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)




Reactions to a Critical Incident


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



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





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




During the Critical Incident



After the Critical Incident




Notes on Caring for the Victims of the Tragedy





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 (  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:



Controlled Studies


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

                /May,                 4-6.

Key points and findings:



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:



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

Key points and findings:



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




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:



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:



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:




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:


Los Angeles.


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:



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:



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:



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-


Key points and findings:



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

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


Key points and findings:



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:





 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:



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

                Evaluation Report. Edmonton Alberta: WMC

Key points and findings:



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:



“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              

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