Sunday, September 11, 2005

How to help those who help: Do no harm

As you've likely noticed, those folks (both civilians and emergency services providers) are facing extreme pyschological trauma. Citizens have been uprooted; they've seen death; they've felt forgotten and abandoned. Emergency services providers -- be they law enforcement officers, National Guard personnel, Coasties, fire fighters, emergency medical technicians, urban SAR specialists, and the list goes on -- have seen destruction and death on a level never before seen.

Everyone involved has experienced psychological trauma; everyone has been through a "critical incident." Critical Incident Stress Management is a crisis intervention tool which provides crisis first aid. As the International Critical Incident Stress Foundation defines it,
CISM is a comprehensive, integrative, multicomponent crisis intervention system. CISM is considered comprehensive because it consists of multiple crisis intervention components, which functionally span the entire temporal spectrum of a crisis. CISM interventions range from the pre-crisis phase through the acute crisis phase, and into the post-crisis phase.
The Coast Guard has several CISM teams, each coordinated by one of our Work-Life staffers at a support command. CISM-trained personnel have deployed down to the Gulf coast. My fear is they will fly-in and do more harm than good.

The ICISF, the primary organization which sets the protocols for this model of crisis intervention, has issued a couple of emails in the last week. They, too, seem concerned.

Responding to Katrina: Effective Assistance is Based Upon Prudent Planning

Images broadcast from the areas stricken by Katrina's wrath engender a myriad of reactions such as shock, awe, disbelief, anger, sympathy, fear, and even betrayal. But for those in the helping professions, a visceral urgency to personally respond may be the primary reaction. Experience has taught us well that such urges are to be tempered with a prudent assessment of need, a realistic assessment of available resources, and a plan for implementing assistance once on site. The following recommendations are offered as an initial set of guidelines for those considering responding to the disaster mental health needs of those affected by Katrina.

1. All intervention is predicated upon an assessment of a need. Need is not only defined as the determination of the necessity for crisis and disaster mental health support, need also means that such support is desired by those at the local/state level and that such support will effectively augment, rather than complicate or disempower local initiatives. Self-deployment based upon an impulsive need to help is never a good idea.

2. Assistance must be coordinated within an integrated response plan. Ideally, such a plan involves local, state, Federal, and NVOAD resources.

3. Once deployed, effective mental health response should follow the hierarchy of needs described by Abraham Maslow:
a. Meet physiological needs for shelter, food, water, clothing.
b. Meet basic needs for safety, security, and medical care.
c. Meet basic needs to re-establish family and other interpersonal connections. Reuniting families must take priority over all other such support. For rescue and recovery personnel, the establishment of "peer" and mental health support should be emphasized.

4. The principles of psychological first aid are useful guidelines for planning support services beyond that mentioned above:
a. Assess need, assess impairment
b. Stabilize (try to prevent further deterioration of psychological/behavioral functioning through meeting basic needs as described above)
c. Assess need for further support
d. Offer information, education, reassurance, as indicated
e. Connect with sources of continued support
f. Diagnostic and traditional "psychotherapy" functions are not included herein, but are considered as later points on an overall continuum of care.

5. Keep in mind that the psychological/behavioral response to mass disasters typically follow a somewhat predictable trajectory. Civilian reactions will follow a very different course than will the reactions of rescue and recovery personnel. Try not to confuse/intermingle the support services offered to these two groups. The majority of manifest need for rescue and recovery personnel will come weeks post this is written (09/06/05), we are still in the impact phase where the most basic of all needs are the priorities.

6. Be sure to plan for your own well-being. Prepare yourself mentally and physically. If going to the Gulf Coast on assignment, carefully assess your own health before going. This is an extreme hardship assignment. The history of disaster response is replete with examples of helpers becoming victims.

7. Plan a time-limited deployment in order to assist in resource planning and in "self-preservation." Plan for some form of "re-entry" or homecoming for interventionists after their deployment. Don't forget the importance of "debriefing the debriefers" when they come back from an assignment. Disaster response work is highly needed and rewarding, but it is highly stressful, as well.

8. If you are not called, or are called and cannot go out to the impacted disaster area, there may be ways to help in your own communities. Many communities around the country are receiving evacuees and can use trained crisis intervention personnel to help them adjust to their new situations. Local Red Cross or other NVOAD agencies may need volunteers locally to answer phones and help out in their offices. Give them a call and see if you can be of assistance.

9. The media is flooding all of our homes with heart wrenching stories and pictures. Be sure to monitor the "dose" of disaster that you, your family, and especially your children are exposed to. Monitor TV watching, and talk about what you are seeing. Reassure your children that you have a family disaster plan. Now is a good time to review your disaster plan as a family and update the plan and supplies as needed.
A second email addresses the fly-in and shit fear directly:
Within areas that have been affected by Hurricane Katrina, many first responders and other care providers are still on scene and effectively in the "Operations Mode."

At this time, as in most disasters, the priorities will be
1. Meet physiological needs for shelter, food, water, clothing
2. Meet basic needs for safety, security and medical care
3. Meet basic needs to re-establish family and other interpersonal connections, and
4. Timely/accurate information flow.

The suggested tool for "timely information flow" would be the Crisis Management Briefing (CMB). Please review the article found here for additional information about this component in the CISM toolbox.

Of the many tools that are available when providing Crisis Management services, Debriefings (per the ICISF Model) should be utilized rarely if at all at this stage of a disaster. The CISD should only be used with homogenous groups of people who worked on the disaster together. Their mission should be complete and they should have experienced approximately the same level of exposure. No personnel should be forced to participate. Should you wish to review the appropriateness of an ICISF Debriefing for a particular circumstance, please feel free to contact the ICISF office.
Emergency services providers who are on scene and working are in operations mode; operations mode is not the time to ask someone to bare their emotional soul. Too often, people providing crisis intervention or crisis management services, particularly in large events, rush in too early.

While I don't know specifically what is going on down south with regard to crisis intervention and CISM, I have a suspicion. And I suspect they're doing too much, too soon. I can only hope they do no harm.

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