Ernest Dempsey — George W. Doherty is the President of the Rocky Mountain Region Disaster Mental Health Institute and author of a series of publications on the subject of mental health and crisis intervention. His institute is now inviting papers and presentations for the 10th Rocky Mountain Region Disaster Mental Health Conference in the following subject areas:
Crises in The American Heartland: Rural West; Challenges Facing Returning Military and Families; Reports concerning Sandy, Connecticut, Aurora and related areas; Energy impacts on rural areas and communities in the American west; other disasters and critical incidents. Workshops will include CISM and development of CISM Teams in rural Wyoming for POST Credit. Other related presentations will be considered if applicable (submit abstract for consideration). Contact can be made through email - firstname.lastname@example.org or email@example.com; phone through 307-399- 4818.
George is here to tell us more about the subject of crisis intervention and mental health, particularly in the rural west in America.
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Ernest: George, I’d first like to ask you about Critical Incident Stress Management, or CISM. What exactly does it mean?
George: The crisis intervention model "Critical Incident Stress Management (CISM) developed by George Everly, PhD and Jeff Mitchell, PhD, has evolved to become one of the leading crisis intervention models used in the world, CISM is a comprehensive, multicomponent crisis intervention model. It is a psychoeducational model whose interventions range from the pre-crisis phase through the acute crisis phase and into the post-crisis phase. CISM uses strategies such as one-on-one interventions, critical incident stress defusings, and demobilizations. It is important to point out that CISM is not therapy, nor is it designed to replace formal therapy. To keep CISM in its proper perspective, the following analogy may be useful: "CISM is to formal therapy what emergency medical services are to formal surgery".
Ernest: So what are some of the major principles of CISM?
George: When CISM interventions are promptly delivered by trained personnel, the need to seek formal therapy later on may be alleviated; the clinician must know the general principles that relate to the legal aspects of professional mental health practice. The clinician's decisions about the client's treatment should be made on clinical grounds. Appropriate critical incident crisis-care can provide needed emergency mental health services, help prevent formation of some types of PTSD, and therapeutically modulate long-term effects of calamity for victims and emergency-care providers. This includes pre-incident preparedness, early intervention with psychological first aid, and post-disaster treatment using CISD, grief counseling, brief multimodal therapy, referral to traditional therapy or counseling if needed, and follow-up. Any intervention must encompass principles such as psychological first aid, ensuring safety, security, survival, shelter, and other basics. People in crisis are extremely vulnerable. They are open to hurt as much as help. The goal of crisis counseling should be to protect them from further harm while providing them with immediate assistance in managing themselves and the situation.
Ernest: Who is the 10th Rocky Mountain Region Disaster Mental Health Conference for?
George: The presentations and content of the 10th Annual Conference are intended to help train and update first responders, mental health professionals, chaplains, nurses, social workers, military, and others who are involved in responding to disasters/critical incidents either directly or in follow-up. The major goal is to help provide information, services, etc for first responders to help mitigate their personal emotional responses to working with various incidents. Another goal is to provide mental health professionals and others in the community with information to help them assist military and their families re-integrating into civilian life and returning to an equilibrium that helps place their traumatic experiences into a perspective as part of their lives that they can handle. It attempts to help mitigate possible PTSD, anxiety, and depression and, hopefully, help decrease incidence of incident-related suicides. Presentations/Papers presented at the conference will be published in the Spring of 2014 by Loving/Healing Press in print and on Kindle. The Proceedings will also provide documentation (certificate) for Continuing Education credits for re-licensure requirements in most mental health professions.
Ernest: What are some common misconceptions about the rural west and disaster preparedness?
George: Beyond the fact that rural culture differs from urban culture, there are additional considerations about ethnic cultural differences that need to be taken into account by practitioners who provide services in different rural areas. This is especially important when providing short-term interventions following major disasters, critical incidents, and other crises in a culture not one's own. Crisis care providers give rural emergency services a unique character. Mental health providers work in many different domains within rural hospital environments and clinics, but their services in rural hospital emergency rooms may be the most critical. Crises in schools take on different aspects at various levels. Stress in rural areas is often overlooked due to smaller populations. Crisis counseling programs need to be sensitive to the unique experiences, beliefs, norms, values, traditions, customs, and language of each individual and build on the strengths and resources of survivors of disasters and their communities.
Much of the history of the United States is concerned with the westward expansion of a civilization that had its beginnings on the eastern shores of the North American continent. It gradually pushed west, displacing many of the First Nation or Native American indigent peoples in the process. The Spaniards were the first men of European origins to penetrate the vast regions between the Rocky Mountains and the Pacific Ocean. Much of that area remains rural, encompassing ranching, farming, mining, and other rural endeavors.
Ernest: What are some of the special challenges unique to rural western disasters?
George: Rural practice encompasses some very challenging areas for mental health providers. It involves populations that are spread over large distances, with towns sometimes up to 100 – 200 + miles between population areas. High levels of need are present in some areas with very limited access to services involving medical care, mental health services, and many other services often taken for granted by those living in urban environments. There is an ongoing overall migration to more urban settings. Responders in law enforcement, firefighting, nursing, and other areas are very often dependent upon volunteers to respond. Lifestyles are sometimes difficult for professionals to become accustomed to, resulting in either a loss of services or a constant turnover. It is increasingly important that our mental health and other first responders become aware of recent research, training, and approaches to crisis intervention, traumatology, compassion fatigue, disaster mental health, critical incident stress management, post-traumatic stress, and related areas in rural environments. Additional areas impacting our rural areas include energy development with the accompanying influx of temporary workers and the effects of the concurrent boom. The return of our military (mostly National Guard and Reserve) following Active Duty deployments to Iraq and/or Afghanistan) is another area that affects the rural west. Re-integration of our veterans and re-adjustment to civilian life and families is critical.
Some additional areas of concern in rural environments include:
- Quality of life as we observe declines in America's wealth as it affects rural areas. This involves such things as problems of hunger and agriculture, education, and rural poverty impacting our farmers and ranchers.
- Physical issues such as land, air, and water resources, cheap food policies, chemicals and pesticides, animal rights, corruption in food marketing and distribution, and land appropriation for energy development.
- Direct service issues include the need to accommodate a wide variety of mental health difficulties, client privacy and boundaries, and practical challenges.
- Some indirect service issues include the greater need for diverse professional activities, collaborative work with professionals having different orientations and beliefs, program development and evaluation, and conducting research with few mentors or peer collaborators.
- Professional training and development issues include a lack of specialized relevant courses and placements.
- Some practical issues include limited opportunities for recreation, culture, and lack of privacy.
Having an understanding and working relationships in these areas are important and can contribute much to developing plans for disaster response and recovery in rural areas.
Ernest: Why are there special challenges for military veterans returning home to the rural west?
George: There comes a time when the military member (Regular, Reserve, or National Guard) returns from deployment and there comes a time when they seek to re-establish their lives. They attempt to return to what many refer to as "normality". However, it is very difficult to define what "normality" is or involves. Still, a Return to an Equilibrium that incorporates their experiences is a more viable concept.
An area of concern for our returning Veterans, their families, and for our country in general, involves trained personnel. The military has trained nurses, medics, doctors, and other medical and psychological professionals. These Veterans not only have training in their professions, but also are experienced. It is difficult for many of them upon return home to get the needed licenses and certifications to be able to use their skills and trainings in civilian applications. They are required to undergo trainings and education which they already have through military experience. They are required to redo trainings in many circumstances, costing time as well as money. There are no current ways that they seem to be able to get credit for the trainings and experiences they already have by either CLEP testing or other means. As they already have most of the trainings as well as experience, they need to be able to get credit for what they have already accomplished.
In the western states in rural and frontier areas (e.g., Wyoming, Nevada, Arizona, New Mexico, Montana, Idaho, Alaska, and other areas), we have a great need for both medical, nursing, psychological, and other trained professionals to provide services for not just our returning military, but also for civilians in those areas. Many of our small and isolated towns, communities, clinics, etc need such professionals. Too often, people in these areas may need to travel 100 or more miles in order to get professional help. A system that includes already trained, experienced professionals can help fill those gaps. A system of traveling professionals and/or traveling clinics with such professionals would be able to provide such services cost-effectively to those who need and seek such help. Such a system can be effectively backed up by computer and communication systems with specialists and other assistance from larger communities with larger hospitals when needed. The personal contact by medical and psychological professionals is very important and much appreciated in rural communities.
When the professional presence comes to and knows the community, the problems the community deals with and the people living there, the health care needs and those providing them are really appreciated. They are part of the community. They are not just someone who may see clients/patients for a 15 minute block of time after traveling many miles and often involving overnight stays at a motel. They are not dealing with someone in a "medical ivory tower". The community provider is someone they know and talk with who is someone who understands the community, not just an entity to whom a large fee is paid who has very little knowledge of the rural concerns. They most likely know their profession well, but they often have no time to become part of the small rural/frontier community. Rural community practitioners can find ways to consult with those who live and work in the larger settings. One asset for these rural/frontier are our returning trained military Veterans. This is a resource and opportunity for all that should not be overlooked or taken lightly.
Re-integration back into our rural communities, together with their skills, experience and community acceptance pose some of the biggest challenges facing many of our Veterans.
Ernest: From the previous conferences and existing research studies, could you tell us what kinds of helpful resources are available or are being developed by researchers to benefit the vulnerable communities?
George: Cell phone systems in many areas of the rural west regularly experience "black holes" with no service. Computer systems in many rural/frontier settings are only beginning to develop the uses of computers at full potential. Computers are used regularly in many schools (more so than ten years ago). Most county fairs focus strongly on rural activities. All have a strong understanding and appreciation of rural values. These may be similar in some ways to those that existed in most farming and ranching areas throughout the country in the 1950s. They remain quite vibrant in the rural west and are alive and well through many rural organizations, such as Farm Bureau, 4H, FFA, Rodeo, Ag Extension Services and other related agricultural and rural-oriented organizations. Many western rural residents are descendants of ranchers and farmers who originally homesteaded their lands. People in the west are quite often members of the Guard and Reserve. Some also become active duty members of the Navy, Air Force, or Marines. Agriculture and Energy development (e.g., wind, solar, nuclear, etc) are two of the major industries in the rural west. Agriculture (supported by a number of major Agriculture Departments in Land Grant Universities) provides a major proportion of the national food supply. Energy development (e.g., coal, oil, uranium, wind, solar and others) are increasingly important in western states. Land Grant Universities and Community Colleges, including Extension Services and related resources remain valuable assistants to our rural residents. Additional resources include FEMA, Red Cross, and various local and state agencies and organizations, both public and private.
Ernest: How is digital media used (e.g., online conferencing) in the conferences like the Fall 2013 one?
George: Online conferencing and trainings, etc. is still in the developmental stages, but definitely has great potential for growth and implementation in the rural west. It is an area being seriously considered for expanding the delivery of conference information as well as workshop presentations for the Fall, 2013 10th Annual Rocky Mountain Region Disaster Mental Health Conference. Current implementation depends, at least partially, on available resources, including financial support, and presentations submitted.
Teleconferencing in its various forms helps provide different methods for improving communication and enhancing interactions between the professionals and clients. If used appropriately, these techniques can not only improve interactions in a timely manner, but also reduce costs involved in the provision of such services for clients as well as the professionals. Familiarity with and comfort in the use of such techniques and technologies can help facilitate these interactions.
Successfully using videoconferencing technology in mental and behavioral health settings is dependent on a number of factors. These include telepresence, technical audio and video considerations, and cleaving to videoconferencing etiquette. These are also limited by the kind of videoconferencing software and the equipment available.
Mental health professionals must be aware of the remote site as being part of their clinical milieu. Some important factors include:
- Referrals, Client Education, Consent – Methods and approaches for safeguarding and delivering each of these needs to be developed and tested out before implementing.
- Delivery of Care – Develop techniques and methods for this, including translations for those in additional languages.
- Conferences, Workshops, Consultation – These represent some very cost-effective methods for training for both presenters and attendees. A great way to provide continuing education.
- Referrals, Client Education, Consent – Methods and approaches for safeguarding and delivering each of these needs to be developed and tested out before implementing.
The following are a few of the factors practitioners should be aware of and probably use as major guidelines:
- Avoiding Harm – Serious potential for damage to online clients can arise from many sources.
- Managing Crises and Emergencies – Crises and emergencies lead to heightened risks. It is all a matter of degree. There is no standard definition of an emergency or crisis.
- Is Any Help Better Than No Help? – Situations in which any help is better than none raise interesting issues. If one can do more good than harm, then do it
- Suicide Risk –Mental health professionals are expected to do what they can to prevent suicide.
- Terminating the Professional Relationship – Such an event should be discussed with the client prior to implementation. A policy or protocol should be available and spelled out for client at intake as part of the agreement client signs. Common sense should rule.
- Standards of Care – In the United States, state law defines the standards of care. Basically, a standard of care relates to the pattern of practice the profession generally accepts as reasonable under the relevant circumstances.
- Practice and Treatment Guidelines – There is no doubt that various groups concerned with telehealth technologies will rapidly develop both practice and treatment guidelines including: providing such services in conjunction with community colleges and other resources can help our health care practitioners and others reach out to our rural areas. One example of where such an approach can be very helpful will be among our Veterans in rural communities. Well thought-out and planned approaches for implementation and maintenance and sustainability can make it work effectively.
Ernest: To end this conversation, I’d like to know if the proceedings of the conference will be available to the general public?
George: The Proceedings of the Conference are published in book/journal format each year following the Conference. They are usually available in the early spring following the conference, Copies will be sent to each presenter and further copies can be ordered from our publisher Loving/Healing Press, Inc, 5145 Pontiac Trail, Ann Arbor, MI 48105 or through Rocky Mountain Region DMH Press, Box 786, Laramie, WY 82073 (An Imprint of Loving Healing Press, Inc.) You can order copies through these or through Amazon.com. You can also order our other books and previous Proceedings. All are also available on Kindle. Books and previous editions of Proceedings are also available as CEU courses online through http://www.psychceu.org. All courses have been approved by various accrediting bodies for Continuing Education Credit for re-licensure purposes. Check the website or contact the Institute for further information.
Ernest: George, thank you very much for informing our readers on this topic.
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Check George Doherty’s books on mental health at the Loving Healing Press of Michigan.