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Critical Incident Stress Management

Roger M. Solomon, Ph.D. Robert Macy, Ph.D.

A critical incident can be conceptualized as an event which is outside the usual range of

experience and challenges one’s ability to cope. These are events that have the potential

to overwhelm one’s usual psychological defenses and coping mechanisms (Everly and

Mitchell, 1999). Often, these are situations that can overwhelm a person’s sense of

vulnerability and control (Solomon, 1995).

crisis intervention framework for managing the emotional aftermath of critical incidents.

Critical incident stress management is a

This chapter will outline a general framework for critical incident stress management that

is applicable to a wide variety of at risk populations. However, population specific

knowledge and experience is needed to appropriately apply the framework. For example,

just to mention a few variables, population specific knowledge is relevant for different:

Age groups (e.g. children, adolescents, and adults)

Occupational groups (e.g. for example, emergency service personnel may require more specialized services than other occupational groups (Solomon, 1995)).

Cultural considerations (e.g. different cultures have different grieving rituals and timing of rituals) Further, for each impacted population, the intervention team should consider the particular needs, requests, neighborhood-specific cultural identities, rituals and support systems, as well as the ethnocultural and linguistic variabilities of these populations.

Critical incident stress management should be viewed as part of the general field of crisis intervention. The goals of crisis intervention (Everly, 2000; Dunning, 2000) are:

Mitigate the impact of the event

Stabilization – prevent symptoms/distress/impairment from getting worse

Promote recovery – enhance resilience, group/ community cohesion, and other naturally occurring healing, salutogenic factors

Re-establish functional capacity or

Seek further assessment and/or higher level of care

It is important to provide appropriate intervention according to the phase of emotional

recovery the survivor is experiencing. The following is a brief description of general phases survivors of critical incidents may experience (Solomon, 1988). However, it is important to realize that not everybody goes through these phases. Some people experience the critical incident and simply cope, with little or no shock phase and minimal emotional impact.

Phases of Recovery


Incident occurs – During moments of peak stress people experience different levels


perceived vulnerability and lack of control, and consequently different levels of

peritraumatic dissociation. Peritraumatic dissociation, the dissociation experienced


during and shortly after the event, is correlated with post-traumatic stress disorder (Marmar and Weiss, 1997) . It may be useful to assess the level of peritraumatic dissociation a person experienced during the incident to help determine what kind of emotional and psychological support is needed.

II Shock – first 24-72 hours (or longer). After a critical incident, people may

experience a number of reactions. Emotions may be blunted and numbed due to

dissociation and denial. Other people may experience intense emotion. confusion, agitation, and oversensitivity.

There can be

During the initial hours and days following an incident, people need a sense of safety and security. Initial priorities are helping people feel safe (or at least realize the danger is over in the immediate present), orienting them to available resources, and conducting triage to determine who may need immediate medical/psychological evaluation and

The goal of psychological intervention is stabilization - emotional


containment and providing constructive coping strategies to decrease arousal, increase control, and to prevent distress or impairment from getting worse. Exposure to arousing

stimuli should be minimized. People whose functioning and ability to cope are impaired should be referred for further assessment and treatment.

III Emotional Impact

wear off and the reality of what happened, and its emotional impact (e.g. awareness of vulnerability/lack of control) may start to hit. There may be alternating phases of intrusion and avoidance or hypervigilance and numbing (Horowitz, 1976, van der Kolk, 1987). The emotional impact affects different people at different times. For many, the emotional impact hits within the first 72 hours (Mitchell and Everly 1996). Often, it is longer. Following the September 11, 2001 World Trade Center attacks in New York City

the author observed the emotional impact starting to hit eye witnesses within the first two


the attacks. The emotional impact was delayed for emergency service personnel who were focused on their task, seemingly hitting several weeks to months following return to

usual duty. Typical reactions include (but are not limited to):

- At some point, the initial denial/dissociation/numbness starts to

However, the impact appeared to take longer to hit for people directly involved in

Heightened sense of danger/hypervigilance


Intrusive thoughts and images

Dissociative symptoms

Distress upon being reminded of the incident

Avoidance of thoughts, feelings, and reminders of the incident

Arousal symptoms (including difficulty sleeping, restlessness, difficulty concentrating, irritability, poor concentration)

Extreme physical and emotional fatigue or exhaustion

Guilt about the incident or about surviving the incident

Desire to isolate self from friends or family

IV Coping – As the emotional impact begins to hit, hopefully the survivor starts to face,

understand, work through, and come to grips with the emotional impact of the incident.


However, some people may resist dealing with the incident. Denial of emotional impact

or avoidance of dealing with the incident can impede constructive coping.

some people there can be a gap between experiencing emotional impact (Impact phase)

and starting to cope constructively with it (Coping Phase).

Hence, for

It is important to assess when the emotional impact is hitting so interventions can be

timed appropriately. Interventions during the Impact and Coping phases are longer in duration than interventions during the Shock phase, and go into more depth about the

impact of the event. Such interventions can be too intense during the Shock phase.

It is equally important to assess readiness for intervention. The emotional impact may be

hitting, but the survivor may be in denial, want to be left alone, or prefer to avoid dealing with the incident. Usual CISM interventions can increase resistance, overwhelm

psychological defenses and be too intense for the person. Low key, individual strategies

to engage the person in a healing process are more appropriate.

The goal of interventions during the Impact and Coping phases is to promote positive coping. Helping people understand and come to grips with what happened, and the teaching adaptive coping strategies and self-care planning, are key interventions during this time frame. People having prolonged difficulty coping should be referred for further assessment and treatment.

V Resolution/integration – The survivor reaches a state of acceptance and integration of

the experience. In the authors’ experience the following levels of awareness signify the

assimilation and accommodation of the incident into one’s world view:

“I am vulnerable (this is part of the human condition), but not helpless “

“I cannot always control what goes on around me, but I can control my response to it”

I survived, I am safe today, and have choices about how I approach the future.

However, the aftermath of the event is not necessarily over.

VI Learning to Live with it – For some, experiencing a critical incident can be like

crossing a fence……

The survivors’ world view may have significantly changed, altering perceptions of self, environment, and the world (Janoff-Bulman, 1992). It is not uncommon for people who seemingly have integrated the specific incident to be experiencing later adaptation problems because their world view has been altered. The survivor knows he/she is vulnerable and has to learn to live with it. The memory of the incident may not be as

losing one’s naiveté……with no possibility of jumping back.


haunting as the disturbance in the sense of self and the person’s relationship with his or her surroundings (van der Kolk, 1996). Adjustment to this new world can take many

months (Everly, 1995).

facilitating adaptation needs to be available.

Consequently, appropriate follow-up intervention geared toward


Salutogenic Approach

A guiding philosophy for interventions is a salutogenic approach that focuses on promoting and maintaining health. Interventions should engage and support individual, group, and organizational factors that promote recovery. (Dunning, 2000). A person’s coping ability and sense of well being is connected with a person’s sense of coherence (Antonovsky, 1987, 1990, 1991, 1993; Dunning, 1999) – the extent the stress is experienced as:




People need to comprehend the event – what happened and how it happened. Manageability refers to the person having constructive strategies to cope with the event, the circumstances, and the consequences. Positive meaning refers to understanding the

impact of the event and its significance in one’s life, and what can be done to integrate the experience in a positive, self-enhancing way.

Interventions can also promote resilience and hardiness – the capability to recover after

stress or adjust to dramatic changes (Higgins, 1994, Dunning, 1999).

Maddi (1982) have discussed the concept of hardiness as composed of three characteristics:

Kolbasa and




Commitment refers to the belief that you and your world are important and worthwhile enough to fully engage in coping with the incident. Control refers to the belief that if you

are actively engaged in adaptive behaviors, you can positively influence much of what happens in your daily life. Though one cannot control all circumstances, one can control his/her response to it. Challenge refers to the belief that most everything that happens, whether positive or negative, is an opportunity to enhance performance, leadership, morale, conduct, and health. In other words, there is much to gain from actively coping with a problem. Negative circumstances are challenges to deal with, not avoid. Hence, interventions that promote resilience and hardiness promote the belief that an active coping process can transform the stressfulness of a problem into something manageable and growth promoting. The self is viewed as capable, hardy, and an active participant in the world.

Interventions can take a salutogenic, resilience building approach that encourage an

active coping process and reinforce a person’s sense of coherence, rather than focusing

on the inherent threat and terror of the incident.

understand what happened, broaden and deepen their perspective, and make the incident comprehensible. Control and manageability can be emphasized through teaching coping skills and strategies to lower physiological arousal, increase positive social contacts, encourage problem solving and formulation of adaptive self-care plans. Finding positive meaning can be supported in a number of ways (Dunning, 1999). For example:

Gaining sufficient information to process the event and answer important questions

Interventions can help people


(e.g. information about the event, normal reactions to threat exposure, coping strategies)

Learning from the event

Accepting a new definition and expectation about what the future might be

Focus on making the experience an event to be mastered, with one’s support system (both at work and at home) acting as validators and supporters of the process

Explore ways in which negative cognitions and meanings can be reexamined for their positive strength or resolution

Commemoration to provide an opportunity to mourn, provide a ritualistic closure to the event and for remembrance, and to place the event within the context of history and the future.

Realizing that bad things happen but the people have the ability to cope and adapt to changing circumstances

Indeed, trauma can lead to positive growth (Tedeschi, Park, and Calhoun, 1998). Trauma can reinforce a person’s ability to deal with adversity, clarify values and put life in perspective. Many individuals experience a sense of competence and resilience as a result of a critical incident (Shalev, 2000; Dyregrov and Solomon, 2000).

Organizational consultation

Providers of services need to work with the management of the organizations impacted to coordinate delivery of services. What may be needed, when, for how many, are logistical issues that continue to change over time. Ongoing coordination and cooperation is very important for effective delivery of services, evaluation of services and mutual feedback as to their effectiveness, and planning for future services. Mental health consultants can help managers understand the needs of survivors, what interventions can be helpful, the timing of these interventions, and how to support personnel effectively.

The organization also plays a large role in the recovery of personnel. Concerned leadership that lets personnel know that they are important and cared about is crucial (Solomon and Mastin, 1999). The organization can promote coherence (comprehension, manageability, and positive meaning). Management can help with comprehension by making facts available. Manageability of the incident can be helped by the organization providing the resources needed to help personnel deal constructively with event. Positive meaning can be facilitated through supportive communication. For example, positive organizational messages for emergency service personnel after the September 11 attacks were:

“We were not at fault”

“It was bad, but we are supporting each other”

“If we were not there it would have been worse – we made a difference”

Multiple, and multifaceted interventions

To promote coherence, resilience and facilitate recovery there needs to be ongoing involvement with the organization and organizational processes, not a one-intervention


approach. It is essential that there are multiple interventions over time that meet the changing needs of the survivors and are appropriately tailored to the phase of recovery the survivor is experiencing.

It is unfortunate that the majority of studies evaluating critical incident stress debriefing

(CISD, see below) as an effective treatment for the prevention of PTSD have focused only on single session interventions conducted by either minimally trained or minimally

experienced debriefers (Lee, et al 1996; Bisson, et al 1997; Conlon, et al 1999; Mayou, 2000; Carlier, et al, 2000;, van Emmerik, et al.). There has been an erroneous assumption that a single intervention, such as a CISD, can prevent PTSD from developing (Shalev, 2000). A CISD was never intended to be psychological treatment for either the prevention of PTSD or for symptom reduction of PTSD (Everly and

Mitchell, 1999, Mitchell and Everly and Mitchell, 2000).

evidence that CISD can prevent PTSD (Ruzek, 2001). Studies where the CISD format was utilized for individuals and couples and/or the CISD format was loosely structured have shown that symptoms worsened for some individuals. The problem with these studies is that the CISD format developed and used extensively for group interventions was used for individuals and couples, and therefore is not a valid and accurate test of the

CISD model.

At the present time, there is no

Studies have shown that statistically significant positive effects have resulted from CISD. CISD may assist with group cohesion and morale (Shalev, 2000). Debriefing, emphasizing the narrative, resulted in a significant reduction in anxiety and increase in self-efficacy with Israeli combat soldiers.(Shalev, 1998). CISD was shown to be effective

in reducing alcohol use after UN peace keeping missions (Deahl 2000). There is a

general sense that CISD is worthwhile and beneficial (Robinson and Mitchell, 1993).

Many of the CISD studies have methodological flaws, such as not defining the type of debriefing intervention, the training of the CISD providers, the tools used to evaluate effectiveness, and measuring effectiveness several months after the debriefing was provided, a period of time in which the victims could have been exposed to additional traumatic events (Dyregrov, 1998; Mitchell and Everly, 2000b). These methodological shortcomings make it difficult to generalize from singular CISD investigations so as to reach any definitive conclusion about the specific effectiveness of CISD interventions. However, recent meta-analytic reviews (Everly, Boyle, and Lating, 1999; Every and Boyle, 1999) have shown CISD can have a positive therapeutic effect when the intervention model is clear, when the intervention leaders are appropriately trained, and the assessment procedure for effectiveness is adequate (Dyregrov, 1998; Flannery, 1999; Mitchell and Everly, 2000b).

A CISD can be likened to a funeral. After a death, a funeral is a ritual that provides

closure for many people. However, if one is particularly close to the deceased, the funeral is only a beginning. Similarly, a CISD may provide closure for some of the people involved in the incident. But if a person is particularly impacted by the event, the CISD is only a beginning. To expect one intervention to be effective for dealing with a significant incident is naïve. CISD is part of critical incident stress management (CISM),


which is a continuum of care that carefully addresses the evolving needs of critical incident survivors. People involved in a critical incident should be offered a menu of appropriate intervention choices that is embedded within a larger framework that extends over time (e.g. providing services starting from the immediate aftermath up to one year). Research shows that that a multifaceted, multidimensional framework can have therapeutic benefits (Everly, Flannery, and Eyler, 2002); Flannery, 1999; Leeman- Conley, 1990). The fact that some people experience worse symptoms after a debriefing may not be a failure of this intervention (though inexperienced interveners, inappropriate timing and loosely structured phases may have contributed to a negative outcome) as much as it is a lack of appropriate follow-up.

Community Partnership

People can have a variety of psycho-social and medical needs following a critical


local community leaders and groups; local psychological, clergy and medical providers; social services; and local schools. The CISM team can establish partnerships, linkages and referral protocols with community and medical services to facilitate efficient and effective referrals

It is important for the CISM team to work with community resources such as

Critical Incident Stress Management

Table 1 lists the critical incident stress interventions according to timing and clinical outcome. The following interventions are for normal people experiencing normal reactions to the critical incident. These interventions are not treatment for trauma, nor a substitution for appropriate treatment. These are interventions geared toward emotional containment and stress management, not opening up emotions or behavioral change (as in psychotherapy). Consequently, it is important that those conducting interventions have appropriate training and significant experience in critical incident stress management so as to provide appropriate structure and emotional containment and avoid the risk of over- exposing participants (Dyregrov, 1997)

Table 1 here

Interventions in the immediate aftermath: Stabilization (first 48 hours or longer)

Immediately following a critical incident, people need a sense of safety, security, and

caring. The transitional state after the event, when the person tries to validate, verify, and understand their experience, is a critical period where traumatized people are suggestible

and prone to dissociate when cued (Yahuda and McFarlane, 1995).

often leaves victims feeling abandoned, uncared for, bitter about the lack of concern, and potentially creates a secondary wound (Shalev, 2000). But it is important to respond appropriately and not increase levels of stress and arousal, which can increase the toxic effects of the critical incident (Shalev, 2000; Pitman, 1989). The following tasks are important immediately following the incident.

To provide nothing


Survival, safety and security needs are first priority. People first have to feel safe from immediate danger for arousal to begin to lower and recovery to begin. The setting for interventions should be carefully selected in order to allow survivors to

feel safe in their physical environment.

CISM team are perceived by the survivors as being safe and caring then heightened threat detection, a normal response immediately following critical incidents, will usually attenuate.

If the physical environment and the

Structure to reinforce a sense of control and safety. After a critical incident, survivors can be experiencing psychological chaos. Providing structure can help provide a sense of control. Having a place to go where there is safety, structure, and support, will facilitate emotional recovery and constructive coping.

Orientation - help survivors become oriented to immediate local services. Organizations and communities often have protocols and services available following a critical incident. Survivors are comforted by knowing what is available, what to expect, and how to access available services.

Communication with family, friends, and linking into community.


of social ties and promoting factors that increase group cohesion is very important

after a critical incident. Isolation can be very pervasive and harmful after a traumatic event (Shalev, 2000).Van der Kolk (2002) points out that people, like all primates, are programmed to seek out others for the soothing and regulation that they cannot provide for themselves.

Coping skills to lower arousal and deal constructively with the event. Recent information suggests that reducing physiological arousal (e.g. heart rate, blood pressure, vasoconstriction, adrenalcortisol production) shortly after exposure, may be as important as clarifying and working through the impact of the event (Shalev,


The following interventions are appropriate for the immediate aftermath of a critical incident.

Phase I Stabilization (first 24 hours - 48 hours)

A. Assessment of functioning/needs

B. Critical Incident Stress Orientation (Information/education sessions)

C. Demobilization

D. Defusing

E. Individual crisis intervention

F. Referral to community resources

A. Assessment of functioning/needs (triage) to determine what is needed. Rather than CISM team members rushing on scene to find someone to support (as has happened too often in the past), an assessment should be conducted to evaluate the impact of the event


and what is needed.

need immediate referral for treatment.

Some people may be coping well and others may be in crisis and


Critical Incident Stress Orientation (CISO): A group psycho-educational intervention


provide post-incident education in a safe environment. This intervention can be

helpful for small and large groups. Typically there is an introduction phase where people can be given information on the event (what is known and not known). Next is a teaching phase where covering normal stress reactions, coping strategies (e.g. to lower arousal), and a description of available services and interventions. Getting together with others in a secure, safe environment provides structure, reinforces group cohesion and reduces isolation, and provides an opportunity for triage. Providing education on coping can help to lower arousal, increase control

A CISO is appropriate when there are many people impacted, there is little information

about how people are impacted, when there are groups of people with varying “circles of risk” (e.g. various levels of involvement and impact), or when there are time constraints. CISO’s are an excellent way to offer supportive services without exposing survivors to potentially harmful incident narratives.


Demobilization (Mitchell and Everly, 1996): This is an intervention usually provided


emergency service personnel after a large scale event, when there are too many people

involved to provide more personalized services. It is designed to be a quick informational and rest session after the event. The demobilization serves as a transition between being on scene and going home or returning to routine duty. It also serves a secondary function as a screening opportunity to assure that individuals who may need assistance are identified after the traumatic event. After being relieved from the scene of the incident, units can report to a place where they receive a brief lecture (e.g. 10 minutes) on critical incident stress and coping, and have a few minutes (e.g. 20 minutes) for food and rest.

D. Defusing (Mitchell and Everly, 1996): a group meeting or discussion about a critical

incident conducted within the first few hours following an event. Typically those who

share the same perspective are put in the same group, e.g. a work group, those at the scene or who share a particular perspective. This reinforces the salutary benefits of

utilizing group cohesion and identification, and reducing isolation. helpful in validating and normalizing experience.

Groups can be very

A defusing is typically takes 20-45 minutes in length. The goals are to mitigate

the impact of the event, reduce symptoms promote the recovery process, and

assess need for further services. There are typically three phases. An Introduction Phase begins the defusing where leaders are introduced and the purpose and goals

of the defusing process is described. Confidentiality (agreeing to respect each

other’s privacy and not discloses what is shared in the group) is emphasized. Participants are also told that they do not have to speak. It is encouraged, but not mandatory. Next is an Exploration Phase where participants are asked to describe what just happened. The emphasis is on sharing experiences and reactions. This


enables a rapid ventilation, equalization of the information, and restoration of

cognitive processing of the event.

should be no deep probing of emotions or efforts to break down psychological defenses. Lastly, there is a Teaching Phase where reactions are normalized and stress reduction strategies are taught. The leaders stay available after the defusing.

A few clarifying questions are asked, but there

Note that the process involves starting out cognitive with a description of one’s Involvement, then some exploration of reactions, and ending cognitive with


Hence, containment is emphasized.

Where getting together with other people who have experienced the same event can be normalizing and validating, the psychological condition of those experiencing severe reactions can be exacerbated by exposure to other people’s reactions. Someone experiencing severe reactions should not be subjected to a group process and steps should immediately be taken get the person to a calm setting where appropriate medical and psychological assessment can be conducted.

E. Individual crisis intervention – When a person is particularly upset an individual

session is warranted as exposure to other people’s stories can intensify that person’s


issues privately than in a group.

Further, it is common that people are more comfortable discussing personal

F. Referral: If people are severely impacted, and not coping well, a referral for further

assessment and treatment is needed. Prime examples of conditions requiring referral


Acute stress disorder (ASD) Depression Complicated bereavement reactions Fear, anxiety, physiological arousal at a level that interferes with functioning Anger control problems Severe dissociative states Functional disability Substance abuse Relationship disturbance



Interventions to facilitate coping and resource identification

As the emotional impact hits, interventions geared toward fostering adaptive coping are needed. People need skills and strategies to deal with symptoms. An important of part of recovery is the identification of available resources that can help promote recovery. These resources include social network (friends and family), community services, professional services, religious institutions, medical services, etc. The following interventions may be appropriate:

Phase II Coping and resource identification (24 hours – 12 weeks)

A. Assessment to determine appropriate interventions

B. Critical Incident Stress Debriefing

C. Individual intervention/stabilization

D. Family Services

E. Information/Education sessions

F. Eye Movement Desensitization and Reprocessing (EMDR)/Cognitive-Behavioral Therapy (CBT)

G. Referral to community resources

A. Assessment to determine what interventions are appropriate, and when, should be conducted after a few days. Some issues to be decided include:

Magnitude of Impact: Survivors of critical incidents will sustain different reactions to the event based on their physical and psychological proximity to the event and to the decedents. Those who are closest physically to where the event took place and those who are psychologically closest to the decedents may experience the most acute arousal and longer periods of adjustment. The magnitude of the impact may also be influenced by the type and frequency of prior traumatic exposure, current coping skills and access to a trusted social network and the presence or absence of current health risk behaviors.

Number of People Impacted: It is important to verify “circles” of risk or how many survivors would be considered to be in the “first circle” (those impacted the most intensely), how many would be considered to be in the “second circle” (those impacted less intensely) and so on. Normally first circle survivors would be offered CSID interventions separately form second circle survivors.

How are people coping: CISD should never be used as a substitute for the culturally appropriate mourning rituals used by the survivor community such as wakes and funerals, or family and community meetings and memorial


services. Prior to conducting a CISD it is imperative that the CISM team get a good sense of how the impacted community, family (s) and individuals are coping with the impact of the event and what type of coping strategies they may be employing. The goal of such an assessment is to identify adaptive coping strategies and make sure CISD interventions are not going to interrupt those while also identifying maladaptive coping strategies that the CISM team might be able to change.

What do the survivors need-what have they requested: Although CISD can provide extraordinary support and learning for groups impacted by a critical incident, mandatory CISD, at least in civilian populations, may actually increase arousal and avoidance symptoms (van Emmerik, 2002). The CISM team must spend enough time in the impacted community to educate that community about the CISM process and ascertain which survivors are voluntarily ready for CISD interventions.

Verify incident specifics: Prior to conducting any of the CISM interventions it will be important for the CISM team to gather information from appropriate sources in order to verify what actually happened, including where it happened, when it happened, what was the sequence of events, who were the eyewitnesses, who may be at fault, the status of any investigations, what issues are still unresolved, and what are the major incident rumors active in the community.

B. Critical incident stress debriefing (CISD) (Mitchell and Everly, 1996): A structured group discussion, conducted with homogeneous groups (e.g. groups that share the same perspective on the incident), that is usually provided 1-14 days post crisis. However, after mass disasters it may be used 3 weeks or more post incident. The goals are to mitigate acute symptoms, assess need for follow-up, promote recovery, and if possible, facilitate psychological closure. A major outcome is the normalization and legitimization of thoughts, reactions, and symptoms through hearing other people share their experience and education. Constructive coping is also emphasized in the teaching phase.

CISD is a seven stage process. Similar to the defusing, the CISD starts at a cognitive level, transitions into a brief discussion of emotional reactions, and transitions back to a cognitive level with a teaching phase. This intent of this structure is to provide structure and emotional containment.

Introduction Phase – Debriefing team members are introduced and the debriefing’s

(With some groups it is important to differentiate

between a CISD, where the purpose is to deal with the emotional effects of the incident and a tactical or administrative debriefing, where the purpose is to go over what happened in terms appropriateness of action and learning from it.) Ground rules are explained and serve the purpose of providing safety and structure. Ground rules usually include an agreement of confidentiality, talking only about one self and not

purpose and process are explained.


others, and although talking is encouraged it is voluntary (a person does not have to talk and can gain a lot out of just listening), turning off pages and phones, and a request to complete the process.

Fact Phase – Each participant’s involvement is explained on a cognitive, factual level.

Thought Phase– Each participant describe cognitive reactions (e.g. primary thoughts when they realized what was happening) which serve to transition to emotional reactions.

Reaction Phase – The worst part of the event, and emotional reactions, are identified. There is not probing of emotion and psychological defenses are respected.

Symptom Phase - Participants identify their personal symptoms of distress. Talking about symptoms also transitions back to a cognitive level.

Teaching Phase – Participants are educated about normal reactions and adaptive coping strategies. This often is a short lecture but may include each participant identifying personal resources that can provide support and aid in recovery, and coming up with a self-care plan.

Re-Entry Phase – Questions are answered, issues are clarified, summary statements are made and closure is put on the process.

C. Individual intervention/stabilization - Survivors experiencing significant symptoms

may benefit may also benefit from individual sessions where issues can be dealt with in more depth. A debriefing is oriented toward dealing with the incident, not dealing with personal concerns. For survivors experiencing severe symptoms, individual sessions with the goal of stabilization and referral to appropriate psychological/medical assessment and treatment are more appropriate than a CISD.

D. Family services - It is important to have programs for family members. If someone is

experiencing significant levels of stress, it is brought home to the family. The family

may be ill equipped to deal with the survivor. Further, family members may have their own stress reactions to the event which impinge on the family atmosphere and interfere with recovery.

E Information/education sessions – Education/information sessions have many applications. For example:

Teach or reinforce coping skills

Provide new information about the event as it becomes available

A way to reach out to different impacted groups (e.g. family members, friends of survivors, people indirectly impacted by the event

F. EMDR/CBT - For people experiencing significant symptoms psychotherapy is


indicated. Two therapeutic methods that have received empirical support are Eye Movement Desensitization and Reprocessing (Shapiro, 2001) and Cognitive Behavioral Therapy (Foa, 1995; Bryant et al, 1999).

H. Referral services: Survivors may have a variety of psychosocial and medical needs that cannot be met through CISM interventions, and can be referred to appropriate community resources as needed.

Interventions to promote recovery and resolution (2 weeks-52 weeks)

Recovery Support (2 weeks – 52 weeks)

A. Ongoing assessment of at risk populations

B. Ongoing evaluation of services and interventions

C. Follow-up on referrals made

D. Follow-up debriefings and meetings

E. Post Critical Incident Seminars

F. Referral to community resources

A. Ongoing assessment of at risk individuals: As described above, studies have

shown that symptoms can worsen after interventions. The incident can violate a person’s world view (Janoff-Bulman, 1992), creating difficulty adjusting to a perceived new world. Where a person once felt secure and in control, post event the person knows he or she is vulnerable, and negative events are beyond one’s control. For some people, adapting to this perceived new world, even if the triggering incident has been resolved, can be difficult (Everly, 1995; Shapiro and Solomon, 1995). Consequently, follow-up support and services may need to continually available.

Populations at risk for PTSD - The CISM model is appropriate for normal populations. Assessment of populations at risk for PTSD should be an ongoing process. Extensive epidemiological research on the correlations between type of trauma, specific population samples and increased risk for the development of PTSD indicate that certain traumatic incidents and certain population groups predispose survivors to be at a significantly increased risk for the development of PTSD, irrespective of prior trauma or current coping strategies and resources. Obviously the CISM team must consider these carefully as they plan their continuum of care for the impacted community. Some of the most notable non-military (excluding combat veterans or military personnel) trauma exposures that may place particular survivors at significantly increased risk include (period prevalence of PTSD is equal to or greater than 200 per 1000):

A. Rape, for both females and males (Foa, et al, 1995)

B. Homelessness – particularly homeless mothers (North, et al, 1994; Bassuk, et al,


C. Unexpected violent death of loved one, for both females and males (Breslau,




Early pregnancy loss (particularly pregnant mothers in the first term) (Englehard, et al, 2001)

E. Refugee status, for both youth and adults, (Ferrada-Noli, et al, 1998, Weine, et al, 1998, Koraric, et al, 2000)

F. Terrorist attacks, e.g. especially people needing primary medical care (Taubman- Ben-Ari, et al, 2001)

G. Court involved youth removed from parental custody (Famularo, et al, 1989)

H. Sniper attacks on schools, for both youth and adults (Pynoos, et al, 1987)

I. Sexual abuse, for youth (McLeer, et al 1988, 1992)

J. Natural disasters, especially earthquakes and hurricanes (Norris, 1992); Goenjian, 1993; Howard, et al, 1999, Ackerman, et al, 1998)

K. Domestic violence, e.g. battered women (Kubany, et al, 1996)

L. Hotel and home fires, e.g. burn victims and parents of burned children (Rizzone, et al, 1994; Powers, et al, 1994).

In order to make sure that CISM interventions do no harm and maximize the beneficial aspects of CISD, trauma exposure type and impacted population type should be considered carefully. Professional resources with expertise in psychological trauma should be identified and utilized.

B. Ongoing evaluation of services and delivery systems – Evaluating the effectiveness of

services and interventions goes hand in hand with ongoing evaluation of at risk populations. Some ways to evaluate services are brief psychometric scales (e.g. Impact of Event Scale; Weiss and Marmar, 1997), face to face or telephone follow-up sessions, follow-up group sessions, and communication with appropriate work place personnel.

Evaluating delivery systems is also important. Have the various groups of survivors identified during previous assessment received appropriate services? Are services easily accessible or perceived as inconvenient? Are services being utilized or ignored? Are announcements and descriptions of services available reaching the intended populations and communicated in a clear fashion? Interventions and delivery systems can be continually modified and fine-tuned based on feedback and ongoing evaluation.

C. Follow-up on referrals made – Are people referred to community or medical resources making contact? Are services being utilized and meeting the needs of those referred? Following up with referral sources and with the people referred can evaluate the effectiveness of referrals.

D. Follow-up debriefings and meetings - The impact and the meaning of the incident

change with time. Further debriefings and group meetings can help foster integration of the incident, adjustment to a world now perceived as different, and enhance resilience to strengthen an individual and group’s ability to cope.

E. A group intervention that may be helpful is the Post-Critical Incident Seminar (PCIS).

The PCIS is a multi-day e.g. 3-4 days), multi-modal intervention utilized by a number of organizations, such as the Federal Bureau of Investigation (McNally and Solomon, 1999),


for follow-up support. After several months have passed there is some psychological distance from the event. To only spend a few hours talking about the incident can serve to open things up emotionally, with insufficient time to examine and work through the meaning and current impact of the event. The multi-day format allows the time to tell one’s story, interact with other people who have experienced a critical incident (which is extremely helpful in validating and legitimizing reactions to the incident), receive education on typical reactions and coping skills, and further work through the incident. This format has been found to be effective in lowering trauma symptoms (Solomon and Kaufman, in press). The addition of EMDR to this structure was found to lead to more symptom reduction than having the workshop only (Solomon and Kaufman, in press). The PCIS is typically provided within four to 18 months of a critical incident, with participation voluntary. The PCIS participants may be people involved in the same incident, or consist of people who experienced different critical incidents. The number of participants can vary according to the needs of the group and resources available, but typically is between 12 and 30.

F. Referrals to community and medical services need to be made on an ongoing basis.

Conclusion CISM provides structured, multiple session, phase oriented assessment and treatment interventions that are designed to augment normal recovery processes in normal populations, having normal reactions to abnormal events, over a normal period of time. CISM may be utilized quite effectively among a number of populations impacted by the incident. However, specialized knowledge and experience of the population being serviced is necessary to ensure appropriate, credible, and effective interventions. We have emphasized the importance of taking a longitudinal approach and providing a continuum of interventions to meet changing needs over time. One-time interventions may be sufficient for some, but not for all. Research showing some people may develop worse symptoms after a one-time intervention may be as much a failure of appropriate follow-up as inappropriate timing, inexperienced interveners, and loosely structured interventions. It is important to take a salutogenic approach and focus on promoting healing factors that facilitate recovery. Providing safety, structure, facilitating group cohesion, social support, facilitating a sense of coherence, and teaching skills and strategies that promote recovery and resilience are important outcomes of CISM. The CISM team also needs to pay close attention to giving choice to those impacted by the event. Those impacted by the incident must be afforded an opportunity to play a central role in the resolution and recovery from the incident. Finally, CISM is not provided in a vacuum, but within the community context. The CISM team needs to be part of a community wide network so services can be coordinated and support systems sources can be identified and quickly utilized. The CISM team can best achieve results through partnering with local community leaders and groups, local psychological, clergy and medical professionals, social services, and local schools.


Table 1 Critical incident stress interventions according to timing and clinical outcome

I Stabilization (first 24 hours - 48 hours)

A. Assessment of functioning/needs

B. Demobilization

C. Defusing

D. Individual crisis intervention

E. Information/education sessions

F. Referral to community resources

II Coping and resource identification (24 hours – 12 weeks)

A. Assessment to determine appropriate interventions

B Critical Incident Stress Debriefing

C. Individual intervention/stabilization

D. Information/Education sessions


F. Referral to community resources

III Recovery Support (2 weeks – 52 weeks)

A. Ongoing evaluation of services and interventions

B. Ongoing assessment of at risk populations with incident management partners

C. Follow-up on referrals made

D. Follow-up debriefings/meetings

E. Post Critical Incident Seminars (retreat setting)

F. Referral to community resources



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