Critical Incident Stress Management (CISM) at Sea: Preventing Traumatic Stress

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.