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Responding to critical incidents in schools Flashcards

1
Q

What is a critical incident?

A
  • An incident charged with profound emotion which may involve serious injury or death
  • Incident generating a high level of immediate or delayed emotional reaction
  • Incident involving serious threat or extremely unusual circumstances
  • Incident attracting unusual attention from the community or media
  • Surpassing an individual, group or organisation’s normal coping mechanisms

(Cheshire County Council, 1995)

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2
Q

Could the Covid-19 pandemic be considered a Critical Incident?

A
  • Profound Emotional Reaction
  • Involving Illness and Death
  • Unusual attention from the media (and community)?
  • Surpassing an individual, group or organization’s ability to cope?
  • Around 126 Deaths of Education Workers (age 20-64) due to coronavirus between 9th March & 25 May 2020 (ONS, 2020).
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3
Q

Key questions for psychological theory, research and practice.

A
  • How do people (including children and young people) “typically” respond to critical incidents? Why do people respond in the way they do?
  • Why are people affected differently?
  • What are the psychological needs created by critical incidents?
  • How are these needs best supported and/or addressed?
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4
Q

Post trauma stress

A
  • “The development of certain characteristic symptoms following a psychologically distressing event, which is outside the range of normal human experience”
    • (APA, DSM 1987)
    but “a normal reaction of normal people to events which, for them, are unusual or abnormal”(Parkinson, 1993)
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5
Q

What is the impact?

A
  • Flashbacks and intrusive memories
  • Headaches
  • Difficulty concentrating
  • Feeling guilty typically ‘it was my fault’
  • Feeling detached from others

(Parkinson, 1993)

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6
Q

When might symptoms be considered problematic?

A

Post Traumatic Stress Disorder (PTSD)

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7
Q

what is PTSD?

A

Occurs when symptoms of PTS

  • emerge later
  • persist or intensify long after the event. i.e. more than six weeks (?)
  • disrupt normal living
    • (Diagnostic Statistical Manual (DSM)-IV, American Psychiatric Association (APA), 1993)
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8
Q

DSM Symptom Criteria

A

Updated diagnostic category (DSM V, APA, 2013)

Involves four aspects:

  • Re-experiencing
  • Avoidance
  • Arousal
    -Negative Cognition and Mood

DSM V, (APA, 2013)

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9
Q

What about PTSD in children and young people?

A
  • Diagnosis for children above 6 years is the same as adults

But symptoms in younger children may differ and may include
- re-enacting events
- repetitive play
- emotional and/or behavioural difficulties

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10
Q

What influences peoples’ reactions?

A
  • Age
  • Experience
  • Personality
  • Nature of the incident
  • Degree of involvement

(McNally, 2003)

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11
Q

Trauma, PTS, PTSD & PTG

A
  • Dose of trauma doesn’t necessarily = symptoms
  • ‘ The vast majority of people exposed to serious traumatic events do not develop PTSD’ (McNally, 2003)
  • And some people ultimately learn and grow from their experience (Joseph, 2011). i.e. they experience some Post-Trauma Growth (PTG)
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12
Q

Theoretical Perspectives
Life-Belief Model (Janoff-Bulman, 1985) what do people develop and what does critical incidents lead to?

A
  • People establish core beliefs:
    • We are invulnerable – safe & secure
    • Life has meaning and purpose
    • We are good and respectable people

Critical Incidents lead people to:
- Question their beliefs about themselves.
- Become aware of their own mortality & vulnerability
- Search for meaning. Asking ‘Why to me?’ type questions

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13
Q

Theoretical Perspectives Human Needs Model (McCann & Pearlman, 1990) what do people develop and what does critical incidents lead to?

A
  • People develop:
    • Core beliefs, expectations & assumptions about their life
    • Such as the human need for stability, safety, trust, self-esteem, independence, power and closeness

Critical Incidents
- Disrupt these core beliefs, expectations and assumptions.
- Challenge people’s ability to protect or fulfil their needs.
- Leading them to question and change their view about how these needs can be met.

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14
Q

Crisis Intervention Theory (Caplan,1964)

A
  • Usually in human experience the cognitive-emotional aspects are in balance.
  • A traumatic event creates an imbalance between the two and leads to an ‘emotional crisis’
  • Leading to a reaction to the critical incident across four stages
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15
Q

what are the 4 stages of crisis intervention theory?

A
  • Impact
  • Withdrawal and confusion
  • Adjustment
  • Reconstruction

People need to work through or be supported through this process, in order that they do not get stuck.

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16
Q

Links to Grief & Bereavement Theory

A

denial
pain
realisation
resolution

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17
Q

Psychosocial Model/Framework(Joseph, Williams & Yule, 1997)

A

event stimuli
event cognition
appraisal mechs
emotional state

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18
Q

What are the needs of those affected by critical incidents?

A
  • Acknowledgement and Recognition
  • Information
  • Opportunity to talk
  • Formal and informal rituals
  • Routines and normality
  • Return and reintegration

(Parkinson, 1997)

19
Q

What is the aim of Critical Incident Support?

A
  • To help those affected to understand the impact of trauma on themselves and others.
  • To plan for peoples’ reactions and needs of individuals and groups affected.
  • To coordinate and manage the organisation and community response

(Warrington Borough Council, 2007)

20
Q

What Levels of Support Required?

A

Level 1 Someone there -> First Hours
Level 2 A Listening Ear-> First Days
Level 3 Structured (Group) Support -> First weeks
Level 4 Specialist Therapy or Counselling -> First few months

(Hindmarch, 2002)

21
Q

community level support

A

Planning & Preparation

  • Local Authorities and Schools should be
  • “Wise Before the Event” (Yule & Gold, 1989)
22
Q

EP work at a Local Authority and community/universal level - what do they do

A
  • Training and development activities for staff
  • Links and liaison with other agencies/services
  • Simulation and practice
  • Involvement in emergency planning exercises
  • Critical Incident Team co-ordination and development considering the needs of the community affected
  • Supporting the community and/or coordinating/responding to incidents as, and when, appropriate (……….and learning from them)
    • (see Pousada, 2006)
23
Q

Support in Major Disaster/Incident

A
  • To provide a fully coordinated psychosocial response to a disaster.
  • Plans should include:
    • immediate practical help.
    • support for the affected communities in caring for those involved in the disaster.
    • clear roles and responsibilities for all professionals involved.
    • faciltiate access to specialist mental health, evidence-based assessment and treatment services as appropriate

( NICE, 2005)

24
Q

Components of Critical Incident Management Plan

A
  • Pre-incident education and mental preparedness.
  • On scene crisis intervention support
  • Demobilization and Defusing.
  • Critical Incident Support/Psychoeducation
  • Support for Families and Children
  • Follow up and link to appropriate support services

adapted from Mitchell & Everly, 2000)

25
Q

How do Critical Incidents Impact on schools and organisations?

A
  • Incidents can directly or indirectly affect a school or organisation. They:
    • Can be an onsite, offsite or multi-site
    • May affect school staff and senior managers
    • May generate a lot of media interest
    • May generate reaction in parents
    • May generate over-zealous helping, callers and visitors
    (Cheshire County Council, 1995)
26
Q

What is the Impact of trauma on Organisations?

A
  • Can bring out the ‘Best and Worst’ in people
  • Magnify difficulties or strengthens existing relationships
  • Can lead to closing of ranks creating an ‘in group’ versus ‘out group’
  • Competing pressure to stop or to carry on as normal
  • Shared experience creates an opportunity for people to both give and seek support

(Hindmarch, 2002)

27
Q

EPs work helping schools as Organisations with Critical Incidents what do they do?

A
  • EPs work to support schools to be ‘Wise before the Event’ (Yule & Gold, 1989)
  • But plans and responses need to be flexible
  • EPs may help Schools to
  • develop a plan for handling the feelings and reactions of people
  • Preparing a media statement
  • Preparing information for parents, pupils and staff
  • Considering and arranging appropriate support for staff, parents and the pupils involved
  • Engaging a wider Critical Incident Support Team (including Educational Psychologists & Other Professionals)

Managing the response to critical incidents in schools (Warrington BC Guidance, 2007)

28
Q

how do EPs support at group level?

A

Different forms of short-term post-incident “group” support

  • Demobilisation
  • Defusing
  • Debriefing

(Parkinson, 1997; Mitchell, 1983; Dyregrov, 1987)

  • Psychological First Aid
    (Brymer et al, 2006)
  • Structured Group-based Trauma-Focussed-CBT (see Dorsey et al, 2017)
29
Q

what model is critical incident debriefing based on?

A
  • Critical Incident Stress Debriefing (CISD)(Mitchell, 1983)
  • Psychological Debriefing (Dyregrov,1987)
30
Q

Aims of debriefing?

A
  • To create a shared narrative
  • To help integrate cognitive and emotional memory
  • To connect past, present & future
  • To provide psycho-education
  • To support normalisation
    • (Mitchell and Everly, 1996; Dyregrov, 1998)
31
Q

What’s the evidence of impact of debriefing ?

A
  • ‘Psychological debriefings can be very effective in reducing intrusive thoughts.’(Stallard and Law,1993, p.663)
  • But approach criticised for not differentiating responses for individuals (e.g. Bisson et al, 2009)

Adult CISD studies have found
- While some evidence of its perceived helpfulness and satisfaction of those involved.
- There was no evidence that it was effective in preventing PTSD in individuals
- Van Emmerick et al (2002)

32
Q

systematic reviews of CISD

A

Systematic Reviews of CISD suggest the evidence for its use is at best inconclusive, and some argue potentially harmful for individual primary victims (BPS, 2002, Cochrane Collaboration, 2004; Bisson et al 2009)

It is therefore currently not recommended as a method of treating or preventing PTSD (NICE, 2018)

33
Q

Psychological first aid

A
  • “ non-intrusive, supportive and practical assistance” (WHO, 2010)
  • Aim to
    • Create calm conditions
    • reduce initial distress
    • promote functioning and coping
  • Flexible approach which
    • acknowledges Individual differences in reactions although given in response to a group’s needs
34
Q

8 Core Components of Psychological First Aid - first 4

A
    1. Contact and Engagement
      - Goal: To initiate contact with or to respond to contacts by students and staff in a non-intrusive, compassionate, and helpful manner.
    1. Safety and Comfort
      - Goal: To enhance immediate and ongoing safety, and to provide physical and emotional comfort.
    1. Stabilization (if needed)
      - Goal: To calm and orient the emotionally overwhelmed or disoriented students and staff.
    1. Information Gathering: Current needs and concerns
      - Goal: To identify immediate needs and concerns, gather additional information and tailor Psychological First Aid for school intervention to meet these needs.
35
Q

8 Core Components of Psychological First Aid - last 4

A
    1. Practical Assistance
      - Goal: To offer practical help to staff and students in addressing immediate needs and concerns.
    1. Connection with Social Supports
      - Goal: To help establish brief or ongoing contacts with primary support persons or other sources of support, including family, friends and other school and/or community helping resources.
    1. Information on Coping
      - Goal: To provide information about stress reactions and coping to reduce distress and promote adaptive functioning.
    1. Linkage with Collaborative Services
      - Goal: To link students and staff with available services needed at the time or in the future. (Brymer et al (2006; 2012)
36
Q

Effectiveness of Psychological First Aid

A
  • Evidence-base for PFA is still insecure, although support of expert opinion
  • Has logical links with grief and bereavement theory
  • Some evidence that it promotes calm and connection
  • “Evidence-consistent” rather than “evidence-based”
    • Aucott & Soni, 2016)
  • Considered by some as an appropriate response to a CI (Fox et al, 2012)
  • But other approaches needed to address PTSD in Individuals and groups ( e.g. TF-CBT (Dorsey et al, 2017))
37
Q

What considerations need to made for children affected by CI?

A
  • Developmental issues in child
  • Modalities of expression and conversation
  • Involvement of parents
  • Role of peer group
  • Level of engagement
  • Self disclosure, confidentiality & coping skills
  • Potential for secondary traumatization & retraumatization.
    • (Wraith, 2000)
38
Q

What are the recommended interventions for individuals?

A

NICE (2005) guidance suggests the importance of the following:
- Psychological first aid (PFA)
- Watchful waiting
- Eye Movement Desensitisation Reprocessing
- Trauma-focused Cognitive Behaviour Therapy

39
Q

Evidence-based interventions for individual adults? x2

A
  • Eye movement desensitization and reprocessing (EMDR)
    • Person recalls an important aspect of a traumatic event
    • Whilst following repetitive side to side movements, sounds or taps as the traumatic image is remembered and focused on
  • Trauma-focused Cognitive Behavoiural Therapy (TF-CBT)
    • Help confront traumatic memories
    • Modify misinterpretations of threat
    • Develop skills to cope with stress.
      • (NICE, 2005, PTSD guidance)
40
Q

Updated Guidelines (NICE, 2018)

A
  • Active monitoring & follow-up contact after one month.
  • Planning Treatment and Supporting Engagement.
  • Intervention Individual Trauma Focused CBT for age 7-17 years
  • Prevention …. Group Trauma Focused CBT for individuals shared experience of major trauma for age 7-17 years ( Some emerging evidence)
  • Could consider use of EMDR …. but PFA not mentioned…?
41
Q

Trauma Focussed Cognitive-Behavioural Therapy (TF-CBT) aim & stages 1-5

A
  • TF-CBT aims to help a person to restructure their core beliefs, thoughts and ideas by:
    • Stage 1 – establishing a rapport, encouraging person to tell their story and express feelings.
    • Stage 2 – help the person make sense of story - new coping skills linked to re-experiencing, avoidance, arousal and negative cognitions/mood
    • Stage 3 – involves cognitive restructuring – to help person obtain control, rebuild and replace shattered beliefs.
    • Stage 4 - re-establish relationships and confidence.
    • Stage 5 - develop strategies to prevent relapse.

(Meichenbaum,1994)

42
Q

The evidence-base for children and young people?

A
  • Intervention of choice is trauma-focused CBT for individual children of 10years upwards (Wolpert et al, 2006)
    • Little conclusive evidence to support the efficacy of EMDR and other interventions with children and young people.
    • A need for better evidence base and audit of all interventions (NICE, PTSD guidance 2005)
  • Individual Trauma Focused CBT could be considered for CYP age 7-17 after 3 months
  • If a large-scale trauma and shared experience - Group TF-CBT could also be considered ( NICE, PTSD Guidance, 2018)
  • But a call for a further review of evidence on TF-CBT (see Dorsey et al, 2017)
43
Q

In summary…..EPs can be involved in …….. what 5 things

A

1.planning before the Incident
- Supporting local authority and school planning and training to be “Wise Before the Event” (Yule & Gold, 1989)

  1. Immediate Aftermath
    • Coordinating and facilitating psychological support (something akin to psychological first aid)
      - Short-term
    1. Working to support normalisation and psycho-education (including on occasions offering psychoeducation material and structured group support where homogenous group and experiences occur)
  2. Short to Medium-term
    • Involved in watchful waiting, screening and assessing helping to identify those individuals who may need further support and sometimes offering short term support
  3. Medium to Long-term
    • Referring, or offering interventions to, individuals those who have longer term needs.
    • Using learning from an Incident for future training & support

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