• Best if the group generates the symptoms
• What are you experiencing as a result of this
  event?
• Who here has been feeling (blank)?

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Teaching Phase

• What can you expect as normal reaction to
  abnormal event
• What can you do to help yourself and others
• Cognitive, emotional, physical, behavioral
• Tap into natural coping techniques of the group
• Give concrete examples and suggestions

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Re-Entry Phase

• What can come out of this incident?
• Informational handouts made available

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Post Debriefing Work

• Refreshments offered
• Mingle with participants
• Touch base with at-risk individuals
• Debriefing of the Debriefers

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Demobilization

• Used as exit procedure from a large scale
  incident
• 10 minutes for information
• 20 minutes for food and rest
• Used as a heads-up of possible stress
  reactions, symptoms, and coping techniques

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Applications for Schools

• Intervention MUST be age appropriate
• Can use group format for discussion and teaching
  of students and teachers
• Teachers and staff could be debriefed prior to
  student defusing
• Defusing format may be more appropriate for
  students
• Follow-up on at-risk students important

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Types of School Defusings

• Classroom Discussion
• Drop-in Counseling Centers

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Words of Caution

• Know your limits
• Know your own issues
• Debriefing of the debriefers is essential to
  avoid team burn-out
• Should have good, general knowledge about grief
  and loss issues
• Grief and loss may complicated a critical incident

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NOVA Model
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Goals of the NOVA Model

• Guide the release of emotional steam
• Address great numbers of individuals
• Establish commonality, peer group validation
• Establish social support and rebuild community
  bonds
• Mobilize community resources
• Promote hope for the future

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NOVA Formula

• SS -----------------gt VV -----------------gt PP
• Security - confidentiality, ground rules
• Sensory - 5 senses
• Vent - 6 emotions
• Validate - permission, commonalty
• Prediction - what are you facing
• Preparation - coping skills

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Psychological Rationale

• Survivors need to know what happened
• facts are important
• Trauma is a path violation (a new path results)
• Survivors want to stay in the present - this
  helps them put it in perspective and begin to
  move on

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GCI Psychological First Aid

• Provide facts - dispel rumors
• Share stories - allow grief
• Normalize grief symptoms
• Regain a sense of control
• Screen for referral
• Meet counseling needs
• Bring closure - shift to the future

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Where?

• Group crisis intervention (GCI)
• In the community
• At or near site of tragedy
• Using common ground and public space

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When? First 72 Hours

• Assignment
• Arrival
• Orientation
• Community GCI
• Meetings
• Detectives
• Victims
• Families
• Pastors

• Team meeting
• Funeral
• Community GCI
• Subgroup meetings
• Elementary, Middle etc.
• Community leaders
• Media interview
• Transition meeting

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GCI - at Convenient Time for About 1-2 Hours

• 10 minutes introduction
• 35 minutes - focus on physical sensations
• 25 minutes - focus on emotional reactions
• 10 minutes - focus on the future
• 10 minutes - review wrap-up

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GCI Considerations

• Begin counseling immediately
• Be non-judgmental
• Provide feeling you are an authority
• Facilitate social support
• Engage in problem solving
• Focus on building persons self-concept
• Know when to refer
• Keep notes

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Description of Group Crisis Intervention NOVA
Protocols

• Basic Protocol
• Group Defusing Protocol
• Extended Trauma Protocol
• Repetitive Group Intervention Protocol
• Retrospective Group Intervention Protocol

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Group Crisis Intervention Basic Protocols

• Takes place at or near the site of the community
  trauma event
• Takes place within the first days or week of the
  trauma event
• Group session lasts 1 1/2 hours to 3 hours
• Allows facilitators to thoroughly address the
  three basic elements of crisis intervention
• All victim and survivor populations can benefit
  from participation

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Group Intervention Team Roles

• Group Facilitator
• Scribe
• Caregiver

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Group Intervention Team Roles -Group Facilitator

• One person should be in charge
• Only team member who talks during the group
  session
• Responsible for introducing the session, stating
  the guidelines, asking the questions, providing
  validation, assisting group members in validating
  each other, summarizing the session, and
  concluding it.
• Seated at the open-end of the horseshoe or in the
  circle

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Group Intervention Team Roles -Scribe

• The Scribe is not the facilitator but is an
  active member of the group crisis intervention
  team
• Records notes on a flip chart of participant
  crisis reactions
• Contributes only when called upon by the
  facilitator
• Should stand while taking notes and be as
  unobtrusive as possible

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Group Intervention Team Roles -Scribe

• Provides emotional and practical support to the
  facilitator, if needed
• Takes over the group if the leader (facilitator)
  cannot continue
• If no other team caregivers are available, the
  Scribe should leave the room to care for a
  distressed participant

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Group Intervention Team Roles -Caregiver

• Gives individual attention to group participants
  who seem to need this
• Specifically, if a participant begins to
  experience emotional distress, the caregiver
  would go over and assist, support, care for
  that individual
• Ideally, there should be more than one caregiver
  available

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Group Intervention Team Roles -Others

• Other Crisis Intervention Team Members should be
  prepared to replace the scribe if the scribe must
  replace the facilitator
• Other Crisis Intervention Team Members can assist
  with individuals in crisis

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Group Crisis Intervention Session Procedure
-Overview

• Approximately 1½ to 3 Hours of Group Work
• Stage One Safety Security / Introductions and
  orientation  
• Stage Two Ventilation Validation / First
  series of questions
• Stage Three Prediction Preparation / Second
  series of questions
• Stage Four Summarize the session
• Stage Five Close the session

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Session Procedure Stage One (10 Minutes)

• Facilitator provides introduction or orientation
  for the session
• Facilitator provides an Agenda for the session
  designed to help the group define the crisis
  reaction, provide some crisis intervention, and
  to predict and prepare the group for possible
  future events

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Session Procedure Stage One

• SAFETY SECURITY concerns are addressed
• The Crisis Response Team Members should be
  available during and after the session to
• help survivors solve immediate problems
• help them identify a safe place to stay if needed

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Session Procedure Stage One

• help identify a support system / link to other
  groups of survivors, information on community
  services and resources
• provide privacy for expression of emotions
• Facilitator reviews ground rules for the session
• Permission given to participants to express
  thoughts and reactions they might have
  boundaries are - no physical violence or verbal
  abuse

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Session Procedure Stage One

• Individuals can choose to identify themselves or
  remain anonymous when they talk
• Reminder regarding purpose of the session -review
  of reactions not a critique of what happened
• Confidentially of communication

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Session Procedure Stage Two (35 Minutes)

• Facilitator guides the group through questions
  designed to review immediate physical sensory
  perceptions and emotional reactions of shock and
  disbelief. Participants are given an
  opportunity for VENTILATION VALIDATION.
• VENTILATION occurs when the victim / survivor is
  enabled to tell their own story.

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Session Procedure Stage Two

• First series of questions
• Where were they when it happened?
• Who were they with?
• What did they see, hear, smell, taste or touch at
  the time?
• What did they do? How did they react at the
  time?

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Session Procedure Stage Two

• Second series of questions
• What has happened in the last 48 hours?
• Since the time of the disaster, what are some of
  the memories that stand out in your mind?
• How have you reacted?

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Session Procedure Stage Two

• VALIDATION is a process through which the crisis
  responder makes it clear that most reactions to
  horrific events are not abnormal.
• The emphasis should be on the fact that most
  types of reactions such as fear, anger,
  frustration, guilt, shame and grief are not
  unusual

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Session Procedure Stage Two

• Validating responses
• Take your time, its all right to cry after
  someone you love has been injured.
• Its not unusual for us to think back on ways
  that we could have avoided a disaster, but you
  are not responsible for the behavior of a
  murderer.
• Its very difficult to think you will ever feel
  good again when such a bad thing has happened to
  you.

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Session Procedure Stage Two

• Recognize and emphasize similarities between
  participant responses
• Be alert to any signs of potentially harmful
  responses and follow through with assessment of
  risk, parent contact, and referral information

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Session Procedure Stage Three (10 Minutes)

• Facilitator guides group through questions
  designed to
• Elicit participant expectations for the future
• Review effective coping strategies
• Help participants PREDICT PREPARE for what may
  happen over the next few weeks, months, or year.
  

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Session Procedure Stage Three

• PREDICTION refers to helping survivors predict
  the practical issues that will face them in the
  aftermath 
• Some may be required to act as witnesses in court
• Funeral arrangements  
• Assist survivors to predict possible emotional
  reactions

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Session Procedure Stage Three

• Stress reactions that might occur in families
  should be addressed
• Dont underestimate the effects of a crisis on
  children. Provide appropriate handouts for
  parents.
• (Refer to handout Developmental Stress Reactions
  in Children)

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Session Procedure Stage Three

• Help survivors PREPARE or plan for the issues
  raised above. 
• Third series of questions
• After all youve been through, what do you think
  will happen at your job in the next few days?

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Session Procedure Stage Three

• Do you think that your family has been or will
  continue to be affected?
• Do you have any practical concerns about what
  will happen next?
• How will you deal with the problems or issues
  that have been raised?

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Session Procedure Stage Three

• Reinforce positive coping methods, and suggest
  alternatives to negative methods
• If possible, answer questions about problems
• Suggest referrals if available

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Session Procedure Stage Four

• Facilitator transitions to summarizing what has
  been said during the session
• Scribe no longer takes notes 
• Facilitator reviews the notes and uses them to
  identify
• Descriptions of acute sensory perceptions
• Descriptions of emotional turmoil
• Concerns about the future
• Coping strategies

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Session Procedure Stage Five

• Facilitator closes the session 
• Thank the group for participating
• Express regret that the tragedy happened to the
  group
• Offer participants support for the future
• Offer to remain in the room for a few minutes to
  respond to additional questions or concerns

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Logistics

• Public facility
• School, church basement, auditorium
• Comfortable seating
• Horseshoe or circle arrangement
• Supplies
• Flipcharts, markers,water, tissues, toilet,
  smoking area
• Team
• Facilitator, scribe, caretaker