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MISSION STATEMENT: To minimize the potentially harmful stress-related symptoms associated with critical incidents affecting emergency service personnel and their families through timely confidential crisis intervention that is empathic and respectful toward all involved.
Introductory Problem Statement Emergency services personnel have become increasingly aware of the toll that the unique stressors they encounter in their occupations may take on the quality of their lives. The very nature of their jobs may expose these individuals routinely or periodically to stressful events which they may or may not be able to work through satisfactorily on their own. Factors that cause stress to one individual may be non-stressful for another, but research has shown that a very small percentage of emergency personnel are actually not affected by stress. Approximately one-half of the large percentage of those who demonstrate symptoms related to stress can resolve these alone - the other one-half continue to be affected. Responses to stress may be immediate and incident specific; they may be delayed for a period of time after an incident; or they may be cumulative, building up over a long period of time and can include many incidents. Multiple factors affect an individual’s response to stress and include factors specific to the stressor, such as the individual’s personal qualities and past experiences and the resources available to him. It has been demonstrated that certain events, such as the death of a child, the death of a co-worker, high-rise fires and multiple casualty incidents, are particularly stressful for emergency workers. Any of these events, plus a host of others, may cause or contribute to a critical incident for an emergency worker or for a group of workers. A critical incident has been defined by Mitchell as, “Any situation faced by emergency service personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later…. All that is necessary is that the incident, regardless of the type, generates unusually strong feelings in the emergency workers.”* A critical incident has also been described as any event which overwhelms the capacities of a person to psychologically cope with the incident.
Mitchell, Jeffrey T.; When Disaster Strikes…The Critical Incident Stress Debriefing Process; JEMS; January, 1983; pp 36-39
Copyright 2001 Patricia L. Tritt, RN,MA
CRITICAL INCIDENT EXAMPLES Death of an emergency services worker, i.e. law enforcement, fire fighter or other emergency personnel in the line of duty, including during the incident, en route to or following the scene, or during a training exercise. Serious line of duty injury. Suicide of a crew member or other unexpected death. Mass casualty incidents. Serious injury or death of a civilian resulting from emergency services operations, i.e. auto accident, etc. Police shooting. Events that seriously threaten the lives of responders. Death of a child or violence to a child. Loss of life of a patient following extraordinary and prolonged expenditure of physical and emotional energy during rescue efforts by emergency services personnel. Incidents that attract excessive media coverage. Personal identification with the victim or the circumstances. Events where the victims are relatives or friends of emergency personnel. Any incident that is charged with profound emotion. Any incident in which the circumstances were so unusual or the sights and sounds so distressing as to produce a high level of immediate or delayed emotional reaction.
GROUPS SERVED BY THE SNOWY RANGE CISM TEAM
Fire services - paid or volunteer EMS service - paid or volunteer Law enforcement personnel Search and rescue personnel Ski patrol organizations Hospital personnel
II. TEAM MISSION The mission of the team is not to debrief the public or victims of disasters. However, the mental health members may make appropriate referrals. Exceptions will be discussed with the clinical or program coordinator. CISM Teams provide debriefing following critical incidents to any emergency response agency requesting assistance. The focus of this service is to minimize the harmful effects of job stress, particularly in crisis or emergency situations. The highest priorities of the team are to maintain confidentiality and to respect the feelings of the individuals involved. It is not the function of a team to replace on-going professional counseling, but to provide immediate crisis intervention. Through the CISM process, a team provides emergency personnel tools to potentially alleviate stress related symptoms. CISM Teams also provide education regarding critical incident stress to emergency services workers. CISM Teams provide services to emergency/first responder personnel, hospital personnel, and spouses.
TYPES OF INTERVENTIONS Several types of interventions may be conducted depending upon the circumstances of a particular incident. Intervention may be on an individual one-on-one basis or, ideally, in small groups. The following types of interventions, singularly or in combination, are most commonly utilized:
A. Pre-Incident Education:
Pre-incident education regarding stress, stress recognition and stress reduction strategies is an essential part of the CISM process. Educational programs for line and command staff also include information on critical incident stress debriefings, how to contact a team, and on-scene considerations. Programs should be provided for recruits, refresher training, and veteran personnel. Programs for spouses and significant others may also include stress recognition and management. On-Scene Support Services: Three types of services for prolonged or large scale incidents may be provided: One-on-one sessions with rescuers exhibiting signs of obvious distress Consultation to the Incident Commander or command officers Assistance to victims of the incident as needed Demobilization/De-escalation/Decompression: Utilized during or following a large scale incident as units are released from the scene to determine if all personnel are accounted for, make announcements, etc. A mental health professional or experienced peer takes 15 minutes to provide information on the signs and symptoms of stress reactions that may occur. Lasts a maximum of 30 minutes. Unit may be released from duty or return to the station in service. Incident Commander may require that all personnel go through a demobilization session before they are released from the scene. Defusing: A mini-debriefing for a small core or working group (such as an engine company) conducted at the station shortly after the incident, usually within 3-4 hours. Provides information about the incident and general information and advice on stress reactions. In some circumstances a defusing may involve a more in-depth discussion of participants’ feelings and reactions. May be led by an experienced peer debriefer. A defusing may eliminate the need for a formal debriefing. Formal Debriefing: Ideally conducted within 24-72 hours of the incident. Confidential non-evaluative discussion of the involvement, thoughts, and feelings resulting from the incident. Also provides discussion and education regarding possible stress-related symptoms. Individual Consults: One-on-one counseling for concerns related to the incident. May require a mental health professional. Providing individual counseling is not a function of the CISM Team. However, team clinicians may be utilized for referrals. Significant Other Support: Includes the following services: Educational programs for significant others, Debriefings for significant others, Bereavement support, Grief and crisis counseling, and Family support
Specialty Debriefing: Providing debriefing interventions for groups not directly involved in emergency services or otherwise outside the realm of the CISM Team. May be requested if services are not available in the mental health community. Informal Discussion: An informal leaderless discussion of the event by individual crews following return to quarters. Initial discussion occurs spontaneously in many groups and is not structured. It may be facilitated by a team peer member who is present. The focus of the discussion should be the group’s reaction to the event rather than a critique. Follow-up Services: Conducted following individual consults, defusings, debriefings, demobilizations, and significant other support in the weeks or months after an incident. May include an informal debriefing session, phone or personal follow-up. Concern with detecting delayed or prolonged stress syndrome. May also be used to evaluate debriefing services offered.
THE DEBRIEFING PROCESS Emergency services personnel, command staff, emergency management, medical control authorities (e.g., Public Health, Hospital, Nursing, etc.) are responsible for identifying and recognizing significant incidents that may require debriefing. When an occurrence is identified as a “critical incident”, a request for debriefing should be made as soon as possible. The team is activated by a call to the dispatch center in the Sheriff’s Office. Appropriate call information is obtained and relayed to the Snowy Range CISM Team. CISM interventions are coordinated by a designated team member to promote the quality of the services and to ensure appropriate procedures are followed. The team member also schedules requests for education/inservice presentations. A team member contacts the agency requesting services to: Assess the need for a formal debriefing, a defusing, or a referral. Determine the nature of the incident. Team members should coordinate a time and location to meet prior to and following the debriefing to discuss the incident, available resource information, and the approach to be used during and after the debriefing. At times, they may wish to visit the incident site before the debriefing. Arrange a time and location if a formal debriefing is indicated. Debriefings are optimally conducted within 24-72 hours of the incident, and should not generally extend beyond one week. A 24 hour normalizing period following the incident is recommended. If large numbers of personnel are involved, debriefing begins with those most involved with the incident. A defusing may be appropriate within 24 hours of the incident. Debriefing Process Considerations Include: The location selected for the debriefing should be free of distractions. Other potential sites include schools, churches or other meeting facilities. Crew quarters or station may also be utilized if appropriate to the circumstances. All emergency personnel involved in the incident should be invited to the debriefing and encouraged to attend. This includes, but is not limited to fire, law enforcement, dispatch, EMS personnel, and hospital emergency department personnel. A time for the debriefing should be selected that is most convenient for as many responders as possible and for the team members. Agency management or command officers should be encouraged to relieve personnel from duty during the debriefing. The environment should be free of interruptions, phone calls, radios, and pagers. Turn off pagers, cell phones, radios, and other communication devices. The team member contacted selects a debriefing team from available members. To assure the quality of the process, the team must consist of at least one mental health professional and two to three team members. The average team consists of 3 members. The mental health professional is the designated team leader. Team members who have responded to the incident should not be debriefers. Guidelines For Debriefings: Strict confidentiality must be maintained. All information regarding agencies involved, situation debriefed, and issues discussed shall not be divulged before or after a debriefing except with team members or as part of the team continuing education process. No mechanical recordings or written notes will be made during a debriefing. It is up to the team to enforce this rule during the debriefing. No media personnel (TV, radio or newspapers) will be allowed to attend a debriefing. In the event that these individuals are present without team knowledge, phrases such as “Everything said here is off the record” may be helpful. This does not guarantee, however, that information will not be reported. Participants in the debriefing may speak to the media either before or after the debriefing. It is important for team members to explain that individuals speak only for themselves and NOT for anyone else in the debriefing. Debriefers may speak to the media, but only to educate about the process of CISM and to discuss the effects of stress. All other inquiries should be referred to a Team Coordinator or other designated individual. Debriefings are not a critique of the incident. The team has no evaluation function of tactical procedures. The debriefing process provides a format in which personnel can discuss their feelings and reactions and thus reduce the stress resulting from exposure to critical incidents. The goal of the CISM is to encourage ventilation of emotions and a re-balancing of the individual and the group, and to educate group members regarding normal stress reactions.
General Format For Formal CISM Introductory Phase - Introduction of the CISM Team, description of the debriefing process, establish ground rules. Fact Phase - Self introduction of participants, description of what the participants heard, saw, and did during the incident. Each participant is included in turn by completing the circle. Thought Phase - At what point did the participants realize this was an unusual situation? Content question: “What did you think at the time?” Reaction Phase - Sharing of feelings at the scene, now, and in past situations, if applicable. Content question: “What was the worst part for you?” Symptom Phase - Perceived unusual experiences at the time of and/or since the incident. Expression of participant’s stress response syndromes. Content questions: “What symptoms let you know that this was different from other situations?” “What was your most intense reaction at the scene?” “What were your reactions later?” “What’s not going away?” Teaching Phase - Team discusses stress response syndrome and normal signs, symptoms, and emotional reactions. Re-entry Phase - Wrap up loose ends, answer additional questions, provide final reassurances, establish a plan of action. Content questions: “What was your moment of strength?” “What did you feel good about in yourself?” “What was positive about your response?” “What will be valuable in the future?” Referrals are made at the descretion of the debriefing team clinician. The CISM Team should follow-up with the debriefed agency in an appropriate period of time. The team leader and peer members may also provide appropriate follow-up. The potential need to debrief the debriefers must be considered by the debriefing team. Following the death of an emergency services worker in the line of duty, two debriefings are indicated. The first should ideally occur on the day of the death if possible. The second should occur as soon as possible after the funeral. Postponing the second debriefing for a week is probably too long.
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