Critical Incident Stress Management

What Is CISM?

Understanding CISM

Critical Incident Stress Management, or CISM, is an intervention protocol developed specifically for dealing with traumatic events.  It is a formal, highly structured and professionally recognized process for helping those involved in a critical incident to share their experiences, vent emotions, learn about stress reactions and symptoms and given referrals for further help if required.  It is not psychotherapy.  It is a confidential, voluntary and educative process, sometimes called 'psychological first aid'.

First developed for use with military combat veterans and then civilian first responders (police, fire, ambulance, emergency workers and disaster rescuers), it has now been adapted and used virtually everywhere there is a need to address traumatic impact in peoples lives.

There are several types of CISM interventions that can be used, depending on the situation.  Variations of these interventions can be used for groups, individuals, families and in the workplace.

Debriefing  is a proactive intervention involving a group meeting or discussion about a particularly distressing critical incident. Based on core principles of crisis intervention, the CISD is designed to mitigate the impact of a critical incident and to assist the persons in recovery from the stress associated with the event. The CISD is facilitated by a specially trained team which includes professional and peer support personnel. Also called Critical Incident Stress Debriefing (CISD). Ideally it is conducted between 24 and 72 hours after the incident, but may be held later under exceptional circumstances.

Defusing  is an intervention that is a shorter, less formal version of a debriefing . It generally lasts from 30 to 60 minutes, but may go longer and is best conducted within one to four hours after a critical incident. It is not usually conducted more than 12 hours after the incident. Like a debriefing, it is a confidential and voluntary opportunity to learn about stress, share reactions to an incident and vent emotions. The main purpose is to stabilize people affected by the incident so that they can return to their normal routines without unusual stress. Where appropriate, a formal debriefing also be required.

Grief and Loss Session  is a structured group or individual session following a death and assists people in understanding their own grief reactions as well as creating a healthy atmosphere of openness and dialogue around the circumstances of the death.

Crisis Management Briefing  is a large, homogeneous group intervention used before, during and after crisis to present facts, facilitate a brief, controlled discussion, Q & A and info on stress survival skills and/or other available support services.  May be repeated as situation changes.

What Is A Critical Incident?

A critical (or traumatic) incident is any event outside the usual realm human experience that is markedly distressing (e.g. evokes reactions of intense fear, helplessness, horror, etc.) Such critical incidents usually involve the perceived threat to one's physical integrity or the physical integrity of someone else. Most importantly, critical incidents are determined by how they undermine a person's sense of safety, security and competency in the world. This results in a form of psychiatric injury, also called traumatic impact or traumatic stress.

 Examples of Critical Incidents

Individual/Personal

• Automobile accident, or any accident involving serious injury and/or property damage
• Industrial accidents involving serious injuries or fatalities
• Sudden or unexpected death of a relative, friend or colleague
• Sexual assault/abuse
• Robbery and violent crimes
• Domestic violence
• Child abuse and/or injury or death of a child
• Psychological/emotional abuse
• Suicide or attempted suicide
• Homicide(s)
• Line of duty death or injury among emergency/law enforcement personnel
• Any life threatening experience
• Adverse/negative publicity
• Observing or being aware of unethical acts
• Observing any of the individual or community critical incidents

Community/World

• Fires
• Floods
• Earthquakes
• Hurricanes
• Tornadoes
• Multiple injury/fatality accidents
• Large scale environmental pollution
• Terrorism
• Acts of war
• Child related traumatic events
• Homicides in the community
• High publicity crimes of violence or sex
• Community disasters
• Being an emergency worker/first responder in critical incidents and disasters (Police, Fire, EMS etc)

As you can see, you need not be directly involved to be adversely affected by a critical incident.. Generally, the closer you are to the actual event and the people involved, the more severe the impact. However, television and news media coverage, especially excessive and/or graphic depictions, may serve to increase the likelihood of experiencing traumatic impact, especially anxiety and feelings of not being safe.

Symptoms of Traumatic Impact 

Even though the event may be over, you may now be experiencing or may experience later, some strong physical, psychological and behavioral reactions to the traumatic event. No one is immune from these reactions. It is quite normal for people to experience these aftershocks when they have passed through a horrible event. This does not imply weakness or craziness. It simply indicates that the traumatic event was just to powerful and overwhelming.

Symptoms of traumatic impact can vary from person to person. Some people will experience many symptoms, others just a few. For some, the effect is rapid. For others symptoms may occur weeks, months or even years later. The effects can even be cumulative over time. With Acute Stress, the symptoms go away within a few weeks. If the symptoms last more than one month, seek medical help and counseling specific for Post Traumatic Stress immediately. The sooner treatment begins, the better the chances are for a full recovery.

Examples of Reactions to a Critical Incident or Other Traumatic Stress:

Physical Symptoms  *Any of These syptoms may require  medical attention.

• Chills

• Thirst

• Fatigue

• Nausea

• Fainting

• Twitches

• Vomiting

• Dizziness

• Weakness

• Chest pain

• Headaches

• Elevated BP

• Rapid heart rate

• Muscle tremors

• Shock symptoms

• Grinding of teeth

• Visual difficulties

• Profuse sweating

• Difficulty breathing

Cognitive/Mental Symptoms

• Confusion
• Nightmares
• Nightmares
• Uncertainty
• Hyper-vigilance, watchful
• Suspiciousness
• Intrusive images
• Blaming someone
• Poor problem solving
• Poor abstract thinking
• Difficulty with numbers
• Poor concentration/memory
• Disorientation of time, place or person
• Difficulty identifying objects or person
• Heightened or lowered alertness
• Increased or decreased awareness of surrounding

Emotional Symptoms

• Fear

• Guilt

• Grief

• Panic

• Denial

• Anxiety

• Agitation

• Irritability

• Depression

• Intense anger

• Apprehension

• Emotional shock

• Emotional outbursts

• Feeling overwhelmed

• Loss of emotional control

• Thoughts of suicide/homicide

• Inappropriate emotional responses

Behavioral Symptoms

• Withdrawal

• Antisocial acts

• Inability to rest

• Intensified pacing

• Erratic movements

• Change in social activity

• Change in speech patterns

• Loss or increase of appetite

• Hyper-alert or sensitive to environment

• Increased alcohol consumption

• Change in usual communications

Understanding Traumatic Impact

It has only been in the last 25 years that we have come to an understanding of how critical events affect human beings. The studies of traumatic impact began in earnest with the return of the Viet Nam veterans in the late 1960's and early 70's. However, historical records contain anecdotes of the problem since the 6th century B.C. Names such as shell shock, soldier's heart, combat stress, battle fatigue, stress breakdown, rape trauma, child abuse and battered wife syndromes have been given to the phenomenon. Since 9/11/2001, we have come to realize how an whole nation can be traumatized by witnessing horrific events.

In 1980, the American Psychiatric Association officially recognized Post Traumatic Stress Disorder in it's diagnostic and Statistical Manual of Mental Disorders and legitimized the very real problem of traumatic impact. In 1994, they added Acute Stress disorder to differentiate between short term reactions and long term effects of psychiatric injury. 

Unlike most physical injuries, psychiatric injuries are largely invisible and harder to comprehend. However, they are no less real and have life damaging and threatening consequences if left untreated. Suicide or homicide is not an uncommon result of untreated traumatic impact.

Research has shown that the mind and body form a complex and totally integrated system that communicates through biochemical messages. One part of the system can't be activated without a the other responding. When a person is exposed to the threat of danger in a critical incident, the human 'flight or fight' response is activated. This causes our physical and mental survival instincts to automatically shift in to overdrive. Our heartbeats and breathing rates go up, we may begin to sweat, our muscles tighten as our bodies prepare to take action. Mentally, we become focused on escaping or avoiding the danger, or conversely, we can become frozen in our tracks. We have all experienced this in some small way, such as in a close call while driving through an intersection.

If the threat subsides quickly, with little or no injury or damage, the fight or flight response ceases and our systems return to normal within a short period of time. However, the more severe the threat and/or injury, the more property damage there is and/or the longer the threat continues to be present, the more prolonged and severe are the fight or flight responses. This is the basis for traumatic stress and traumatic impact. As the body's biochemical systems continue to be significantly aroused, the more deeply entrenched the adverse affects become and the mind and body begin to deteriorate in their ability to function normally.

If there is early and appropriate intervention and resolution, the Acute Traumatic Stress Disorder symptoms will subside within a few weeks and there will be few, if any, lingering affects. However, if the critical incident/ injury was severe, undermined a person's sense of safety, security and competency and/or was prolonged or cumulative to other stressors, Post Traumatic Stress Disorder may develop. This diagnosis is not made until the symptoms have lasted at least one month. The symptoms and associated problems often continue for years without proper treatment.

Treatment:

If you suffer from traumatic impact, Acute Stress or Post Traumatic Stress Disorder, you are not crazy, weak, stupid or mentally ill. You are simply experiencing a normal human reaction to an abnormal event.

Help is readily available.

Your Critical Incident Stress Management professional can refer you to the appropriate ongoing medical and mental health professionals that are specially trained to treat these problems. A combination of medications that correct the chemical imbalances associated with PTSD as well as cognitive therapy has proven to be the most effective course of treatment. This is a complicated mind/body disorder that requires a multi-faceted treatment approach.

Most importantly, it is your personal resolve and determination to overcome the effects of traumatic impact that will have the most influence in determining your outcome. Accepting the reality of traumatic impact as well as availing yourself of the help and support you need is of utmost importance. It is more than one person can accomplish on their own.