Thoughts for Combat Stress Support Services

By Jeffrey T. Mitchell, Ph.D., CTS

President Emeritus

International Critical Incident Stress Foundation

 

Important Crisis Intervention Background and Terminology

 

1. Crisis:

 

A crisis is an acute emotional reaction to a powerful stimulus or demand.  Combat is one of the most mentally and physically demanding experiences that often produces a crisis reaction or a state of emotional turmoil. There are 3 characteristics of all crises: 1) the usual balance between thinking and emotions is disturbed. 2) The usual coping mechanisms fail. 3) There is evidence of impairment in the individual or group involved in the crisis.

 

2. Crisis Intervention:

 

TEMPORARY, but ACTIVE and SUPPORTIVE entry into the life of individuals or groups during a period of extreme distress. “Emotional First Aid.” Just as physical self aid and buddy care can be performed in the field, so can psychological first aid. There are many different psychological first aid tactics.  Different interventions tools, however, are used for individuals vs. groups.

 

3. Providers of Crisis Intervention:

 

Although some elements of the fields of Psychiatry / Psychology are crisis oriented, most frequently crisis intervention is provided by soldiers, firefighters, emergency medical or search and rescue personnel, police officers, physicians, nurses, clergy, hospital workers, communications personnel and community members.

 

4. Societal Influences on the Development of Crisis Intervention:

 

Ø     Religion

Ø     Warfare

Ø     Disasters

Ø     Medicine

Ø     Law enforcement

Ø     Fire fighting

Ø     Emergency Medical Services

Ø     Psychiatry / Psychology

 

5. History of Organized and Systematic Crisis Intervention:

(Note: Crisis intervention is often referred to as “early intervention”)

 

Ø     1906 Edwin Sterlin – Crisis intervention tactics used in a mining disaster in Europe

Ø     1917 Thomas Salmon – Used crisis intervention procedures on the battlefields of World War I

Ø     1943 Eric Lindermann – Applied crisis intervention techniques to the survivors of the Coconut Grove fire Boston, MA

Ø     1960´s Gerald Caplan – Contributed most of the modern crisis intervention theory

Ø     1970´s - The field of CISM begins in 1974. It is a subset of crisis intervention.  It shares the same goals, principles and interventions although it focuses its efforts on generally healthy populations within operational agencies or organizations.  It has less emphasis on the general population than do the fields of psychiatry and psychology.

Ø     1980 and 90‘s - refinements to the CISM field; expansion to military, schools, businesses, industries, and communities.

 

6. Goals of Crisis Intervention:

 

Ø     Mitigate impact of event (lower tension)

Ø     Facilitate normal recovery processes, in normal people who are having normal reactions to abnormal events

Ø     Restoration to adaptive function

 

7. Principles of Crisis Intervention:

 

Ø     Simplicity – People respond to simple, not complex, in a crisis

Ø     Brevity – Minutes up to 1 hour in most cases (3-5 contacts typical)

Ø     Innovation – Providers must be creative to manage new situations

Ø     Pragmatism – Suggestions must be practical if they are to work

Ø     Proximity – Most effective contacts are closer to familiar areas and they are provided by people who are functioning in similar roles as the people who are impacted by the traumatic experience

Ø     Immediacy – A state of crisis demands rapid intervention

Ø     Expectancy – The crisis intervener works to set up expectations of a reasonable positive outcome

 

8. Critical Incidents:

 

These are powerful traumatic events that initiate the crisis response.  These events are usually outside of the usual range of normal human experiences either in job settings or in one’s personal life.  Examples are combat, line of duty deaths or serious injuries to operations personnel.  Child deaths, multiple casualty events, knowing the victims, and severe threats of or actual acts of violence are among many “critical incidents” that may involve military and emergency services personnel.

 

9. Critical Incident Stress (CIS):

 

Critical Incident Stress is a state of cognitive, physical, emotional and behavioral arousal that accompanies the crisis reaction.  The elevated state of arousal is caused by a distressing critical incident.  If not managed and resolved appropriately, either by oneself or with assistance, CIS may lead to several psychological disorders including Acute Stress Disorder, Post Traumatic Stress Disorder, Panic Attacks, Depression, Abuse of Alcohol and other drugs, etc.

 

10. Critical Incident Stress Management:

 

One of the possible collections of crisis intervention tactics that are combined into a common sense support package is called “Critical Incident Stress Management.”  It represents a comprehensive, systematic, integrated and multi-tactic crisis intervention approach to manage critical incident stress after traumatic events.  CISM is simply a coordinated program of tactics that are linked and blended together to alleviate the reactions to extremely traumatic experiences.

 

 

 

11. Who Uses Multi-Tactic Early Intervention Programs?

 

Ø     Many school districts and individual, public or private schools

Ø     American / International Red Cross

Ø     Austrian Red Cross

Ø     Japanese Red Cross

Ø     Canadian Red Cross

Ø     Critical Incident Stress Management Foundation of Australia

Ø     National Organization of Victims Assistance

Ø     Salvation Army

Ø     Church of the Brethren

Ø     Community Crisis Centers

Ø     Crisis Hot Lines

Ø     Hospitals

Ø     Clergy

Ø     Motorola Communications

Ø     United Auto Workers

Ø     Amtrak

Ø     Martin Marietta Corporation

Ø     Airlines

Ø     Air Traffic controllers (US, Canadian, German, Portuguese, European)

Ø     Association of Traumatic Stress Specialists

Ø     American Academy of Experts in Traumatic Stress

Ø     International Critical Incident Stress Foundation

Ø     National and International Disaster Relief Agencies

Ø     Police Departments

Ø     Fire Services

Ø     Emergency Medical Services Organizations throughout the world

Ø     United States Army

Ø     United States Air Force

Ø     United States Navy

Ø     United State Marine Corps

Ø     United States Coast Guard

Ø     National Health Trust of the United Kingdom

Ø     Federal Aviation Administration

Ø     United States Department of Agriculture

Ø     Environmental Protection Agency

Ø     The United Nations

Ø     Federal Bureau of Investigation

Ø     Secret Service

Ø     US Marshals Service

Ø     Bureau of Alcohol, Tobacco, and Firearms

Ø     Federal Emergency Management Agency

Ø     Homeland Security (many branches)

Ø     Swedish National Police

Ø     Finish Police

Ø     German Air Force, Navy and Army

Ø     A great many other organizations, agencies and private practitioners

 

12. Critical Incident Stress Debriefing:

 

One technique in a package of interventions is a specific, 7-step small group crisis intervention tool designed to assist a homogeneous group (unit, fire attack team, special operations group, company, squad, station, or precinct) after an exposure to the same significant traumatic event.  It is called “Critical Incident Stress Debriefing (CISD)” and it is simply a discussion of the traumatic event.  It is not a stand alone process.  It should never be provided outside of an integrated package of interventions within a Critical Incident Stress Management (CISM) program.  Under no circumstances should this group crisis intervention tool be considered psychotherapy or a substitute for psychotherapy.

 

13. General Crisis Concepts

 

“A relatively minor force, acting for a relatively short time,

can switch the balance to one side or another,

 to the side of mental health or the side of mental ill health” (Gerald Caplan, 1961)

 

 

• Any person is vulnerable to a crisis at almost any time in their life. Combat situations heighten that vulnerability.
• A crisis reaction is always distressing to the person involved even though others may not see the crisis event as upsetting.
• Most crises are sudden and unexpected and people may not be mentally prepared to manage them.  Proper operational training and mental and physical fitness can mitigate the crisis reaction but they can never fully eliminate it.
• Crises are temporary.  Most acute crisis reactions subside in 24 to 72 hours.  The immediate reduction of stimuli helps to shorten the duration of the crisis reaction.
• The usual coping methods that help a person to cope on a day-to-day basis tend to fail during a crisis.
• Crisis events produce at least a potential for dangerous or undesirable behaviors for those who endure them.
• Most distressed people react positively to even a limited amount of support provided by others. (Mitchell and Resnik, 1986).

 

Reactions to a Critical Incident

• Helplessness
• Mental confusion and disorganization
• Decision making and problem solving difficulties
• Intense anxiety
• Shock, denial and disbelief                                              
• Anger, agitation and rage
• Lowered self esteem
• Fear
• Body or hand tremors
• Withdrawal from others
• Emotionally subdued, depressed
• Grief
• Apathy
• Physical reactions such as nausea, shakes, headaches, intestinal disturbance, chest pain or difficulty breathing.  Any person who is experiencing chest pain, difficulty breathing or any other severe physical symptoms should be evaluated by medical staff as quickly as possible.

 

Keep in mind that a typical crisis reaction is characterized by three main features:

 

1. Thinking shrinks and feelings become dominant.  A state of disequilibrium is established as a result of the crisis.
2. Usual coping mechanisms fail to resolve the situation.  The person then feels more out of control. 
3. There is evidence of impairment of normal functions.  The simultaneous presence of alcohol and other drugs can further impair the person and set the stage for severe deterioration in performance and emotional control.

 

Strategic Planning in Crisis Management

 

1.     TARGET- who needs help and who does not?

2.     TYPE – what type of help should they get?

3.     TIMINING – what is the best time to deliver the assistance?

4.     THEME –what issues influence decision making, timing or services?

5.     RESOURCES – what resources will it take to provide the services?

 

Steps in Response to a Crisis

 

1. Assess the situation and its impact on those involved
2. Establish rapport (simultaneous with assessment)
3. Explore the crisis problem
4. Explore the feelings and reactions of those involved (Careful listening and acknowledgement of a person’s emotions and reactions is far more valuable than advice giving.)
5. Generate and explore possible alternatives
6. Develop and implement a crisis action plan
7. Check on plan’s success. Follow-up
8. Referrals if necessary

 

Examples of Possible Crisis Intervention Services

 

• Information, guidance, education and instruction
• Chaplain support services (particularly important within the military)
• General crisis assessments
• Immediate supportive interventions such as food, rest and other necessities
• Peer support (paraprofessional) programs (training of peer support personnel is essential)
• Individual crisis support (trained peers, corpsmen, sergeants, lieutenants, captains)
• Crisis telephone hotlines
• Walk-in Crisis clinics
• Mobile crisis services
• Poison control centers
• Group crisis support for both large and small groups (trained crisis support teams)
• Immediate crisis counseling (chaplains, mental health professionals)
• Family support services
• Field hospital medical staff
• Rear area hospital emergency room social services
• Disaster services
• Emergency psychiatric assessments (usually at the battalion level)
• Referrals for depression suicidal ideation, alcohol and other drug abuse, AIDS, violence, child abuse, sexual assault, psychiatric emergencies, significant other battering, and crime victimization   Many of the above services are obviously dependent on location, type of mission, security, transportation, intensity of emotional reaction, urgency of condition, availability of resources and other factors. All services are not equally available in all locations and under all circumstances (Roberts, 2000).

 

 

 

14. Stress

 

There are four main types of stress. They are:

 

1. General Stress

2. Cumulative Stress

3. Critical Incident Stress

4. Posttraumatic Stress Disorder (PTSD)

 

Normal Stress Pathways

 

General stress and critical incident stress reactions (numbers 1 and 3) are both normal pathways of stress.  General stress occurs as a result of the demands of everyday living.  People usually deal with their general stress, recover from it and move on in life.  As long as the stress is not excessive or prolonged, people can stay healthy and productive.

           

Critical Incident Stress is also a normal type of stress.  It is a normal stress reaction in normal people to an abnormal event.  It is not necessarily a pleasant reaction despite its normalcy.  A normal reaction does not mean absence of pain.  The pain of the experience lets us know that the situation is so intense that it demands our attention.  This is part of a normal human drive toward survival.  Critical incident stress is simply a heightened state of arousal that results from an exposure to some powerful traumatic event.

 

Abnormal, Dangerous or Disruptive Stress Pathways

 

The other two types of stress (numbers 2 and 4) are not normal pathways of stress.  They are both capable of producing considerable disruption in the lives of those who suffer through these conditions.  If these types of stress continue without attention they may set the stage for deterioration in health and performance.

 

Cumulative stress is a pathological pathway of stress.  If people experience cumulative stress, that is, an excessive accumulation of unresolved general stress, they are more prone to develop physical illness and emotional distress.  Cumulative stress starts off with a warning phase which is characterized by four primary symptoms – chronic fatigue, boredom, anxiety and depression.  If those signals are ignored, mild symptoms such as more frequent colds, gastro-intestinal distress, headaches, alcohol use, feelings of intense anger and other physical and emotional symptoms appear.  If it is still not resolved, cumulative stress can escalate into more and more severe symptoms until a person develops persistent physical and emotional problems which require professional mental health and medical intervention.

 

Posttraumatic Stress Disorder (PTSD) is the most destructive form of stress.  It comes about as a direct result of unresolved critical incident stress.  Once it is diagnosed, PTSD typically requires mental health intervention to overcome it.  Six criteria must be in place for a diagnosis of PTSD.  They are:

1.      It starts with an exposure to a horrible, threatening or disgusting event. The same events that initiate the critical incident stress reaction are the very ones that bring about PTSD.  Of course, PTSD does not start unless the critical incident stress is not resolved.

2.      Intrusion symptoms.  A person sees, hears, smells, tastes or feels some aspects of the event over and over.  Or the person has distressing dreams and nightmares or may have trouble controlling obsessive thoughts of the event.

3.      A person with PTSD will attempt to avoid any reminders of the event.  That includes places, people, conversations, circumstances or other things that remind a person of the horrible experience.

4.      PTSD will cause people to be excessively aroused.  They may have trouble sleeping, resting, relaxing or they frequently anticipate further harmful events.

5.      The symptoms of PTSD must last at least thirty days for the diagnosis to be made.

6.      PTSD produces considerable disruption in normal life pursuits.  People have trouble with home and work circumstances when they are suffering from PTSD.  They are stuck and unable to participate as they had always done before the traumatic event.

 

Tactics for Controlling Stress

 

No single stress management technique or tactic will be equally applicable to all people, under all circumstances and at all times.  Common sense suggests, therefore, that we must have a collection of techniques which can be utilized for different people under different circumstances.  This is much like having a tool box full of many tools that are designed for use under a variety of different circumstances.  Pick the right tool for the job and the task is easier and has a better chance of success.  Likewise, if we pick the right stress management technique the task is made easier and the success potential is enhanced.

 

Before the Critical Incident

 

• Be informed about critical incidents, critical incident stress and the crisis response.  Informed people are better able to manage critical incident stress when it strikes.
• Provide crisis intervention information at all levels of an organization.
• Make sure policies and procedures for support services are in place.
• Establish a well trained support team and make sure that it is trained to provide a variety of services to individuals and groups under different circumstances.
• Keep physically fit. People who are fit in body are usually more confident and mentally capable of managing duress.
• Anticipate potential problems before they arise and you will be more ready to deal with them should they occur.

 

 

During the Critical Incident

 

• Calm yourself.  Try some deep breaths to help to give you a few seconds to think how you are going to approach the situation.
• Being involved in a situation can be distressing, but try not to become overwhelmed by the intense stimuli of the situation.
• Take frequent breaks.  Brief rest periods, some food and fluids can help to keep you alert. Actual work periods may vary from situation to situation.  Typically a two hour work period should be considered a maximum and should be followed by a twenty minute to a half hour down time before work resumes on the crisis situation.  Circumstances of a mission may not allow this suggestion.  Then the suggestion is that personnel take advantage of any opportunity to rest when it arises.
• Remind yourself that you have the skills to support others in a crisis.
• A sense of humor helps but be careful with it.  Do not force humor.
• Do not over control your emotions.  A brief and controlled discharge of emotions is healthier than completely suppressing your emotions.
• Limit caffeinated products.  They drive the stress response.
• Alcohol should be avoided altogether in a crisis since it interferes with Rapid Eye Movement (REM) sleep patterns.  REM sleep is vital to manage stress reactions.  It is during the REM sleep cycles that the brain processes the traumatic events of the last few days.
• Avoid too much sugar, foods high in fat content, processed foods and white bread. Eat balanced meals with some proteins, complex carbohydrates and some fruits and vegetables.  Again, suggestions like this are not possible in combat conditions.  Then survival by whatever means available is the highest priority.
• No one should get less than four hours of sleep in twenty four hours.  “Four in twenty four” cannot, however, become the persistent rule.  It is an exception to the rule and it is applied only in unusual circumstances.  Too little sleep threatens health in many ways.  Thinking and decision making are certainly impaired with sleep deprivation.
• Limit exposures to gory sights and disturbing sounds and smells.  This is especially so when children are involved.
• Call in supportive resources to assist one’s personnel according to their needs.

 

After the Critical Incident

 

• Rest
• Eat nutritious meals
• Physical exertion exercise helps to reduce the chemicals of distress in a person’s body. Even walking can be very helpful, but only if one is physically able to do exercise.
• Attend group support services when they are offered by a trained crisis team.  They can “take the edge off” of a bad incident.  Most importantly, they can be very helpful for other members of the group.  Everyone gets a sense of the “big picture”. Comments made by one member often clarify the experience for others.  Group discussions of traumatic experiences often enhance group cohesion and group performance.
• Restore normal routines as soon as possible.
• Keep yourself active.  Do not permit boredom to get established.
• Express you feeling to people you trust.
• Dreams and memories of the tragedy are common.  They generally decrease over several weeks time.  If they remain intense after three weeks to a month has passed, the person should seek out support team members for assistance or a referral.
• Do not joke with fellow workers about the tragedy too much.  Some people are sensitive to the experience and have still not fully recovered.
• Do not engage in criticism of others.  Correct mistakes for the future, but do not cause others to feel guilty.
• Anger is a frequent emotion after the intensity of a major event.  Do not take it personally.  It should subside in a reasonable time.  If not, refer the person for help.
• Focus on the here and now.  Telling old war stories is not always helpful.
• Listen to those who want to talk about their experience.
• Shedding tears after a painful event is perfectly normal.  But frequent uncontrolled crying spells accompanied by sleep disturbance and an inability to return to normal activities is an indication that a person needs assistance.
• Help each other.  Try to understand and care for each other.  No one can support you as well as one who does the same work. 

 

 

Notes on Caring for the Victims of the Tragedy

 

• Protect the victims from further stress such as the press, curiosity seekers, gory sights and sounds, or additional exposures to the horror of the incident.
• Ask the victims what they need most.  Suggest possibly helpful things if they cannot think of anything.
• Mobilize the necessary resources to assist the victims. Reconnect group members.
• Listen carefully to the victims.  They need opportunities to express themselves. Provide accurate, current and timely information and reassurance.  Do not tell them that they are “lucky” Keep yourself calm and your voice soothing and reassuring.
• Manage victim needs as they arise.  Use appropriate touch if they seem receptive.
• Children are the most vulnerable to psychological harm during a disaster.  Special care should be afforded children.

 

 

 

15. The Research Behind Crisis Intervention (Early Intervention)

 

NOTE:  One cannot legitimately separate Critical Incident Stress Management from the field of Crisis Intervention or Early Intervention.   The entire field of CISM is a subset of the field of crisis intervention and shares directly in its history, goals, principles and interventions.  Therefore, studies which evaluated the effectiveness of the goals, principles and appropriate, well-designed applications of crisis intervention services, are studies which can be applied to CISM.   It should be noted, however, that CISM is a more focused set of crisis interventions designed specifically to manage the traumatic stress associated with exposures to critical incidents. 

The primary focus in the field of CISM is to support staff members of organizations or members of communities which have experienced a traumatic event.  What CISM does not share with the field of crisis intervention is the range of the populations served.  For example, CISM does not focus on primary victims such as auto accident victims, dog bite victims, women suffering post-partum depression, women who have lost a child in a miscarriage, child abuse victims, substance abusers, victims of elder abuse or sexual assault victims all of whom are typically served through various other crisis intervention programs.  Should primary victims with those concerns come into contact with crisis intervention trained personnel, the best course of action is a referral to appropriate crisis intervention or psychotherapy resources which are beyond the central focus and capabilities of most support teams.

The following is only a brief summary (by category of study type) of important studies which support early intervention.  By no means should the list be considered all inclusive.  Many more studies are summarized in a document entitled, Crisis Intervention and Critical Incident Stress Management Research Summary which can be found on the ICISF web site in the “Related Articles & Resources” section (www.icisf.org/articles).  It is suggested that readers actually read the original documents for the most accurate information.

 

Randomized Controlled Trials - (RCT)

 

 

1. Deahl, M., Srinivasan, M., Jones, N., Thomas, J., Neblett, C., and Jolly, A.

(2000).  Preventing psychological trauma in soldiers. The role of operational  stress training and psychological debriefing. British Journal of Medical

                Psychology, 73, 77-85.

Key points and findings:

 

·         106 British soldiers involved in a United Nations peacekeeping operation in Bosnia

·         All soldiers received an Operational Stress Training Package.

·         Random selection into groups receiving CISD or no CISD

·         At 6 month follow-up, CISD group had significantly lower prevalence of alcohol abuse than no-CISD group.

·         CISD group members had lower scores on psychometrically assessed anxiety than no-CISD group.

·         CISD group members had lower scores on psychometrically assessed depression than no-CISD group.

·         CISD group members had lower scores on psychometrically assessed PTSD symptoms.

 

2. Campfield, K. & Hills, A. (2001). Effect of timing of Critical Incident Stress

                Debriefing (CISD) on posttraumatic symptoms. Journal of Traumatic Stress,

                14, 327-340.

Key points and findings:

 

• 77 robbery victims
• CISD provided at less than 10 hours compared to CISD provided at greater than 48 hours.
• Victims were assessed at 2 days, 4 days, and 2 weeks.
• Post Traumatic Stress symptoms decline was significantly greater for the group with the more immediate CISD. Not only did they have fewer symptoms, but they also had less severe posttraumatic stress symptoms in each of the four different measurements over the two weeks.

 

Controlled Studies

 

1. Leeman-Conley, (1990). After a violent robbery. Criminology Australia, April

                /May,                 4-6.

Key points and findings:

 

• Bank employees in Australia
• Compared one year without a CISM program to a year with a CISM program
• 107 employees in each year
• In the year without assistance there were 281 sick days within a week of the robbery.  There were 668 sick days taken over the next six months.  These numbers are much higher than average lost days when there have been no robberies.  Average cost of medical benefits and other workers compensation was $18,488 (AUS).
• After the CISM program (called the “Post Hold-up Support Program”) was instituted, the sick time utilization was 112 sick days within a week and 265 days during the next six months.  This occurred despite the fact that there were more robberies in the year when help was available.  Average medical and other workers compensation costs dropped to $6,326 (AUS).
• 60% reduction in sick time utilization over year without assistance
• 66% reduction in workers compensation payouts over year without assistance

 

2. Bohl, N. (1991). The effectiveness of brief psychological interventions in police

                officers after critical incidents.  In J.T. Reese and J. Horn, and C. Dunning

                (Eds.) Critical Incidents in Policing, Revised (pp.31-38).  Washington, DC:

                Department of Justice.

Key points and findings:

 

• Naturalistic randomized study
• 40 police officers who received CISD within 24 hours of a critical incident were compared to 31 who had not received CISD within 24 hours.
• The final evaluation took place 3 months later.
• Those with CISD were less depressed.
• Those with CISD were less angry.
• Those with CISD were less anxious.
• Those with CISD had less stress symptoms.

 

3. Bohl, N. (1995). Measuring the effectiveness of CISD.  Fire Engineering, 125-126.

Key points and findings:

 

• Naturalistic randomized study
• Follow up investigation to the 1991 study
• 30 firefighters who received CISD within 24 hours of a critical incident were compared to 35 who did not receive CISD.
• The final evaluation took place at three months.
• Anxiety symptoms were found to be less in the CISD group.
• Symptoms of stress were less in the CISD group than in the non-CISD group.

 

4. Boscarino, J. A., Adams, R.E. and Figley, C.R.  ( 2005). A prospective cohort

study of the effectiveness of employer sponsored crisis intervention after a major

disaster,  International Journal of Emergency Mental Health, 7 (1), 9-22.

 

Key points and findings

 

• 1681 subjects in New York five Burroughs were followed fro two years after September 11
• Those who received group crisis intervention support services sponsored by their employers recovered better than those without such crisis services.
• Those with support services from their employers fared better on lowered use of alcohol, less stress symptoms, less PTSD symptoms, and a number of other measures.

 

 

4. Jenkins, S.R. (1996). Social support and debriefing efficacy among emergency

                medical workers after a mass shooting incident. Journal of Social Behavior

                and Personality 11, 447-492.

Key points and findings:

 

• 29 emergency medical personnel were studied subsequent to a mass shooting in Kileen, Texas. 23 died and another 32 were wounded.
• 15 EMS personnel were given CISD within 24 hours.
• 14 EMS personnel received no CISD.
• Repeated assessments 8-10 days after CISD and at 1 month
• Recovery from the trauma most strongly associated with participation in the CISD process
• CISD was useful in reducing symptoms of depression and anxiety for those who participated in the CISD compared to those who did not.
• Trauma related symptoms decreased in CISD group.

 

5. Chemtob, C., Tomas, S., Law, W., and Cremniter, D. (1997). Post disaster

                psychosocial                 intervention.  American Journal of Psychiatry, 134, 415-417.

Key points and findings:

 

• 41 crisis response workers in Hurricane Iniki
• Time-lagged design (one group finished their work as the other started theirs)
• Pre-intervention test for second group was concurrent with post-intervention assessment of the first group
• Impact of Events Scale (IES)
• Psychometrically assessed posttraumatic stress was significantly reduced in both groups after CISD and an educational program was presented.
• True study of CISM (multi-tactic approach)

 

6. Hokanson, M. (1997) Evaluation of the Effectiveness of the Critical Incident

                Stress management Program for the Los Angeles County Fire Department. Los

                Angeles, CA: LACoFD.

Key points and findings:

 

• Fire service personnel in Los Angeles County, California
• 3000 surveys distributed.
• 2124 (70.8%) completed.
• 600 of the 2124 had participated in a CISD.
• Goals of the LACoFD CISM program were to accelerate the recovery process after traumatic events.
• To reduce the psychological impact of the event
• 56.3% of respondents experienced a significant reduction of trauma-related symptoms within 72 hours of the CISD compared to only 45.5% indicating reduction of symptoms without CISD.
• The 72 hour incremental recovery utility for CISD was 10.8% beyond the personnel in the groups that did not receive CISD.
• 74.1% of the respondents experienced a significant reduction of trauma-related symptoms within one week after the CISD compared to only 65.5% of the personnel in the groups that did not receive CISD.
• The one week incremental recovery utility for CISD was 8.6%.
• The reduction in symptoms after CISD has implications for medical care, sick leave utilization and workers compensation claims.
• In addition the CISD process was effective in facilitating the amelioration of trauma-related symptoms.
• Of the respondents only 13.9% indicated that they had persistent trauma-related symptoms more than 6 months after the trauma and the CISD.
• 16.5% of the personnel in groups not receiving CISD reported persistent trauma-related symptoms.
• The incremental recovery utility was 2.6% for the CISD in this analysis.
• These findings have implications for workers’ compensation disability claims and the incidence of early retirement and turnover.

 

 

7. Wee, D.F., Mills, D.M. and Koelher, G. (1999).  The effects of Critical Incident

                Stress                 Debriefing on emergency medical services personnel following the Los

                Angeles civil disturbance. International Journal of Emergency Mental

                Health, 1, 33-38.

Key points and findings:

 

• 65 emergency medical personnel were studied after exposure to urban riots in

Los Angeles.

• 42 were given CISD within 1 to 14 days after riot.
• 23 received no-CISD.
• Frederick Reaction Index (self-report symptoms of PTSD)
• Assessed 3 months after the CISD
• Those who received the CISD had significantly less symptoms of PTSD than those without the CISD.

 

8. Nurmi, L. (1999). The sinking of the Estonia: The effects of Critical Incident

                Stress                 Debriefing on Rescuers. International Journal of Emergency Mental

                Health, 1, 23-32.

Key points and findings:

 

• Sinking of Estonia, a large ferry boat. 994 killed.
• 105 emergency response personnel who retrieved bodies were compared to 28 emergency department nurses who received bodies at their hospitals.
• CISD provided to emergency response personnel.
• Supervisor support was the only service provided to the nurses.
• Impact of Events Scale and Penn Inventory utilized.
• Psychometrically assessed trauma symptoms were consistently lower in CISD groups compared to control group.
• Self reported satisfaction with CISD ranged from 63% to 84%.

 

9. Richards, D. (2001). A field study of critical incident stress debriefing versus

                critical incident stress management. Journal of Mental Health, 10, 351-362.

Key points and findings:

 

• Assessment of the Critical Incident Stress Debriefing (CISD) tactic versus Critical Incident Stress Management (CISM) comprehensive program.
• After robberies:
• 225 people received only CISD.
• 299 people received a comprehensive program including CISD.
• Services were initiated 3 days after the event.
• Used Impact of Events Scale, General Health Questionnaire and Posttraumatic Stress Disorder scale
• Assessed at 3 days, 1 month and 6-12 months
• Both interventions were found to be very helpful.
• However comprehensive CISM was far more effective than CISD alone when evaluated on the follow-ups.

 

10. Watchorn, J.H. (2001). Surviving Port Arthur: The role of dissociation in the

                impact of and    its implications for the process of recovery. Hobart, Tasmania,

Ausatralia: University of Tasmania.

Key points and findings:

 

• 96 emergency services personnel involved in response to the Port Arthur massacre in which a lone gunman killed 32 visitors in a historic area of Tasmania, Australia.
• Experiencing dissociative symptoms at the time of the incident was predictive of long term psychological and physiological distress
• Those who experienced dissociation at the event but disclosed their related thoughts and feelings at the group debriefings showed significantly less long-term psychological distress.
• CISD appears to provide an opportunity for the necessary psychological processing to commence and assist emergency services personnel in managing what might otherwise develop into PTSD.
• Baseline data were established.
• Follow-up assessments were made at 8 months and 20 months.

 

Meta Analyses

 

1. Everly, G.S., Jr. and Boyle, S. (1999). Critical Incident Stress Debriefing (CISD):

                A meta-analysis. International Journal of Emergency Mental Health, 1, 165-

                168.

Key points and findings:

 

• 5 peer reviewed studies were subjected to meta-analysis.
• 341 subjects
• Specific “ICISF Model” CISD
• Various self- report measures of psychological symptoms were utilized.
• Cohen’s D (measure of effectiveness of an intervention) =.86  That represents a high positive effect of specific “ICISF Model” debriefings (CISD).

 

2.  Everly, G.S., Jr., Boyle, S. and Lating (1999). Effectiveness of psychological

                debriefing with vicarious trauma: A meta-analysis. Stress Medicine,15, 229-

                233.

Key points and findings:

 

• 10 peer reviewed studies
• 698 subjects
• Group psychological debriefings were evaluated.
• Various self- report psychological measures were utilized.
• Cohen’s D (measure of effectiveness of an intervention) = .54  That represents a modest positive effect of group debriefings.

 

3. Everly, G.S., Jr., Flannery, R. B., Jr., Eyler, V. and Mitchell, J.T. (2001)

                Sufficiency analysis of an integrated multicomponent approach to crisis

                intervention:        Critical Incident Stress Management. Advances in Mind-Body

                Medicine, 17,      174-183.

Key points or findings:

 

• A statistical “sufficiency analysis” of CISM argues strongly that CISM may be considered an empirically validated clinical intervention.

 

Other

 

 1. Swanson, W.C. and Carbon, J.B. (1989). Crisis intervention: Theory and

                Technique.  In Task Force Report of the American Psychiatric Association. 

                Treatments of Psychiatric Disorders. Washington, DC: APA press.

Key points and findings:

 

• When writing for the American Psychiatric Association Task Force Report on Treatment of Psychiatric Disorders, state, “Crisis intervention is a proven approach to helping in the pain of an emotional crisis.” (p.2520).
• Crisis intervention (rapid and acute psychological intervention following critical incidents and traumatic events) has demonstrated itself to be an effective means of reducing psychological morbidity.

 

2.  Western Management Consultants. (1996). The Medical Services Branch CISM

                Evaluation Report. Edmonton Alberta: WMC

Key points and findings:

 

• Data were collected, analyzed and reviewed by an independent evaluation organization, Western Management Consultants.
• Of 582 nurses working in British Columbia, Alberta, Manitoba and Ontario, 236 (41%) responded to the survey.
• 65% of the nurses had at least one critical incident per year in the workplace.
• CISM was instituted by the employer (Federal Government of Canada) as a means of reducing critical incident-related stress and discord.
• 82% of the nurses who had used CISM services reported that the services met or exceeded their expectations.
• 89% of the nurses in the overall sample indicated that they were satisfied with CISM services.
• 99% of nurses indicated that the CISM program had helped them to reduce the number of sick days taken on the job.  A review of three years of sick time utilization confirmed this finding to be true.
• “Survey data suggest MSB CISM significantly reduced turnover among field nurses” (p.53).
• As many as 24% of the nurses who experienced a critical incident contemplated leaving their jobs, but did not after a CISM intervention.  Estimates are that a single nurse replacement would cost $38,000 (CAD).
• Financial evaluations revealed a $7.09 benefit-to-cost ratio.  That may be interpreted as a 700% return on the investment of the Canadian Government.
• “It is evident that the quality of the existing program is exceptional.  The MSB program is a state-of-the-art program that should be emulated by other employers, and sets a standard by which alternatives should be judged.” (Western Management Consultants, 1996, p. iv).

 

3. Ott, K., and Henry, P. (1997). Critical Incident Stress Management at Goulburn

                Correctional Centre: A report. Goulburn, NSW, Australia: NSW Department

                of Corrective Services.

 

Key points and findings:

 

• CISM program installed in 1995.
• Peer support and mental health professionals
• 90% reduction in costs of assisting stressed employees.
• Lowered sick time utilization, turnover of personnel and premature retirements

 

“Quotable Quotes”

 

1. “In all the controversy, criticism and research debate…certain constants are emerging. The most effective methods for mitigating the effects of exposure to trauma…, those which will help keep our people healthy and in service, are those which use early intervention, are multi-modal and multi-component…and these components are used at the appropriate time with the right target group.”

Dr. Hayden Duggan, International Association of Fire Chief’s ICHIEFS on line resource, 09/01/02

 

2. “There Has Never Been a Study That Indicates That Harm Has been Done By Any CISM Service If The Following Two Conditions Are Present:

Ø     Personnel have been properly trained in CISM

Ø     Providers are adhering to well published and internationally accepted standards of CISM practice (J. Mitchell, 2003; 2004)

 

3. “…The evidence that debriefing may lead to less subsequent alcohol abuse suggests that coping styles may be enhanced by this early intervention.” (Litz et al. Clinical Psych. 2002)

 

Setting up a crisis support program or need additional information?

 

ICISF                                               (410) 750-9600                        www.icisf.org

3290 Pine Orchard Lane

Suite 106

Ellicott City, MD 21042                              

 

If a major disaster should strike your community, your crisis support team should be notified immediately and the team should handle the following:

 

1.     Assessment.

a. Target the groups or individuals who need help.

b. Type of help needed by whom?

c. Timing of the interventions chosen?

d. Theme(s) associated with the incident?

e. Resources needed to manage the situation?

2.     Call for additional supportive resources as required.

3.     Provide demobilizations to crew at the end of the first exposure to the incident.

4.     Advice and consultation to management and supervisors.

5.     One-on-one support services as required.

6.     Crisis Management Briefings to crews about to be deployed.

7.     Respite centers to provide food, rest, information, etc.

8.     Screening of arriving support personnel to assure that people have the appropriate training and credentials to provide services.

9.     Planning for the next few shifts from the earliest stages of the disaster.

10. Continue Crisis Management Briefings as the situation evolves.

11. Liaison with other support groups to assure the best possible interactions between the support  team and other organizations.

12. Once the situation goes beyond the first shift the picture changes and different services are generally required.

13. Defusing services may be necessary if a specific unit was exposed to a particularly distressing event.

14. One-on-ones will need to be given as the needs arise.

15. Outreach to personnel on the scene by having roving teams periodically checking on people’s welfare.  However, every effort should be made to keep a low profile and not be intrusive.

16. The greatest need is for information and that should be provided frequently.  Make sure the information is:

a.      Accurate

b.     Current

c.     Timely

17. The small group crisis intervention service, Critical Incident Stress Debriefing (CISD) will typically not be set up until the situation is complete.  It is not unusual for CISD services not to be held for weeks to months after a disaster has occurred.  Three conditions need to be present to justify a group support process.  They are:   

·        The group must be homogeneous

·        The situation must be completed or shifted to non-acute stages

·        The group should have had about the same level of exposure to the traumatic event

Use other types of support services first before considering CISD.  Make sure the primary conditions are in place before providing them.

18.  Be prepared to replace support team leadership if they

    become too emotionally involved or fatigued.

19. Provide community support services when necessary appropriate.

20. Follow-up the group CISD session(s) with one-on-one crisis intervention.  It is never to be used as a stand alone.

21. Provide family support services as required.

22. Have referral resources available if they should be needed.

23. Provide post incident education.

24. Assist in managing the anniversary programs.

25. Assist people who are delayed in requesting assistance, but who are showing a need for additional support.

 

 

          My very best thoughts go out to all of you who are engaged in the defense of the United States.  Thank you for your dedication, your sacrifice, your courage, your leadership and your love of your fellow human beings.

- Jeffrey T. Mitchell, Ph.D.

  April, 2005