Critical Incident Stress Management

Crisis Management Briefings (CMB)
Critical Incident Stress Debriefing (CISD)
Definitions
Defusing
Demobilizations
Examples of Critical Incidents
Frequently Asked Questions
Helping Children Cope after a Critical Incident
Myths About The Impact of Critical Incidents
Possible Reactions
Psychological First Aid
Who is Subject to Critical Incident Stress?

Crisis Management Briefings (CMB)

A crisis management briefing (CMB) is a great crisis communication tool that was created for those in leadership positions. It is designed to facilitate a town meeting or when a group of people assemble. This can provide empowering information to them. The information that is imparted can help decrease inappropriate rumors and correct any misinformation. When there is a huge event that impacts a large group of people, this method is the best way for a leader to address such a mass group of people. Refer to http://www.icisf.org/

What are Crisis Management Briefings (CMB)?

A large group crisis intervention technique
Designed for use with large groups of primary victims (up to 300 at a time)
May be implemented with civilians after disasters, students after school-related incidents, employees after work-related crises
Has application with large groups of emergency services personnel and military units Goals The goals of Crisis Management Briefings (CMB):
Provide information
Rumor control
Reduce sense of chaos
Provide coping resources
Facilitate follow-up care
Promote cohesion and morale
Assess further needs of group
Restore personnel to adaptive functions Process
Step 1 – Assemble participants Identify target groups Plan on how to bring these people together Plan on a good time to bring these people together
Step 2 – Provide facts regarding crisis Give the information that is known Give the information that is not available Talk in a manner that will help reduce the emotions surrounding the event Be very careful not to cross any boundaries when it comes to confidentiality
Step 3 – Discuss and normalize common behavioral/psychological reactions Discuss common reactions Normalize as much as possible Discuss possible behavioral issues
Step 4 – Discuss personal and community stress management and resources Give a handout of resources that can help assist Review stress management techniques
Questions and answers may be included throughout the process

Critical Incident Stress Debriefing (CISD)

The following information is meant to be a resource for those peer supporters who have been trained to conduct a CISD. It is not meant to encourage peer supporters to do a CISD alone. It is important to follow THE HELPING TRIAD (refer to Resource section of this app) when conducting a CISD, refer to: http://www.icisf.org/

What is a CISD?

Facilitated by a member of the helping triad
Structured group discussion
Provided after a critical incident
Requires a team approach
MUST HAVE at least one mental health professional
Ensures confidentiality
Participation should be voluntary (with some exceptions)
Not therapy nor a substitute for treatment
Not investigative
Goals:
Goals for a CISD
- T o decrease their emotional reactions to the event
- To lower tensions in the group
- To help normalize the reactions to the event
- To help identify those in the group who may need more peer support
- To help identify those who need a referral to a mental health professional
- Helps put the event into perspective
- Helps put the pieces of the event together
- Builds camaraderie within working groups
Process
- Plan a convenient time for the CISD
- Make sure the group is psychologically ready (time varies)
- Find an environment that is free of distractions
- Provide a convenient location for all involved
- Make sure all involved personnel are invited to attend
- Ensure homogeneous groups
Plan for one to three hours
Size of the group should be no more than 20
Put the chairs in a circle
Provide tissues
Have hosting agency provide refreshments
There are seven steps to the ICISF Critical Incident Stress Debriefing Process http://www.icisf.org/
They are as follows:
Introduction
- Participants introduce themselves
- Describe the process, including confidentiality and ground rules
- No notes or recording devices
- Silence phones
- It is not a complaint session
- It is not a blame session
- It is not an investigative critique
- Participation is voluntary
- Explain that CISD is not psychotherapy
- The Peer Supporter shall review his/her Statement of Clarification (Refer to example in “Crisis Intervention” section)
- Highly encourage participation for mutual benefit
- Provide an explanation of the questions that will be asked of the group
- Limit group breaks (take care of drinks, restroom, etc. ahead of time)
- Remind him or her that it is not a tactical debriefing
Fact Phase

Each participant’s involvement is explained on a factual level.
Find out what happened from his or her perspective.
Address the facts in chronological order (i.e., who arrived first, what happened next, etc.).

Thought Phase

Participants share initial and subsequent thoughts.
Find out what their most prominent thought was regarding the incident.
Ask if there was any particular thoughts that are bothering them.
Reaction Phase

Participants share feelings they had at the scene and are having now.
Ask them to describe what part of the event distressed them the most.
Symptom Phase Participants share physical or behavioral changes they have experienced since the event.
What have they experienced since the event?
Have there been any reactions that they have noticed in themselves since the event occurred?
Teaching Phase

Participants are educated about normal reactions.
Talk about adaptive coping strategies
Provide guidance on future reactions Teach stress management coping skills
Talk about resources Discuss resiliency
Re-entry Phase
Participants are provided the opportunity to ask questions.
Clarification of issues
Summary statements are made about debriefing process.
Normalizing their reactions is reiterated
Summarize the lessons learned from the event
Provide handouts

Defusing

A defusing is a process that can help a small core group of individuals who have been impacted by a critical incident. It is usually a homogenous group of people and conducted within eight hours of the critical incident. A defusing can help put a plan together for a formal debriefing at a later time. The defusing is an opportunity to reduce the distress that may be experienced immediately after the event. Follow-up services need to be provided after a defusing occurs. Peer supporters can enhance their defusing skills by going to the International Critical Incident Stress Foundation (ICISF) CISM training. http://www.icisf.org/

What is a defusing?

On-the-scene brief intervention for impacted individuals
Usually conducted within the first 8-12 hours after an event
Usually lasts under an hour
Homogeneous (alike) group attend
Provides support designed to take the edge off
Facilitated by a Mental Health Professional or in some cases, a Chaplain or a Peer Supporter

Goals:

Provide information regarding possible symptoms and reactions that may impact the individual following a critical incident and to help mitigate those reactions.
Provide an avenue to recognize those that may need additional assistance and help in the recovery process.
Help normalize and lower tensions by decreasing tension.
Help identify those who may need additional support.
Provide opportunity for the group to receive written information on reactions.

Process

There are three steps in a defusing. They are as follows:

Step 1 – Introduction
- Introduce team members
- Present guidelines
- Encourage participation
- Participants introduce their professional role, i.e., “I am Judy and I was the dispatcher.”
- Explain the goals of the process Remember:
- Team members will listen first and inform later
- Each participant’s experience is important
- Purpose is not to place blame or find fault
- Not a tactical investigative process
- No discussion of violations or procedures
Step 2 – Exploration
- Ask the participants to explain what happened from their perspective.
- Encourage the participants to share their experiences and reactions.
- Assess whether one-on-one followup is necessary or a debriefing needs to be done in the future.
- Be supportive
Step 3 – Information
- Normalize participants’ responses
- Explain possible reactions
- Provide suggestions on coping mechanisms and self-care
- Discuss wellness tips such as nutrition, substance abuse and exercise
- Encourage family-fun activities
- Summarize
- Conduct Q & As
- Provide CISM educational handouts/contact numbers

Remember Defusings are usually not done after a disaster which impacts a large number of people. Demobilizations are usually used for such an event (Refer to Demobilizations in the section of the app). If there is a line of duty death, a debriefing should be provided, not a defusing. (Refer to Critical Incident Stress Debriefing).

Demobilizations

Demobilizations is a term that came from the military and is now used for large events involving first responders. This is usually a one time, end of the shift, large group, dissemination of information. It gives peer support and supervisors an opportunity to provide more assistance to those who have been impacted. For more information refer to http://www.icisf.org/

What is a demobilization?

An intervention usually provided to emergency service personnel after a large scale event when there are too many people involved to provide a more personalized service
Provides quick information and rest
Provides an opportunity to screen for those who may need more assistance
Facilitated by a trained Critical Incident Stress Management Team (Helping Triad – Refer to Resource section of this app)
The optimal time is immediately after personnel have been released from the major incident and before the personnel return to normal
duties
Lets the participants know if a debriefing is planned for the future
Keeps work teams together
Gives peer support a chance to hand out information on coping skills

Goals
Goals for a demobilization:

Check on the wellness of those involved in the incident
Help reduce the emotional reactions of the event
Give those who are affected, time to settle down and rest before they go back to work
Provide a chance for them to get something to eat
Explain stress management/coping skills
This is a good time to assess the need for any other critical incident stress management services to be provided

Process

Step 1 – Location
- Make it close to the incident
- Make it convenient for an easy transfer of personnel
- Make sure that several large rooms are available
Step 2 -Length of time
- Plan on it lasting approximately 30 minutes
- Provide 10 minutes for a peer supporter/MHP/Chaplain to provide information
- Give the participants at least 20 minutes for food and rest
Step 3 – Complete these tasks for a successful demobilization:
- Check in groups as they arrive
- Keep work teams together
- If further care (debriefing) is necessary, make the announcement
- Provide a handout on coping skills (see Resource section of this app for trifold)

Frequently Asked Questions

What is a Defusing?

It is a brief intervention for impacted individuals that is conducted within the first 8-12 hours after an event. A defusing typically lasts less than an hour. The goal of a diffusing is to provide information regarding possible symptoms and reactions that may impact the individual following a critical incident and to help mitigate those reactions. It also provides an opportunity to recognize
those who may need additional assistance.

What is Critical Incident Stress Debriefing (CISD)?

A CISD is a small group intervention designed to provide the skills necessary to physically and psychologically survive a traumatic event. It is an educational process for all personnel involved conducted within 24-72 hours after the incident.

Are critical incident debriefings the same as therapy?

No, it is not therapy. CISD’s provide an opportunity to talk about experiences and reactions with their team.

Will my department find out what is said in the debriefing?

Confidentiality is stressed among all of the participants. Hopefully, no one will violate the ground rules of confidentiality. There is no guarantee that information will be told to department personnel from the participants. The helping triad will NOT disclose information gleaned from a debriefing unless permission is given by the participants. In rare circumstances, if information is discussed in the debriefing process that clearly demonstrates there is a need to breach confidentiality due to ethical concerns, that will be explained at that time.

What are some signs of critical incident stress?

Increased anxiety, fear, inability to sleep, eat, irritability, withdrawal, nightmares, guilt, panic, hypervigilence to name a few. Refer to Possible Reactions in this section.

How can one overcome critical incident stress?

Talk about your feelings, avoid using alcohol or drugs, keep your regular routine, or consult with a mental health professional. It may be possible that EMDR is necessary to help mitigate the reactions. Refer to EMDR section of this app.

Helping Children Cope after a Critical Incident

A critical incident can be defined as any event that causes unusually strong emotional reactions that have the potential to interfere with the ability to function normally. Critical incidents can be scary for anyone, especially children. Children see and think about the world in a different way than adults do and they may have a hard time expressing how they feel.

If you remain aware of the warning signs and continue to encourage them by offering support, encouraging him or her to talk about their feelings, and help them consider the assistance of a professional counselor then you are providing them with the resources they need to emotionally work through the traumatic event. Warning signs are different with children of different ages.

Below is a list of some of the warning signs children of different age groups may show and how to help them cope:

Infants and Toddlers:

Signs and symptoms may only last a short time. But ongoing or repeated stress may affect your child in the long term. If you’re concerned about your child’s extreme behavior, please call your child’s doctor right away.

Warning Signs

– Acting aggressively
– Becoming more clingy
– Changes in their mood, eating or sleeping habits
– Excessive crying
– Throwing more temper tantrums

Tips for helping them cope

– Have your child supervised at all times
– Hold and comfort your child as often as possible
– Redirect the aggression to positive activities
– Speak calmly
– Give your child a lot of attention

Preschoolers (ages 3 – 5 years)

Warning Signs

– Regression (reverting to infant/toddler tendencies)
– More fearful than normal
– Becoming more clingy
– Changes in their mood, eating or sleeping habits
– Disobedience, hyperactivity or throwing temper tantrums

Tips for helping them cope

– Keep your child supervised at all times
– Try to keep a normal, daily routine
– Talk to them without judgement
– Reassure them often
– Subroung your child with loved ones
– Keep them excited about events that are happening in the future
– Try not to focus on immature behavior
– Turn off the electronics
– Spend extra time with them if possible

School-aged children (ages 5 – 12 years)

Warning Signs

– Regression (reverting to younger behavior)
– Withdraw
– Competing for attention
– Worrying about being away from parents
– Having trouble focusing

Tips for helping them cope
– Spend extra time with them if possible

Myths About The Impact of Critical Incidents

Myth:

Critical incident experiences are uncommon.
Fact:
If you are in the public safety/first responder profession, it is common to be involved in a critical incident. Myth: If people were just stronger, they could get over critical incidents. Fact: It has nothing to do with a person being weak or strong. Many critical incidents can impact them temporarily due to the emotional nature of the event.

Myth:

Every critical incident survivor will need therapy.
Fact: Critical incident survivors may need peer support, family support and spiritual guidance more than they need therapy. However, therapy can help.

Myth:

Emotional reactions after a critical incident mainly happen to women.
Fact: Emotional reactions happen equally among men and women.

Myth:

PTSD is rare among public safety/first responders.
Fact: PTSD is often missed and often misdiagnosed for public safety/first responders.

Possible Reactions

Peer supporters/supervisors will want to pay close attention to those individuals who have been exposed to a critical incident. Hopefully, those impacted by the incident will be afforded an opportunity to recover from the emotional impact. This can begin with recognizing the wide spectrum of reactions. The follow are some examples of reactions people may experience:

Physical Reactions

Nausea
Vomiting
Rapid heart rate
Insomnia
Body chills
Body twitches
Elevated blood pressure
Profuse sweating
Muscle tremors
Fainting
Dizziness
Thirst
Visual difficulties
Fatigue
Chest pain
Stomach aches
Headaches
Bowel problems

Emotional Reactions

Fear
Guilt
Responsibility guilt
Irritability
Frustration
Depression
Anger
Emotional outbursts
Feelings of being overwhelmed
Emotional shock
Anxiety
Panic
Grief reaction
Denial
Loss of emotional control
Hostility
Feelings of isolation
Emotional numbing
Emotional conflict
Loss of Interest

Cognitive Reactions

Feelings of uncertainty
Hypervigilance
Suspiciousness
Intrusive images
Nightmares
Confusion
Heightened alertness
Lowered alertness
Distorted perceptions
Lack of concentration
Poor attention
Poor abstract thinking
Lack of problem solving skills
Blaming
Flashbacks
Feelings of vulnerability
• “What if?”

Behavioral Reactions

Sleep difficulties
Burnout
Marital/Relationship discord
Family problems
Anti-social acts
Restlessness
High-risk behaviors
Withdrawal
Startled reaction
Change in social activities
Decrease in appetite
Increase in appetite
Increase in substance abuse
Re-evaluation of life circumstances

Psychological First Aid

Psychological First Aid is a term that is used when a peer supporter/mental health professional/chaplain on a critical incident stress management team attends immediately to the needs of those involved in a critical incident. These may involve a triage of practical, safety and emotional needs.

Plan of Action

Contact and engage

Make respectful contact
Give your first name
Get his/her first name
Build rapport
Be supportive
Encourage the person to talk
Be a good listener
Do not argue about perceptions
Be straightforward
Be direct

Safety and Comfort

Provide water
Provide blankets
Provide food
Restore calmness

Stabilization and Orientation

Ask calming questions
Be positively engaged
Offer reassurance
Be positively engaged
Offer reassurance

DO NOT SAY:

It’s all in your head
Snap out of it
Get control of yourself
Calm down
It will be okay

Provide explicit instructions for him or her to do a simple task or activity

Information gathering

Obtain family contact information
Obtain names of those they want contacted
Do they need to make a phone call
You are a bridge for them to contact loved ones

Provide resources for practical assistance (examples)

Clearing snow
Animal care
Help with medications
Provide more food

Refer for social support

Community Centers
Neighbors
Churches
Red Cross
Peer Support
Chaplains
Mental Health Professional

Provide information on coping

Explain importance of breathing exercises
Give handouts
Discuss coping skills
Provide encouraging words
Allow for self-disclosure
Discuss past experiences and coping skills

Key Reminders for Peer supporters and supervisors

Protect
Listen
Calm
Connect
Direct

Who is Subject to Critical Incident Stress?

If you live on this earth, you probably will be involved in a traumatic event that will overwhelm your coping skills. However, there are Public Safety/First Responders who, due to the very nature of their jobs, will be involved in many critical incidents throughout their career. The following list is NOT all inclusive.

Firefighters
- EMT’S
- Paramedics
- •Dispatchers
Law Enforcement
- Patrol
- Dispatchers
- Detectives/investigators
- Pilots
- Administrators
- Corrections
- Federal agents (all branches)
- Forensic technicians
- Coroner/Medical examiners
- Public Information Officers
Records clerks
District attorney personnel
Probation/Parole officers
Support staff for any public safety department
Emergency room personnel
Family/significant others of public safety employees