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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
American Psychiatric Association
(1994). Diagnostic and Statistical Manual
for Mental Disorders (4th Edition).
Washington, DC: American Psychiatric Press.
Davis, J. A. (March, 1993).
On-site critical incident stress debriefing
field interviewing techniques utilized in
the aftermath of mass disaster. Training Seminar
to Emergency Responders and Police Personnel,
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 style and dynamic
psychotherapy. Archives of General Psychiatry,
30, 768-781.
Mitchell, J. 1. (1988). Stress:
The history and future of critical incident
stress debriefings. Journal of Emergency
Medical Services, 7-52.
Mitchell, J. T. (September/October,
1986). Critical incident stress management.
Response, 24-25.
Mitchell, J. T. (January,
1983). When disaster strikes: The critical
incident stress debriefing process. Journal
of Emergency Medical Services.
Young, M. A. (1994). Responding
to communities in crisis. National Organization
for Victim Assistance. NOVA, Washington, D.C.
©1998 by
The American Academy of Experts in Traumatic
Stress, Inc. |
