| Introduction
Caught off guard
and "numb" from the impact of a critical
incident, individuals and communities are often
ill-equipped to handle the chaos of such a catastrophic
situation. Consequently, survivors often struggle
to regain control of their lives as friends, family,
and loved ones may be unaccounted for or are found
critically injured, lay dying or are already dead.
Additionally, the countless others who have been
traumatized by the critical event may eventually
need professional attention and care for weeks,
months and possibly years to come. The final extent
of any traumatic situation may never be known
or realistically estimated in terms of trauma,
loss and grief. In the aftermath of any critical
incident, psychological reactions are quite common
and are fairly predictable. Critical Incident
Stress Debriefing (CISD) can be a valuable tool
following a traumatic event.
Since the late
1970s and early 1980s, the victim assistance movement
has received more positive attention than ever
and has gained tremendous momentum with the passage
of state and federal legislation designed to provide
resources and services to those who are physically
or emotionally traumatized or victimized (Young,
1994; Davis, 1993). One organization dedicated
to assisting trauma survivors is the National
Organization for Victim Assistance (NOVA). An
important division of NOVA involves its Crisis
Response Team (CRT) and emergency trauma specialists;
these individuals are placed on "stand-by"
for any national or international emergency considered
to be a critical incident.
Directed by Marlene
A. Young, Ph.D., NOVA is a highly respected non-profit
organization that has responded to many "high
profile" tragedies such as the Mount St.
Helens' eruption in 1980, the Air Florida airline
crash of 1982, the South Korean airline Flight
007 Disaster of 1983, the Mexico earthquake of
1985, and the Milwaukee Jeffrey Dahmer serial
murders to name only a few (Young, 1994).
NOVAs CRT personnel
are all highly trained specialists in Disaster
Management, Debriefing, Victim Assistance, Victimology
and Crisis Intervention in times of community
crisis (man-made crisis, natural or industrial
disasters). All NOVA team members are highly experienced
trauma workers and crisis intervention response
specialists who go as national volunteers to various
disasters as a public service to the requesting
community or state.
The NOVA Team
is carefully selected and typically represents
a cross-section of the community where it is to
be deployed. Most NOVA Teams are made up to represent
various disciplines to better assist the community
such as Clergy, Emergency Service Providers, Media
Relations, Public Safety Personnel and other professionals
representing the disciplines of Education, Nursing,
Psychology, Psychiatry, Victim Advocates, Law
Enforcement, and Medicine.
When specifically
requested, NOVAs main objective is to provide
intense and immediate emergency consultation,
crisis intervention services with additional follow-up
during a limited period of time. Usually one team
of 10 specialists will be deployed and will work
up to 3-4 days. The activated team will be relieved
by additional teams as needed depending upon the
magnitude of the catastrophe.
What
is a Critical Incident?
The author defines
examples of a "critical incident" as
a sudden death in the line of duty, serious injury
from a shooting, a physical or psychological threat
to the safety or well being of an individual or
community regardless of the type of incident.
Moreover, a critical incident can involve any
situation or events faced by emergency or public
safety personnel (responders) or individual that
causes a distressing, dramatic or profound change
or disruption in their physical (physiological)
or psychological functioning. There are oftentimes,
unusually strong emotions attached to the event
which have the potential to interfere with that
persons ability to function either at the crisis
scene or away from it (Davis, 1992; Mitchell,
1983).
Clinically, traumatic
events and their impact on individuals are fairly
predictable. When a person has been "exposed"
to a critical incident, either briefly or long-term,
this exposure can have a considerable impact on
their global functioning. Historically, some of
the first documented cases of traumatic stress
or what used to be called "transient situational
disturbance" (TSD) can be traced to military
combat.
In time, researchers
began to find evidence that emergency workers,
public safety personnel and responders to crisis
situations, rape victims, abused spouses and children,
stalking victims, media personnel as well as individuals
who were exposed to a variety of critical incidents
(e.g., fire, earthquake, floods, industrial disaster,
workplace violence) also developed short-term
crisis reactions.
Trauma
Reactions
NOVA personnel
refer to short-term crisis reactions as the "cataclysms
of emotion" where feelings and thoughts run
the gamut and include such diverse symptomatology
as shock, denial, anger, rage, sadness, confusion,
terror, shame, humiliation, grief, sorrow and
even suicidal or homicidal ideation. Other responses
include restlessness, fatigue, frustration, fear,
guilt, blame, grief, moodiness, sleep disturbance,
eating disturbance, muscle tremors or "ticks",
reactive depression, nightmares, profuse sweating
episodes, heart palpitations, vomiting, diarrhea.
hyper-vigilance, paranoia, phobic reaction and
problems with concentration or anxiety (APA, 1994;
Horowitz, 1976; Young, 1994). Flashbacks and mental
images of traumatic events as well as startle
responses may also be observed. It is important
to consider that these thought processes and reactions
are considered to be quite normal and expected
with crisis survivors as well as with those assisting
them. Some of the described symptoms surface quickly
and are readily detectable. However, other symptoms
may surface gradually and become what the author
calls "long-term crisis reactions."
These responses can be masked within other problems
such as excessive alcohol, tobacco and/or drug
use. Interpersonal relations can become strained,
work-related absenteeism may increase and, in
extreme situations, divorce can be an unfortunate
by-product. Survivor guilt is also quite common
and can lead to serious depressive illness or
neurotic anxiety as well (APA, 1994; Mitchell,
1983; Young, 1994).
What
is Critical Incident Stress Debriefing (CISD)?
Debriefing
is a specific technique designed to assist others
in dealing with the physical or psychological
symptoms that are generally associated with trauma
exposure. Debriefing allows those involved with
the incident to process the event and reflect
on its impact. Ideally, debriefing can be conducted
on or near the site of the event (Davis, 1992;
Mitchell, 1986). Defusing, another component
of CISD, allows for the ventilation of emotions
and thoughts associated with the crisis event.
Debriefing and defusing should by provided as
soon as possible but typically no longer than
the first 24 to 72 hours after the initial impact
of the critical event. As the length of time between
exposure to the event and CISD increases, the
least effective CISD becomes. Therefore, a close
temporal (time) relationship between the critical
incident and defusing and initial debriefing (i.e.,
there may be several) is imperative for these
techniques to be most beneficial and effective
(Davis, 1993, Mitchell, 1988).
Research on the
effectiveness of applied critical incident debriefing
techniques has demonstrated that individuals who
are provided CISD within a 24-72 hour period after
the initial critical incident experience less
short-term and long-term crisis reactions or psychological
trauma (Mitchell, 1988; Young, 1994). Subsequently,
emergency service workers, rescue workers, police
and fire personnel as well as the trauma survivors
themselves who do not receive CISD, are at greater
risk of developing many of the clinical symptoms
the author has briefly outlined in this article
(Davis, 1992; Mitchell, 1988). From the authors
perspective, when applying debriefing techniques,
an appropriate and effective protocol must be
followed when assisting responders and crisis
survivors of any critical incident.
Most approaches
to CISD incorporate one or more aspects of a seven-part
model. The model that the author suggests here
consists of several key points that can be followed
as a general guideline and applied when addressing
responders and survivors who are involved in man-made,
natural or industrial disasters.
An Emergency Crisis
Intervention Response Specialist must lay the
constructive groundwork for an initial "assessment"
of the impact of the critical incident on the
survivor and support personnel by carefully reviewing
their level of involvement before, during and
after the critical incident (Mitchell, 1988, 1986;
Young, 1994).
As a general guideline,
the author suggests incorporating these seven
(7) key points into the debriefing process when
providing assistance to survivors and emergency
rescue workers.
Seven
CISD Protocol Key Points:
1. Assess the
impact of the critical incident on support personnel
and survivors.
2. Identify immediate
issues surrounding problems involving "safety"
and "security."
3. Use defusing
to allow for the ventilation of thoughts, emotions,
and experiences associated with the event and
provide "validation" of possible reactions.
4. Predict events
and reactions to come in the aftermath of the
event.
5. Conduct a "Systematic
Review of the Critical Incident" its and
impact emotionally, cognitively, and physically
on survivors. Look for maladaptive behaviors or
responses to the crisis or trauma.
6. Bring "closure"
to the incident "anchor" or "ground"
support personnel and survivors to community resources
to initiate or start the rebuilding process (i.e.,
help identify possible positive experiences from
the event).
7. Debriefing
assists in the "re-entry" process back
into the community or workplace. Debriefing can
be done in large or small groups or one-to-one
depending on the situation. Debriefing is not
a critique but a systematic review of the events
leading to, during and after the crisis situation.
First, the "debriefer
or facilitator" assesses individuals'
situational involvement, age, level of development
and degree of exposure to the critical incident
or event. Consider that different aged individuals,
for example, may respond differently based on
their developmental understanding of the event
(Davis, 1993) .
Second, issues
surrounding safety and security surface,
particularly with children. Feeling safe and secure
is of major importance when suddenly and without
warning, individuals' lives are shattered by tragedy
and loss.
Third, ventilation
and validation are important to individuals
as each, in their own way, needs to discuss their
exposure, sensory experiences, thoughts and feelings
that are tied to the event. Ventilation
and validation are necessary to give the
individual an opportunity to emote.
Fourth, the debriefer
assists the survivor or support personnel in predicting
future events. This involves education about and
discussion of the possible emotions, reactions
and problems that may be experienced after traumatic
exposure. By predicting. preparing and planning
for the potential psychological and physical reactions
surrounding the stressful critical incident, the
debriefer can also help the survivor prepare
and plan for the near and long-term future.
This may help avert any long-term crisis reactions
produced by the initial critical incident.
Fifth, the debriefer
should conduct a thorough and systematic review
of the physical, emotional, and psychological
impact of the critical incident on the individual.
The debriefer should carefully listen and evaluate
the thoughts, mood, affect, choice of words and
perceptions of the critical incident and look
for potential clues suggesting problems in terms
of managing or coping with the tragic event.
Sixth, a sense
of closure is needed. Information regarding
ongoing support services and resources is provided
to survivors. Additionally, assistance with a
plan for future action is provided to help "ground"
or "anchor" the person during times
of high stress following the incident.
Seventh, debriefing
assists in short-term and long-term recovery
as well as the re-entry process. A thorough
review of the events surrounding the traumatic
situation can be advantageous for the healing
process to begin.
Clinical
Case Study: The Oklahoma City Aftermath
Children in kindergarten
through the sixth grade, principals, school psychologists,
nurses, guidance counselors, teachers, school
staff members, community leaders, and public officials
were debriefed. Oklahoma and its community-at-large
were all suffering. Many were suffering from short-term
crisis reactions. Dozens of others needed attention
for acute posttraumatic stress disorder (PTSD),
sleep disturbance, anxiety, acute reactive depression
and phobic disorder. Some could not be left alone
because of overwhelming fear, loss of personal
control over their environment, their community,
their lives, and their families. Almost everyone
in this close, tight-knit community knew someone
who had been hurt, seriously injured or had died.
All Oklahoma citizens suffered from the tragedy.
Oklahoma was and remains a community in crisis.
One elementary
school had lost 35 individuals to the bombing.
Many high school students during the initial aftermath
became suicidal and required an immediate mental
health response.
Over two years
later, the author firmly believes that CISD and
intervention services averted many of the major
long-term psychological injuries that could have
potentially been experienced from such a traumatizing
event. Considerable follow-up measure and referrals
to mental health professionals were indicated
and suggested.
Children and their
families' emotional reactions were carefully kept
in check while they, optimistically, prayed for
the excavation of a loved one. Still, countless
others, realizing the worst, awaited confirmation
and death notification from support personnel.
And, for several others, notification never came
(i.e., loved ones were never found).
Concluding
Comments
During the four
days the author had spent in Oklahoma City, he
personally debriefed over 1,100 individuals in
groups of 25-50 every half hour on the hour. He
provided one-to-one crisis intervention and outreach
to dozens of others at various times. During the
debriefings, the author saw individuals who had
difficulty coping or needed immediate intervention
due to the experience of acute psychological reactions.
Still many others, observed during the debriefings
in groups, were so traumatized that the author
could act only as a "referral agent"
to the local public service agencies, school counselors,
school psychologists, school nurses, mental health
community service providers and hospitals for
assessment and further care.
The author was
emotionally and physically exhausted working 12-15
hour days three of the four days he was present.
On the third day, the author had his chance to
grieve and mourn realizing that Oklahoma, Oklahoma
City and Oklahomans represented, realistically,
Anytown, USA. The author, knowing that his wife
and three-week old daughter eagerly awaited his
arrival in San Diego made life seem a lot better.
Tragically, the author could not say the same
for many of individuals he had counseled. For
them death, loss, sadness and the cataclysms of
emotion were their reality. All Americans were
victims of this critical incident. As communities
and as a nation, the Oklahoma bombing tragedy
brought a sense vulnerability to us all. This
disaster could have happened to any town in America
at any given time.
Despite all the
tragedy and sadness, one symbol stood out among
all the ruin and rubble. The flag of our beloved
United States stood proudly on top of the demolished
Alfred P. Murrah Federal Building and was visible
among the devastated citizens and city in Oklahoma
during the aftermath. It stood until the building
was imploded several weeks later.
As Americans,
this flag symbolically stands as the strength
of our country in times of peace and also in time
of great despair and tragedy. Now, in the aftermath
of Oklahomas great sorrow, our flag still symbolically
stands to unify all Americans for one common good
- the assistance of survivors, especially those
who remain in Oklahoma with their lives permanently
altered by this tragic critical incident forever.
References
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Association (1994). Diagnostic and Statistical
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Washington, DC: American Psychiatric Press.
Davis, J. A.
(March, 1993). On-site critical incident stress
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San Diego, CA.
Davis, J. A.
(May, 1992). Graduate seminar in the forensic
sciences: Mass Disaster Preparation and Psychological
Trauma. Unpublished Lecture Notes, San Diego,
CA.
Horowitz, M.
(1976). Stress response syndrome, character
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768-781.
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NOVA, Washington, D.C.
©1998
by The American Academy of Experts in Traumatic
Stress, Inc. |
