Critical Incident Stress
Management
2014 AAEM Workshop
Dr. B R Johnson
The responder is often a victim as
well
Crisis
 An acute response to a Critical Incident
wherein:
– Psychological homeostasis has been disrupted
– Usual coping mechanisms have failed
– Some evidence of impairment is present
What is Stress?
"The nonspecific response of the body to any
demand made upon it" (Selye)
"Demands on the person which tax or exceed
his adjustive resources" (Lazarus)
"A particular relationship between the person
and the environment that is appraised by the
person as taxing or exceeding his/her resources
and endangering his/her well-being"
Components of Stress
 necessary for life
 subjective
anything that
Threatens us
Pushes us
 positive and negative
Scares us
Worries us
Thrills us
Prolonged Stress…
Physical Effects
muscle tension
headaches
lack of energy
stomach problems
immune system
high blood pressure
strokes
sexual problems
Prolonged Stress...
Psychological effects
depression
anxiety
anger
confusion
irritability
impatience
fear
negativism
memory problems
helpless/hopeless
Prolonged Stress...
Behavioral effects
Alcohol and drug
use
Change in usual
behavior
Withdrawal
Acting out
Silence / talkative
Under / Overeating
Hypervigilance
Impulsive
HISTORY
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Trauma has been around forever
During WW I it was called “shell shock”
In WW II we called it “lack of moral fibre”
Twice as many Viet Nam vets have
committed suicide as were killed in the war
 We’re learning how to manage traumatic
stress
 CISM is not psycho therapy
WHAT KINDS OF INCIDENTS CAN
TRIGGER CIS?
 A line of duty death
 The death of a child
 Incidents involving single / multiple
casualties or injuries
 Significant injury/threat to firefighters
 Incidents attracting heavy media coverage
 Major Accidents (Air Crashes, etc.)…
 Line of Duty Death(s)…
 Serious Line of Duty Injury(s)…
 Suicide of a Co-Worker…
 Disaster / Multi-Casualty Incident(s)…
 Shooting(s)…
REMEMBER
CIS IS
A NORMAL REACTION
TO AN
ABNORMAL EXPERIENCE
Why Prepare?
 “The psychological states of emergency
response personnel can have a direct effect
on the mental and physical health of
survivors of a trauma or disaster”
 (Glass, 1956)
Seven Basic Truths
 Many experiences
can be traumatic
 Some are traumatic
to some, but not to
all
 Various factors may
make some more
vulnerable than
others
 Traumas create
reactions now and
later
 Experiencing these
reactions means
the situation was
serious for you
 Reactions
sometimes get
worse before they
get better
 Sometimes they
reappear later
Critical Incidents
 Are events which have significant power to
overwhelm an individual’s normally effective
ability to cope
 Individuals who experience a critical incident
are faced with the demand to respond
 They often respond in ways which require
exceptional physical or heroic effort
Critical Incidents
 Critical Incident Stress
affects nearly 90% of all
emergency personnel
 Are emotionally charged
events
 The effects of critical incident
stress can be intensified, influenced, or mitigated by our
personal, family, and developmental issues
 Symptoms usually subside within a few weeks
Crisis Intervention
 Urgent and acute psychological “first aid”
characterized by:
– Immediacy
– Proximity
– Expectancy
– Brevity
Goals of Crisis Intervention



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Stabilization of symptoms
Mitigation of symptoms
Restoration of independent functioning
Facilitation to higher level of care if
necessary
At the heart of any field of study or practice
resides a basic vocabulary. Unfortunately, the
field of crisis and disaster mental health
intervention has been plagued by the lack of a
standardized nomenclature.
So we will review several key terms and concepts
for clarification.
Definitions
 CRITICAL INCIDENTS are unusually
challenging events that have the potential to
create significant human DISTRESS and can
overwhelm one’s usual coping mechanisms.
 In other words, and abnormal event that evokes a
normal response (CIS/PTS) to that abnormal
event
Definitions
 The psychological DISTRESS in response to
critical incidents such as emergencies, disasters,
traumatic events, terrorism, or catastrophes is
called a
PSYCHOLOGICAL CRISIS
(Everly & Mitchell, 1999)
Critical Incident Stress (CIS)
is also known as
Post Traumatic Stress (PTS),
which is not the same as
Post Traumatic Stress Disorder (PTSD).
CIS/PTS is a normal response
of normal people to an abnormal event.
CIS/PTS reactions may look similar to some
symptoms of PTSD.
If the CIS/PTS does not get resolved,
it may turn into the disorder (PTSD).
Only a trained, Mental Health professional
can diagnose PTSD.
THE NEED
 About 50% of disaster workers likely to develop
significant distress
(Myers & Wee, 2005, Dis. Men. Hlth)
 As many as 45% of those Directly Exposed to mass
disasters may develop PTSD or Depression
(North, et al., 1999, JAMA)
 Dose-response relationship with exposure is a key
factor in development of PTSD (DSM-IV R)
The Need in EMS?
 Incidence of Posttraumatic Stress with EMS in urban
setting (NYC)
(9.3%) met the strict DSM-III-R criteria for PTSD
 Another (10%) had the required number and
combination of symptoms for PTSD, but these
symptoms had not persisted for the 1 month required by
the DSM-III-R criteria.
 Thus, a total of 19.3% of subjects who completed the
survey were shown to be suffering from PTSD
symptoms.
Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers,
Medscape Psychiatry & Mental Health eJournal 2(5), 1997. © 1997 Medscape
The Need in EMS? (cont.)
 The interaction between age and several other factors,
however, was significant, including:
– Study participants between the ages of 18 and 24
who graduated from a rural high school were nearly
3 times as likely to have PTSD as those from urban
or suburban high schools
– The prevalence of PTSD increased significantly with
the total number of previous medical emergency
work jobs
Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers,
Medscape Psychiatry & Mental Health eJournal 2(5), 1997. © 1997 Medscape
Lessons Learned From The Workplace
Post disaster crisis intervention (CISM) was
associated with reduced risk for:
–
–
–
–
major depression
anxiety disorder
global impairment
compared with comparable individuals who did not receive
this intervention
(Boscarino, et al, IJEMH, 2005).
Crisis Intervention (CI)
 An active, short-term, supportive, helping
process.
 Acute intervention designed to mitigate the crisis
response (CIS/PTS).
 NOT psychotherapy or a substitute for
psychotherapy.
Crisis Intervention (CI)
Goals:
1. Stabilization
2. Symptom reduction
3. Return to adaptive functioning, or
4. Facilitation of access to continued care
(adapted from Caplan, 1964, Preventive Psychiatry)
IMPORTANT!
Crisis intervention targets
the RESPONSE,
not the EVENT, per se.
Thus, crisis intervention and disaster
mental health interventions must be
predicated upon assessment of need.
Important CISD Considerations &
Ground Rules

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Strict Confidentiality agreed upon by participants and team
Timing is important
Location and physical environment appropriate
Closed circle format
Participation voluntary
No notes, recording devices
No breaks (Try to limit breaks until after group is finished)
Not operational critique, not investigation
Not a “blame” session
Not therapy, nor substitute for treatment
Psychological Crisis
An acute RESPONSE to a trauma, disaster,
or other critical incident wherein:
1. Psychological homeostasis (balance) is
disrupted (increased stress)
2. One’s usual coping mechanisms have failed
3. There is evidence of significant distress,
impairment, dysfunction (PTS/CIS)
(adapted from Caplan, 1964, Preventive Psychiatry)
Comparison
San Diego, CA
Cerritos, CA
Air Crash - 1978
Air Crash - 1986
Total Killed
Plane Survivors
Homes Destroyed
Killed On Ground
Emergency Personnel
Body Parts Found
125
0
16
15
300
10,000
82
0
16
15
300
10,000
Comparison
Support Services Provided
San Diego, CA
Cerritos, CA
Air Crash - 1978
Air Crash - 1986
Sporadic One on One

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On Scene One on One
Demobilizations
12 Debriefings
Hot Line Number
One on One Follow Up
Comparison
Personnel Lost in 1 Year
San Diego, CA
Cerritos, CA
Air Crash - 1978
Air Crash - 1986
Police
5
Fire
7
Paramedics
17
Increase in
Mental Health
Services
increase of 31%
- 1
1%
increase of
Example 1…
 100 trauma victims
 Intervention began after 6 months
 Average cost = $46,000.00 ea.
 94% filed civil litigation
Friedman, et al, EAP Digest, 1988
Example 2…
 100 trauma victims
 Intervention began within 6 months
 Average cost = $8,300.00 ea.
 13% filed civil litigation
Friedman, et al, EAP Digest, 1988
Critical Incident Stress can be
MANAGED!
Normal signs and symptoms of
stress
 Physical Symptoms:
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Nausea
Tremors
Chills
Diarrhea
Rapid heart rate
Muscle aches
Dry mouth
Shaking
Visual problems
Fatigue
 Emotional Symptoms:
–
–
–
–
–
–
–
–
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Anxiety
Denial
Fear
Survivor guilt
Uncertainty of feelings
Depression
Grief
Hopelessness
Feeling overwhelmed, lost,
or abandoned
– Wishing to hide or die
– Anger
– Feeling numb
Normal signs and symptoms of
stress
 Behavioral:
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–
–
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Change in activity
Withdrawal
Suspiciousness
Change in communication
patterns
Changes in interpersonal
interactions
Variations in food
consumption
Excessive humor
Excessive silence
Unusual behavior
Increased smoking or
alcohol consumption
 Cognitive:
–
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–
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–
–
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Confusion
Inability to pay attention
Difficulty calculating
Memory problems
Inability to concentrate
Repeated flashbacks
Nightmares
Blaming others
Disrupted logical thought
process
HOW DO WE MANAGE CIS?
We do this through a program called Critical Incident
Stress Management. The components of CISM
are:
 PRE-INCIDENT EDUCATION
 ON SCENE INTERVENTIONS
 DEFUSINGS
 DEBRIEFINGS
 FOLLOW UP
CISM is a strategic intervention
system.
It possesses numerous
tactical interventions of which
CISD is one.
CISM increases the rate of normal
recovery, in normal people, who are
having normal reactions to abnormal
events
CISM
 Critical Incident Stress Management was
first recognized and techniques to respond
were developed in the 1980’s
 The first team was in Virginia, today there
are hundreds of teams worldwide
CISM
 Was designed to assist in the prevention,
management, and recovery from a
significant stress
 Include pre-incident education, defusing,
debriefings, support services, follow-up
services, individual consults, peer
counseling, and disaster management
 CISM interventions are provided by
especially trained individuals
A seven phase process developed
to:
 Minimize the emotional and physical impact of an
event
 Prevent burn-out
 Educate participants regarding normal stress
reactions
 Mitigate stress responses
 Help to keep careers, relationships, and
physical/mental health intact with little residual
damage
 Can be delivered in a 6 hour course
Defusing
 Defusing:
– An abbreviated version of a debriefing in a small group process
– Helpful when a full debriefing cannot be organized
– Is held very soon after the event—ideal time within first 3 hours post
event
– Three main segments:
 Introduction
 Exploration
 information
– Four main goals:
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Rapid reduction in the intensity to reactions
A normalizing experience
Re-establishment of the social network of the group
To assess whether a full debriefing will be necessary
DEFUSING
 Ideal time 1-2 hours after incident
 20-45 minutes in length
 Done in a group, led by a team of Peer
debriefer(s)
 Not an operational critique but venting of
emotions
The seven phases of a formal
debriefing:
1.
2.
3.
4.
5.
6.
7.
Introduction
Fact phase
Thought phase
Reaction phase
Symptom phase
Teaching phase
Re-entry phase
THE DEBRIEFING PROCESS
1.
2.
3.
4.
5.
6.
7.
INTRODUCTION AND GROUND RULES
DESCRIPTION OF THE FACTS
RESPONDERS THOUGHTS
RESPONDERS REACTIONS
EXPLANATION OF CIS SYMPTOMS
STRATEGIES FOR COPING WITH CIS
CONCLUSION
DEBRIEFINGS
 A more in depth version of a Defusing
 They are held 24-72 hours after an incident
 Done in a group led by a team of at least one
mental health professional, trained in the fire
service, and one firefighter trained in CISM.
 Not an operational critique but venting of emotions
A formal debriefing:
 Ideal debriefing time is between 24 and 72
hours post event
 Generally lasts for 2-3 hours
 Is a seven stage process
What makes defusings and
debriefings effective?
 Early intervention
 Opportunity for catharsis
 Opportunity to verbalize about the trauma with
those who experienced it
 Behavioral structure
 Psychological structure
 Group support
 Peer support
 Promotes follow-up
Demobilization
 Demobilization:
– A very brief intervention that takes place immediately following the event
– Primary stress prevention and intervention technique
– Two main segments:
 Brief period where personnel are given information to assist them with
management of stress reactions
 A rest and nutrition/rehydration period prior to return to duties
– Goals of demobilization:
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To provide a transition from the traumatic event or critical incident to the routine
To reduce the intensity of immediate stress-related reactions
Assessment of group for additional needs
To educate the group about potential stress reactions
To provide information about additional support
To establish positive expectations about outcome
Common Problems
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Failure to understand ingredients of CISM
Failure to understand group processes
Inappropriate timing of interventions
Group size
Group is too heterogeneous
Incomplete instructions/expectations
Participants rush from FACT to REACTION
Professionals trained in CISM can
provide:
Defusing
Demobilization
Debriefing
Recommendations for follow-up
Critical Incident Stress
 No one is immune from responding to the
stress of a critical incident
 Critical incident stress may occur hours,
days, or even months after a critical event
 You may experience symptoms of stress
and not even know it
 Suffering the stress effects following a
critical incident stress is NORMAL
In the days immediately after a
critical event
 Maintain your schedule, alternate physical
activity with relaxation
 Remember that you are having normal
reactions to an abnormal event
 Reach out and spend time with others---they
care
 It is ok to talk about your feelings
After a critical event
 Do things that feel good to you or provide you with
comfort
 Avoid drugs and alcohol to numb your emotions
 Keep a journal
 Don’t make life-altering changes at this time
 Do make daily decisions and assume control over
your life
 Get plenty of rest, eat nutritiously, and take care of
yourself
Know your community’s resources!
Find out who provides CISM
services and make contact, if you or
some one that you care about has
experienced a critical incident.
CONCLUSION
 You provide a valuable service – the job
isn’t easy
 The likelihood of you being exposed to a
critical incident is increasing
 Just as you take care of your equipment,
you need to take care of yourselves