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.

A CISD team consists of:

1. 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.
2. 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 debriefing.
3. 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.
4. 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.
5. 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:

CISD Preparations

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, where, how.

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 be made.

Where- CISDs can be held anywhere that is private and quiet.  The ideal debriefing room consists of:

• Privacy
• Quiet
• 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
• Well-ventilated
• 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.

Room Arrangement

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 distraction.

Food

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.

Organization Preparation

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
• Confidentiality
• 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 time.  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 debriefing begins.

An Onsite 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.