CISD-Critical Incident Stress Debriefing

What is a Critical Incident?

     The author defines examples of a "critical incident" as a sudden death in the line of duty, serious injury from a shooting, a physical or psychological threat to the safety or well being of an individual or community regardless of the type of incident. Moreover, a critical incident can involve any situation or events faced by emergency or public safety personnel (responders) or individual that causes a distressing, dramatic or profound change or disruption in their physical (physiological) or psychological functioning. There are oftentimes, unusually strong emotions attached to the event which have the potential to interfere with that persons ability to function either at the crisis scene or away from it (Davis, 1992; Mitchell, 1983).

     Clinically, traumatic events and their impact on individuals are fairly predictable. When a person has been "exposed" to a critical incident, either briefly or long-term, this exposure can have a considerable impact on their global functioning. Historically, some of the first documented cases of traumatic stress or what used to be called "transient situational disturbance" (TSD) can be traced to military combat.

     In time, researchers began to find evidence that emergency workers, public safety personnel and responders to crisis situations, rape victims, abused spouses and children, stalking victims, media personnel as well as individuals who were exposed to a variety of critical incidents (e.g., fire, earthquake, floods, industrial disaster, workplace violence) also developed short-term crisis reactions.

Trauma Reactions

     NOVA personnel refer to short-term crisis reactions as the "cataclysms of emotion" where feelings and thoughts run the gamut and include such diverse symptomatology as shock, denial, anger, rage, sadness, confusion, terror, shame, humiliation, grief, sorrow and even suicidal or homicidal ideation. Other responses include restlessness, fatigue, frustration, fear, guilt, blame, grief, moodiness, sleep disturbance, eating disturbance, muscle tremors or "ticks", reactive depression, nightmares, profuse sweating episodes, heart palpitations, vomiting, diarrhea. hyper-vigilance, paranoia, phobic reaction and problems with concentration or anxiety (APA, 1994; Horowitz, 1976; Young, 1994). Flashbacks and mental images of traumatic events as well as startle responses may also be observed. It is important to consider that these thought processes and reactions are considered to be quite normal and expected with crisis survivors as well as with those assisting them. Some of the described symptoms surface quickly and are readily detectable. However, other symptoms may surface gradually and become what the author calls "long-term crisis reactions." These responses can be masked within other problems such as excessive alcohol, tobacco and/or drug use. Interpersonal relations can become strained, work-related absenteeism may increase and, in extreme situations, divorce can be an unfortunate by-product. Survivor guilt is also quite common and can lead to serious depressive illness or neurotic anxiety as well (APA, 1994; Mitchell, 1983; Young, 1994).

What is Critical Incident Stress Debriefing (CISD)?

      Debriefing is a specific technique designed to assist others in dealing with the physical or psychological symptoms that are generally associated with trauma exposure. Debriefing allows those involved with the incident to process the event and reflect on its impact. Ideally, debriefing can be conducted on or near the site of the event (Davis, 1992; Mitchell, 1986). Defusing, another component of CISD, allows for the ventilation of emotions and thoughts associated with the crisis event. Debriefing and defusing should by provided as soon as possible but typically no longer than the first 24 to 72 hours after the initial impact of the critical event. As the length of time between exposure to the event and CISD increases, the least effective CISD becomes. Therefore, a close temporal (time) relationship between the critical incident and defusing and initial debriefing (i.e., there may be several) is imperative for these techniques to be most beneficial and effective (Davis, 1993, Mitchell, 1988).

     Research on the effectiveness of applied critical incident debriefing techniques has demonstrated that individuals who are provided CISD within a 24-72 hour period after the initial critical incident experience less short-term and long-term crisis reactions or psychological trauma (Mitchell, 1988; Young, 1994). Subsequently, emergency service workers, rescue workers, police and fire personnel as well as the trauma survivors themselves who do not receive CISD, are at greater risk of developing many of the clinical symptoms the author has briefly outlined in this article (Davis, 1992; Mitchell, 1988). From the authors perspective, when applying debriefing techniques, an appropriate and effective protocol must be followed when assisting responders and crisis survivors of any critical incident.

      Most approaches to CISD incorporate one or more aspects of a seven-part model. The model that the author suggests here consists of several key points that can be followed as a general guideline and applied when addressing responders and survivors who are involved in man-made, natural or industrial disasters.

      An Emergency Crisis Intervention Response Specialist must lay the constructive groundwork for an initial "assessment" of the impact of the critical incident on the survivor and support personnel by carefully reviewing their level of involvement before, during and after the critical incident (Mitchell, 1988, 1986; Young, 1994).

As a general guideline, the author suggests incorporating these seven (7) key points into the debriefing process when providing assistance to survivors and emergency rescue workers.

Seven CISD Protocol Key Points:

1. Assess the impact of the critical incident on support personnel and survivors.

2. Identify immediate issues surrounding problems involving "safety" and "security."

3. Use defusing to allow for the ventilation of thoughts, emotions, and experiences associated with the event and provide "validation" of possible reactions.

4. Predict events and reactions to come in the aftermath of the event.

5. Conduct a "Systematic Review of the Critical Incident" its and impact emotionally, cognitively, and physically on survivors. Look for maladaptive behaviors or responses to the crisis or trauma.

6. Bring "closure" to the incident "anchor" or "ground" support personnel and survivors to community resources to initiate or start the rebuilding process (i.e., help identify possible positive experiences from the event).

7. Debriefing assists in the "re-entry" process back into the community or workplace. Debriefing can be done in large or small groups or one-to-one depending on the situation. Debriefing is not a critique but a systematic review of the events leading to, during and after the crisis situation.

First, the "debriefer or facilitator" assesses individuals' situational involvement, age, level of development and degree of exposure to the critical incident or event. Consider that different aged individuals, for example, may respond differently based on their developmental understanding of the event (Davis, 1993) .

Second, issues surrounding safety and security surface, particularly with children. Feeling safe and secure is of major importance when suddenly and without warning, individuals' lives are shattered by tragedy and loss.

Third, ventilation and validation are important to individuals as each, in their own way, needs to discuss their exposure, sensory experiences, thoughts and feelings that are tied to the event. Ventilation and validation are necessary to give the individual an opportunity to emote.

Fourth, the debriefer assists the survivor or support personnel in predicting future events. This involves education about and discussion of the possible emotions, reactions and problems that may be experienced after traumatic exposure. By predicting. preparing and planning for the potential psychological and physical reactions surrounding the stressful critical incident, the debriefer can also help the survivor prepare and plan for the near and long-term future. This may help avert any long-term crisis reactions produced by the initial critical incident.

Fifth, the debriefer should conduct a thorough and systematic review of the physical, emotional, and psychological impact of the critical incident on the individual. The debriefer should carefully listen and evaluate the thoughts, mood, affect, choice of words and perceptions of the critical incident and look for potential clues suggesting problems in terms of managing or coping with the tragic event.

Sixth, a sense of closure is needed. Information regarding ongoing support services and resources is provided to survivors. Additionally, assistance with a plan for future action is provided to help "ground" or "anchor" the person during times of high stress following the incident.

Seventh, debriefing assists in short-term and long-term recovery as well as the re-entry process. A thorough review of the events surrounding the traumatic situation can be advantageous for the healing process to begin.

For any more information, please contact Gail St. Onge @ Spiritwood Ambulance Base.