In an effort to assist individuals to cope with their critical incident stress reactions, critical incident stress management (CISM) programs, which include critical incident stress debriefings (CISD), have been adopted in public safety, emergency, and first-responder organizations. Critical incident stress debriefing was created by Jeffrey T. Mitchell in the mid-1970s to assist paramedics, law enforcement officers, and firefighters experiencing stress as a result of a critical incident. The model has gained popularity and has been adopted by the military, medical staff, and transportation agencies (such as the railroads and airlines). There has been conflicting research as to the effectiveness of CISM to prevent psychopathology or post-traumatic stress disorder (PTSD), with some evidence indicating that this intervention is even harmful by exacerbating the symptoms of PTSD. In view of this, the question arises whether it is ethically justifiable to utilize this model to assist emergency and public safety personnel, or even if it is ethical to not afford these professionals any type of intervention or assistance.
Critical incidents are those events in which emergency personnel, such as nurses, doctors, firefighters, medics, law enforcement, and other first responders/public safety personnel experience an extreme emotional reaction, which may affect them at the scene or post incident. These events may include catastrophic events, such as the September 11, 2001, terrorist attacks or the December 14, 2012, shooting spree in Newtown, Connecticut, or smaller-scale events, such as traffic accident fatalities. Note that critical incidents also include floods and disasters, such as Hurricane Katrina, which devastated the Louisiana and Mississippi Gulf areas, or Super Storm Sandy, which impacted the northeast region of the United States. Personal loss or violence, such as the death of a loved one or domestic violence, experienced by public safety, first responders, and emergency personnel can also be deemed critical incidents.
However, not all critical incidents are traumatizing to all persons. How and whether a person will be impacted is contingent upon (1) the individual involved and his or her physical or emotional health as well as their social support system, (2) the individual’s assessment of the situation, and (3) the cause and effect of the situation. Jörg Leonhardt contends that a critical incident may be traumatizing if the person experiencing the incident has feelings of hopelessness, and personal guilt and experiences high levels of angst as a result of the incident. A critical incident may be traumatizing if there is a threat to an individual’s health or life and depends on the intensity of the incident. Responses to critical incidents can manifest at the behavioral, cognitive, emotional, or psychological level, and may ultimately result in PTSD for the individual. CISM does not seek to eliminate stress symptoms, nor is it a cure for PTSD or other psychological symptoms.
Responses to critical incidents may occur in three phases. The first, which is an acute stress reaction, manifests at or during the event and may last up to 24 hours post event. Individuals may experience stress and stress symptoms that should subside with individual coping strategies. The second, which is acute stress disorder, may occur within 24 hours and up to one month after the critical incident. Individuals’ experience extensive stress and stress symptoms, yet their individual coping strategies are not working. The third and final phase, chronic stress disorder, is present at least one month past the incident, in which massive stress and stress symptoms continue to exist and with more frequency and intensity; coping strategies are still ineffective. According to Leonhardt, if left untreated,
15 percent of persons experiencing chronic stress disorder will develop PTSD. It is estimated that law enforcement officers have a 20 to 30 percent chance of developing PTSD at some point in their career.
Critical Incident Stress Management consists of seven components. These seven components are:
- Precrisis preparation. Precrisis intervention, is part of the precrisis phase described above. As law enforcement, public safety, and other organizations anticipate (and prepare for) crisis incidents, these agencies have education and planning resources in place to mitigate the stress of emergency response before it may occur.
- Demobilization. While rare, large-scale events require informal briefings, or “town meetings.”
- Defusing. Defusing is structured small group discussion, in three stages, provided within hours of a crisis for purposes of assessing, and triaging acute symptoms of stress with the goal of mitigation.
- Critical incident stress debriefing. Critical incident stress debriefing (CISD) is a seven-phase, structured group discussion. CISD is usually provided 1 to 10 days postcrisis, with the intent to mitigate acute symptoms, assess the need for follow-up, and if possible provide a sense of postcrisis psychological closure.
- Crisis intervention/counseling support.
Crisis intervention or counseling support may be one-on-one sessions to provide more intensive resources and therapeutic support throughout the full range of the crisis spectrum.
- Family crisis intervention. Critical incidents not only affect the first responder or public safety professional, but also their immediate family and loved ones. As such family crisis intervention and organizational consultation is made available.
- Follow up. Follow-up and referral mechanisms for assessment and treatment of the first responder and/or family members, if necessary.
Critical incident debriefings are one aspect of CISM. Debriefings are techniques that allow responders to deal with physical and psychological symptoms experienced as a result of exposure to a critical incident. These symptoms may include nightmares, flashbacks of the incidents, nausea, fatigue, problems with memory and concentration, anxiety and depression, as well as physical symptoms. Debriefings may occur on site or days later in a neutral venue and last from one to three hours (depending on the extent of the critical incident). Debriefings afford participants an opportunity to defuse and express their thoughts and emotions associated with the event.
Jeffrey Mitchell’s CISD, known as the Mitchell model, is a process consisting of seven components. Mitchell’s model encompasses three phases. The first phase, the precrisis phase, includes stress management and mitigation for both individuals and the organization. The second, the acute crisis phase, includes those initiatives while the crisis is occurring. The third and final phase, the post-crisis phase, includes endeavors once the critical incident has concluded. The goals of the crisis intervention are (1) stabilization and cessation of distress experienced by the responder, (2) mitigation of acute signs of distress, and (3) restoration of independent coping strategies, or if warranted, facilitation of more intensive care.
According to Jeffrey Mitchell, critical incident stress debriefings must be small, homogenous groups of approximately 20 persons, in which all members are no longer exposed to or involved in the critical incident. In turn, all members of the group must have had the same level of exposure to the critical incident and be psychologically ready and able to participate in and be engaged in the dialogue.
Debriefings begin with an introduction (Phase One), in which team members introduce themselves and describe the process. These team members, while often not mental or behavioral health professionals, are well trained for this process. Phase Two of debriefings includes respondents to debrief and share the facts of the event. In this fact phase, respondents introduce themselves and share their role in the critical incident. There is little detail of what occurred, only basic facts related to the event, and recollection is the cognitive domain. Phase Three is when respondents are asked to share their thoughts and transition from discussing the phenomenon from the cognitive to the affective domain. Phase Four is when respondents discuss the impact of the critical incident on their lives and focus on emotions such as anger, confusion, or loss. Phase Five involves respondents identifying the symptoms they have experienced. Team members seek to identify cognitive, physical, behavioral, or emotional symptoms the respondents may be experiencing. In Phase Six, team members educate respondents about the symptoms they have been experiencing and provide resources and information to manage that stress. In Phase Seven, respondents are allowed to ask questions or make final statements. This phase is also sometimes referred to as re-entry.
Once debriefings have concluded, one-on-one sessions are often provided to reinforce that which was taught during the seven-stage process.
Some of the skills that facilitators in CISD need are active listening, questioning, and ability to provide support and encouragement.
The American Red Cross Advisory Council on First Aid, Aquatics, Safety and Preparedness conducted an exhaustive review of the literature in 2010. That literature review revealed that there is not any significant evidence revealing that CISD, either as an independent intervention or part of an exhaustive CISM program, is effective in eliminating or minimizing the onset of PTSD. However, those studies that indicate that CISM and CISD show some promise indicate that CISM personnel are properly trained in the area of CISM and that they adhere to the accepted standards of CISM. This proper training includes education in stress recognition and management, debriefing guidelines, group dynamics, and the formal processes of CISM in and of itself.
There are a number of ethical considerations associated with CISD. While agencies have an ethical obligation to provide debriefings to staff exposed to a crisis incident, providers also have an ethical obligation to minimize possible risk of harm when offering debriefings. In turn, providers as well as group participants also have an ethical obligation to maintain confidentiality and security of participant records. The providers, if licensed, professional, therapeutic counselors, must also adhere to their prescribed code of ethics (such as the code of the American Psychological Association). Providers also have an ethical obligation to ensure that they have the appropriate training to work with their client(s). There is also some question of the ethics in mandating that an individual go through CISD when he or she may not be prepared to discuss the same (given that debriefings are as soon as one to 10 days post incident), whereas it is unethical to withhold intervention for those persons exposed to a critical incident. In terms of evaluating the effectiveness of CISD, there is a question of ethics as it pertains to withholding treatment in the random control groups.
Research reveals that persons who participate in CISD report a decrease in symptoms at a quicker rate than those who do not participate in the debriefings. In turn, emergency service workers, first responders, and the like who do not receive CISD are at a greater risk to develop symptoms related to critical incident stress, such as sleep disturbances, excessive fatigue, or difficulty concentrating. Those persons who receive CISD within
24 to 72 hours post incident experience less psychological trauma and crisis reactions.
- Campfield, Kerriane and Andelma Hills. “Effect of Timing of Critical Incident Stress Debriefing on Posttraumatic Symptoms.” Journal of Traumatic Stress, v.14/2 (2005).
- Hokanson, Melvin and Bonnita Werth. “The Critical Incident Stress Debriefing Processing in the Los Angeles Fire Department: Automatic and ” International Journal of Mental Health, v.2/4 (2000).
- Leonhardt, Joerg. “Critical Incident Stress Management.” http://www.eagosh.org/ cmsv6/?q=node/130 (Accessed October 2013).
- Mitchell, J. T. “When Disaster Strikes: The Critical Incident Stress Debriefing Process.” Journal of Emergency Medical Services, v.8/1 (1983).
- Munroe, J. F. “Ethical Issues Associated With Secondary Trauma in Therapists.” In Secondary Traumatic Stress, B. H. Stamm, ed. Lutherville, MD: Sidram Press, 1995.
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