| A fitting
breaks during an underway replenishment, and a Sailor
is knocked overboard. Four hours later, his shipmates
pull his lifeless body from the sea.
A Sailor, distraught over news
from back home, hangs himself in his berthing space.
His shipmates find the body and attempt CPR, but
it's too late.
A popular Senior Chief has sudden
heart attack while on the bridge, and dies despite
the corpsman's best efforts.
In the Arabian Gulf, a cruiser
is rammed by a tug trying to smuggle oil from Iraq
- three Sailors are injured.
In each of these (invented) incidents,
there are a number of people who will be directly
affected-who will suffer from what the experts call
a "critical incident" and traumatic stress.
How affected they may be will depend on a variety
of factors. One of the most important of these is
how we respond to help them.
There is no firm definition for
a "critical incident," because it varies
from person to person and from time to time. Basically,
a critical incident is any crisis event with sufficient
impact to overwhelm the usual coping skills of an
individual or group. Critical Incident Stress, therefore,
is the stress reaction that a person or people may
suffer in response to the incident. Among the common
responses are sleeping and eating problems, intrusive
images, increased startle reflex, confusion in thinking
or decision making, memory problems, emotional shock,
anger or grief, and so on.
Sailors suffering from such symptoms
may benefit significantly from Critical Incident
Stress Management (CISM). CISM is not therapy, and
does not "cure" people's stress responses.
Rather, CISM is a proven means of assisting people
in their own healing by reducing the severity and
longevity of symptoms, and thus restoring them to
function much sooner. It is not perfect, and some
people suffering from traumatic shock may go on
to develop posttraumatic stress disorder (PTSD),
but for the vast majority, CISM brings significant
benefits. This article proposes a model of CISM
for deployed shipboard use, with an emphasis on
reducing stress reactions and returning commands
to full readiness as expeditiously as possible.
The "classic" CISM model
was developed by Dr. Jeffrey Mitchell of the University
of Maryland for use with emergency services personnel
and promulgated by the American Critical Incident
Stress Foundation, which was founded in 1989 (the
name was changed to the "International Critical
Incident Stress Foundation" in 1991 to reflect
the expansion of the model beyond US boundaries).
Initially developed for firefighters, paramedics
and police officers, use of the Mitchell Model has
been expanded for use in natural disasters, school-based
incidents, and a variety of other settings, including,
in recent years, the U.S. military.
Major Naval Hospitals in the U.S.
have set up "SPRINT Teams" - crisis response
teams which include mental health professionals,
medical and nursing personnel, chaplains, and enlisted
Hospital Corpsmen. These teams respond on short
notice to major incidents anywhere in the world.
While not following the classic Mitchell Model (their
personnel are all hospital staff, rather than "peers"),
their debriefings are highly regarded.
In 1998, the U.S. Navy Chaplain
Corps offered its members a four-day training entitled
"Ministry in Trauma and Disaster," which
included the two-day certification course in Basic
Critical Incident Stress Management. This ensured
that virtually every active duty chaplain had received
at a minimum, the basic CISM training. For some
it was new, while others had been working with the
Mitchell Model for a number of years.
While the training was undoubtedly
valuable, it is unfortunately not always easily
applied within the context of military deployments.
The Mitchell Model relies on the use of trained
teams of Peer Support Personnel, working with Professional
Support Personnel (mental health professionals or
clergy). Such teams may not always be available
or even feasible in a deployed context.
Should there be a "Critical
Incident" aboard a ship at sea, as a result
of either combat or accident, it is quite possible
that the ship's crew will have to rely solely on
deployed assets, and not depend on outside personnel.
A ship at sea may quite simply not be within range
of any shore-based assistance. If the post-incident
response cannot be provided by already-deployed
personnel, it may not be provided at all, and certainly
not in an expeditious fashion.
A second issue which could have
a impact on the ability to bring in a CISM Team
following an incident at sea has to do with command
climate. U.S. Naval ships, and particularly cruisers,
destroyers and frigates, are remarkably insular
- the officers and crews are trained to look inward,
to their own resources, rather than for outside
help. In wartime, this is of course essential, as
each ship, while perhaps part of a Battle Group,
remains an individual fighting unit, detecting and
engaging the enemy. Ship's crewmembers bond with
one another very closely, especially during deployments
and times of stress. Outsiders, even those who are
themselves in the Navy, may be seen as just that
- outsiders. A Team brought from another similar
command - from another ship within the Battle Group,
for example, may well be more accepted than a group
of shore-based medical personnel, who might not
be seen as really understanding the problem.
While these problems are directly
related to ships' deployments, there are other areas
in which the Mitchell Model for CISM must be adapted
to fit into the Navy's structure. First, the Navy
normally assigns Mental Health Professionals (MHP)
to sea duty only aboard aircraft carriers, although
chaplains are available on most ships with crews
of 385 or more. Destroyers and frigates, however,
carry neither a chaplain nor a medical doctor, the
latter function being performed by a Hospital Corpsman
with special training for Independent Duty.
It would also be challenging to
maintain CISM Teams within the Navy structure. Sailors
are rotated to new duty stations every two to five
years, creating constant turnover. In order to maintain
a roster of "Peer" team members, the command
would have to be constantly training new people
to replace those being rotated out. Such training
will have to be seen as a priority of the Mitchell
Model is to work at all aboard ships at sea.
Modifying the Mitchell Model
for Sea Duty
In order to provide appropriate
Critical Incident Stress Management, therefore,
some modification may have to be made to the proven
Mitchell Model - modifications designed not to improve
it, but to allow it to be used under the particular
circumstances of sea deployments. In making these
proposals, I understand that they may reduce the
effectiveness of the post-critical incident stress
intervention. However, a modified response is better
than no response at all.
The proposed modified response
is based on a presupposition - that there will be
at least one other ship close enough to the affected
vessel that a small team may be flown over to provide
assistance. In cases where that is not possible
(i.e., an independently steaming ship, for example),
then the sole resources will be those already on
board.
The first, and essential, modification
involves the roles within the debriefing team. Although
Mitchell and Everly include chaplains with mental
health professionals (MHPs) as Professional Support
Personnel, their model calls for each debriefing
team to include (and be led by) a mental health
professional. There are two problems with this in
the deployed context. First, MHPs are almost non-existent
at sea. While aircraft carriers may have one, any
smaller ship will not. Thus, while it may be relatively
easy to crossdeck a chaplain from another ship to
assist, finding an MHP in the middle of the Pacific
may sometimes be impossible.
Second, I believe that it is important
to acknowledge the centrality of chaplains to CISM
within the Navy. The ship's command chaplain or
chaplains is normally a known and trusted entity
within the command structure, and is seen by the
officers and crew both as a professional caregiver
and as part of the crew. As such, aboard ship he
or she already serves in the role of counselor/mental
health professional, and will have access in ways
no outside professional would. Further, within the
Navy, there is little onus attached to seeing the
chaplain, in large part because the chaplain's role
encompasses not just mental health issues but religious
and social functions as well. On many ships, the
chaplain serves not merely as counselor and religious
leader, but as the officer in charge of volunteer
projects, the library officer, and a variety of
other roles as well. People interact with the chaplain
in any or all of these roles, in addition to hearing
the chaplain's daily evening prayers. Chaplains
are seen as being "part of the team" aboard
ships in ways civilian mental health professionals
or clergy members can hardly appreciate.
Team Members
A deployed CISM Team, unlike the
equivalent team ashore, will require tremendous
flexibility in terms of its training and make-up.
It is preferable that a Central CISM Team be organized
at the Battle Group level for training and coordination,
but with individual teams trained on each of the
ships in the Battle Group. This is necessary because
ships in the same Battle Group, while in communication
with one another, are frequently separated by hundreds
of miles.
The Battle Group's senior chaplain,
normally the command chaplain aboard the aircraft
carrier, should be responsible for the Central CISM
Team's coordination. He or she will work with the
carrier's assigned MHP, as well as with the Admiral's
Chief of Staff, to ensure a systematic, timely and
appropriate response to any critical incident.
The Mental Health Professional
assigned to the carrier (normally a psychiatrist)
will be the Central CISM Team's Clinical Director.
The MHP will provide training and supervision to
the member teams, and in the event of an incident
beyond helicopter range of the carrier will be available
for consultation via ship-to-ship radio or by message
traffic.
The role of the Chief of Staff
is in many ways essential - as a senior line officer
working directly with the Admiral, he or she brings
both authority and credibility to the Central CISM
Team. In the aftermath of a critical incident at
sea, it is that authority which will ensure transportation
and billeting for the CISM team, and the Chief of
Staff's experience and expertise will be invaluable
in the decision-making process both before and following
incidents.
Team members aboard the carrier
and other ships should be drawn from a variety of
areas and pay grades. Each ship in the Battle Group
should have a team of at least six to eight members,
including a chaplain and an Religious Program Specialist
(chaplain's assistant). The other members should
be drawn from a variety of departments and rates,
and some two-thirds of the members should be junior
enlisted, with one third being drawn from the ranks
of chief petty officers and officers. On mixed-gender
ships, the team should, if possible, be mixed gender
as well.
Pre-Incident Inoculation
Appropriate education should be
provided through General Military Training to all
crew members in the symptoms and effects of traumatic
stress, along with some of the ways in with which
it may be dealt. This is important for a number
of reasons. First, by increasing the crew's awareness
of the effects of traumatic stress before an incident,
they are less likely to be completely blindsided
by them and less likely to be afraid that they are
"going crazy" when they suffer from inability
to sleep, loss of appetite, intrusive images or
thoughts, etc. This is where the CISD mantra, "These
are the normal responses of normal people to abnormal
circumstances," becomes invaluable.
Second, simply by being aware of
the possible effects in advance, those effects may
be lessened-when you don't know that a particular
stress response is "normal," it adds to
your stress!
And third, by training Sailors
in ways to deal with the effects of stress, they
will be far better prepared to deal with them in
healthy ways. A concomitant benefit is that the
stress relieving techniques taught as part of a
traumatic stress inoculation class will also carry
over to help the Sailors deal with the other stressors
in their lives, increasing morale and productivity.
Included in the training should
be some specific stress reduction techniques which,
if taught as part of the GMT (General Military Training)
on all ships within the Battle group, may then be
drawn on by the CISM Team following a critical incident.
Such techniques may include, but need not be limited
to - diet, exercise, neuro-muscular relaxation,
meditation or visualization, breath control, and
so on.
CISM Response at Sea
The response to a critical incident
at sea will be dependent upon a variety of factors
- the incident itself, the ship's location in relation
to other Navy ships or shore facilities, the assets
available from such ships or shore bases, and so
on.
In the case of an incident aboard
a vessel traveling with a Battle Group, half-a-dozen
trained team members including the carrier's Mental
Health Professional, a CISM-trained chaplain, and
four Shipmate Support Personnel (peers), plus a
Religious Program Assistant (RP) as administrator,
should be flown over within twenty-four hours of
the incident. They will need to be provided with
billeting, messing, and an appropriate space in
which to work - the ship's classroom/library may
be best. Arranging such spaces will normally be
part of the job of the RP.
Soon after arrival, the MHP or
Chaplain should meet with the Commanding or Executive
Officer and the Command Master Chief, to briefly
explain the process, goals, and desired outcomes
of the Critical Incident Stress intervention, and
to hear the concerns and needs of the command's
leadership. This is essential - without the support
of the command, there is little hope for any kind
of success.
Meanwhile, team members should
be getting as much information as possible about
the incident, and to get a sense of how many people
may have been involved and in what ways - the "Incident
Review." Contact with shipboard medical personnel,
the Leading Chiefs and Division Officers of affected
divisions, and other personnel is appropriate and
necessary. At the same time, however, the members
of the team must be aware that their role is not
to interfere in the post-incident repairs or the
daily working of the ship, and should be sensitive
in making their requests for time or help. In any
case, within an hour of arrival or less, the members
of the team should know what is going to be necessary
- defusings, debriefings, one-on-ones, or any combination
thereof - and be able to establish a plan of action
with which to proceed.
In the event that the affected
ship is not within helicopter range of the aircraft
carrier, but can be reached from other ships, some
modifications will become necessary. The role of
team leader will fall to a CISM-trained chaplain,
rather than an MHP. That chaplain, along with an
RP and a group of Shipmate Support Personnel, should
be flown over as soon as possible. The chaplain
would then meet with the CO/XO and Command master
Chief, while the other team members do the incident
review.
In those cases where there is no
other Navy ship within helicopter range to respond
following a critical incident, the response must
come from within the affected ship itself. Crew
members trained as part of the CISM team should
gather with the team leader (chaplain or, in the
case of destroyers and frigates, Independent Duty
Corpsman) to evaluate their own stress levels before
attempting to work with others, bearing in mind
that they, like their shipmates, will have been
affected by the traumatic incident. Such one-on-ones
or defusings they do attempt should be approached
with caution, and no full-fledged debriefing should
be attempted. As soon as assistance from another
ship is available, team members themselves, as well
as crew members, should be debriefed as appropriate
by an outside team.
Training
The training of Shipmate Support
and Professional Support personnel in the military
is problematic, given the general guidelines provided
by Jeffrey T. Mitchell and George S. Everly in their
instructional guide for CISM. Few if any active
duty Navy personnel, MHPs, chaplains, or peers,
have participated in the requisite fifteen to twenty-five
debriefings expected of instructors, and both time
and financial constraints ensure that civilian instructors
cannot be used.
The psychiatrists assigned to aircraft
carriers, if they are to serve as CISM Clinical
Directors, should receive ICISF Basic and Advanced
CISM training in order to fully familiarize themselves
with the model. CISM is sufficiently different from
the various techniques psychiatrists are usually
taught and therefore, such training is essential.
Already, however, the Navy has
provided Basic CISD training to members of the Chaplain
Corps, using ICISF-certified instructors, through
the 1998 Professional Development Training Courses
(PDTCs). A core group of those chaplains should
now be trained through the Advanced CISD and Peer
Counseling level (at least one per Battle Group),
and those chaplains could be utilized as mentors
and trainers for those with less experience. In
addition, detailed, step-by-step training curricula
should be devised that would enable ships' chaplains
to train Shipmate Support Personnel (i.e., peers),
as well as provide Trauma Inoculation GMT (General
Military Training) for the entire crew.
Training standards for team members
aboard deployed ships must, by the nature of naval
deployments, be somewhat different from those for
shore-based CISM teams. The relatively extensive
training suggested by Drs. Mitchell and Everly,
which includes both Basic and Advanced CISD courses,
plus Peer Counseling and Family Support Services
courses for a total of 56 hours of training, would
be optimal, but difficult to provide in the pre-deployment
period of workups, drills and inspections.
However, Shipmate Support Personnel,
in order to function effectively, must have as a
minimum, training in Basic CISD and Crisis Intervention.
Such training should follow the general guidelines
presented by Mitchell and Everly in terms of course
content, but should be adapted for shipboard use.
Particular emphasis during this training must be
placed on teaching the participants to recognize
the symptoms of Critical Incident Stress in themselves.
This is necessitated by the fact that, in a deployed
setting, no outside personnel may be available to
assist following a critical incident, and the caregivers
may be numbered among the "victims" of
the incident. Again, while this is certainly less
than optimal, it is better than having no one provide
care at all.
As stated earlier, it is probable
in a deployed setting that the Team Leader in each
case will be a chaplain, rather than a mental health
professional. Training for such chaplains, given
their central role, is essential. Every chaplain,
before deploying, should receive as a minimum Basic
and Advanced CISD training, as well as a short course
in methodology for teaching the principles of CISM
aboard ship. The responsibility for training the
Shipmate Support Personnel will fall on the Command
Religious Program, and easy-to-adapt lesson plans,
etc., should be provided to the chaplain well before
deployments.
The Religious Program Specialists
(chaplain's assistants) assigned to the Command
Religious Program will be responsible for organizing
and coordinating the team, and should receive not
only the same training as Shipmate Support Personnel
(whether or not they're actually team members),
but appropriate organizational training as well.
Conclusion
The Mitchell Model of Critical
Incident Stress Management, as an integrated system
of services designed to prevent and/or mitigate
traumatic stress, assist and accelerate recovery,
restore the affected person to function, and maintain
worker health and welfare, is the most effective
model available to the Navy for the initial response
to traumatic stress. It is not perfect - no model
is -but when used appropriately, it can consistently
reduce the negative effects of traumatic stress,
both in terms of severity and longevity, in the
majority of people so treated. Originally designed
for firefighters, police, paramedics and other emergency
services personnel, it has proven effective in a
wide variety of cases both within and outside of
the military.
The Mitchell Model, to be used
by Naval ships at sea, must be modified to fit the
exigencies of deployment. Such modification should
be restricted to the minimal possible under the
circumstances, to avoid straying too far from the
proven techniques. The modifications proposed in
this article constitute just such an effort.
The benefits of putting such a
model for Critical Incident Stress Management into
effect are many. In the short term, the crew of
a ship suffering from a traumatic incident will
be more fully operational much more quickly, thus
increasing operational readiness. In the long term,
the provision of such a program, and the consequent
reductions in the effects of traumatic stress and
improvements in morale, can help our retention rates
at a time when we are seeking to keep experienced
Sailors in the Navy.
Recommended Reading
Giodano, D.A., Everly, G.S.,
& Dusek, D.E. (1986). Controlling Stress
and Tension (Fifth Edition). Allyn and Bacon.
Mitchell, J.T., & Everly,
G.S. (1994). Human Elements Training for Emergency
Services, Public Safety and Disaster Personnel.
Chevron Publishing.
©1999 by The
American Academy of Experts in Traumatic Stress,
Inc. |
