You don’t have to have a death at work place to have a critical incident, CRITICAL INCIDENTS CAN BE ASSOCIATED TO MANY THINGS, and it can impact your staff in various ways, DEATH is just one of many! As crises and disasters become epidemic, the need for effective crisis response capabilities becomes obvious. Critical Incident Stress Management, or CISM, is an intervention protocol developed specifically for dealing with traumatic events. It is a formal, highly structured and professionally recognized process for helping those involved in a critical incident to share their experiences, vent emotions, learn about stress reactions and symptoms and given referral for further help if required. It is not psychotherapy. It is a confidential, voluntary and educative process, sometimes called ‘psychological first aid’.
The term “debriefing” is widely used and means many different things. In fact, there are many different types of “debriefings” in use in the world today. Most forms of debriefing do not equate to the “Critical Incident Stress Debriefing.” One needs to be very careful and know exactly what type of debriefing they are discussing. Precision in the use of terminology is extremely important. Inaccurate definitions lead to faulty practice and flawed research.
Critical Incidents and Adverse Events
Critical Incident Impact
Severity of stress related to a critical incident is determined by personal interpretation of the event, perceived seriousness of the incident, length of exposure, pre-existing coping strategies, and available social support.
When a critical incident occurs, a cascade of emotions may overwhelm an otherwise healthy individual’s coping skills. These symptoms can result in reduction in work performance, burnout, poor sleeping habits, inability to concentrate, excessive alcohol consumption, and contemplation of a career change.
Acute Traumatic Stress
Acute traumatic stress occurs soon after the incident and negatively affects quality of life both at work and home. Symptoms of acute traumatic stress can include sleep disturbance, withdrawal, poor concentration, changes in interactions with others, depression, anxiety, and excessive use of illegal substances or alcohol.
Critical Incident Stress Management (CISM) Model
The CISM model is a comprehensive, multicomponent program to maintain or restore the individual(s) involved to their usual state of health by alleviating the severe effects of traumatic stress. The interventions are conducted throughout three stages of the model: pre-crisis, acute crisis, and post-crisis to address preparing for an incident, the reactions that immediately follow an incident, and the possible long-term effects from experiencing a critical incident. Critical incident stress management model may be used by individuals, families, and organizations and should be facilitated by trained personnel. The seven core components of CISM are briefly discussed below.
Pre-Crisis Stage Intervention
This phase of the model occurs prior to a critical incident. It includes stress management and stress resistance education, instruction in relaxation techniques, and developing and strengthening coping skills.
Acute Crisis Stage Interventions
Demobilization and consultation
This intervention occurs immediately after the incident to assess immediate reactions to the event and provide information on next steps. This session typically lasts 10-15 minutes and is led by a person of authority. After the short session, all parties are encouraged to relax for approximately 20 minutes prior to returning to work. The goal of this brief session is to immediately assist individuals in understanding and managing their preliminary reactions to the event.
A defusing session is an extension of the demobilization and consultation session and occurs after the work day, but before the involved parties depart for the day. This session is conducted by a person of authority and typically lasts an hour. The purpose of this intervention is to recount the details of the event, provide information about potential emotional reactions, offer support, and allow individuals to express his or her concerns surrounding the incident.
Critical Incident Stress Debriefing (CISD)
Critical incident stress debriefing was originally used for emergency service workers, but has been found to be useful in the healthcare field.
The session is designed to provide closure, alleviate signs and symptoms of acute distress, and assess the need for individual follow-up. Emotional support, better mental health of the group, increased job retention, reduced symptoms, and increased productivity are reported benefits of CISD. The seven phases of formal debriefing include introduction, fact phase, thought phase, reaction phase, symptom phase, teaching phase, and re-entry phase.
One-on-one crisis intervention
Crisis intervention includes counseling or provision of psychological support throughout the full range of the crisis spectrum. The goal is to guide each person back to the level of functioning prior to the incident.
Family critical incident stress management
Critical incidents have a significant and devastating impact on families. Family crisis intervention supports the family, promotes patient-provider communication, and provides direction towards closure.
Post-Crisis Stage Intervention
Follow-up and referral for treatment
Critical incidents have overwhelming effects on all parties involved. There may be a need for long-term psychological treatment. Therefore, it is important that a follow-up and referral mechanism is established for anesthesia providers and their families.
Reactions to a Critical Incident or Other Traumatic Stress:
Physical Symptoms *Any of These symptoms may require medical attention.
- Chest pain
- Elevated BP
- Rapid heart rate
- Muscle tremors
- Shock symptoms
- Grinding of teeth
- Visual difficulties
- Profuse sweating
- Difficulty breathing
- Hyper-vigilance, watchful
- Intrusive images
- Blaming someone
- Poor problem solving
- Poor abstract thinking
- Difficulty with numbers
- Poor concentration/memory
- Disorientation of time, place or person
- Difficulty identifying objects or person
- Heightened or lowered alertness
- Increased or decreased awareness of surrounding
- Intense anger
- Emotional shock
- Emotional outbursts
- Feeling overwhelmed
- Loss of emotional control
- Thoughts of suicide/homicide
- Inappropriate emotional responses
- Antisocial acts
- Inability to rest
- Intensified pacing
- Erratic movements
- Change in social activity
- Change in speech patterns
- Loss or increase of appetite
- Hyper-alert or sensitive to environment
- Increased alcohol consumption
- Change in usual communications
Critical Incident Stress Debriefing (CISD) is a specific, 7-phase, small group, supportive crisis intervention process. It is just one of the many crisis intervention techniques which are included under the umbrella of a Critical Incident Stress Management (CISM) program.
The CISD process does not constitute any form of psychotherapy and it should never be utilized as a substitute for psychotherapy. It is simply a supportive, crisis-focused discussion of a traumatic event (which is frequently called a “critical incident”).
A CISD is only used in the aftermath of a significant traumatic event that has generated strong reactions in the personnel from a particular homogeneous group. The selection of a CISD as a crisis intervention tool means that a traumatic event has occurred and the group members’ usual coping methods have been overwhelmed and the personnel are exhibiting signs of considerable distress, impairment or dysfunction.
The Facilitators The CISD is led by a specially trained team of 2 to 4 people depending on the size of the group. The typical formula is one team member for every 5 to 7 group participants. A minimal team is two people, even with the smallest of groups. One of the team members is a mental health professional and the others are “peer support personnel.” A unique feature of CISD is that Critical Incident Stress Management trained peer support personnel (firefighters, paramedics, police officers, military personnel, etc.) work with a mental health professional when providing a CISD to personnel from law enforcement, fire service, emergency medical, military, medical, aviation and other specialized professions.
A peer is someone from the same profession or who shares a similar background as the group members.
CISD A Critical Incident Stress Debriefing is small group “psychological first aid.” The primary emphasis in a Critical Incident Stress Debriefing is to inform and empower a homogeneous group after a threatening or overwhelming traumatic situation. A CISD attempts to enhance resistance to stress reactions, build resiliency or the ability to “bounce back” from a traumatic experience, and facilitate both a recovery from traumatic stress and a return to normal, healthy functions. The Critical Incident Stress Debriefing is not a stand-alone process and it is only employed within a package of crisis intervention procedures under the Critical Incident Stress Management umbrella. A CISD should be linked and blended with numerous crisis support services including, but not limited to, pre-incident education, individual crisis intervention, family support services, follow-up services, referrals for professional care, if necessary, and post incident education programs. The best effects of a CISD, which are enhanced group cohesion and unit performance, are always achieved when the CISD is part of a broader crisis support system.
The Critical Incident Stress Debriefing Process Timing The Critical Incident Stress Debriefing is often not the first intervention to follow a critical incident. A brief group informational process may have taken place and distressed individuals may have been supported with one-on-one interventions. Typically, 24 to 72 hours after the incident the small, homogeneous group gathers for the CISD. Intervention delays may occur in disasters. Personnel may be too involved in the event to hold the CISD earlier. They may not be psychologically ready to accept help until things settle down a bit after they finish work at the disaster scene. In fact, it is not uncommon in disasters that the CISD is not provided for several weeks and sometimes longer after the disaster ends. Depending on the 4 circumstances, a CISD may take between 1 and 3 hours to complete. The exact time will depend on the number of people attending and the intensity of the traumatic event.
Phase 1 – Introduction In this phase, the team members introduce themselves and describe the process. They present guidelines for the conduct of the CISD and they motivate the participants to engage actively in the process. Participation in the discussion is voluntary and the team keeps the information discussed in the session confidential. A carefully presented introduction sets the tone of the session, anticipates problem areas and encourages active participation from the group members.
Phase 2 – Facts Only extremely brief overviews of the facts are requested. Excessive detail is discouraged. This phase helps the participants to begin talking. It is easier to speak of what happened before they describe how the event impacted them. The fact phase, however, is not the essence of the CISD. More important parts are yet to come. But giving the group members an opportunity to contribute a small amount to the discussion is enormously important in lowering anxiety and letting the group know that they have control of the discussion. The usual question used to start the fact phase is “Can you give our team a brief overview or ‘thumbnail sketch’ of what happened in the situation from you view point? We are going to go around the room and give everybody an opportunity to speak if they wish. If you do not wish to say anything just remain silent or wave us off and we will go onto the next person.”
Phase 3 – Thoughts The thought phase is a transition from the cognitive domain toward the affective domain. It is easier to speak of what one’s thoughts than to focus immediately on the most painful aspects of the event. The typical question addressed in this phase is “What was your first thought or your most prominent thought once you realized you were thinking? Again we will go around the room to give everybody a chance to speak if they wish. If you do not wish to contribute something, you may remain silent. This will be the last time we go around the group.”
Phase 4 – Reactions The reaction phase is the heart of a Critical Incident Stress Debriefing. It focuses on the impact on the participants. Anger, frustration, sadness, loss, confusion, and other emotions may emerge. The trigger question is “What is the very worst thing about this event for you personally?” The support team listens carefully and gently encourages group members to add something if they wish. When the group runs out of issues or concerns that they wish to express the team moves the discussion into the next transition phase, the symptoms phase, which will lead the group from the affective domain toward the cognitive domain.
Phase 5 – Symptoms Team members ask, “How has this tragic experience shown up in your life?” or “What cognitive, physical, emotional, or behavioral symptoms have you been dealing with since this event?” The team members listen carefully for common symptoms associated with exposure to traumatic events. The CISM team will use the signs and symptoms of distress presented by the participants as a kicking off point for the teaching phase.
Phase 6 – Teaching The team conducting the Critical Incident Stress Debriefing normalizes the symptoms brought up by participants. They provide explanations of the participants’ reactions and provide stress management information. Other pertinent topics may be addressed during the teaching phase as required. For instance, if the CISD was conducted because of a suicide of a colleague, the topic of suicide should be covered in the teaching phase.
Phase 7 – Re-entry The participants may ask questions or make final statements. The CISD team summarizes what has been discussed in the CISD. Final explanations, information, action directives, guidance, and thoughts are presented to the group. Handouts maybe distributed. Follow-up The Critical Incident Stress Debriefing is usually followed by refreshments to facilitate the beginning of follow-up services. The refreshments help to “anchor” the group while team members make contact with each of the participants. One-on-one sessions are frequent after the CISD ends.