Critical Incident Stress Debriefing
Critical Incident Stress Debriefings (CISD) are the most complex of the CISM
interventions and should not be used in "routine" cases. Proper selection of the
necessary intervention is most important to be effective in mitigating the
effects of stress.
CISDs were designed for intervention with emergency personnel and have since
been further developed for other populations with some modification. Description
of the CISD for emergency personnel will be described in depth and later
modified for Corporate interventions and use by EAPs
CISDs for emergency personnel is a peer management/peer driven process that
uses mental health professionals for oversight and guidance. When considering
the appropriate intervention with emergency personnel, keep in mind that many of
these professionals have experience and training in these emergency/disaster
related fields. What may be considered stressful and traumatic to the lay person
or even the mental health professional, may in fact be routine to the emergency
professional. Not that it doesn't carry a certain degree of stress and concern,
its impact is not severe or disrupting to the person or their lifestyle.
There are events, however, that can be particularly distressing to emergency personnel
where a CISD may be warranted.
|Line of duty death
||Serious line of duty injury
|Suicide of an emergency worker
||Excessive media interest
|Significant event involving children
||Prolonged incident with loss
|Knowing the victim of the event
||Any significant event.
A CISD team consists of:
- Team Leader- A mental health professional is assigned to the
debriefing to use his/her communication skills and engagement qualities to
encourage the group to participate in the debriefing. Their function is to
oversee the psychological well-being of the group and any individuals who may
be struggling with more distress than others. The team leader monitors group
process and assists with helping members to clarify their perspectives and its
part in the seeing the big picture. Pointing out patterns, educating and
listening are the main roles of the team leader. when the group moves to
closing, it is the team leader who brings the group out of the debriefing
experience with emphasis on the positive found in the face of dealing with the
tragedy. An experienced team leader has been through different CISM
events and is familiar with emergency personnel and the work they do. To
become more familiar with emergency services, contact local CISM teams or
services to increase your contact, attend a ride-along, visit emergency rooms
and emergency scenes.
- Co-Leader- the co-leader in a CISD group for emergency personnel is a peer
trained in CISM. The co-leader shares leadership responsibilities with the
leader. The co-leader is closer to the group, that is, not an outsider
to the group where the mental health professional may be. Working close
together in this capacity improves delivery of services by validation the
expertise of the leader. The co-leader is active in all phases of the
debriefing especially the teaching phase. After the debriefing, follow-up
services and availability will inevitably fall into this role as the peer is
there afterwards and easily approachable. The co-leader assigns specific
follow-up tasks to CISD members, i.e. advising the unit supervisor or
contacting group members who may have shown more distress during the
- Door Keeper- the door keeper is assigned to prevent unauthorized
individuals from entering the room where the debriefing is taking place. There
may be many people there for different reasons looking for, or wandering around
for information, support or service. People who were not involved with the
scene, family members of participants in the debriefing, spectators, media and
citizens who just happened to be at the scene of the incident. If it is
an appropriate person arriving late for instance it is through the door keeper
the personnel go through. There may also be times when someone wants to
leave the group. The door keeper encourages a quick return. Personal
breaks for the restroom is generally uneventful and there is quick return.
Sometimes one may leave in distress and the door keeper may have to attend to
this person outside of the group, again attempting to support the person
through the process and return to the group. Personnel that leave suddenly may
be avoiding their turn in the group or struggling internally with their
experience. Reminding them that their sharing is completely voluntary adds
some comfort, that there are one-to-one services after the group, and that their presence can be helpful to others members in the group
even if they remain quiet.
- Clergy- A clergyman who is trained in CISM can offer guidance and support
to members. Trained clergy are aware that it is not time to preach nor pray
during the group. They are aware that there may be different
denominations and non-believers. Their role, however, can offer much
assistance after the debriefing, in following up with personnel who may seek
some spiritual guidance. Prayer may be appropriate in in this capacity.
- Peers- The value of peers trained in CISM when working with
emergency personnel is insurmountable. All service and emergency
personnel form a tight bond with each other. It is very functional and
they are protective of it. Many debriefers seen outside of this structure will
be less effective in reaching the group members. Having a peer in the
co-leader or peer support position helps bridge this gap. Peers role are seen
as very important through out the process especially in the introductory phase
where they might look to you to validate that this process is OK.
Remember, it is the mental health professional that is getting it started, so
the team work that is displayed will go a long way. Attending to the
needs of the group members both speakers and non-speakers is vital. Less
attention to group process, per se, is necessary while greater attention to
each member is suggested. Peers offer:
- Familiarity with the nature and culture of emergency services.
- Rapid intervention.
- An emphasis on the pragmatic, for example, stress management
- Emergency service "peer" personnel are the embodiment of these
characteristics and are therefore an integral pact of the CISD team.
Lets review. An event occurs and a call comes into the 24-hour
communications center from an operations person. Preliminary information is
taken and relayed to the CISM Team Coordinator. After obtaining more information
needed to assess the level of services, it is determined that a debriefing team
need be assembled to provide a CISD. the first questions to answer are when,
When- The ideal debriefing in response to acute,
well-defined critical incidents, takes place between 24 and 72 hours after the
incident. While this may or may not be realistic, it nonetheless is the target
time for the CISD. Since emergency personnel are so cognitively defended,
it takes about 24 hours for them to be ready to talk about the details of their
reactions to the incident. The nature of the event and its "emotional
closeness" to the group will effect this. For instance, in a line of duty death
where tragedy has penetrated the group, shock and denial mechanisms may be in
place longer. Sometimes days or weeks. A CISD done too prematurely
diminishes the value of the experience as the group members are not
psychologically ready. If a CISD needs to be done before there is time to
assemble a team, defusings can be done initially until the CISD is set up.
Running a poorly organized CISD for the sake of responding early is not
effective and can be dangerous.
Waiting too long to do a CISD can also be potentially harmful to members. A
"late" CISD runs the risk of breaking up the reintegrated defense systems
risking re-traumatization In this scenario it is better to not run a debriefing
but meeting with people on an individual basis for support education and
possible referral to a mental health professional.
the 24-72 hour window is the first time frame the coordinator should look to
set up the intervention. as more facts are available to him/her adjustments can
Where- CISDs can be held anywhere that is private
and quiet. The ideal debriefing room consists of:
- Movable Furniture
- Well lighted but with adjustable lights
- Comfortable seats
- Room size is suitable for the size of the group.
- A single door
- Air condition or heated
- No windows which allow a view from the outside
- Available for the full length of the debriefing
- With one or more private rooms for individual counseling.
- No sensory stimulation of the event*
*This last item is added to the original list. If the event was a terrorist
act like 9/11, assembling a debriefing in lower Manhattan for example, or in a
room in the upper levels of a skyscraper will make the debriefing too unsafe
due to the extra stimulation and risk for re-traumatization.
Consider the size of the group. Arrange chairs in circular fashion. Table in
center is optional. Account for personal space. If chairs are touching
each other in the circle, the circle is too small or the room is too small.
Modify this ahead of time. If not, group participants will monitor this as they
sit, often disrupting the circle leaving some of the chairs in the circle and
some out. A small group is between 4-12. Peers should not sit together nor with
group leaders but spread out amongst the group as evenly as possible. The group
leader should sit away from the door and not be involved in monitoring the door
and issues with leaving and arriving late (if possible). Effort should be
made to keep the group protected. Locking the door, posting signs to knock or
return at another posted time and even posting a peer outside the door are
options to deal with maintaining group integrity. Having a peer at he door when
there is media about is a good idea to consider. Having extra chairs nearby the
group or in the group structure for late arrivals will minimize disruption,
however if the group has suffered a loss, having an empty chair in the group can
be too powerful for the intervention process and it should be removed quietly.
An empty chair next to a peer can accomplish this rather easily without
Food is a tool to keep the group hanging around. Served after the group,
members are enticed to have fruit drinks and non stress enhancing foods. This
time allows the CISM team to circulate among the members to offer support,
encouragement and visibility. Cookies, chocolates, alcohol etc. while they may
be the preference, should be discouraged. Food arrangements should be
handled prior to the group and set up outside the group room. access to the food
needs to be after the group.
Prepping the Supervisor- The announcement of the debriefing to the
personnel is likely to be done by their supervisor. He or she must be on board
and educated about what a debriefing is and is not. Their presentation to
the group is key to how meaningful the group is to be perceived and later,
experienced. Key points to highlight with a supervisor are:
- This is not psychotherapy
- This is not investigative
- Participation is good for the organization as well as the individual
- Education on the CISD team and how peers have a major role in the success
of the group
- No documentation
- Much value in the shared experiences with different perceptions.
- Use of self as a role model
It is likely through the supervisor that rooms are arranged, food is ordered,
rules about pagers and radios turned off. Coverage is maintained and education
from the supervisor to the CISD team about the event is also given.
Prepping the organization- the command staff should invite every
member who was involved in the incident. This includes field personnel as
well as well as rank and file. there may be times when this is not in
order. If the organization is assessed as dysfunctional, there may be personnel
who are the target of extreme anger or resentments, issues of mistrust between
rank and file and command staff or if there are issues that are sensitive and
privileged. Separate groups can be arranged to manage these situations.
The organization should be informed that CISD Team members or the
International Critical Incident Stress Foundation is available to answer
questions form the media about the debriefing process.
Prepping the CISD team- the team should arrive 1 hour prior to the
debriefing. this will give the time for the team to review information,
documentation, slides, newspapers, reports, charts and/or diagrams. This
prep time is invaluable. It will help minimize surprises during the debriefing,
and offer some assurance to the personnel that you are educated about the event.
This is the time to ask questions of an operational nature. It is not time to
explore reactions or comment on them. Once this time is complete, the physical
setup of the debriefing is in order, it is time for the team to circulate
amongst the group. Be seen. Be approachable. Be real. It helps take the edge off
during the introduction phase of the group. It is also a time to learn more by
asking task oriented informal questions and converse in a flowing manner rather
than questioning from a memorized script. Information about how the organization
works together or how they get along with command can be ascertained at this
One should be on the alert for any level of dysfunction within the group or their past experience with debriefings. This
process should be about 10-45 minutes. At the conclusion of this step the team
breaks away and has their last meeting before the debriefing.
Strategy Meeting- this is a private huddle to discuss roles and
approach, seating arrangements, and what was learned during the "socializing".
Clarifications, special teaching topics, and resistances are all discussed to
improve coordination of services. Upon completion of this meeting, the
is a group process that incorporates crisis intervention and educational
processes targeted at mitigating the psychological distress associated with a
critical incident or traumatic event. By providing a structure,
participants can discuss the critical incident in a manner which does not leave
them feeling out of control of themselves. While some of the techniques
used are similar to counseling techniques, CISD
is not a counseling or psychotherapy process. Nor is it a substitute.
Debriefing provided by an EAP in
the workplace is often done by one person. In essence you are all of
these roles but how the intervention is staged will reshape the
intervention into a manageable process.
With the integration of PFA,
interventions can be immediate for EAPs.