|Stress Management in Disasters (Pan American Health Organization (PAHO) / Organización Panamericana de la Salud (OPS) - WHO - OMS, 2001, 144 p.)|
Striving together as a team, to
Make that needed difference,
In the lives of those persons who
Devote their lives to the care of others.
Taking time out to listen,
Encouraging those who have lost faith,
Assisting those who need a helping hand to
Make it back to a state of psychological well-being.
SMID Teams provide peer-oriented crisis intervention programs that depend on guidance and assistance from mental health professionals and which emphasize prevention over treatment.
An absence of mental health professionals from SMID Teams could easily result in significant psychological problems being overlooked. The absence of peers, on the other hand, may result in dysfunctional behavior of emergency response workers going unrecognized. Community-based stress management teams, in contrast, may be comprised of mental health professionals only.
SMID Team membership is strictly voluntary (unpaid). Teams work to provide services to any emergency response personnel who may need them but under special circumstances they may also serve community groups. Each SMID Team must have a well publicized call-out procedure. There also needs to be a 24-hour center to which requests for SMID Team services can be directed (e.g., the telephone operator of the Accident and Emergency Department of a general hospital).
To maintain a healthy SMID Team there must be regular team meetings, quality education and cross-familiarization where peer support personnel are trained in issues which are usually the domain of mental health professionals and vice versa.
The goals of such teams are to:
1. Enhance the overall psychological health of the emergency response worker,
2. Reduce the impact of traumatic stress on emergency response personnel and disaster workers, and
3. Accelerate recovery from exposure to stressful events.
Senior personnel of the various emergency organizations served by SMID Teams need to know about the nature of the team, its functions, the type of events it responds to and the manner in which it may be called into action. It would be wise to bring the leaders of these various organizations together in the early stages of the team's development and periodically after it has been established.
Administrative and supervisory personnel must be assured of the following:
1. SMID is primarily a prevention program which encourages recovery from stress and not from disability;
2. SMID services are relatively inexpensive to provide and the benefits are tremendous although difficult to measure;
3. The SMID Team can make suggestions or express its concerns regarding staffing or operational procedures but it cannot over-rule a commanding officer, especially when the team is working at the scene of an incident;
4. The SMID Team will keep the administrative and senior personnel informed about the general nature of the team's activities and about developments in the field of critical incident stress management;
5. The SMID Team will coordinate relevant educational programs for all those organizations utilizing its services;
6. The SMID Team will actively participate in disaster drills or in any other activities that will enhance the quality of the services which it provides.
Regional SMID Coordinating Body in the Caribbean
It is hoped that eventually a Regional SMID Coordinating Body can be set up to oversee SMID Services provided in the Caribbean. Each Caribbean territory or country with at least one SMID Team would then be required to nominate a single representative to serve on such a coordinating body. This body will be headed by the Regional SMID Coordinator and have a Secretariat in one of the member Caribbean territories and countries.
Both representatives and executive officers of such a coordinating body should serve two-year terms with a maximum of four consecutive years. Its success will depend heavily on the cooperation of and feedback from member countries and territories throughout the region.
The proposed duties of the Regional SMID Coordinating Body in the Caribbean will be to:
1. Decide on policies, protocols and procedures for the operations of SMID Teams throughout the region;
2. Coordinate training and serve as the certifying body for training;
3. Keep member organizations up to date with recent clinical developments in the field of critical incident stress management;
4. Evaluate the quality of SMID services provided by member countries or territories;
5. Attract funding to assist member countries or territories;
6. Foster information flow between members;
7. Be the final disciplinary arbitrator.
The Lead Agency serves to establish the environment in which the SMID Team(s) can be developed and supported initially in any given country or territory. The actual services provided by the agency may vary from agency to agency.
Such an agency may be the Government, an emergency response agency, a disaster preparedness agency, a hospital or the psychology department of a college or university.
The Lead Agency may dissolve its role once the team(s) have been established and their Management Committees begin to function effectively. In countries or territories with more than one SMID Team the Lead Agency may continue to function as the local coordinating body for such teams.
The basic functions of the Lead Agency are to:
1. Provide funding and resources during the time of the team's development;
2. Develop a Mission Statement;
3. Establish a management committee;
4. Establish a team membership committee;
5. Assist in the drawing up of rules, standards, protocols and procedures for the team's operation;
6. Develop and coordinate the work of the team(s);
7. Put protocols in place to allow for cooperation with teams headed by other Lead Agencies;
8. Secure release time for staff members to manage and serve the team;
9. Maintain an up-to-date background file and call-out number for all team members;
10. Assist in the development of research and evaluation methods as well as quality assurance.
Management Committee of a SMID Team
The Management Committee is an administrative body which coordinates the work of the SMID Team. Its headquarters will initially be located at the Lead Agency but may eventually be relocated. In some jurisdictions, the Management Committee may perform the role of Lead Agency during the initial development of the team(s). The committee should meet weekly during the setting up phase of the team and monthly once the team has been established.
The Management Committee should comprise:
1. An Administrator
2. An Assistant Administrator
3. A Secretary / Treasurer
4. A Public Relations Officer
5. The Team Coordinator
6. The Team Clinical Director and
7. Support Clerical Staff (1 or 2 persons) who should hold full-time, paid posts.
The Management Committee should have access to the services of a Legal Advisor and an Education Advisor.
The duties of the Management Committee include:
1. The duties of a Lead Agency (if none exists);
2. The establishment of written policies, protocols, rules, regulations and procedures to govern the operations of the SMID Team;
3. Coordination of the initial and on-going training of team members;
4. Initial and on-going recruitment of team members;
5. Selection of appropriate team leadership;
6. Provision of general support for the activities of the SMID Team;
7. Evaluation of team performance;
8. Record keeping, data collection and research.
Team member selection
Persons to serve on a SMID Team will be selected by a Membership Committee which should comprise:
1. The Team Clinical Director,
2. The Team Coordinator,
3. One other mental health professional,
4. Two other peer counselors.
It will be the responsibility of this Committee to ensure that only the most suitable persons serve on the SMID Team. This is crucial for a team's survival and efficient functioning. There should be no "political" appointments to the Team, since the wrong kind of help may be more destructive than no help at all.
The SMID Team needs to comprise as many persons as are necessary to provide a 24-hour service, but 15 to 40 persons will usually be adequate. At least one third of the membership of a SMID Team needs to be professional support personnel and the remainder peer counselors. In any given country or territory, there may be the need for more than one SMID Team.
The persons who make up SMID Teams are:
(a) Professional Support Personnel
· Mental health professionals
(b) Peer Support Personnel
· Fire fighters
· Police officers
· Life guards
· Search and rescue personnel
· Disaster workers
· Prison officers
· Any other first response personnel
For a 30-member team, the following organizational structure is suggested:
1. Team Coordinator (1)
2. Assistant Team Coordinators (4)
3. Clinical Director (1)
4. Other mental health professionals (9)
5. Other peer support personnel (15)
The Team Coordinator, Assistant Team Coordinators and the Clinical Director are elected by the team for a two-year period and they should not hold office for more than four consecutive years.
Team Clinical Director
The Team Clinical Director is a mental health professional who oversees the intervention activities of the team and should hold office for no longer than four consecutive years.
The duties of the Team Clinical Director are to:
1. Work closely with the Team Coordinator to ensure that the appropriate services are provided and that all of the team members work within the limits of their training and experience;
2. Put measures in place to ensure quality services;
3. Represent the SMID Team before the public and before organizations served by the team;
4. Assist with the writing of policies, protocols and procedures;
5. Co-lead team meetings with the Team Coordinator;
6. Assist with the recruitment, selection and training of team members;
7. Liaise with the Team Coordinator to ensure that the necessary support services are available and provided;
8. Conduct periodic reviews of team records and services;
9. Develop cross-familiarization programs for mental health professionals and emergency response personnel;
10. Maintain contact with other organizations in the field of critical incident stress management and keep current with recent developments in the field.
Team Coordinators should also be peer counselors since they better understand the normal operations of emergency organizations. The Team Coordinator is in charge of the day-to-day operations of the team and should hold office for no longer than four consecutive years.
The duties of the Team Coordinator are to:
1. Assess and coordinate requests for SMID services along with the Team Clinical Director;
2. Represent the team at emergency and community meetings;
3. Put measures in place to ensure quality services;
4. Provide general management of the team;
5. Assist with the writing of policies, protocols and procedures;
6. Co-lead team meetings with the Clinical Director;
7. Coordinate with the Clinical Director to ensure that the necessary support services are available and provided;
8. Assist with the recruitment, selection and training of the team's members;
9. Keep current with recent developments and maintain contact with other organizations in the field of critical incident stress management;
10. Develop positive relationships with agencies and community groups;
11. Maintain an up-to-date call-out list of all team members and an up-to-date referral list of mental health professionals;
12. Ensure that distressed debriefers are given appropriate assistance;
13. Keep a written record of all team activities.
Peer support personnel
Peer support personnel on a team are drawn from all of the organizations that may be served by the team. In community situations and education programs it is not necessary to utilize peer support personnel, but in the emergency services the use of peers is absolutely essential. It is important to note that in these organizations peer support personnel often make the first contact with persons who are showing signs of distress after exposure to a traumatic event.
Peer support personnel on SMID Teams need to be trained to provide SMID services. They should be mature, caring, dedicated, possess good interpersonal and social skills, be able to keep information in confidence and be able to work as part of a team.
The duties of peer support personnel are to:
1. Assist with assessing the need for SMID services and make recommendations to the Team Coordinator;
2. Provide peer counseling services;
3. Perform and participate in the delivery of various SMID services under the guidance of mental health professionals;
4. Assist the SMID Team to provide educational programs for their fellow emergency personnel;
5. Participate in peer review sessions;
6. Assist with any other team projects or activities as necessary.
Mental health professionals
Mental health professionals are persons who have the minimal qualifications required in their territories for their various professions, who work as providers of mental health services and who have received the necessary SMID training. Mental health professionals include psychiatric nurses, social workers, mental health occupational therapists, trained counselors, psychologists, psychotherapists and psychiatrists.
Duties of mental health professionals are to:
1. Assist with education of the team;
2. Provide psychological leadership during a debriefing;
3. Assist in the development and provision of follow-up and referral services;
4. Represent the SMID Team before the public and before organizations served by the team;
5. Provide clinical guidance to team members who have intervened in traumatic events;
6. Assist with the collection and interpretation of team data.
It would be advisable for each team to have at least one person who is a member of the clergy. Members of the clergy serving on SMID Teams must be trained in the delivery of SMID services. They will serve the team by providing spontaneous support to team members and distressed persons as necessary. However, clergy must be careful not to impose a given religious perspective on persons with whom they come into contact.
All SMID Team members need to undergo initial and on-going training, since properly trained team members are the key to the success of any SMID Team.
Below is a list of suggested areas of initial and on-going training:
1. SMID training,
2. SMID Team policies, protocols and procedures,
3. SMID services,
4. General stress and its management,
5. Occupational stress and its management,
6. Critical incident stress and its management,
7. Post-traumatic stress syndromes,
8. Anxiety states,
9. Understanding emotion,
10. Basic and advanced counseling skills,
11. Peer support and counseling,
12. Medico-legal considerations of counseling,
13. Crisis intervention skills,
14. Significant other support,
15. Follow-up services and making referrals,
16. Understanding the aftermath of disasters,
17. Grief and bereavement,
18. Effective communication and public speaking,
19. Guidelines about making effective presentations,
20. Interpersonal and social skills training,
21. Conflict interventions and anger management,
22. Understanding how therapeutic groups work,
23. Understanding children and adolescents under stress,
24. Data collection and research techniques.
Setting up a SMID Team
Establishment of an efficient and effective SMID Team will take time and effort. Team development requires careful study and planning, a dedicated development committee, effective leadership, clearly stated goals and objectives and a drive to provide an excellent quality of service once the team is established. Below are a set of guidelines to follow when attempting to set up a SMID Team:
1. Pre-feasibility phase:
(a) Seek approval from administration to investigate the need for and to establish, if necessary, a SMID Team.
(b) Determine whether or not there is a need for a team. Identify the number of traumatic incidents which had a serious emotional impact on emergency service personnel over the last 5 years. If it averages at least 5 incidents per year then a team is indicated. If it averages less than 5, a regional-based team would be better for such a community. Also determine whether adequate peer and mental health support is available for the establishment of a team.
(c) Gather information about the development of similar bodies in other countries.
(d) Form a task force of peer support personnel and mental health professionals to develop the SMID Team.
(e) Solicit funding for set-up and training costs.
2. Pre-establishment phase:
(a) Recruit and select potential team members.
(b) Provide training for potential team members.
(c) Establish written policies, protocols and procedures for team operation.
3. Establishment phase:
(a) Select team members.
(b) Choose the necessary leaders.
(c) Establish the necessary committees.
(d) Coordinate and evaluate team performance.
Maintaining the health of team members
Persons who provide SMID services need to bear in mind that they are themselves vulnerable to stress reactions and that they provide services to persons with very intense emotions. Team members need to take time out when they are feeling overwhelmed or dealing with major problems of their own.
Some incidents are so powerful emotionally that the team members who were involved in debriefing such incidents may need to be debriefed themselves, preferably by members from another team. On such occasions, the debriefers must be flexible and allow team members to re-tell the entire story in chronological order so that everyone can discuss the extent of their involvement.
The team needs to go through the steps of being called out, responding to the scene and setting up with the officer responsible for health and safety issues at the scene.
The team should not attempt "simulated crisis intervention" since emergency response personnel tend not to like such role playing. Instead, the team should familiarize itself with perimeter control points, command post operations, rehabilitation of personnel, the morgue set up, the media section and any other relevant aspects of a possible disaster situation.
Team members could take the opportunity to distribute informational brochures on the goals and functions of the SMID Team at the end of the drill. The handout should contain a clear outline of the team's call-out procedure and the names and telephone numbers of team contacts.
A Peer Review Board reviews complaints (internal and external) about errors or deliberate disregard for commonly accepted SMID practices.
The Peer Review Board is made up of between three and five members of the SMID Team (including both mental health professionals and peer support personnel) who are in good standing. The Board is chosen by the Clinical Director in conjunction with the Team Coordinator. Each member is chosen for a period of two years and they may spend a maximum of four consecutive years on the Board. At least two of the Board members should have served on the previous Peer Review Board. No team members can review his or her own case, hence substitutions can be made by the Clinical Director in consultation with the Team Coordinator in such situations.
The Peer Review Board should gather the facts related to the incident as soon as possible after a complaint is lodged. The Board then meets with the member(s) in question within three days of the complaint, evaluates the information gathered and issues a written report with recommendations to the Clinical Director and Team Coordinator within two days of the meeting with the person under review by the Board.
The Clinical Director and the Team Coordinator can either act on the recommendations of the Board or resubmit the report for further review.
Team membership can be revoked by the Clinical Director, the Team Coordinator or the Peer Review Board. Possible reasons for revoking a person's membership are:
1. Breaches of confidentiality;
2. Failure to comply with policies, protocols and procedures of the team;
3. Misrepresentation of the team;
4. Providing services without the prior authorization of the team;
5. Using one's team membership to enhance one's private business concerns, one's personal social life, etc.;
6. Failure to provide a service that one had agreed to do;
7. Consistent failure to attend team meetings and team education programs;
8. Acting against the expressed directions of the Clinical Director or the Team Coordinator.
Time-out for over-extended team members:
Some team members do not recognize their need for a break. Peers on a team are more likely candidates for over-extension because of their more frequent contact with distressed colleagues. Fellow team members may need to point out the problem to such persons so that they can have time-out to gain control of themselves before they suffer serious damage.
While the matter has to be discussed in a frank and up-front manner, every effort needs to be made to allow the person to realize that they need a break. However, because "burnt out" team members can jeopardize the smooth functioning of the team, if the persons do not gain insight into their problem they may need to be asked to take a break from the team.
Possible warning signals of over-extension:
1. Excessive preoccupation with SMID services provided or with the persons to whom such services were provided;
2. Intense irritability if fellow SMID Team members offer advice;
3. Unfounded anger;
4. Frequent unexplained loss of emotional control;
5. Excessive agitation and restlessness;
6. Disturbed sleep patterns;
7. Chronic feelings of fatigue;
8. Loss of interest in one's job;
9. Excessive withdrawal from contact with others;
10. Attempts to work independently of the team without appropriate supervision;
11. An erroneous belief that one's skills are superior to those of other team members.
Protection from legal action:
Below are some of the protective steps that can be taken to reduce the chances of legal action being taken against a SMID Team:
1. Be familiar with the laws in one's jurisdiction;
2. Provide high quality services;
3. Carefully follow international and local policies, protocols and procedures;
4. Do not participate in breaches of confidentiality, except as noted in the next item;
5. Act in the best interest of actively suicidal or homicidal persons even if it entails a "breach" of confidentiality;
6. Respect the right of persons to refuse SMID services-mandatory participation should be avoided;
7. Always tell persons up front what the services to be provided are all about;
8. Warn recipients of SMID services not to disclose any information that could jeopardize an investigation or implicate them or anyone else;
9. Have practice insurance;
10. Do not allow any type of recording in confidential proceedings;
11. Never turn a defusing or a debriefing into psychotherapy.
Evaluation of SMID services
Formal evaluation of a SMID Team's performance is extremely difficult for a number of reasons:
1. Emergency service personnel resist being evaluated by outsiders especially with respect to their inner thoughts and emotions;
2. Emergency service personnel are normally busy;
3. Emergency and disaster workers are constantly being re-exposed to traumatic events;
4. No laboratory exists in which emergency service personnel can be studied under controlled conditions.
Despite these limitations, SMID Teams must constantly strive to find ways to evaluate the effectiveness and efficiency of their interventions. One should always bear in mind other less formal methods of evaluating team performance, which include:
1. Feedback from persons and organizations which have benefited from SMID services;
2. Team meetings to review services provided; and
3. Reviews of formal complaints by the Peer Review Board.
End of Section Quiz
Please circle the correct answer.
SMID Teams provide peer-oriented crisis intervention programs.
The SMID Team Clinical Director does not sit on the Management Committee of the team.
"Political" appointments to SMID Teams are okay.
The Team Coordinator is a mental health professional.
Members of the Clergy do have a potential role to play in SMID Teams.
A feasibility study should precede the establishment of a SMID Team.
SMID Teams need not participate in routine disaster drills.
Over-extended SMID Team members may need time out from the team.
The Peer Review Board of a SMID Team reviews complaints.
Frequent bouts of anger may be a sign of "burnout" of a team member.
Note: Answers to questions are on Appendix 2. Quiz Answers.