| Introduction
Caught off guard and "numb"
from the impact of a critical incident, individuals
and communities are often ill-equipped to handle
the chaos of such a catastrophic situation. Consequently,
survivors often struggle to regain control of their
lives as friends, family, and loved ones may be
unaccounted for or are found critically injured,
lay dying or are already dead. Additionally, the
countless others who have been traumatized by the
critical event may eventually need professional
attention and care for weeks, months and possibly
years to come. The final extent of any traumatic
situation may never be known or realistically estimated
in terms of trauma, loss and grief. In the aftermath
of any critical incident, psychological reactions
are quite common and are fairly predictable. Critical
Incident Stress Debriefing (CISD) can be a valuable
tool following a traumatic event.
Since the late 1970s and early
1980s, the victim assistance movement has received
more positive attention than ever and has gained
tremendous momentum with the passage of state and
federal legislation designed to provide resources
and services to those who are physically or emotionally
traumatized or victimized (Young, 1994; Davis, 1993).
One organization dedicated to assisting trauma survivors
is the National Organization for Victim Assistance
(NOVA). An important division of NOVA involves its
Crisis Response Team (CRT) and emergency trauma
specialists; these individuals are placed on "stand-by"
for any national or international emergency considered
to be a critical incident.
Directed by Marlene A. Young, Ph.D.,
NOVA is a highly respected non-profit organization
that has responded to many "high profile"
tragedies such as the Mount St. Helens' eruption
in 1980, the Air Florida airline crash of 1982,
the South Korean airline Flight 007 Disaster of
1983, the Mexico earthquake of 1985, and the Milwaukee
Jeffrey Dahmer serial murders to name only a few
(Young, 1994).
NOVAs CRT personnel are all highly
trained specialists in Disaster Management, Debriefing,
Victim Assistance, Victimology and Crisis Intervention
in times of community crisis (man-made crisis, natural
or industrial disasters). All NOVA team members
are highly experienced trauma workers and crisis
intervention response specialists who go as national
volunteers to various disasters as a public service
to the requesting community or state.
The NOVA Team is carefully selected
and typically represents a cross-section of the
community where it is to be deployed. Most NOVA
Teams are made up to represent various disciplines
to better assist the community such as Clergy, Emergency
Service Providers, Media Relations, Public Safety
Personnel and other professionals representing the
disciplines of Education, Nursing, Psychology, Psychiatry,
Victim Advocates, Law Enforcement, and Medicine.
When specifically requested, NOVAs
main objective is to provide intense and immediate
emergency consultation, crisis intervention services
with additional follow-up during a limited period
of time. Usually one team of 10 specialists will
be deployed and will work up to 3-4 days. The activated
team will be relieved by additional teams as needed
depending upon the magnitude of the catastrophe.
What is a Critical Incident?
The author defines examples of
a "critical incident" as a sudden death
in the line of duty, serious injury from a shooting,
a physical or psychological threat to the safety
or well being of an individual or community regardless
of the type of incident. Moreover, a critical incident
can involve any situation or events faced by emergency
or public safety personnel (responders) or individual
that causes a distressing, dramatic or profound
change or disruption in their physical (physiological)
or psychological functioning. There are oftentimes,
unusually strong emotions attached to the event
which have the potential to interfere with that
persons ability to function either at the crisis
scene or away from it (Davis, 1992; Mitchell, 1983).
Clinically, traumatic events and
their impact on individuals are fairly predictable.
When a person has been "exposed" to a
critical incident, either briefly or long-term,
this exposure can have a considerable impact on
their global functioning. Historically, some of
the first documented cases of traumatic stress or
what used to be called "transient situational
disturbance" (TSD) can be traced to military
combat.
In time, researchers began to find
evidence that emergency workers, public safety personnel
and responders to crisis situations, rape victims,
abused spouses and children, stalking victims, media
personnel as well as individuals who were exposed
to a variety of critical incidents (e.g., fire,
earthquake, floods, industrial disaster, workplace
violence) also developed short-term crisis reactions.
Trauma Reactions
NOVA personnel refer to short-term
crisis reactions as the "cataclysms of emotion"
where feelings and thoughts run the gamut and include
such diverse symptomatology as shock, denial, anger,
rage, sadness, confusion, terror, shame, humiliation,
grief, sorrow and even suicidal or homicidal ideation.
Other responses include restlessness, fatigue, frustration,
fear, guilt, blame, grief, moodiness, sleep disturbance,
eating disturbance, muscle tremors or "ticks",
reactive depression, nightmares, profuse sweating
episodes, heart palpitations, vomiting, diarrhea.
hyper-vigilance, paranoia, phobic reaction and problems
with concentration or anxiety (APA, 1994; Horowitz,
1976; Young, 1994). Flashbacks and mental images
of traumatic events as well as startle responses
may also be observed. It is important to consider
that these thought processes and reactions are considered
to be quite normal and expected with crisis survivors
as well as with those assisting them. Some of the
described symptoms surface quickly and are readily
detectable. However, other symptoms may surface
gradually and become what the author calls "long-term
crisis reactions." These responses can be masked
within other problems such as excessive alcohol,
tobacco and/or drug use. Interpersonal relations
can become strained, work-related absenteeism may
increase and, in extreme situations, divorce can
be an unfortunate by-product. Survivor guilt is
also quite common and can lead to serious depressive
illness or neurotic anxiety as well (APA, 1994;
Mitchell, 1983; Young, 1994).
What is Critical Incident
Stress Debriefing (CISD)?
Debriefing is a specific
technique designed to assist others in dealing with
the physical or psychological symptoms that are
generally associated with trauma exposure. Debriefing
allows those involved with the incident to process
the event and reflect on its impact. Ideally, debriefing
can be conducted on or near the site of the event
(Davis, 1992; Mitchell, 1986). Defusing,
another component of CISD, allows for the ventilation
of emotions and thoughts associated with the crisis
event. Debriefing and defusing should by provided
as soon as possible but typically no longer than
the first 24 to 72 hours after the initial impact
of the critical event. As the length of time between
exposure to the event and CISD increases, the least
effective CISD becomes. Therefore, a close temporal
(time) relationship between the critical incident
and defusing and initial debriefing (i.e., there
may be several) is imperative for these techniques
to be most beneficial and effective (Davis, 1993,
Mitchell, 1988).
Research on the effectiveness of
applied critical incident debriefing techniques
has demonstrated that individuals who are provided
CISD within a 24-72 hour period after the initial
critical incident experience less short-term and
long-term crisis reactions or psychological trauma
(Mitchell, 1988; Young, 1994). Subsequently, emergency
service workers, rescue workers, police and fire
personnel as well as the trauma survivors themselves
who do not receive CISD, are at greater risk of
developing many of the clinical symptoms the author
has briefly outlined in this article (Davis, 1992;
Mitchell, 1988). From the authors perspective, when
applying debriefing techniques, an appropriate and
effective protocol must be followed when assisting
responders and crisis survivors of any critical
incident.
Most approaches to CISD incorporate
one or more aspects of a seven-part model. The model
that the author suggests here consists of several
key points that can be followed as a general guideline
and applied when addressing responders and survivors
who are involved in man-made, natural or industrial
disasters.
An Emergency Crisis Intervention
Response Specialist must lay the constructive groundwork
for an initial "assessment" of the impact
of the critical incident on the survivor and support
personnel by carefully reviewing their level of
involvement before, during and after the critical
incident (Mitchell, 1988, 1986; Young, 1994).
As a general guideline, the author
suggests incorporating these seven (7) key points
into the debriefing process when providing assistance
to survivors and emergency rescue workers.
Seven CISD Protocol Key
Points:
1. Assess the impact of the critical
incident on support personnel and survivors.
2. Identify immediate issues surrounding
problems involving "safety" and "security."
3. Use defusing to allow for the
ventilation of thoughts, emotions, and experiences
associated with the event and provide "validation"
of possible reactions.
4. Predict events and reactions
to come in the aftermath of the event.
5. Conduct a "Systematic Review
of the Critical Incident" its and impact emotionally,
cognitively, and physically on survivors. Look for
maladaptive behaviors or responses to the crisis
or trauma.
6. Bring "closure" to
the incident "anchor" or "ground"
support personnel and survivors to community resources
to initiate or start the rebuilding process (i.e.,
help identify possible positive experiences from
the event).
7. Debriefing assists in the "re-entry"
process back into the community or workplace. Debriefing
can be done in large or small groups or one-to-one
depending on the situation. Debriefing is not a
critique but a systematic review of the events leading
to, during and after the crisis situation.
First, the "debriefer or facilitator"
assesses individuals' situational involvement,
age, level of development and degree of exposure
to the critical incident or event. Consider that
different aged individuals, for example, may respond
differently based on their developmental understanding
of the event (Davis, 1993) .
Second, issues surrounding safety
and security surface, particularly with children.
Feeling safe and secure is of major importance when
suddenly and without warning, individuals' lives
are shattered by tragedy and loss.
Third, ventilation and validation
are important to individuals as each, in their own
way, needs to discuss their exposure, sensory experiences,
thoughts and feelings that are tied to the event.
Ventilation and validation are necessary
to give the individual an opportunity to emote.
Fourth, the debriefer assists the
survivor or support personnel in predicting
future events. This involves education about and
discussion of the possible emotions, reactions and
problems that may be experienced after traumatic
exposure. By predicting. preparing and planning
for the potential psychological and physical reactions
surrounding the stressful critical incident, the
debriefer can also help the survivor prepare
and plan for the near and long-term future.
This may help avert any long-term crisis reactions
produced by the initial critical incident.
Fifth, the debriefer should conduct
a thorough and systematic review of the physical,
emotional, and psychological impact of the critical
incident on the individual. The debriefer should
carefully listen and evaluate the thoughts, mood,
affect, choice of words and perceptions of the critical
incident and look for potential clues suggesting
problems in terms of managing or coping with the
tragic event.
Sixth, a sense of closure
is needed. Information regarding ongoing support
services and resources is provided to survivors.
Additionally, assistance with a plan for future
action is provided to help "ground" or
"anchor" the person during times of high
stress following the incident.
Seventh, debriefing assists in
short-term and long-term recovery as well
as the re-entry process. A thorough review
of the events surrounding the traumatic situation
can be advantageous for the healing process to begin.
Clinical Case Study:
The Oklahoma City Aftermath
Children in kindergarten through
the sixth grade, principals, school psychologists,
nurses, guidance counselors, teachers, school staff
members, community leaders, and public officials
were debriefed. Oklahoma and its community-at-large
were all suffering. Many were suffering from short-term
crisis reactions. Dozens of others needed attention
for acute posttraumatic stress disorder (PTSD),
sleep disturbance, anxiety, acute reactive depression
and phobic disorder. Some could not be left alone
because of overwhelming fear, loss of personal control
over their environment, their community, their lives,
and their families. Almost everyone in this close,
tight-knit community knew someone who had been hurt,
seriously injured or had died. All Oklahoma citizens
suffered from the tragedy. Oklahoma was and remains
a community in crisis.
One elementary school had lost
35 individuals to the bombing. Many high school
students during the initial aftermath became suicidal
and required an immediate mental health response.
Over two years later, the author
firmly believes that CISD and intervention services
averted many of the major long-term psychological
injuries that could have potentially been experienced
from such a traumatizing event. Considerable follow-up
measure and referrals to mental health professionals
were indicated and suggested.
Children and their families' emotional
reactions were carefully kept in check while they,
optimistically, prayed for the excavation of a loved
one. Still, countless others, realizing the worst,
awaited confirmation and death notification from
support personnel. And, for several others, notification
never came (i.e., loved ones were never found).
Concluding Comments
During the four days the author
had spent in Oklahoma City, he personally debriefed
over 1,100 individuals in groups of 25-50 every
half hour on the hour. He provided one-to-one crisis
intervention and outreach to dozens of others at
various times. During the debriefings, the author
saw individuals who had difficulty coping or needed
immediate intervention due to the experience of
acute psychological reactions. Still many others,
observed during the debriefings in groups, were
so traumatized that the author could act only as
a "referral agent" to the local public
service agencies, school counselors, school psychologists,
school nurses, mental health community service providers
and hospitals for assessment and further care.
The author was emotionally and
physically exhausted working 12-15 hour days three
of the four days he was present. On the third day,
the author had his chance to grieve and mourn realizing
that Oklahoma, Oklahoma City and Oklahomans represented,
realistically, Anytown, USA. The author, knowing
that his wife and three-week old daughter eagerly
awaited his arrival in San Diego made life seem
a lot better. Tragically, the author could not say
the same for many of individuals he had counseled.
For them death, loss, sadness and the cataclysms
of emotion were their reality. All Americans were
victims of this critical incident. As communities
and as a nation, the Oklahoma bombing tragedy brought
a sense vulnerability to us all. This disaster could
have happened to any town in America at any given
time.
Despite all the tragedy and sadness,
one symbol stood out among all the ruin and rubble.
The flag of our beloved United States stood proudly
on top of the demolished Alfred P. Murrah Federal
Building and was visible among the devastated citizens
and city in Oklahoma during the aftermath. It stood
until the building was imploded several weeks later.
As Americans, this flag symbolically
stands as the strength of our country in times of
peace and also in time of great despair and tragedy.
Now, in the aftermath of Oklahomas great sorrow,
our flag still symbolically stands to unify all
Americans for one common good - the assistance of
survivors, especially those who remain in Oklahoma
with their lives permanently altered by this tragic
critical incident forever.
References
American Psychiatric Association
(1994). Diagnostic and Statistical Manual for
Mental Disorders (4th Edition). Washington,
DC: American Psychiatric Press.
Davis, J. A. (March, 1993). On-site
critical incident stress debriefing field interviewing
techniques utilized in the aftermath of mass disaster.
Training Seminar to Emergency Responders and Police
Personnel, San Diego, CA.
Davis, J. A. (May, 1992). Graduate
seminar in the forensic sciences: Mass Disaster
Preparation and Psychological Trauma. Unpublished
Lecture Notes, San Diego, CA.
Horowitz, M. (1976). Stress response
syndrome, character style and dynamic psychotherapy.
Archives of General Psychiatry, 30,
768-781.
Mitchell, J. 1. (1988). Stress:
The history and future of critical incident stress
debriefings. Journal of Emergency Medical Services,
7-52.
Mitchell, J. T. (September/October,
1986). Critical incident stress management. Response,
24-25.
Mitchell, J. T. (January, 1983).
When disaster strikes: The critical incident stress
debriefing process. Journal of Emergency Medical
Services.
Young, M. A. (1994). Responding
to communities in crisis. National Organization
for Victim Assistance. NOVA, Washington, D.C.
©1998 by The
American Academy of Experts in Traumatic Stress,
Inc. |
