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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. |
