Providing Critical Incident Stress Debriefing (CISD) to Individuals and Communities in Situational Crisis

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.