Critical Incidents: From Response to Action

Background
1. Critical incident support has been part of educational psychologists' roles since early 1990s (Posada, 2006)
2. Typical pattern of response to trauma (from Queensland Department of Education, 1998)
  1. 1: Pre-trauma stability. 2: Traumatic incident. 3: Shock. 4: Denial. 5: Emotional impact. 6: Working through. 7: Acceptance. 8: Normal reactions. 9: post-trauma stability.
3. Typical needs of those affected by critical incidents (Parkinson, 1997): acknowledgement and recognition; information; opoprtunity to talk; formal and informal rituals; routines and normality; return and reintegration.
4. Levels of support (Hindmarch, 2002): Level 1 = Someone there (first hours). Level 2 = A listening ear (First days). Level 3 = Structured group support (first weeks). Level 4 = Specialist support and counselling (first months).
5. Aims of critical incident support (Warrington Borough Council, 2007)
  1. To help those affected to understand the impact of trauma on themselves and others
  2. To plan for people's reactions and needs of individuals and groups.
  3. To coordinate and manage the organisation and community response.
6. Why have crisis support available for schools? (McCaffrey, 2004)
  1. Still valid and needed
  2. Debriefing = useful aid to cognitive restructuring and normalisation
  3. Group work and coaching can lead to self-help and dispel misunderstandings
  4. Work on responding and planning is highly valued by schools and others affected
Evidence-based interventions for individuals
1. NICE (2005): guidance suggests the importance of psychological first aid, watchful waiting, trauma-focused CBT, and eye movement desensitisation/reprocessing.
  1. Michenbaum (1994): Trauma-focused CBT to help confront traumatic memories, modify misinterpretations of threat, and develop skills to cope with stress. Aims to help a person restructure their core beliefs, thoughts, and ideas schemas by...
    1. Stage 1: Establishing a rapport, encouraging person to tell story and express feelings
    2. Stage 2: Help the person make sense of the story. New coping skills linked to re-experiencing, avoidance, arousal, and negative cognitions/mood.
    3. Stage 3: Cognitive restructuring to help the person obtain control, rebuild, and replace shattered beliefs.
    4. Stage 4: Re-establish relationships and confidence.
    5. Stage 5: Develop strategies to prevent relapse.
  2. Eye movement desensitisation and reprocessing = person recalls an important aspect of a traumatic event whilst following the repetitive side to side movements, sounds, or taps as the traumatic image is focused on.
2. Evidence base for children and young people
  1. Intervention of choice is currently trauma-focused CBT for individual children of 10-11 years and upwards (Wolpert et al, 2006)
  2. Little conclusive evidence to support the efficacy of EMDR and other interventions with children and young people
  3. A need for better evidence base and audit for all interventions (NICE, 2005 PTSD guidance)
Types of short-term post-incident support (Parkinson, 1997)
1. Demobilisation
2. Defusing
3. Debriefing
  1. Based on the models of Critical Incident Stress Debriefing (Mitchell, 1983) and psychological debriefing (Dyregrov, 1987)
  2. A structured group process that seeks to reduce the impact of PTS and enhance coping mechanisms in which a group share experiences, thoughts, and feelings about an incident
  3. Usually takes 2-3 hours (depends on size of group)
  4. Aims to... (Mitchell & Everly, 1996; Dyregrov, 1998)
    1. Create a shared narrative
    2. Help integrate cognitive and emotional memory
    3. Connect past, present, and future
    4. Provide psychoeducation
    5. Support normalisation
    6. Ventilation of impressions, reactions, feelings
    7. Promotion of clear understanding of precipitating events and subsequent reactions
    8. Decrease in individual and group tension and sense abnormality
    9. Mobilisation of coping resources
    10. Preparation for future symptoms and identification of avenues for further assistance
  5. Considerations for children (Wraith, 2000)
    1. Involvement of parents
    2. Developmental issues in child
    3. Role of peer group
    4. Modalities of expression and conversation
    5. Level of engagement
    6. Self-disclosure, confidentiality, coping skills
    7. Potential for secondary traumatisation/retraumatisation
    8. Importance of psychological first aid linked to debriefing
  6. Outcomes of CISD (Stallard and Law, 1993)
    1. Reducing intrusive thoughts
    2. Validating a person's experience of trauma
    3. Allowing reinterpretation of their attribution
    4. Providing a forum in which emotions can be discharged
  7. Evidence base for CISD
    1. Adult studies
      1. No evidence that it was effective in preventing PTSD in individuals
      2. Some evidence of its perceived helpfulness and satisfaction of those involved (van Emmerick et al, 2012)
    2. Evidence for CISD and similar interventions is inconclusive (NICE, 2005; Bisson et al, Cochrane Collaboration (2004)
    3. Arguments in support of CISD
      1. Other purposes than preventing PTSD
        Providing psychological first aid, part of a planned response (Mitchall & Everly, 1996), involving the reduction of distress, providing psychoeducation (Dyregrov, 2003)
      2. It seeks to focus on: psychological responses; PTS, not PTSD; normalising rather than pathologising people's reactions (Parkinson, 1997)
      3. Research with bereaved and traumatised groups is notoriously difficult and has many ethical challenges
      4. Real world applied research faces difficulties in establishing controlled quasi-experimental conditions (Dyregrov, 2003)
      5. BUT...
        CISD needs to be part of a group and overall management response and package of care (NICE, 2005)
        Careful consideration of each element of debriefing is required (Dyregrov, 2003)
        Its purpose
        Timing and duration
        Group membership
        Training of facilitators
        Follow up
        Important considerations
        Needs to be part of, not the whole, an overall crisis intervention/plan
        Not given too early
        Requires follow up
        Assessment of group and individuals
        Trained personnel
        Focus on cognitive and psychoeducation
        Correct duration
Impact of traumatic incidents on organisations
1. Incidents can directly/indirectly affect a school/organisation
  1. On-site, offsite, multi-site...
  2. Generate media interest, overzealous helping, callers, visitors....
  3. Reaction in parents and staff
2. Plans and responses need to be flexible and "wise before the event" (Yule & Gold, 1989)
3. Brings out the best and worst in people
4. Magnification of difficulties
5. Strengthens existing (stable) relationships
6. Closing in of ranks, creating in-group vs. out-group
7. Competing pressure to stop or to carry on as normal
8. Shared experience creates opportunity for people to both give and seek support (Hindmarch, 2002)
Managing an incident in schools
1. Develop a plan for handling people's feelings/reactions
2. Prepare a media statement
3. Prepare further information for parents, pupils, and staff
4. Consider and arrange appropriate support for the staff, parents, and pupils involved
5. Involve critical incident response team (including EPs)
EPs role
1. Immediate aftermath: coordinating/facilitating psychological support and psychological first aid
2. Short term: working to support normalisation and psychoeducation
3. Short-to-medium term: identify and support those individuals who need further support
4. Medium-to-long term: referring/offering interventions to individuals and support school planning, training, follow-up
5. Community level
  1. Coordination/training/planning/working with: LA emergency planning officers, HPA, public relations officers, children social care services, emergency services
    1. Example: Pousada (2006)
Components of critical incident stress management
1. Pre-incident education and mental preparedness
2. On scene crisis intervention support
3. Demobilisation, defusing, CISD
4. Support for families/children
5. Follow-up and link to appropriate services

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Critical Incidents: From Response to Action

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	Created by Maisie Rose Woodward almost 9 years ago