Presentations text content in Group Crisis Intervention
Slide1
Group Crisis Intervention
5
th
Edition Slides
Authored by Jeffrey T. Mitchell,
Ph.D.
Slide25
th Edition Categories
Important Information
- Must know information
Critical Information
– Essential for CISM applications
Enrichment Information
– Expands CISM knowledge base
Slide3Objectives:
Define key crisis terms and concepts
Define key stress terms and concepts
Explain CISM
Understand Resistance, resilience and recoveryList elements of CISM strategic planning formula
List components of CISM system
Explain informational vs. interactive groups
Role-play practice
Explain risks if providers are not trained or if they violate standards of practice
Slide46
C
ore Elements of CISM
Surveillance, Assessment and Triage
Listening skills, SAFER-R, Individual Crisis intervention
Strategic assessment and planning
Informational group processes
Interactive group processes
Personal and Community resilience: resistance, resilience, and recovery- (
defined page 17
)
for further reading see appendix 1, page 133
Slide5Section One
Pages 17-34
Key Terms and Concepts:
Crisis and Crisis Intervention
Slide6Key Terms and Concepts of Crisis and Crisis Intervention
Critical Incidents
Powerful traumatic events that initiate the crisis response
Without
critical incidents
there would be no crisis
reactions
and no need
for crisis
intervention.
Slide7The “Terrible Ten”
A sample of Critical Incidents
Line-of-duty death
Suicide of colleague
Serious line-of-duty injury
Disaster / multi-casualty incident
Killing or wounding an innocent person
Slide8“The Terrible Ten”
Significant events involving children
Prolonged incidents especially with loss of life
Personally threatening situations
Events with excessive media interest
Any highly distressing event
Slide9Simply stated….
Crisis is state of heightened
emotional
arousal
…a state of emotional turmoil
Slide10
Crisis
A crisis is an acute emotional reaction to some powerful stimulus or a demand
Slide11PRE-CRISIS
CRISIS
THOUGHTS
FEELINGS
THOUGHTS
FEELINGS
Slide12Types of Crises
Maturational Crises (plural of crisis) – Associated with changes in various stages of life: adulthood, midlife, aging, retirement.
Situational (associated with events such as accidents, deaths, disaster, violence, loss, illness, threats.)
Slide13
Characteristics of a Crisis
Disruption to a person’s state of psychological balance
Usual coping mechanisms fail
Distress, impairment, or dysfunction
(Gerald
Caplan
, MD, 1964)
Slide14STAGES OF CRISIS
pre-crisis
crisis
post-crisis
Point of
impact
Trial and error
Angle of disorganization
2. stuck
1.function
3. improved
*
disorganization
Slide15Crisis event
High anxiety
*
Denial
Anger
Remorse
Grief
Reconciliation
Slide16Crisis and Stress
Crisis and stress are related. When a person has an emotional crisis, there is also a state of Mental and Physical arousal (stress) that goes along with the state of emotional turmoil
Slide17Stress
Without Crisis
We live in stress throughout our existence (24 hours x’s 7days a week – always)
Balancing between eustress and distress
Stress is a state of arousal from mild to extreme. Helps us to stay healthyYou have stress even when you have no crisis.
But you can’t have a crisis without stress.
Slide18Critical Incident Stress
An acute emotional, cognitive, and physical
reaction
that results from an exposure to a powerful, horrible, awful, terrifying, threatening or grotesque stimulus or to an overwhelming demand or circumstance
page 18
Slide19Critical Incident Stress
A state of heightened cognitive, physical, emotional and behavioral arousal that accompanies the crisis
(more to be said in Section Two)
Slide20Crisis Intervention
Crisis intervention is a
t
emporary,
active, and supportive
entry into the life situation of an individual or of a group during a period of extreme distress.
Slide21Groups are
not
treated as individuals and individuals are
not
treated as groups!
Different intervention procedures are used for individuals than those that are used for groups.
Slide22History of Crisis Intervention
…these milestones are amplified on pages 22-28
The beginnings of people helping others is lost in antiquity.
First organized approach to Crisis Intervention – Franco Prussian War (1870-1871)
Simple procedures: reduction of war stimuli, food, rest, fluids, opportunity to speak with medical personnel
Slide23History of Crisis Intervention
World War I –First the French and then the Americans used a similar approach
Crisis intervention helped 65% of psychologically traumatized soldiers to return to front in 3-4 days.
Without crisis intervention, only 40% were able to return to combat and that took 3-4 weeks
. (Thomas Salmon, 1919)
Slide24History of Crisis Intervention
Crisis Intervention has often been called “Psychological First Aid.” That term was first used about 1933. It certainly was applied in WWII.
Crisis Intervention formalized by the work of Gerald
Caplan
and Eric
Lindermann
in the Coconut Grove fire in 1942.
Slide25History of Crisis Intervention
In the early 1970’s the foundations of CISM were set
In the 1980’s Dr. Jeffrey Mitchell developed the CISM program through his work at the University of Maryland Baltimore County.
2007 United Nations adopted CISM program for its employees world-wide.
Slide26Providers of Crisis Intervention
Police
Firefighters
Medical staff
Pre-hospital EMSMilitaryFederal agenciesCommunications personnel
Community volunteers
School personnel
Disaster workers
Mental health professionals
Clergy / chaplains
others
Slide27Goals of Crisis Intervention
Reduce emotional tension
Stabilize the person
Mobilize personal resources
Mitigate the impact of the traumatic event
Slide28Goals of Crisis Intervention
Normalize reactions and facilitate normal recovery processes.
Restore individuals to adaptive functions
Enhance
u
nit cohesion and unit performance in homogeneous groups
Identify individuals who may need professional assistance and refer as necessary
Slide29Principles of Crisis Intervention
Simplicity
Brevity
Innovative
PragmatismProximity
Immediacy
Expectancy
Slide30Steps in Crisis Intervention
8
steps of CI, Albert Roberts, Ph.D
.
Introduction
Assess the situation and the impact on the people involved
Mentally list all the options
Choose the best option
Implement the option immediately
read more on pgs.
28 - 32
Slide31Steps in Crisis Intervention
Reassess the people involved
Maintain, change, or abandon the option
Closure of the intervention
Note: if the person is suicidal, a referral to the next level of care is required.
(8 steps of CI, Albert Roberts, Ph.D.)
Slide32Critical Incident
Stress Management
A
way to remember: Title and Description
C
-
Critical
I
-
Incident
S
-
Stress
M
-
Management
C
- Comprehensive
I - IntegrativeS - SystematicM – Multi-component
Pgs.33 & 34
Slide33Critical Incident
Stress Management
An organized approach to Crisis intervention
A “package” of crisis intervention techniques
CISM is a subset of Crisis Intervention and shares directly in the history, theory, principles, practices, goals and techniques of Crisis Intervention
Pages 32 and 33
Slide34Critical Incident Stress Debriefing
One tactic among many in the CISM system
Not the same as CISM
For homogeneous groups only
Interactive group crisis intervention
7 step model
Covered thoroughly in Section Seven
Slide35Section Two
Stress: Psychological and Behavioral
Reactions to Stressors
pages 37-46
Slide36Stressor
A stressor is a stimulus that causes or initiates the stress response
Slide37Stressor vs.
Stress Response
there is
a difference
Stressor is the stimulus
Stress is
a
rousal in response to a stimulus. It is a
nonspecific response
of the body to any demand
Slide38Stressor vs. Stress Response
there’s a difference
Stress consists of a combination of neurologic, neuroendocrine, and endocrine arousal response mechanisms that can alter every organ and function in the human body. Stress can accelerate the aging process. Stress equals arousal.
Slide39General Adaptation Syndrome
Alarm equals arousal (cognitive, physical, emotional)
Resistance equals behaviors to cope with the arousal
Exhaustion equals the period when energy to maintain resistance is depleted
Concept developed by Dr. Hans Selye
Slide40General Adaptation Syndrome
Stimulus
Resistance
Exhaustion
Recovery
Alarm
baseline
Slide41Main Types of Stress
Eustress- positive
Distress- negative
Page 38
Slide42Eustress vs. Distress
Stress Arousal
Health and performance
Maximum positive effect
Slide43Stress is Usually Not Dangerous Unless…
It Prolonged or Intense
Slide44Cumulative Stress
“Burnout” is an
o
ut-of-date term that is occasionally brought up
Cumulative stress is unmitigated stress arousal that builds over time
Cumulative stress: Three identifiable phases
a) Stress arousal
b) Energy conservation c) Exhaustion
Page 37
Slide45Target Organ
The part of the body, or mind, that is a target of the stress and which develops signs and symptoms of over-arousal
Slide46
Stressor Stress Response
Target
Organ Target Organ Identification
An Example…..
Traffic
jam
Increased Adrenalin
Increased Feelings
of
anxiety, Heart rate
increases,
and
blood
pressure rises,
etc.
Slide47Trauma
A horrific event outside of the realm of usual human experience. The person experiencing it finds it markedly distressing and feels fear, helplessness and horror
Page 38
Slide48Traumatic Stress
Most intense form of distress
A broad range of cognitive, physical, emotional, spiritual, or behavioral reactions
Page 39
Slide49Post Traumatic Stress
Also known as
Critical Incident Stress
Normal response of normal, healthy, people to a terribly abnormal event.
Often overwhelms coping mechanisms
Slide50Critical Incident Stress* is Normal After Trauma
It becomes dangerous to health when it is not resolved
*A
KA Post Traumatic Stress
Slide51Post Traumatic Stress Disorder
If
Critical Incident Stress
is not managed properly and if it remains unresolved, it may turn into one or more psychological conditions that can interfere with normal life functions.
One of the worst conditions is Posttraumatic Stress Disorder (PTSD)
Page 39
Slide52Overview of Criteria for PTSD
Exposure to actual
or
threatened death
,
serious injury or
sexual violence
B.
Symptoms of
intrusion
associated with the traumatic event
C.
Persistent
avoidance
of stimuli associated with the traumatic event
D.
Negative alterations
in thinking and mood Associated with the traumatic event
Slide53Overview of Criteria for PTSD
E.
Marked alterations in
arousal
and
reactivity
associated with the traumatic event.
F
.
Duration of the disturbance(
B.C.D.E
) is at least 30 days
G
.
The disturbance causes clinically
significant distress or impairment
in social, occupational and other important areas of function.
Slide54Overview of Criteria for PTSD
The
disturbance
is not attributable to physiologic effects of a substance (e.g. medication or alcohol) or other medical condition
.
Slide55Other Conditions Resulting From Trauma
Substance abuse
Withdrawal
Depression
Brief
P
sychotic Reaction
Panic attacks
Panic disorder
Changes in personality
Loss of self confidence
Increased anxiety
Increased irritability
Slide56Trauma Membrane
After trauma, people begin to form a membrane around themselves that insulates them from additional trauma. Over time it may block out appropriate help as well. Early intervention is highly recommended.
Slide57Symptoms of Traumatic Stress
Cognitive
Physical
Emotional
BehavioralSpiritual
see, read and remember pages 41-43
Slide58Psycho-traumatology
A study of psychological traumatization
Slide59Section Three
Strategic Planning in Crisis Intervention
&
Critical Incident Stress ManagementPages 46-58
Slide60Effective Staff Support Programs
Comprehensive
Not therapy, but support
Integrative
Systematic
Full support package
Multi-tactic
Slide61Effective Staff Support Programs
Linkage to wide range of resources
Run and staffed by Peer Support Personnel
Contains the Six Core Elements
Slide62Six Core Elements of CISM
Surveillance, Assessment of the event and the impact on the personnel
Strategic Planning
Listening, Individual support, and Crisis Intervention
Informational groups
Interactive groups
Follow-up and referral services
Slide63Assessment
Circumstances
Nature and Magnitude of event
Impact on people exposed
Slide64Characteristics of a Crisis Strategy
Full assessment
Development of goals and objectives
Select the right people to provide the services
Develop a strategic plan of action
Select the right crisis tactics
Slide65Tactical Components of CISM
Pre-event preparation, education, training, planning and policy development
Assessment procedures (nature and magnitude of event, impact on people)
Strategic Planning procedures (5 T’s)
Individual crisis intervention support actions
Slide66Tactical Components of CISM
On scene support services
Informational groups for operations personnel (RITS)
Informational groups for citizens (CMB)
Interactive groups: Defusing
Interactive groups: CISD
Slide67Tactical Components of CISM
Significant other support services
Follow-up services
Referral services for those who need more than what CISM can provide
See pages 52-54 See chart on Pages 55-56
Slide68Strategic Planning Formula
Theme
Target(s)
Types
TimingTeam
Slide69Theme
W
hat are the issues, concerns, questions, threats, circumstances, and special situations that need to be considered?
Pages 50-51
Slide70Targets
Who needs assistance and who does not need assistance?
Slide71Types
What types of help will be most
beneficial?
Slide72Timing
When will the assistance be most useful to those who need it?
Slide73Team
Who is being sent in to provide the assistance and do they have the personality, background, and skills to provide the necessary support
See pages 50-52
Slide74Introduction to Strategic Crisis Planning Exercise
Your instructor will conduct a brief Strategic crisis planning exercise at this time
.
Slide75Section Four
Informational Group Crisis Interventions
Slide76Informational Groups
1. Rest, Information, Transition Services (RITS)
2. Crisis Management Briefing (CMB)
Slide77A change in terminology
RITS was formerly known as “Demobilization”
The name change brings about clarity of function and eliminates confusion with military communities. The need, function and process remains unchanged
Slide78Rest Information Transition Services
Informational
session for staff,
not for use with populations outside of Emergency Services or the military.
Provided once at end of a unit’s first exposure to a major prolonged critical incident (disaster, military operation).
Some form of follow-up is usually required
.
Pages 59 -64
Slide79R
est
I
nformation
Transition Services
Primary purpose: to provide support and information to operations personnel at large scale, complex and prolonged incidents.
Consists of two main segments
1) brief information presentation (10 minutes maximum)
2) rest, food, refreshments (20mins.)
Command then informs personnel of the next steps or tasks (reassignment, rest, etc.)
Slide80Rest Information Transition Services
Only one provider necessary
No efforts to have a discussion
No one asked to speak
Provide information, instructions, guidance only
Have peers available for individual support
Slide81Rest Information Transition
Services
Logistical Considerations
Assemble team
m
embers
Establish
a schedule for arriving
workers
Establish liaison with Incident Management
Establish location within reasonable proximity of the incident that has adequate space for crews
Goals-assessment, mitigate
i
mpact
Page 61
Slide82Rest, Information, Transition Services
Exercise
Slide83Crisis M
anagement
B
riefing
Versatile
informational
group process
Works well with heterogeneous groups
Works with any event that has an powerful impact on the community.
Has been used in schools, businesses, organizations, clubs, hospitals and government agencies.
Slide84C
risis
M
anagement
Briefing
Can be repeated to accommodate huge numbers of people
Can be provided multiple times as long as new information is added each time.
May be done via television or radio if necessary
May be provided at regular intervals during a disaster
Slide85C
risis
M
anagement
BriefingMay be applied to military and emergency services personnel
Generally 20 to 45 minutes
Primary purpose is information, instructions, and guidance only
Slide86C
risis
M
anagement
Briefing
Goals
Provide Information
Rumor Control
Reduce Chaos
Share effective coping
Provide avenues for follow-up care / Referral information
Engender Community Morale / Enhance Morale
Restore to adaptive function
Slide87C
risis
M
anagement
Briefing
Process
Step 1
Assemble participants (Team and Victims)
Step 2
Provide accurate information about the incident
Step 3
Anticipate, discuss and normalize current and potential stress reaction
Step 4
Teach stress management specific to the groups needs
Slide88C
risis
M
anagement
BriefingExercise
Slide89Section Five
Interactive Group Crisis Intervention
Defusing
Pages 69-83
Slide90Yalom
’
s Eleven Most Therapeutic Factors for Effective Groups
Impart information
Instill hope
Altruism
Universal concepts
Corrective
recapitulation
Use socializing techniques
Initiate behaviors
Interpersonal learning
Group cohesiveness
Catharsis
Guidance, nurturing, support, assistance
Slide91Homogeneous Groups
Best served by interactive group processes
The interactive group processes are 1. Defusing and 2. CISD
Understanding and resolving the traumatic experience can best be accomplished in a brief group discussion
Group members learn from each other
Slide92Types of Groups
Primary groups – very homogeneous
Secondary Groups – some familiarity but most heterogeneous
Random groups – extremely heterogeneous
NOTE:
Defusing and CISD were designed only for
h
omogeneous groups never to be used for heterogeneous groups
Slide93Therapeutic
F
actors in Group
Impart information
Instill hopeAltruistic
Universal concepts
Corrective recapitulation
Slide94Therapeutic Factors in Groups
Use socializing techniques
Initiate behaviors
Interpersonal learning
Group cohesiveness
Catharsis (Irvin D.
Yalom
(2005)
Slide95Defusing
An interactive group process
Same day (up to 8 hours after incident ends)
Has little effect or no effect after 12 hours
Group must be homogeneous
If opportunity is missed, provide one-on-one support followed later by CISD
Slide96Defusing
Advantage in defusing is group members emotional guards are down and needs are high.
Groups in crisis are more open to right kind of help
Focus on unit cohesion and unit performance
Slide97D
efusing
In a few cases a defusing may be all the group needs.
In other cases a CISD should follow
If reactions are intense or suppressed and if there appears to be unfinished business, then a CISD is indicated a few days later.
Slide98Defusing
When a CISD is necessary, it is generally made stronger by having had the defusing first.
In a line of duty death situation a 5-phase CISD is provided instead of the defusing
5-phase CISD is taught in the advanced group course.
In a disaster, RITS is provided instead of a defusing
Slide99Criteria for Homogeneous Group
Group members have a relationship with each other before the traumatic event
They have a shared history
They have spent considerable time together prior to the event
They have experienced the same traumatic event.
Slide100Warning!
If the Group is Heterogeneous
Provide informational group services like the RITS (for staff in large scale events) or, more likely, the CMB
Slide101Goals of Defusing
Stabilization of the traumatized group
Restore unit cohesion
Restore unit performance
Assessment tool to determine if group members need something else in addition to the defusing
Slide102Defusing
Don’ts
go beyond 30 minutes
go into detail
try to turn the defusing into a therapy session.
have deep discussions of emotions
Slide103Defusing
Do’s
Brief group discussion
Brief situation overview
Opportunity for a quick assessment of group needs
Run by two trained peers
Rarely a stand alone. It needs follow-up
Slide104Defusing
All providers of defusing must be properly trained in CISM!
“…peer interactions tap into many therapeutic factors.”
(Paturel, 2012)
“groups provide social support, they improve social networks and they can reduce stigma, isolation and feelings of alienation among members.”
(Paturel, 2012)
Slide105Defusing
“…hearing from peers may be more helpful than receiving guidance from a therapist since peers can identify with one another.”
(David
Yalom
, MD, 2005. Theory and Practice of Group Psychotherapy” as reported in Paturel, 2012)
Slide106DEFUSING: 3 PHASES
INTRODUCTION – Introduce team; lay out the guidelines; lower anxiety about the process
EXPLORATION – Allows a brief discussion of the experience. A brief “story” of the event
INFORMATION – Provide information, normalize, teach, guidance, summarize key points
Slide107Introduction Phase
Introduce team members
State purpose / describe process
Motivate participants
Set ground rules
Stress confidentiality
Not investigative
No one forced to speak
All viewpoints are important
Slide108INTRODUCTORY EXERCISE
take a look at pages 86-81
Slide109Exploration Phase
Ask for brief description of event
Ask clarifying questions
Group members share experiences of the event only as much as they wish
Look for themes / concerns
Assess need for more help
Reassure as necessary
Slide110Information Phase
Acknowledge / summarize the exploration provided by the group members
Normalize experiences and / or reactions
Teach key stress survival skills
Emphasize taking care of self
Rest / family life / stress management
Offer additional help such as one-on-ones
Slide111Section Six
Practice Exercises for Defusing
Slide112Section Seven
INTERACTIVE
GROUP CRISIS INTERVENTION
CRITICAL INCIDENT STRESS DEBRIEFING
Pages 91-125
Slide113Critical Incident Stress Debriefing
(CISD)
A structured GROUP discussion concerning a critical incident
First described by Mitchell (1983) for use with homogeneous groups of emergency services personnel
Historical roots in military psychiatry (see HERD, S.L.A. Marshall)
Requires a team approach
Slide114CISD GOALS
Mitigate distress
Facilitate psychological normalization and psychological “closure” (reconstruction)
Set appropriate expectations for psychological / behavioral reactions
Serve as a forum for stress management education
Identification of external coping resources
Serve as a platform for psychological triage and referral
Slide115CISD Team Resources
Minimum: Two CISM trained team members
At least one mental health clinician
Other team member(s) may be “peer support personnel,” spiritual leader, another mental health, or physical health professional
ALL TEAM MEMBERS MUST BE TRAINED IN the interactive group process - CISD
Slide116PLANNING THE CISD
SIZE: group (2-20)
DURATION: 1-3 hours
TIMING: 1-10 days for most incidents (1-3 days for most acute public safety incidents; 3-4 weeks for disasters).
note: Implement when “psychological closure” possible, i.e., disengagement. Timing has more to do with
PSYCHOLOGICAL READINESS than the passage of time
LOCATION: Room with chairs placed in a circle or around a table, isolated away from incident site and distractions
Slide117Convenient time
All involved operations personnel invited
Personnel relieved of duties
Ideal group size is 2 - 20
Homogeneous groups (homogenize with regard to traumatic exposure/ psychological toxicity)
Ideally, one team member for every 5 or 6 participants - minimum of 2
Follow up planning as necessary
CISD
Considerations
Slide118Strict Confidentiality
No breaks
Timing is important
Location and physical environment
Closed circle format
Important CISD Considerations
Slide119COMMON GROUND RULES
Participation voluntary
No notes, recording devices
Try to limit break until after group is finished
Not operational critique, not investigation
Not a “blame” session
Not therapy, nor substitute for treatment
Address issue of confidentiality vs. privilege
Slide120MHP
Peer
PHYSICAL FORMAT
Door
Slide121MHP
Peer
Peer
Door
Slide122MHP
Peer
Peer
Peer
Door
Slide123MHP
Peer
Peer
Peer
Door
Slide124MHP!!!!
Door
Peer
Peer
Peer
Avoid tables
, distractions,
dispatch
speakers, equipment,
And CPR
training
dummies. Try
to avoid snacks till
after.
They
are
impediments to communications!
Slide125CISD STRUCTURED 7 PHASES
INTRODUCTION
FACT PHASE
THOUGHT PHASE
REACTION PHASE
SYMPTOM
PHASE
TEACHING
PHASE
RE
- ENTRY PHASE
Slide126Phase Progression of a CISD
COGNITIVE
AFFECTIVE
INTRODUCTION
FACT
REACTION
THOUGHT
SYMPTOM
TEACHING
RE-ENTRY
Slide127Clarified Phase Progression of a CISD
COGNITIVE
AFFECTIVE
Introduction
Brief Situation Review
Aspect causing most personal distress
First Impressions of the Incident
Signals of Distress
Stress Management and
R
ecovery
P
rocess
Summary
Slide128INTRODUCTION
I
ntroduces team members
Sets expectations
Describes “ground rules”
Ground rules anticipate potential problems and attempts to address them in advance
Addresses confidentiality
Participation in discussion is VOLUNTARY
Preview questions
Slide129INTRODUCTORY EXERCISE
Take a look at Pages 110-113
Slide130FACT PHASE*
Prompt
“Tell who you are and what happened from your perspective.”
*
May still be used when group exposed to multiple stressors, as in disaster out-processing, or culmination of a tour of duty. “Tell us about your experiences.”
Slide131Used when larger than expected group shows up at
CISD
Used when the administrator places the CISD
team members under an arbitrary time restriction
Who arrived first; what happened
Who came in next; what happened, etc.
Alternative Fact Phase:
Slide132THOUGHT PHASE
Prompt
“What was the first or most prominent thought that entered your mind regarding the incident?”
Any unusual or disquieting thoughts?
Slide133REACTION PHASE
Prompts
“What was the worst part of this event for you?”
Any aspects of the event that have caused you the most pain or distress?
If you had the power to erase one single aspect what would you most want to eliminate from the total experience?
Slide134SYMPTOM PHASE
Prompt
“What physical or behavioral changes have you experienced since the event?”
Or, “What has life been like for you since the event?”
Or, “What signals of distress have you noticed in yourself since this happened?”
Slide135TEACHING PHASE
Team members normalize reactions, provide anticipatory guidance, teach stress management, describe external resources available.
Teach to what has been expressed
Encourage participants to continue the recovery process
The group should be used as a resource to identify coping techniques that have been useful in the past.
Slide136RE-ENTRY PHASE
Prompts
Reiterate normalization
Q & A, if indicated
Summarize key points, “lessons learned”
Offer cognitive reframe if useful to facilitate closure, reconstruction
Foster group cohesion, if indicated
Slide137Section Eight
CISD Practice Session
Slide138End of Slide Program
Slide139
Group Crisis Intervention
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