WAR to CISM

Onsite debriefing service is nothing more than crisis intervention. It is immediate attention designed to stabilize and bridge to additional supportive resources. The popular Mitchell Model's origin is from the traditional crisis intervention models developed in the military. It is a model designed to keep our fighting resources, fighting. Similar to the first responder population (police, firemen, rescue teams etc.), the Mitchell Model is designed to keep them responding. So why is this the model of choice for EAPs? You guessed it, EAP's are designed to keep employees working. I'm not saying this to be witty. If you are ever onsite and functioning as or along side an EAP, that is your mission.

From War to Crisis Intervention to CISM


Unable to leave his gun position until YP13 is out of enemy range, he stares in shock at YP3's copilot.		Later in the supply shack, hands covering his face, he gives way.
Photographs by Larry Burrow's report from Da Nang, Vietnam, LIFE APRIL 16. 1965 Vol.58, No15

The evolution of Critical Incident Stress Management, has its origins in 20th century war. Though the impact of combat on soldiers has been studied since the American Civil War, the medical literature on civilians has significantly risen only in the past two decades. Early work is recorded in a book published in 1917, "Shellshock and its Lessons" (Smith, Hatherly) wrote about the nature of "shellshock".

"Whatever may be the state of mind of the patient immediately after the mine explosion, the burial in the dug-out, the sight and sound of his lacerated comrades, or other appalling experiences which finally incapacitate him for service in the firing line, it is true to say that by the time of his arrival in a hospital in England his reason and his senses are usually not lost but functioning with painful efficiency.

"His reason tells him quite correctly, and far too often for his personal comfort, that had he not given, or failed to carry out, a particular order, certain disastrous and memory-haunting results might not have happened. It tells him, quite convincingly, that in his present state he is not as other men are. Again, the patient reasons, quite logically, but often from false premises, that since he is showing certain symptoms which he has always been taught to associate with "madmen," he is mad too, or on the way to insanity. If nobody is available to receive this man's confidence, to knock away the false foundations of his belief, to bring the whole structure of his nightmare clattering about his ears, and finally, to help 'him to rebuild for himself (not merely to reconstruct for him) a new and enlightened outlook on his future - in short, if he is left alone, told to "cheer up" or unwisely isolated, it may be his reason, rather than the lack of it, which will prove to be his enemy."

"We must not suppose, however, that the man who is experiencing some or all of these mental and bodily conditions is at this period necessarily displaying any obvious outward signs of his trouble. There may he no tremor, no twitching, no loss of control of the facial or vocal muscles which would indicate his state even to his neighbours. He may, for a long time, "consume his own smoke." And during this process he may even appear to his comrades to be steadier and more contemptuous of danger than before. Dr. Forsyth has cited some dramatic incidents, in which officers who imagined that their instinctive fear was becoming apparent to the men under their command took unnecessary risks in order to impress these men with the idea that they were not afraid.

It must be understood that this suppression of the external manifestations of an emotion such as fear is but a partial dominance of the bodily concomitants of that emotion. The only changes which can usually be controlled by the will are those of the voluntary or skeletal muscular system, not those of the involuntary or visceral mechanism. While no signs of fear can yet be detected in the face, the body, limbs or voice, these disturbances of the respiratory, circulatory, digestive and excretory systems may be present in a very unpleasant degree, probably even intensified because the nervous energy is denied other channels of outlet."

In an article by Staff Sgt. Kathleen T. Rhem of the American Forces Press Services(2000), she quoted Dr. (Lt. Col.) E. Cameron Ritchie addressing soldiers struggling with "combat stress".

"At the beginning of World War II, we were screening out almost half our potential recruits because we thought they had psychiatric issues," Ritchie said. There were no uniformed psychiatrists at the start of the war, but the Army had them in every division by the end. "We relearned the value of treating people close to the front," she said. Psychiatric care in the military continued to advance so that by the Korean War, mobile psychiatric detachments traveled throughout the theater conducting combat stress control operations at the front lines.

During operations in Vietnam, the military initially did not have strong mental-health intervention. "We didn't think a whole lot about having combat stress casualties, but we certainly had a lot of drug and alcohol problems, and long-term post traumatic stress disorders (termed during the Vietnam War) after Vietnam," Ritchie said.

In more recent operations, the military has aggressively treated potential combat stress reactions. "Somalia, Haiti, Bosnia, Kosovo -- in all those theaters we've had very active psychiatric intervention," Ritchie explained. "We've had mostly Army, but also some Air Force and Navy mental
health workers up at the front providing immediate, first-line psychiatric care." And with good results, she noted. "We've had a very low rate of combat stress reactions. We have had some suicidal behavior, but the rates of psychiatric difficulties have been relatively low in these theaters," she said.

Dr. Ritchie goes on to say, "...soldiers need to know that psychological reactions to traumatic events are normal." Ritchie explained it's also important to treat combat stress casualties as close to the front or to their units as possible and with the understanding they will return to duty. "We've found that if you ship people out of their units, most never go back, and they don't recover as well," she said. "There's quite a bit of stigma attached to being removed from a unit, and some of these people develop chronic psychiatric conditions."

It became clear that treating "shell shocked" soldiers near the front line proved to demonstrate a better return to duty rate which in a war is the goal. That is, intervention that was administered quick, timely and near the scene, produced better results in getting soldiers back to the front line. When soldiers did not receive this type of intervention, and had to go back to hospitals further away, their ability to return to the front line was far less.

The principles of immediacy, proximity, and expectancy continue to be utilized in military services today and in responding to civilian emergency services as well. Briefly, immediacy refers to administering interventions as quickly to those as soon as possible after the incident. Proximity refers to administering the intervention as close to the scene of the event as reasonably possible assuring that safety is achieved and, expectancy refers to delivering the message that the affected will be alright and be able to return to action.

"Take a combination of fear, anger, hunger, thirst, exhaustion, disgust, loneliness, homesickness, and wrap that all up in one reaction and you might approach the feelings a fellow has. It makes you feel mighty small, helpless, and alone... Without faith, I don't see how anyone could stand this."

- Paul Curtis, Private, May 28, 1944. (excerpt from American Experience War Letters)