Additional information on CISD teams can be obtained from: Jeffrey T. Mitchell, PhD, Emergency Health Services Department, University of Maryland, Catonsville, MD. 21228, 301/455-3223

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THE CRITICAL INCIDENT STRESS DEBRIEFING PROCESS

Major disasters over the past five years have brought attention to the fact that rescue workers themselves can become psychological casualties from the overwhelming carnage and suffering they witness. The Critical Incident Stress Debriefing is a simple, but effective tool to help the emergency worker cope with what he has seen, and continue a productive career with minimal long-term effects.

Jeffrey I. Mitchell, MS, is a full-time faculty member of the emergency health Services Program of the University of Maryland Baltimore County. he is the senior author of the book, Emergency Response to Crisis, and holds Masters' degrees in Counseling Psychology and Clinical psychology. He is currently completing work on his PhD, with his dissertation to be on paramedic stress. Mr. Mitchell is a certified EMT-A instructor and has served as an EMS coordinator and a fire fighter/paramedic. He specializes in crisis intervention and critical incident stress debriefings and has facilitated many CISDs, including one held for some rescue workers in the Air Florida 90 disaster.

The broken bodies and the overwhelming wreckage of such tragedies as the 1978 pacific Southwest Airlines crash in San Diego, the Kansas City Hyatt Regency Hotel disaster in 1981 and the past summer's loss of the Pan American 727 in Kenner, Louisiana have dramatically accelerated a growing national trend to recognize and meet the special needs of emergency service personnel. The disasters of these past five years have pointed out clearly that the "stiff upper lip," or "John Wayne Syndrome" (you're not hurt unless a bone is showing), is a fallacy--those who work under the assumption that rescuers are never affected by what they experience are living in serious danger. Among the lessons learned from these tragedies is the fact that rescuers are vulnerable human beings who have all the normal physical and psychological responses to the horror of human suffering.

In an effort to reduce the number of psychological casualties among emergency service personnel, a relatively new form of crisis intervention that is specifically designed to assist them is now under development at the Emergency Health Services Program of the University of Maryland Baltimore County. it is called "Critical Incident Stress Debriefing" and its main goal is to support those who are involved in emergency operations under conditions of extreme stress. A critical incident stress debriefing will generally alleviate the acute stress responses which appear at the scene and immediately afterwards and will eliminate, or at least inhibit, delayed stress reactions. These emotional aftershocks can appear days, weeks or even months later and can seriously affect a person's performance within the emergency organization as well as his relationship within his family.

THE CRITICAL INCIDENT

A critical incident is any situation faced by emergency service personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later. A major disaster is one type of critical incident that comes to mind, but a situation does not have to be of this magnitude to classify as a critical incident. All that is necessary is that the incident, regardless of the type, generates unusually strong feelings in the emergency workers. The following are examples of critical incidents:

The serious injury or death of an emergency team member in the line of duty.

The serious injury or death of a civilian resulting from emergency service operations. This would include a shooting by a police officer or a civilian injury or death caused by the collision of emergency units responding to a fire or EMS call.

Almost any case which is charged with profound emotion such as the sudden death of an infant under particularly tragic circumstances.

Almost any case which attracts extremely unusual attention from the news media.

Any loss of life which follows extraordinary and prolonged expenditures of physical and emotional energy in the rescue.

Any incident which can be considered a serious physical or psychological threat or a sudden loss to the rescuers.

Almost any incident in which the circumstances are so unusual or the sights and sounds so distressing as to produce a high level of immediate or delayed emotional reaction that surpass the normal coping mechanisms of emergency personnel.

STRESS RESPONSE SYNDROMES

Critical incidents produce a characteristic set of psychological and physiological reactions or symptoms (thus the term syndrome) in all people, including emergency service personnel. Since the American Civil War it has been known that soldiers and others exposed to war and disasters or critical type incidents have experienced, among other symptoms, restlessness, irritability, excessive fatigue, sleep disturbances, anxiety, startle reactions, depression, moodiness, muscle tremors, difficulties concentrating, nightmares, vomiting, diarrhea, and suspiciousness. Even Freud was impressed with the quantity and intensity of the stress response symptoms experienced by World War I veterans. He found that those who had been exposed to traumatic events repeatedly experienced mental imaged of those frightening scenes even when they tried to forget them. More recently, researchers have concluded that just viewing gory sights or hearing disturbing sounds is enough to trigger stress responses in people.

The physical and emotional symptoms which develop as part of a stress response are considered normal in every way. They develop in most people facing stress, threat or loss, and are primitive responses of the mind and body designed to help the person survive. The stress response syndromes, although normal, have the potential to become dangerous to the emergency service worker's health if symptoms become prolonged. They sap energy and leave the person vulnerable to illness. Under certain conditions, they may have the potential for life-long after effects. They are especially destructive when a person denies their presence or misinterprets the stress responses as something going wrong with him.

There are many methods to deal with a stress response syndrome. Among them are strenuous physical exercise and special relaxation programs within 24 hours after the critical incident. But one of the most effective methods to deal with a stress response syndrome, especially in emergency personnel, is a Critical Incident Stress Debriefing (CISD).

The CISD is an organized approach to the management of stress responses in emergency services. it entails either an individual or group meeting between the rescue worker and a caring individual (facilitator) who is able to help the person talk about his feelings and reactions to the critical incident. Basically, the CISD has three parts. The first part allows for an initial ventilation of feelings by the rescuer and an assessment by the facilitator of intensity of the stress response in the workers. Part two of the CISD entails a more detailed discussion of the signs and symptoms of the stress response and provides for support and reassurance from the facilitator. The third part of the CISD is the closure stage where resources are mobilized, information is provided, a plan of further action may be designed and referrals, if necessary, are made.

The victim of stress response syndrome responds remarkably well to this supportive crisis intervention format if the intervention takes place timely. Within 24 to 48 hours is the ideal time for intervention. As the length of time between the incident and the CISD grows, the effectiveness of the intervention decreases. After about six weeks the effectiveness is minimal and the person is then considerably more vulnerable to lifelong emotional fallout form the incident. For example, several years ago a drilling platform in the North Sea broke apart and toppled over in a storm. There was a great loss of life. Survivors were brought to port in two groups which arrived several hours apart. The first group was hospitalized and interviewed by psychiatrists as part of their treatment. The word that the first group was being seen by psychiatrists somehow reached the second group of survivors. When the second group arrived, they were also hospitalized, but had decided on the way in that being seen by psychiatrists was a weakness. They refused to be interviewed by the psychiatrists. Today, the members of the group which allowed psychiatric interviews are well adjusted and functioning normally in life. Most have returned to their former jobs at sea. Many members of the group which refused help are currently experiencing a variety of distressing emotional and physical symptoms and are unable to work in their old jobs even though some of them received a debriefing several months after the incident.

There are essentially four types of Critical Incident Stress Debriefings. Each has its own purposes and procedures but the overall goals are basically the same: to protect and support EMS personnel and to minimize the development of abnormal stress response syndrome which may cause lost time and effectiveness at work and problems within the family.

The On-Scene or Near-Scene Debriefing. This is the briefest form of CISD. It is typically performed by a mental health professional familiar with emergency operations but may be performed by a chaplain or an officer not directly responsible for the management of the scene. In any case the facilitator functions as an observer/advisor and watches for the development of acute reactions. Checklists of symptoms are available form several sources and should be utilized, since a single symptom is not indicative of an acute stress reaction. The facilitator briefly checks on the well-being of the personnel, offers encouragement and support and suggests to command officers which individuals or groups may need a break or a change in duties. The facilitator spends some time with those who are resting and allows some ventilation of feelings and reactions. A key to helping the personnel here is a good listening ear. The Israeli army has instituted this very type of CISD and has found it very successful in cutting down the incidence of prolonged serious stress reactions in combat troops.

The Initial Defusing. The initial defusing is a form of CISD which is usually performed very shortly (within a few hours ) after the critical incident. It may be led by a mental health professional but it is more often organized and led by command officers. At times there is no designated leader. The whole initial defusing may be quite spontaneous as those who had been involved, in the critical incident gather around after cleaning equipment and preparing their units for the next call. They start talking about their feelings and reactions to the incident and the defusing is underway.

It really does not matter whether the initial defusing is led by a specific person or completely spontaneous. What does matter is that the atmosphere of the initial defusing is positive, supportive and based on care and concern for the team members. No one should be criticized for how they feel. Instead, they should be allowed free expression of feelings with acceptance, support and understanding from each other and their leaders.

The best format for this initial defusing would be a mandatory team meeting as soon as possible after the conclusion of the incident. About one hour is usually enough to go through the process. During this time, the team members and leaders should check on each other's well-being and provide support and friendship to those who seem to be hardest hit by the incident. This is not the time for criticizing personnel or critiquing the incident. No responsibility for malfunctions should be distributed to any of the team members; just understanding.

The Formal CISD. The formal CISD is typically led by a qualified mental health practitioner 24 to 48 hours after the conclusion of the incident. A skilled professional is usually necessary in this debriefing because the emotional content released during the session may overwhelm an untrained facilitator. The facilitator should be skilled in human communications and should have a fairly good background in group dynamics or group interactions. A good working knowledge of stress response syndromes and the operational procedures of the emergency service group are essential for the success of the debriefing.

In the majority of cases, a formal CISD is generally not organized for the first 24 hours because the EMS personnel are still too worked up to be able to deal appropriately with an in-depth group discussion of the incident, especially as it relates to their inner feelings. They are trained to suppress emotional reactions during and for a brief time after an incident. Natural feelings of denial and avoidance predominate during the first 24 hours. Often emergency service workers attempt to intellectualize about the incident, and they run it through their minds over and over as they try to make sure that they handled their part correctly. Several hours after the incident their cognitive activities decrease and fairly intense feelings may then come to the surface. This is the time for a CISD (In some situations they may occur earlier than 24 hours. The one-day time limit is only a guide.)

The formal CISD should be mandatory for all personnel involved in the scene. At times a joint debriefing between police, fire and EMS personnel is extremely beneficial. Again, this is not an incident critique. The tone must be positive and understanding. Everyone has feelings which need to be shared and accepted. The main rule is - no one criticizes another; all listen to what was, or is, going on inside each other.

The formal CISD follows this general format:

A. Introductory Phase. The facilitator begins by introducing himself or herself. The rules of the process are then described. The need for absolute confidentiality is carefully explained. Members are encouraged to make a pact with each other to be silent forever regarding details of the debriefing, especially any details which could be associated with any particular individual. Participants in a debriefing need to be assured that the open discussion of their feelings will in no way be utilized against them under any circumstances.

B. The Fact Phase. Most facilitators begin this phase by asking the participants to describe some facts about themselves, the incident and their activities during the critical incident. They are asked to state who they are, their rank, where they were, what they heard, saw, smelled and did as they worked in and around the incident. Each person takes a turn adding in the details to make the whole incident come to life again in the CISD room.

C. The Feeling Phase. Once all participants have shared sufficient factual information to bring the incident into vivid memory, the facilitator begins to ask feeling-oriented questions. "How did you feel when that happened?" "How are you feeling now?" "Have you ever felt anything like that in your life before?" Again each person in the room gets a chance to answer these and a variety of other questions regarding their feelings. At times, a facilitator has to do very little. People start talking and the whole process goes along with only limited guidance from the facilitator. What is important under these circumstances is that the facilitator makes sure that no one gets left out of the discussion and that no one dominates the discussion at the expense of others. People will most often discuss their fears, anxieties, concerns, feelings of guilt, frustration, anger and ambivalence. All of their feelings, positive or negative, big or small, are important, and need to be expressed and listened to.

D. The Symptom Phase. This phase of the debriefing concerns itself most with answering the questions, "What unusual things did you experience at the time of the incident?" "What unusual things are you experiencing now?" and "Has your life changed in any way since the incident?" The participants are urged to discuss what is going on now in their homes and in their jobs as a result of their experiences. In other words, they are describing their own versions of stress response syndromes.

E. The Teaching Phase. The facilitator takes this opportunity to teach the group something about the stress response syndromes. The emphasis is on describing how normal and natural it is for emergency service people to experience a variety of signs, symptoms, and emotional reactions to the critical incident they lived through.

F. The Re-Entry Phase. This final phase seeks to wrap up loose ends, answer outstanding questions, provide final reassurances and make a plan of action. Groups often need a direction or specific activity after a debriefing and this is an opportune time to work out a plan for such an activity. For example, in one case where a drunk driver killed several people, EMS personnel made a plan to appear in court at the trial in full uniform as a form of protest against light sentences for drunk driving. It gave them a sense of purpose and unity. Summary comments are then offered and the personnel are advised about getting additional help should they need it.

All six segments of the CISD usually take three to five hours to complete.

The Follow-up CISD is performed several weeks or months after a critical incident. it is not always necessary, but when it is, its main purpose is to resolve some issue or problem that came up as a result of the critical incident and is still present. The follow-up CISD may be performed with the entire group, a portion of it, or with an individual. it is by far the most difficult CISD for the facilitator to perform and is closely identified with a therapy process. More than one session may be necessary to achieve the goals of relieving emergency personnel from a set of painful psychological and physical reactions, but the end result is well worth the extra effort. Once freed from frustration, anxiety and guilt, emergency personnel are able to function happily again in their jobs and in their homes.

CONCLUSION

The simplicity of the critical incident stress debriefing should not cause one to underestimate its value.  Well-executed CISDs have an enormous potential to alleviate overwhelming emotional feelings and potentially dangerous physical symptoms.  When used properly, they can extend the careers of personnel, thus saving great outlays of resources to replace perfectly good men and women who have seen too many broken bodies and too much human misery.

6.   POST TRAUMATIC STRESS DISORDER:

RECOGNIZING IT, TREATING IT

Post traumatic stress disorder (PTSD) is the usual diagnosis that mental health people apply to persons who have suffered severe trauma in their lives and develop certain symptoms as a result.

Such trauma is defined in the diagnostic and statistical manual, third edition as an event outside the range of usual human experience, and event which would prove remarkably distressing to almost anyone. The stressor could be a serious threat to one's life or physical integrity, serious threat or harm to one's family, sudden destruction of one's home or community, or the witnessing of anothers serious injury or death. Crime could cause each of these situations.

PTSD is characterized by psychologically re-experiencing the event through nightmares, daydreams, flashbacks and/or intense distress when reminded of the original event. There may be symptoms of avoiding things that remind one of the trauma, social isolation, a feeling of being different from other people and a general lack of interest in the world. Other symptoms include tension and anxiety, such as difficulty falling asleep, irritability, outbursts of anger, trouble concentrating or being exceptionally jumpy.

Any individual who has experienced trauma may suffer from these symptoms. Being in crisis, however, doesn't mean the individual will develop PTSD. PTSD may occur if the victim hasn't had the opportunity to work through their crisis.

To recognize PTSD in individuals, counselors should first understand the theory of why people develop psychological distress following a major shock. We developed this acute trauma model after years of experience in counseling survivors of traumatic events. The model has three distinct phases of acute post-trauma reactions: the shock phase, the impact phase and the recovery phase.

The first phase, shock, generally begins during the actual traumatic event and can last a few days or even a few weeks. Two emotional responses normally characterize the shock phase: Immobilization and denial.

During immobilization, the typical response is one of confusion, disorganization and an inability to perform simple, routine tasks. For instance, during a robbery a store clerk may be unable to open the cash register. At the same time, the victim may also experience denial, refusing to believe that the trauma is actually happening.

Shock may manifest itself through perceptual changes in which time is altered and events seem to be happening in slow motion. Visual perceptions are modified; people sometimes have a derealized "out-of-body" experience or may feel they are simply observing rather than participating in the event. Another frequent alteration is a tunnel vision that causes the victim to focus on one aspect of the trauma to the exclusion of everything else.

That same store clerk who couldn't open the cash register visually focused solely on the robber's gun throughout the hold-up; in fact, form what he was he and the gun were the only things in the store. Later, when talking to police, he couldn't remember what the perpetrator looked like or whether anyone else was present during the crime.

Not all trauma victims experience the shock phase. People trained to deal with trauma regularly, such as military, police, or medical emergency workers, may initially bypass these reactions, though residual elements are often evident.

Once the shock and disbelief subside, the impact phase begins. This phase takes hold with a period of anger and/or extreme anxiety that manifests itself through trembling, crying, or subjective feelings of tension, anxiety, or outrage. This anger is commonly displaced: in the robbery's aftermath, the aforementioned store clerk becomes extremely angry with the store's owner and the police. He is not angry with the perpetrator.

As the impact phase continues, the victim moves to the "what-if-and-maybe" stage, the process of self-doubt. Victims will go to great lengths to invent different scenarios, ignoring the actual fact and outcome of the trauma. "If only i'd been five minutes earlier..." "If only I had reacted more quickly..."

We often see self-blame in ambulance crews or police officers who have been involved in critical incidents. This guilt may last indefinitely, if not dealt with, as the victim embroiders more and more elaborate "if only" stories. The "if only" stories are encouraged by intrusive thoughts of the trauma, such as flashbacks. The more involuntary thoughts the victim has of the trauma, the more "if only" versions they'll create.

This self-doubt eventually will bring about the final part of the impact phase, depression. The trauma victim becomes irritable and feels isolated, misunderstood, helpless and bereft of hope for the future. "Leave me alone, there's nothing wrong with me" is the prevailing attitude.

If the victim fails to face the trauma at this point, they will continue to oscillate between anger/anxiety and depression and will be unable to progress to the recovery phase, to try to reclaim a normal life. The ptsd becomes chronic.

If the trauma is dealt with right away, the chances of getting stuck in this glitch are slim. If a victim sees a crisis counselor at the scene of the crime or soon afterward, it is likely they will return to normal functioning sooner than they would otherwise. The counselor explains to them what they're experiencing, why they are experiencing it and what to expect next. Victims need the assurance that what they're feeling is normal.

Once a person resolves the guilt and returns to a relatively symptom-free mode of functioning, they may remain there for sometime. A new disturbance, though, or a reminder of the original trauma, can cause symptoms to recur. Similarly, an accumulation of the stresses of daily life, such as financial problems, employment difficulties, or ill health, may also cause the trauma survivor to regress. But with effective treatment, survivors can learn to control many of the symptoms of anxiety and depression, and so function more productively.

Those subject to constant high levels of stress, such as emergency response workers or police, seem unable to remain in a symptom-free mode because of constant immersion in trauma. Victims who haven't worked through their trauma, who don't understand what they are experiencing, may become trapped in the anxiety/depression cycle.

Without support, individual reactions to such ongoing stress may be unhealthy. People experiencing incessant intrusion and anxiety tend to self-medicate in an attempt to alleviate their symptoms; alcohol and drugs can become a severe problem.

A less obvious form of self-medication is sensation seeking to get symptom relief through an adrenaline rush. Some people suffering chronic post traumatic stress disorder have interests in high risk activities like parachuting, driving motorcycles, or rock climbing. Another way some victims of ptsd relieve stress is the constant seeking of excitement through numerous sexual encounters.

When a victim suffering ptsd becomes trapped in the anxiety/depression cycle, their guilt overwhelms them. They feel guilty for surviving and responsible for the fate of others or for the event having happened in the first place.

Termed "existential guilt," this guilt is characterized by the survivor's confusion over having lived and the meaning of this survival. For instance, if the trauma includes death of other individuals we sometimes see variations on this theme: the survivor wishes to change places with the person who died, and the guilt is expressed as "I should have died, and they should have lived." Because their own lives have been so chaotic since the trauma, they feel that the person who died would have had a better life with more to live for, failing to recognize that it's likely this person would be struggling with similar emotions.

After hearing about the trauma during an interview, I frequently ask, "How come you lived through that?" Often i get the response, "I don't know, I ask myself that question all the time," or, on a more positive note, "Perhaps there is some purpose for my life after facing the probability of my own death."

Content guilt, as opposed to existential guilt, is a result of a person's having done something to ensure their survival, such as hiding under a table during a shooting. This is a much easier from of survivor guilt to recover from because there are actual behaviors to talk about and understand.

Because survivor guilt has both emotional and intellectual components, a major goal in counseling is to separate the feeling and thinking elements. The survivor must learn that it is okay to feel sad about someone's having died or been injured in a traumatic situation, but it is neither rational nor appropriate to feel totally responsible for the person's death. The situation or perpetrator should be blamed, not the survivor.

To keep the victim accessible to counseling, however, the counselor cannot say "You have nothing to feel guilty about," because victims often cling to their guilt for comfort. The counselor should attack the guilt through the issue or responsibility. Getting survivors to share responsibility for what happened starts with pointing our other factors involved in the incident. One of the factors may be time and space; they may have been in the wrong place at the wrong time. They may have been the victim of a random act.

Survivors of trauma tend to remember the traumatic situation in an unchanged way; their initial perception of the event is the way they continue to view it, as if the traumatic event were frozen in their memories. The healing process involves thawing those memories and looking at them realistically. Because the memories have a negative focus, the goal of re-thinking is simply to look at the original trauma in a different light.

As pointed out earlier, victims, when having intrusive thought about the traumatic incident, automatically follow the original thought with a host of "what-if-and-maybe" versions of the event, reinforcing their guilt and self-blame. To help victims stop this negative behavior, tell clients to simply shake their heads "No" and say to themselves "No, here is what happened." In effect they train themselves to look only at the reality of a the situation, and to live with it.

In dissolving the "what-ifs-and-maybes" and the anxiety/depression cycle, the first step a client goes through in re-thinking is confusion. This positive sign shows they are beginning to doubt their original perception. They're realizing that the trauma has other facets that have been ignored, forgotten, or devalued. Make a point of letting the client know why this confusion is a good sign, because it is a sign of change.

Finally, victims' religious beliefs may need to be addressed. Victims with religious convictions find these beliefs either strengthened or weakened by the experience. I urge all trauma counselors to have some contact with the clergy in their community. Talking to the clergy can do much to alleviate individual guilt.

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