| A
fitting breaks during an underway replenishment,
and a Sailor is knocked overboard. Four hours
later, his shipmates pull his lifeless body from
the sea.
A Sailor, distraught
over news from back home, hangs himself in his
berthing space. His shipmates find the body and
attempt CPR, but it's too late.
A popular Senior
Chief has sudden heart attack while on the bridge,
and dies despite the corpsman's best efforts.
In the Arabian
Gulf, a cruiser is rammed by a tug trying to smuggle
oil from Iraq - three Sailors are injured.
In each of these
(invented) incidents, there are a number of people
who will be directly affected-who will suffer
from what the experts call a "critical incident"
and traumatic stress. How affected they may be
will depend on a variety of factors. One of the
most important of these is how we respond to help
them.
There is no firm
definition for a "critical incident,"
because it varies from person to person and from
time to time. Basically, a critical incident is
any crisis event with sufficient impact to overwhelm
the usual coping skills of an individual or group.
Critical Incident Stress, therefore, is the stress
reaction that a person or people may suffer in
response to the incident. Among the common responses
are sleeping and eating problems, intrusive images,
increased startle reflex, confusion in thinking
or decision making, memory problems, emotional
shock, anger or grief, and so on.
Sailors suffering
from such symptoms may benefit significantly from
Critical Incident Stress Management (CISM). CISM
is not therapy, and does not "cure"
people's stress responses. Rather, CISM is a proven
means of assisting people in their own healing
by reducing the severity and longevity of symptoms,
and thus restoring them to function much sooner.
It is not perfect, and some people suffering from
traumatic shock may go on to develop posttraumatic
stress disorder (PTSD), but for the vast majority,
CISM brings significant benefits. This article
proposes a model of CISM for deployed shipboard
use, with an emphasis on reducing stress reactions
and returning commands to full readiness as expeditiously
as possible.
The "classic"
CISM model was developed by Dr. Jeffrey Mitchell
of the University of Maryland for use with emergency
services personnel and promulgated by the American
Critical Incident Stress Foundation, which was
founded in 1989 (the name was changed to the "International
Critical Incident Stress Foundation" in 1991
to reflect the expansion of the model beyond US
boundaries). Initially developed for firefighters,
paramedics and police officers, use of the Mitchell
Model has been expanded for use in natural disasters,
school-based incidents, and a variety of other
settings, including, in recent years, the U.S.
military.
Major Naval Hospitals
in the U.S. have set up "SPRINT Teams"
- crisis response teams which include mental health
professionals, medical and nursing personnel,
chaplains, and enlisted Hospital Corpsmen. These
teams respond on short notice to major incidents
anywhere in the world. While not following the
classic Mitchell Model (their personnel are all
hospital staff, rather than "peers"),
their debriefings are highly regarded.
In 1998, the U.S.
Navy Chaplain Corps offered its members a four-day
training entitled "Ministry in Trauma and
Disaster," which included the two-day certification
course in Basic Critical Incident Stress Management.
This ensured that virtually every active duty
chaplain had received at a minimum, the basic
CISM training. For some it was new, while others
had been working with the Mitchell Model for a
number of years.
While the training
was undoubtedly valuable, it is unfortunately
not always easily applied within the context of
military deployments. The Mitchell Model relies
on the use of trained teams of Peer Support Personnel,
working with Professional Support Personnel (mental
health professionals or clergy). Such teams may
not always be available or even feasible in a
deployed context.
Should there be
a "Critical Incident" aboard a ship
at sea, as a result of either combat or accident,
it is quite possible that the ship's crew will
have to rely solely on deployed assets, and not
depend on outside personnel. A ship at sea may
quite simply not be within range of any shore-based
assistance. If the post-incident response cannot
be provided by already-deployed personnel, it
may not be provided at all, and certainly not
in an expeditious fashion.
A second issue
which could have a impact on the ability to bring
in a CISM Team following an incident at sea has
to do with command climate. U.S. Naval ships,
and particularly cruisers, destroyers and frigates,
are remarkably insular - the officers and crews
are trained to look inward, to their own resources,
rather than for outside help. In wartime, this
is of course essential, as each ship, while perhaps
part of a Battle Group, remains an individual
fighting unit, detecting and engaging the enemy.
Ship's crewmembers bond with one another very
closely, especially during deployments and times
of stress. Outsiders, even those who are themselves
in the Navy, may be seen as just that - outsiders.
A Team brought from another similar command -
from another ship within the Battle Group, for
example, may well be more accepted than a group
of shore-based medical personnel, who might not
be seen as really understanding the problem.
While these problems
are directly related to ships' deployments, there
are other areas in which the Mitchell Model for
CISM must be adapted to fit into the Navy's structure.
First, the Navy normally assigns Mental Health
Professionals (MHP) to sea duty only aboard aircraft
carriers, although chaplains are available on
most ships with crews of 385 or more. Destroyers
and frigates, however, carry neither a chaplain
nor a medical doctor, the latter function being
performed by a Hospital Corpsman with special
training for Independent Duty.
It would also
be challenging to maintain CISM Teams within the
Navy structure. Sailors are rotated to new duty
stations every two to five years, creating constant
turnover. In order to maintain a roster of "Peer"
team members, the command would have to be constantly
training new people to replace those being rotated
out. Such training will have to be seen as a priority
of the Mitchell Model is to work at all aboard
ships at sea.
Modifying
the Mitchell Model for Sea Duty
In order to provide
appropriate Critical Incident Stress Management,
therefore, some modification may have to be made
to the proven Mitchell Model - modifications designed
not to improve it, but to allow it to be used
under the particular circumstances of sea deployments.
In making these proposals, I understand that they
may reduce the effectiveness of the post-critical
incident stress intervention. However, a modified
response is better than no response at all.
The proposed modified
response is based on a presupposition - that there
will be at least one other ship close enough to
the affected vessel that a small team may be flown
over to provide assistance. In cases where that
is not possible (i.e., an independently steaming
ship, for example), then the sole resources will
be those already on board.
The first, and
essential, modification involves the roles within
the debriefing team. Although Mitchell and Everly
include chaplains with mental health professionals
(MHPs) as Professional Support Personnel, their
model calls for each debriefing team to include
(and be led by) a mental health professional.
There are two problems with this in the deployed
context. First, MHPs are almost non-existent at
sea. While aircraft carriers may have one, any
smaller ship will not. Thus, while it may be relatively
easy to crossdeck a chaplain from another ship
to assist, finding an MHP in the middle of the
Pacific may sometimes be impossible.
Second, I believe
that it is important to acknowledge the centrality
of chaplains to CISM within the Navy. The ship's
command chaplain or chaplains is normally a known
and trusted entity within the command structure,
and is seen by the officers and crew both as a
professional caregiver and as part of the crew.
As such, aboard ship he or she already serves
in the role of counselor/mental health professional,
and will have access in ways no outside professional
would. Further, within the Navy, there is little
onus attached to seeing the chaplain, in large
part because the chaplain's role encompasses not
just mental health issues but religious and social
functions as well. On many ships, the chaplain
serves not merely as counselor and religious leader,
but as the officer in charge of volunteer projects,
the library officer, and a variety of other roles
as well. People interact with the chaplain in
any or all of these roles, in addition to hearing
the chaplain's daily evening prayers. Chaplains
are seen as being "part of the team"
aboard ships in ways civilian mental health professionals
or clergy members can hardly appreciate.
Team Members
A deployed CISM
Team, unlike the equivalent team ashore, will
require tremendous flexibility in terms of its
training and make-up. It is preferable that a
Central CISM Team be organized at the Battle Group
level for training and coordination, but with
individual teams trained on each of the ships
in the Battle Group. This is necessary because
ships in the same Battle Group, while in communication
with one another, are frequently separated by
hundreds of miles.
The Battle Group's
senior chaplain, normally the command chaplain
aboard the aircraft carrier, should be responsible
for the Central CISM Team's coordination. He or
she will work with the carrier's assigned MHP,
as well as with the Admiral's Chief of Staff,
to ensure a systematic, timely and appropriate
response to any critical incident.
The Mental Health
Professional assigned to the carrier (normally
a psychiatrist) will be the Central CISM Team's
Clinical Director. The MHP will provide training
and supervision to the member teams, and in the
event of an incident beyond helicopter range of
the carrier will be available for consultation
via ship-to-ship radio or by message traffic.
The role of the
Chief of Staff is in many ways essential - as
a senior line officer working directly with the
Admiral, he or she brings both authority and credibility
to the Central CISM Team. In the aftermath of
a critical incident at sea, it is that authority
which will ensure transportation and billeting
for the CISM team, and the Chief of Staff's experience
and expertise will be invaluable in the decision-making
process both before and following incidents.
Team members aboard
the carrier and other ships should be drawn from
a variety of areas and pay grades. Each ship in
the Battle Group should have a team of at least
six to eight members, including a chaplain and
an Religious Program Specialist (chaplain's assistant).
The other members should be drawn from a variety
of departments and rates, and some two-thirds
of the members should be junior enlisted, with
one third being drawn from the ranks of chief
petty officers and officers. On mixed-gender ships,
the team should, if possible, be mixed gender
as well.
Pre-Incident
Inoculation
Appropriate education
should be provided through General Military Training
to all crew members in the symptoms and effects
of traumatic stress, along with some of the ways
in with which it may be dealt. This is important
for a number of reasons. First, by increasing
the crew's awareness of the effects of traumatic
stress before an incident, they are less likely
to be completely blindsided by them and less likely
to be afraid that they are "going crazy"
when they suffer from inability to sleep, loss
of appetite, intrusive images or thoughts, etc.
This is where the CISD mantra, "These are
the normal responses of normal people to abnormal
circumstances," becomes invaluable.
Second, simply
by being aware of the possible effects in advance,
those effects may be lessened-when you don't know
that a particular stress response is "normal,"
it adds to your stress!
And third, by
training Sailors in ways to deal with the effects
of stress, they will be far better prepared to
deal with them in healthy ways. A concomitant
benefit is that the stress relieving techniques
taught as part of a traumatic stress inoculation
class will also carry over to help the Sailors
deal with the other stressors in their lives,
increasing morale and productivity.
Included in the
training should be some specific stress reduction
techniques which, if taught as part of the GMT
(General Military Training) on all ships within
the Battle group, may then be drawn on by the
CISM Team following a critical incident. Such
techniques may include, but need not be limited
to - diet, exercise, neuro-muscular relaxation,
meditation or visualization, breath control, and
so on.
CISM Response
at Sea
The response to
a critical incident at sea will be dependent upon
a variety of factors - the incident itself, the
ship's location in relation to other Navy ships
or shore facilities, the assets available from
such ships or shore bases, and so on.
In the case of
an incident aboard a vessel traveling with a Battle
Group, half-a-dozen trained team members including
the carrier's Mental Health Professional, a CISM-trained
chaplain, and four Shipmate Support Personnel
(peers), plus a Religious Program Assistant (RP)
as administrator, should be flown over within
twenty-four hours of the incident. They will need
to be provided with billeting, messing, and an
appropriate space in which to work - the ship's
classroom/library may be best. Arranging such
spaces will normally be part of the job of the
RP.
Soon after arrival,
the MHP or Chaplain should meet with the Commanding
or Executive Officer and the Command Master Chief,
to briefly explain the process, goals, and desired
outcomes of the Critical Incident Stress intervention,
and to hear the concerns and needs of the command's
leadership. This is essential - without the support
of the command, there is little hope for any kind
of success.
Meanwhile, team
members should be getting as much information
as possible about the incident, and to get a sense
of how many people may have been involved and
in what ways - the "Incident Review."
Contact with shipboard medical personnel, the
Leading Chiefs and Division Officers of affected
divisions, and other personnel is appropriate
and necessary. At the same time, however, the
members of the team must be aware that their role
is not to interfere in the post-incident repairs
or the daily working of the ship, and should be
sensitive in making their requests for time or
help. In any case, within an hour of arrival or
less, the members of the team should know what
is going to be necessary - defusings, debriefings,
one-on-ones, or any combination thereof - and
be able to establish a plan of action with which
to proceed.
In the event that
the affected ship is not within helicopter range
of the aircraft carrier, but can be reached from
other ships, some modifications will become necessary.
The role of team leader will fall to a CISM-trained
chaplain, rather than an MHP. That chaplain, along
with an RP and a group of Shipmate Support Personnel,
should be flown over as soon as possible. The
chaplain would then meet with the CO/XO and Command
master Chief, while the other team members do
the incident review.
In those cases
where there is no other Navy ship within helicopter
range to respond following a critical incident,
the response must come from within the affected
ship itself. Crew members trained as part of the
CISM team should gather with the team leader (chaplain
or, in the case of destroyers and frigates, Independent
Duty Corpsman) to evaluate their own stress levels
before attempting to work with others, bearing
in mind that they, like their shipmates, will
have been affected by the traumatic incident.
Such one-on-ones or defusings they do attempt
should be approached with caution, and no full-fledged
debriefing should be attempted. As soon as assistance
from another ship is available, team members themselves,
as well as crew members, should be debriefed as
appropriate by an outside team.
Training
The training of
Shipmate Support and Professional Support personnel
in the military is problematic, given the general
guidelines provided by Jeffrey T. Mitchell and
George S. Everly in their instructional guide
for CISM. Few if any active duty Navy personnel,
MHPs, chaplains, or peers, have participated in
the requisite fifteen to twenty-five debriefings
expected of instructors, and both time and financial
constraints ensure that civilian instructors cannot
be used.
The psychiatrists
assigned to aircraft carriers, if they are to
serve as CISM Clinical Directors, should receive
ICISF Basic and Advanced CISM training in order
to fully familiarize themselves with the model.
CISM is sufficiently different from the various
techniques psychiatrists are usually taught and
therefore, such training is essential.
Already, however,
the Navy has provided Basic CISD training to members
of the Chaplain Corps, using ICISF-certified instructors,
through the 1998 Professional Development Training
Courses (PDTCs). A core group of those chaplains
should now be trained through the Advanced CISD
and Peer Counseling level (at least one per Battle
Group), and those chaplains could be utilized
as mentors and trainers for those with less experience.
In addition, detailed, step-by-step training curricula
should be devised that would enable ships' chaplains
to train Shipmate Support Personnel (i.e., peers),
as well as provide Trauma Inoculation GMT (General
Military Training) for the entire crew.
Training standards
for team members aboard deployed ships must, by
the nature of naval deployments, be somewhat different
from those for shore-based CISM teams. The relatively
extensive training suggested by Drs. Mitchell
and Everly, which includes both Basic and Advanced
CISD courses, plus Peer Counseling and Family
Support Services courses for a total of 56 hours
of training, would be optimal, but difficult to
provide in the pre-deployment period of workups,
drills and inspections.
However, Shipmate
Support Personnel, in order to function effectively,
must have as a minimum, training in Basic CISD
and Crisis Intervention. Such training should
follow the general guidelines presented by Mitchell
and Everly in terms of course content, but should
be adapted for shipboard use. Particular emphasis
during this training must be placed on teaching
the participants to recognize the symptoms of
Critical Incident Stress in themselves. This is
necessitated by the fact that, in a deployed setting,
no outside personnel may be available to assist
following a critical incident, and the caregivers
may be numbered among the "victims"
of the incident. Again, while this is certainly
less than optimal, it is better than having no
one provide care at all.
As stated earlier,
it is probable in a deployed setting that the
Team Leader in each case will be a chaplain, rather
than a mental health professional. Training for
such chaplains, given their central role, is essential.
Every chaplain, before deploying, should receive
as a minimum Basic and Advanced CISD training,
as well as a short course in methodology for teaching
the principles of CISM aboard ship. The responsibility
for training the Shipmate Support Personnel will
fall on the Command Religious Program, and easy-to-adapt
lesson plans, etc., should be provided to the
chaplain well before deployments.
The Religious
Program Specialists (chaplain's assistants) assigned
to the Command Religious Program will be responsible
for organizing and coordinating the team, and
should receive not only the same training as Shipmate
Support Personnel (whether or not they're actually
team members), but appropriate organizational
training as well.
Conclusion
The Mitchell Model
of Critical Incident Stress Management, as an
integrated system of services designed to prevent
and/or mitigate traumatic stress, assist and accelerate
recovery, restore the affected person to function,
and maintain worker health and welfare, is the
most effective model available to the Navy for
the initial response to traumatic stress. It is
not perfect - no model is -but when used appropriately,
it can consistently reduce the negative effects
of traumatic stress, both in terms of severity
and longevity, in the majority of people so treated.
Originally designed for firefighters, police,
paramedics and other emergency services personnel,
it has proven effective in a wide variety of cases
both within and outside of the military.
The Mitchell Model,
to be used by Naval ships at sea, must be modified
to fit the exigencies of deployment. Such modification
should be restricted to the minimal possible under
the circumstances, to avoid straying too far from
the proven techniques. The modifications proposed
in this article constitute just such an effort.
The benefits of
putting such a model for Critical Incident Stress
Management into effect are many. In the short
term, the crew of a ship suffering from a traumatic
incident will be more fully operational much more
quickly, thus increasing operational readiness.
In the long term, the provision of such a program,
and the consequent reductions in the effects of
traumatic stress and improvements in morale, can
help our retention rates at a time when we are
seeking to keep experienced Sailors in the Navy.
Recommended
Reading
Giodano, D.A.,
Everly, G.S., & Dusek, D.E. (1986). Controlling
Stress and Tension (Fifth Edition). Allyn
and Bacon.
Mitchell, J.T.,
& Everly, G.S. (1994). Human Elements
Training for Emergency Services, Public Safety
and Disaster Personnel. Chevron Publishing.
©1999
by The American Academy of Experts in Traumatic
Stress, Inc. |
