joan reed, msw, acsw, lcsw director of school services erica muhlenkamp, msw, lcsw program manager...

Joan Reed, MSW, ACSW, LCSW

Director of School Services

Erica Muhlenkamp, MSW, LCSW

Program Manager School Services

Community Health Network

Behavioral Health Services

Crisis Intervention in Violent Times

Crises are dangerous opportunities. Chinese Proverb

Fear Words

CrisisTragedy

Emergency Trauma

Catastrophe

CRISIS .....

OCCURS WHEN A PERSON’S STRESSORS

OUTWEIGH THEIR ADAPTIVE CAPACITIES

Crisis is….

Any situation a person finds

themselves in, in which their

traditional ways of coping are

ineffective or maladaptive.

Feeling Helpless and Hopeless

Types of Crises

Events that threaten a person’s well being

oDeath related to suicide of a friendoGang activityoSnipersoHostage-takingoRapeoAccidental or expected death

Natural DisastersoEarthquakesoFires

ADAPTIVECAPACITIES

STRESSORS

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Well Functioning

Adaptive Capacities in Daily Life

• Physical health• Physical abilities• Cognitive IQ• Emotional IQ• Spiritual connection• Education or experience• Community or family support• Personality

Sources of Stressors

• Financial• Addictions• Residual past traumas or loss• Work dissonance• Family discord• Physical or mental illness• Others???????????????

ADAPTIVECAPACITIES

STRESSORS

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Crisis / Trauma

Soooooooooo….

HOW MUCH OF WHAT YOU DO

DO IS REALLY

CRISIS INTERVENTION?

Crisis Intervention is NOTPsychotherapy

Therapy is inappropriate in crisis situations because

1. people have already been bombarded with overwhelming change

2. people in crisis are highly stressed by events and conditions around them

3. people in crisis are often out of touch with their coping skills

4. people in crisis do not feel safe -- therapy depends on people feeling safe enough to explore the possibility of personal change

SELF ACTUALIZATION

INTELLECTUAL & SPIRITUAL GROWTH

LOVE AND BELONGINGNESS

COGNITIVE FUNCTIONING (ACTIVITIES OF DAILY LIVING)

SAFETY & SECURITY

BASIC HUMAN / SURVIVAL NEEDS

Maslow’s

“Basic Hierarchy of Human Needs”

What People in Crisis Need

1. To talk about what happened2. To relate what has happened to other

events in their lives3. To explain to themselves what has

happened so they can acknowledge it4. To reconnect with positive coping skills5. To be given a list of resources for further

help6. To be encouraged to attempt to continue

their usual routine.

Crisis Response

CRISIS AFFECTS THE WHOLE PERSON !

CognitivePhysical

EmotionalBehavioralSpiritual

Responding to a Person in Crisis

1) Managing the situation

A person who is upset can produce a form of emotional contagion.o To counter this, one must present a calm,

reassuring demeanoro Clarify that the person is upseto If possible, indicate why the person is upset

(correct rumors and distorted information)o State what can and will be done to help the

person

Responding continued…2) Mobilizing Support

The person needs support and guidance.

Staff can otry to engage the person in a problem-solving

dialogueonormalize the reaction ofacilitate emotional expression (e.g., through use of

empathy, warmth, and genuineness)ofacilitate cognitive understanding by providing

information

Responding continued…ofacilitate personal action by the person (e.g., help

them do something to reduce the emotional upset and minimize threats to competence, self-determination, and relatedness)

o encourage their buddies/friends to provide social support

o contact the person's family to discuss what's wrong and what to do

o refer the person to a specific counseling resource

Responding Continued…Move the person from Victim to ActoroPlan with the person promising, realistic, and appropriate actions they will pursue when they leave you

oBuild on coping strategies the person has displayed

oIf feasible, involve the person in assisting with efforts to restore equilibrium

Responding Continued…Connect the person with Immediate Social Support

Peer buddies, other staff, family -- to provide immediate support, guidance, and other forms of immediate assistance

Provide for Aftermath Interventions

Be certain that individuals needing follow-up assistance receive it

Responding continued…3) Following-up

Over the following days (sometimes longer), it is important to check on how things are progressing.

oHas the person gotten the necessary support and guidance?

oDoes the person need help in connecting with a referral resource?

oIs the person feeling better? If not, what additional support is needed and how can you help make

certain that the person receives it?

Major Facets of Crisis Response

in the Community

During the emergency

Communication osounding the alarm if necessary oclarifying additional steps oproviding information about the event othe location of first aid stations if needed orumor control odealing with the media okeeping track of students and staff oresponding to families o interfacing with rest of the district and community

Major Facets Continued…Direction and Coordination

orunning an emergency operations center omonitoring problemsoproblem solving

Health and Safety omitigating hazards to protect people providing them

with medical and psychological first aid oproviding for search and rescue, security, evacuation

Aftermath Response Immediate aftermathoCommunication

clarifying causes and impact and debunking rumors providing information about available resources for

medical and psychological helpo Direction and coordination

determining need to maintain emergency operations center

continuing to monitor problems and problem solveoHealth and safety

continuing with activities initiated during the event

Crisis Mode----Hyper-vigilance

Aftermath ResponseRestoring Equilibrium

oBe calm, direct, informative, authoritative, nurturing, and problem-solving oriented

oCounter denial by encouraging people to deal with facts of the event

oGive accurate information and explanations of what happened and what to expect -- never give unrealistic or false assurances

Minimizing

Aftermath ResponseoTalk about their emotional reactions

oEncourage them to deal with such reactions as another way of countering denial and other defenses that interfere with restoring equilibrium

How the crisis is handled determines

whether growth or disorganization will result

A CRISIS CAN

LEAD TO PERSONAL GROWTH

Convey a sense of hope and positive expectation -- that while crises change things, there are ways to deal with the

impact.

The Crisis Reaction: Mind’s Response

Initial cognitive reaction of shock, denialRegression

Cataclysm of emotions• Fear and terror• Anger, fury, and outrage• Confusion and frustration • Guilt or self-blame• Shame or humiliation• Grief or sorrow

Reconstruction of new life equilibrium

A Crisis Changes Things

BRAIN 101

ANATOMY & PHYSIOLOGY

YOUR BRAIN…..IN CRISIS

Pg. 2-14PARIETAL

OCCIPITAL

CEREBELLUM

FRONTAL

PRE FRONTAL

BRAIN STEM

The Brain’s StructureLimbic system: capacity for

emotion, differentiation of perceptions and response

• Hippocampus: perceives, registers and associates data; provides context

• Amygdala: adds emotional content to the sensory information

The Brain’s Structure

Cortex / Neocortex: connects, comprehends,

plans

Thalamus: internal alarm system (sends alarms to amygdala more quickly

than to neocortex)

Cognitive Processing 101

“Normal” Processing

Receive sensorial stimuliStimuli is determined not to be

threatening or dangerous (thalamus)

Organize and interpret information as usual (cortex and neo-cortex)

Emotional content added (limbic system)

Cognitive Processing 101

“Traumatic” Processing

Receive sensorial stimuli Stimuli is determined to be threatening or dangerous (thalamus) Emotions trigger physical and emotional reactions that override cognitive processing (limbic system) Scattered emotional information interferes with cognitive processing (cortex and neo-cortex)

The Shifting Balance of Thought & Emotion

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Everyday Trauma After Crisis

EmotionThought

Traumatic and Narrative Memory:

Traumatic Narrativeimages, sensation, affective semantic and symbolicand behavioral states

does not change over time social and adaptive

state-dependent; cannot be evoked at will can be evoked at will

automatically evoked in can be condensed or expandedspecial circumstances on social demandsNo condensed in time

Elements of Crisis Intervention

THE NOVA MODEL

Safety and Security

Ventilation and Validation

Prediction and Preparation

Safety• Safety is a “physical” issue

• Address physical safety or medical needs

• Address survival needs such as food, clothing or the need for warmth and sleep

• Provide information and a source of communication

Security - An Emotional Issue

To promote security a caregiver needs to:

• Privacy for the expression of emotions.

• Confidentiality of communication.

• Reassurance

• Sense of control

• Sense of emotional safety.

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Be certain that support systems are in place for care givers

RememberoIn the midst of a crisis, it is hard to remember all the specific steps and preparatory plans that have been discussed.

oEach site and each person responsible for crisis response needs to have a checklist that provides a ready and visible reference guide for use during a crisis

Tools for Understanding and Responding: Safety and Security

Help survivors contact loved ones.Help with immediate problem-solving.Help re-establish a sense of control over small

things first, then go on to larger things.

Use “reactions” and “responses” rather than “feelings” and “sharing.”

Sit down to talk.Help them obtain information they need.Give permission for crisis reactions.Promote physical comfort.

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Ventilation

• LET THEM TELL THEIR STORY

• Compassionate presence

• Effective LISTENING

Processing

Validation

• VALIDATE THEIR REACTIONS

• Focus on the commonality of reactions

• Let survivors use and identify their own words for their crisis and reactions

• Repeat key elements of the story

Tools for Understanding and Responding: Ventilation &Validation

Ask survivors to describe the event.Ask them to describe reactions/responses.Let them talk as long as they need to.Validate when there are natural pauses.Don’t ask “why” questions.Avoid interruptions whenever possible.

Let them know you care.Avoid telling of your own experiences.Be alert to signs that survivor plans to harm self

or others.

Pages 4 - 7 thru 18

A Sense That One Can Never Do

Enough

Prediction• Ask what problems will be faced in the

next days and how the individual plans to cope

• Identify practical issues that may arise

• Identify emotional reactions that might occur

• One of the most important concerns of survivors is “what is going to happen next?”

Tools for Understanding and Responding: Preparation &

Prediction

• Provide information on practical issues• Provide referrals• Explain specifically how long assistance

might be available• Identify solvable problems & solve them• Don’t make promises that can’t be kept• Possible emotional & physical reactions

should also be predicted.

So…….Two most important things that people in crisis need that each of you can do…………..

• Let them tell their story

• Validate their crisis reactions

•AND THAT GOES FOR US AS CAREGIVERS TOO!

Care of the Caregivers

CARE OF OTHERS CANNOT EXCEED CARE OF THE CAREGIVERS

Caregivers need to talk about:• what happened• what they did• what they thought or felt• what the experience means to them• stress reactions• how they coped or are coping• what went well and what could be done differently

“I can be most present by being close enough to the fire to empathetically feel the heat, and yet separate enough to not be singed

or need to flee.”Lattanzi, M. (1984). Professional Stress: Adaption, Coping, and

Meaning. Family Therapy Collections.

8. What bothers you the most about what happened? 9. Do you think anyone could have done something to prevent it? Yes No

Who?

 10. Thinking back on what happened,

not at all a little more than a little very much

 How angry do you feel about it? 1 2 3 4

  How sad do you feel about it? 1 2 3 4

  How guilty do you feel about it? 1 2 3 4

  How scared do you feel? 1 2 3 4

Questions for Briefing1. Where were you when the event occurred? (Directly at the site? nearby? out of the area?)

2. What did you see or hear about what happened?

3. How are you feeling?

4. How well do you know those who were involved?

 5. Has anything like this happened to you or any of your family before?

 6. How do you think this will affect you/your family in the days to come? (How will your life be different now?)  

Finding BalanceIntention

When your day begins, close your eyes, take several deep breaths, and ask yourself, “What is my intention for today?” If you have small children or loud chickens demanding your attention before you are conscious, ask yourself this while you are feeding your children or gathering your eggs, but create an intention for the day.

At the end of your day, before sleep overtakes you, ask yourself, “What can I put down? What am I ready to be done with? What don’t I need to carry with me for another day?” Put it down, and don’t pick it up again the next day.

Finding BalanceGratitude

At both the beginning and end of your work day, take a distinct moment to think of one thing you are grateful for.

Every single day, think of one person you are grateful to and tell that person so. You can start with those close to you and slowly branch out to expressing your gratitude for all the “teachers” in your life.

Advocate for your workplace to create a forum where you and your colleagues can express gratitude to one another. Take the lead in thanking others.

Finding Balance Mindfulness Designate a day of rest. Whether you identify is as Shabbat or the Sabbath or simply a day off, designate a weekly day of non-obligation for yourself. This will serve to remind us that if we are truly to reconnect with ourselves, work and creation must stop. Our day of rest will also remind us that who we are as individuals and as members of society is about our deepest essence and not about what we produce during the week.

Finding BalanceIn addition to your day of rest, allot some time for yourself each day when you don’t obligate yourself to anything, but instead give yourself total freedom to delight in one of your favorite states of being. Be present with this for however long you are able. Notice how you feel when you free yourself from obligation and allow yourself to be centered within.

Local Response Needs?

Contact I-CART• Indiana Crisis Assistance Response Team• 317-596-2202• www.i-cart.org