# Session No. 23

### Course Title: Disaster Response Operations and Management

### 

### Session Title: Critical Incident Stress Management

## Time: 50 minutes

**Objectives:**

23.1 Define Post-traumatic Stress Disorder (PTSD)/Critical Incident
Stress (CIS) and explain why it occurs after disaster.

23.2 Discuss who may be affected by PTSD/CIS.

23.3 Identify the common signs of PTSD/CIS.

23.4 Explore why it is necessary to address PTSD/CIS and what can be
done to effectively overcome it.

**Scope:**

In the following session, the professor explores the nature of
psychological disturbances that result from emergency situations and
devastating disasters. Post-Traumatic Stress Disorder (PTSD)/Critical
Incident Stress (CIS) are defined and a discussion about why they occur
takes place. The session illustrates that both victims and responders
may become victims of PTSD/CIS. After identifying the typical symptoms
of PTSD/CIS, the session concludes with an explanation of what can be
done to effectively deal with those who are suffering from this
condition.

**Session Requirements:**

1.  Instructor Reading:

> Allen, Richard D. 1993. *Handbook of Post Disaster Interventions*.
> Select Press: Corte Madera, Ca.
>
> American Academy of Experts in Traumatic Stress. 2002. *Trauma
> Response* (Special Edition for Survivors of Traumatic Events and Those
> Who Care for Them). 13 (1).
>
> Austin, L.S. 1992. *Responding to Disaster: A Guide for Mental Health
> Professionals*. American Psychiatric Press: Washington, D.C.
>
> Barnett-Queen, Timonthy and Lawrence H. Bergmann. 1989. "Counseling
> and Critical Incident Stress." *The Voice* (August/September): 15-18.
>
> Bowencamp, Christine. 2000. "Coordination of Mental Health and
> Community Agencies in Disaster Response." *International Journal of
> Emergency Mental Health* 2(3): 159-165.
>
> Bryant, Richard and Allison Harvey. 2000. *Acute Stress Disorder: A
> Handbook of Theory, Assessment, and Treatment*. American Psychological
> Association: Washington, D.C.
>
> Corneil, Wayne. 1989. "Firefighters Suffer Critical Incident Stress:
> Stress in the Aftermath of Disasters." *Emergency Preparedness Digest*
> 16 (1): 24-27.
>
> Craine, Randy and Ter Bagdasarian. 2003. "Early Identification and
> Management of Critical Incident Stress." *Critical Care Nurse* 23 (1).
>
> Department of Health and Human Services. 2000. "Field Manual For
> Mental Health and Human Service Workers in Major Disasters."
> Rockville, Maryland.
>
> Doepel, David G. 1991. "Crisis Management: The Psychological
> Dimension." *Industrial Crisis Quarterly* 5: 177-188.
>
> Everly, George S. 2000. "The Role of Pastoral Crisis Intervention in
> Disasters, Terrorism, Violence and Other Community Crises."
> *International Journal of Emergency Mental Health*. 2 (3).
>
> Everly, George S. 1999. "Toward a Model of Psychological Triage: Who
> Will Most Need Assistance?" *International Journal of Emergency Mental
> Health* 3: 151-154.
>
> Flannery, Raymond. 2003. "Psychological Trauma and Post-traumatic
> Stress Disorder: A Review." International Journal of Emergency Mental
> Health. 77-82.
> [www.icisf.org/articles/Acrobat%20documents/TerrorismIncident/PsyTrauPTSD.pdf](http://www.icisf.org/articles/Acrobat documents/TerrorismIncident/PsyTrauPTSD.pdf).
>
> Flannery, Raymond and George S. Everly. 2003. "Crisis Intervention: A
> Review." International Journal of Emergency Mental Health. 119-125.
> [www.icisf.org/articles/acrobat%20documents/TerrorismIncident/CrsintRev.pdf](http://www.icisf.org/articles/acrobat documents/TerrorismIncident/CrsintRev.pdf).
>
> Fox, Marilyn and Don Bowlus. 1996. "Critical Incident Stress Effects
> on Wildland Firefighters." *Wildfire* (March): 41-46.
>
> Garrity, Thomas E. 1989. "The Need For Psychological Assistance in the
> Fire Service." *The Voice* (August/September): 14.
>
> Gibbs, Margaret, Juliana R. Lachenmeyer, Arlene Broska and Richard
> Deucher. 1996. "Effects of the AVIANCA Aircrash on Disaster Workers."
> *International Journal of Mass Emergencies and Disasters* 14 (1):
> 23-32.
>
> Hall, Molly J., Anne E. Norwood, Robert J. Ursano, Carol S. Fullerton,
> and Catherine J. Levinson. 2002. "Psychological and Behavioral Impacts
> of Bioterrorism." *PTSD Research Quarterly* 13 (4): 1-8.
>
> Harris, Vickie. 1989. "Beyond Critical Incident Stress." The Voice
> (August/September): 16-18.
>
> Harris, Marag, Mustafa Baloglu and James R. Stacks. (2002). Mental
> Health of Trauma-Exposed Firefighters and Critical Incident Stress
> Debriefing." *Journal of Loss and Trauma* 7: 223-238.
>
> Hiley-Young, Bruce and Ellen T. Gerrity. 1994. "Critical Incident
> Stress Debriefing (CISD): Value and Limitations in Disaster Response."
> *NCP Clinical Quarterly* 4(2).
>
> Hopkins, Jim and Charisse Jones. 2003. "Disturbing Legacy of Rescues:
> Suicide." *USA Today* September 23, 13A.
>
> International Critical Incident Stress Foundation, Inc. 2004. CISM
> Information Pamphlet. Ellicott City, Maryland.
>
> Irving, P. and A. Long. 2001. "Critical Incident Stress Debriefing
> Following Traumatic Life Experiences." *Journal of Psychiatric and
> Mental Health Nursing* 8 (4).
>
> James, Alma. 1992. "The Psychological Impact of Disaster and the
> Nature of Critical Incident Stress for Emergency Personnel." *Disaster
> Prevention and Management* 1 (1): 63-69.
>
> Jenkins, Sharon Rae. 1998. "Emergency Medical Workers' Mass Shooting
> Incident Stress and Psychological Recovery." *International Journal of
> Mass Emergencies and Disasters* 16 (2): 181-197.
>
> Jocius, Patricia. 1994. "Critical Incident Stress: What to Look For
> and What to Do." *ASPEP*: 163-169.
>
> Kriner, Stephanie. 2000. "Red Cross Caseworker Helps Oklahoma City
> Move On." 24 April.
> <http://www.disasterrelief.org/Disasters/000420Oklahoma2/>.
>
> Kurexzka, Authur W. 1996. "Critical Incident Stress in Law
> Enforcement." *FBI Law Enforcement Bulletin* 65 (2/3).
>
> McEvoy, Mike. 2004. *Straight Talk about Stress: A Guide for Emergency
> Responders*. National Fire Protection Agency: Quincy, Mass.
>
> McNally, V. and R. Solomon. 1999. "The FBI's Critical Incident
> Management Program." *FBI Law Enforcement Bulletin* 68 (2).
>
> McWhirter, Ellen Hawley and Marc Linzer. 1994. "The Provision of
> Critical Incident Stress Debriefing Services." *Journal of Mental
> Health Counseling* 6 (4).
>
> Mitchell, Jeffrey T. 1988a. "Stress: The History, Status and Future of
> Critical Incident Stress Debriefings" *JEMS* 13 (11): 47-52.
>
> Mitchell, Jeffrey T. 1988b. "Stress: Development and Functions of a
> Critical Incident Stress Debriefing Team." *JEMS* 13 (12): 43-46.
>
> Mitchell, Jeffrey T. 1987. "Effective Stress Control at Major
> Incidents." *Maryland Fire and Rescue Bulletin* (June): 3, 6.
>
> Morrissette, Patrick J. 2004. *The Pain of Helping: Psychological
> Injury of Helping Professionals*. Brunner-Routledge: New York, NY.
>
> Neely, Keith W. and William J. Spitzer. 1997. "A Model for a Statewide
> Critical Incident Stress (CIS) Debriefing Program for Emergency
> Services Personnel." *Prehospital and Disaster Medicine* 12 (2):
> 114-118.
>
> North, S. Carol. 2002. "Coping Function and Adjustment of Rescue
> Workers After Oklahoma City Bombing." Journal of Traumatic Stress 15
> (3): 171-175.
>
> Patterson, Karen. 2002. "In Disaster's Wake Use of 'Debriefing' to
> Help People Cope May not Work, Experts Say." *Dallas Morning News*
> Monday, September 30: 1C, 5C.
>
> Phifer, F. James. 1990. "Psychological Distress and Somatic Symptoms
> After Natural Disaster: Differential Vulnerability Among Older
> Adults." *Psychology and Aging* 5 (3): 412-420.
>
> Sheehan, D.C. 1999. "Stress Management in the Federal Bureau of
> Investigation: Principles for Program Development." *International
> Journal of Emergency Mental Health* 1 (1): 39-42.
>
> Texas Department of Health, Division of Emergency Preparedness.
> "Stress Reactions to Traumatic Events." Austin, Texas.
>
> Ursano, Robert, and Carol Rullerton and Ann Norwood. 2003. *Terrorism
> and Disaster: Individual and Community Mental Health Interventions*.
> Cambridge University Press: Cambridge, UK.
>
> Ursano, Robert, and Carol Fullerton, Kelley Vance, Tzu-Cheg Kao. 1999.
> "Posttraumatic Stress Disorder and Identification in Disaster
> Workers." *American Psychiatric Association* 156: 353-359.
>
> Violanti, John and Douglas Paton and Christine Dunning. 2000.
> *Posttraumatic Stress Intervention: Challenges, Issues and
> Perspectives*. Charles C. Thomas Publisher: Springfield, Il.
>
> Witt, Howard. 2005. "Tragedy Haunts the Heroes." *Chicago Tribune*.
> Monday, April 18.

1.  Student Readings:

> Doepel, David G. 1991. "Crisis Management: The Psychological
> Dimension." *Industrial Crisis Quarterly* 5: 177-188.
>
> or
>
> James, Alma. 1992. "The Psychological Impact of Disaster and the
> Nature of Critical Incident Stress for Emergency Personnel." *Disaster
> Prevention and Management* 1 (1): 63-69.
>
> and
>
> Mitchell, Jeffrey T. 1988b. "Stress: Development and Functions of a
> Critical Incident Stress Debriefing Team." *JEMS* 13 (12): 43-46.

2.  Handouts:

Definitions of PTSD/CIS

Events that Produce PTSD/CIS

Other Factors that Lead to PTSD/CIS

Symptoms of PTSD/CIS

Where Debriefings Came From

Steps to Deal with PTSD/CIS

Components of CIS Debriefing

Characteristics of Effective Programs

Sample PTSD/CIS Program

**Remarks:**

1.  The professor should emphatically emphasize that while most people
    quickly recover emotionally from disasters, others may experience
    many negative psychological impacts that are not visible to
    untrained professionals.

2.  Tact and sensitivity should be used when discussing PTSD/CIS as
    there is a strong possibility that some of the students
    (particularly first responders) have witnessed many gruesome
    disaster scenes, exhibited signs of PTSD/CIS, required stress
    management counseling, or failed to fully recover from past
    on-the-job experiences.

3.  This session will give most of its attention to PTSD/CIS among first
    responders. However, many of the same principles are applicable to
    anyone who suffers from PTSD/CIS after a disaster.

4.  The professor should understand that PTSD/CIS debriefings are
    sometimes known as Critical Incident Stress Management programs.

5.  Possible guest speakers for this session include representatives of
    the American Red Cross, state mental health departments, and others
    who have experienced PTSD/CIS or have helped to provide counseling
    after a disaster.

6\. The professor should read over Objective 23.3 in detail before
conducting the class exercise.

7\. The professor may wish to read a report issued by the National
Institute of Mental Health. It can be accessed at
[www.nimh.nih.gov/research/massviolence.pdf](http://www.nimh.nih.gov/research/massviolence.pdf).

8.  The following organizations offer additional information about
    trauma-related disorders:

**The National Institute of Mental Health**

[www.ninh.nih.gov/publicat/reliving.cfm](http://www.ninh.nih.gov/publicat/reliving.cfm).

**The National Alliance for the Mentally Ill**

Call 1-800-950-6264 or visit
[www.nami.org/helpline.ptsd.html](http://www.nami.org/helpline.ptsd.html)

**The National Mental Health Association**

Call 1-800-969-6642 or visit
[www.nmha.org/infoctr/factsheets/34.cfm](http://www.nmha.org/infoctr/factsheets/34.cfm)

**The Anxiety Disorders Association of America**

Visit [www.adaa.org](http://www.adaa.org/)

**The National Center for Post-Traumatic Stress Disorder**

Call 802-296-6300 or visit [www.ndptsd.org/](http://www.ndptsd.org/)

**The PTSD Alliance**

Call 1-877-507-PTSD, or visist
[www.PTSDAlliance.org](http://www.PTSDAlliance.org/)

**International Critical Incident Stress Foundation, Inc.**

10176 Baltimore National Pike, Unit 201, Ellicott City, Md 21042

\(410\) 750-9600 or [www.icisf.org](../www.icisf.org)

**Objective 23.1 Define Post-traumatic Stress Disorder (PTSD)/Critical
Incident Stress (CIS) and explain why it occurs after disaster.**

**Requirements:**

**Present the following information as a lecture.**

I. **Aside from being affected physically** in a disaster (either from
personal injury or loss of property), **individuals may also succumb to
emotional distress**. This psychological harm is commonly referred to as
**Post-traumatic Stress Disorder (PTSD), Critical Incident Stress
(CIS),** or other similar terms.

> A. **"Post trauma stress disorder (PTSD) is the clinical diagnosis
> given by psychiatrists to the development of specific symptoms
> following a psychologically traumatic event not generally encountered
> in human experience"** (Corneil 1989, 24).
>
> B. **Critical incident stress (CIS) is defined as unusual work stress
> resulting from any trauma, crisis, or event that overwhelms available
> coping mechanisms and potentially interferes with normal functioning
> of emergency service personnel"** (Mitchell in Fox and Bowlus 1996,
> 41).
>
> C. **". . . A critical incident implies any event which has sufficient
> emotional power to overwhelm an individual's ability to cope. Critical
> incidents have the potential to produce such strong reactions so as to
> interfere with one's ability to function either on-scene or later"**
> (Harris 1989, 16).
>
> D. **"By definition, a traumatizing event is one that is outside the
> normal range of everyday life events and is experienced as
> overwhelming by the individual" (Doepel 1991, 179).**

II\. There are **multiple reasons** why some people experience **PTSD or
CIS**. This may be from the **event itself or other stressors in a
person's life or work**.

> A. Mitchell has illustrated that the situation that produce
> psychological harm may include: "Any event that has significant
> emotional power to overwhelm usual coping mechanisms, **line-of-duty
> deaths, serious line-of-duty injuries, emergency-worker suicide,
> disasters, unusually tragic deaths to children, significant events
> where the victims are relatives or friends of emergency personnel,
> events that attract excessive media attention, events that seriously
> threaten the lives of the responders**" (Mitchell 1988, 45).
>
> B. "Such events as **line-of-duty deaths, serious line-of-duty
> injuries, suicide of a co-worker, mass casualties or serious injury to
> children, calls involving relatives or known victims, prolonged
> rescues with loss or incidents with high media coverage** may trigger
> such reactions" (Harris 1989, 16).
>
> C. "A traumatic event usually involves being the **victim of a crime,
> the death of a loved one** in tragic circumstances, **a threat** --
> whether perceived or actual -- to one's own life, to a family member
> or close friend, or the **witnessing of an actual death** or serious
> injury" (**Doepel 1991, 179).**
>
> D. "Such events as **large-scale disasters, major fires** with
> considerable numbers of **victims**, accidents with multiple victims,
> or **loss of colleagues** have been determined as traumatic for
> firefighters" (Corneil 1989, 24).
>
> E. **"**In the aftermath of crises in the workplace (e.g., industrial
> accidents, natural disasters, acts of terrorism, or the traumatic
> death of an employee), corporate officers and mangers are **confronted
> with a staggering array of issues, many of which require an
> instantaneous or almost instantaneous response**. At the same time,
> **these managers are themselves under severe stress originating from
> at least three sources:**
>
> 1\. **the nature of the crisis and their action or inaction during the
> event, which can result in shock, confusion, guilt, denial and
> anger;**
>
> 2\. **their lack of experience in dealing with such events, leading to
> feelings of uncertainty about appropriate responses; and**
>
> 3\. **the expectation placed upon them by the various stakeholders
> (employees, vendors, clients, shareholders and the wider community) to
> reestablish control, safety and confidence in the organization"**
> (Doepel 1991, 177).
>
> **F.** "Exposure to **cold, heat, strenuous physical labor,
> excitement, fatigue, limited food and water and no toilet facilities**
> can be the foundation of a stress reaction. In addition, the
> psychological impact of **frightening, disgusting, frustrating, or
> overwhelming events** adds to the potential of stress reactions in
> emergency workers" (Mitchell 1987, 3).
>
> **G.** But, the **occurrence of death is probably one of the most
> significant factors leading to PTSD** (Gibbs et. al. 1996).

**Objective 23.2 Discuss who may be affected by PTSD/CIS.**

**Requirements:**

**Present the following information as a lecture.**

I. **Most individuals who experience a disaster or other traumatic event
will not suffer any type or long-term psychological distress.**

> A. "Regardless of the location of the traumatizing event, **the
> majority of traumatized persons recover"** (Doepel 1991, 180).
>
> B. "'We know that **the majority of people will get through most kinds
> of trauma without long-term post-traumatic symptoms**,' says Dr. David
> Spiegel, of Stanford University" (in Patterson 2002, 1C).

II\. However, **"Sixty to 70 percent of people experience a serious
trauma in their lifetime, and 8 to 10 percent of the population will
suffer from post-traumatic stress disorder at some time"** (Patterson
2002, 5C).

> A. **"Critical incident stress reactions can happen to anyone, at
> anytime"** (Harris 1989, 16).
>
> B. **"A substantial minority \[of those involved in disasters and mass
> emergencies\] . . . will have chronic PTSD"** (in Patterson 2002, 1C).
>
> C. This may include **everyday citizens affected by disaster** and
> **even** **first responders**.

III\. **Everyday citizens become victims of PTSD/CIS.**

> A. **Those** **affected by disaster** may experience **significant
> trials**.
>
> 1\. **Death** of family members, friends and co-workers.
>
> 2\. **Loss of personal property** (e.g., home or car).
>
> B. **Unemployment** due to business closures.
>
> 1\. Stressful **dealings** with **insurance claim adjusters**.
>
> 2\. **Insufficient** federal or NGO **relief assistance**.
>
> 3\. **Being overcome with a feeling that dreams have faded.**

IV\. **First responders may also become victims of PTSD/CIS.**

> A. **Firefighters, paramedics and police officers** **witness** many
> **grim realities** of their professions.
>
> 1\. On a daily basis they see **gruesome injuries and appalling
> deaths** among **those in the community** and even **within their own
> departments**.
>
> B. They also are **confronted** **with** **other challenges** that
> lead to PTSD/CIS.
>
> 1\. "There is also evidence that people who choose emergency services
> work may have **personality traits** different from the average person
> who has chosen a less demanding or risky job. These 'rescue
> personality' traits include being **action-oriented; obsessive; highly
> dedicated; risk takers; highly motivated by internal factors; having a
> need for immediate gratification, to be in control of themselves and
> the situation, and to help or rescue others**. Rescue workers also
> tend to experience a **difficult time expressing emotions**. This
> difficulty may be in part the result of the demand placed on an
> individual to be a team player, to not be the weak link, and to be
> able to remain in total (emotional) control at all times in order to
> maintain status among peers. Consequently, **many of the workers in
> these professions have subscribed to the traditional 'macho image'
> myth that they should be able to handle anything, coolly and without
> emotion"** (Fox and Bowles 1996, 41-42).
>
> 2\. "Wildland firefighters **face special hazards** in addition to the
> general occupational stressor facing people who work in emergency
> services. These include **breathing poisonous chemicals contained in
> wildfire smoke, temperature extremes, lack of any protective breathing
> apparatus, working in steep and burning terrain, night assignments,
> long shifts, and consecutive days spent away from home on fire
> assignments**" (Box and Bowlus 1996, 41).

V. There are some **characteristics** that may make some people **more
prone to become afflicted with PTSD/CIS than others**.

> A. **"Some groups at particular risk of mental problems following a
> catastrophe:**
>
> 1\. Those who **already have acute stress** of other serious symptoms
> from the trauma, and those who had a **pre-existing psychiatric
> disorder**.
>
> 2\. Others at risk are those who have **lost a loved one**,
>
> 3\. Those **wounded in the disaster**,
>
> 4\. and those who were **exposed to the trauma intensely and for a
> long time**.
>
> 5\. **Children and the elderly** may also be more vulnerable"
> (Patterson 2002, 5C).
>
> B. Harris has identified several **additional** important **factors
> leading to PTSD/CIS**:
>
> 1\. **"Psychosocial development**, or your life situation and past
> experiences, may influence susceptibility (e.g., responding to a SIDS
> call if you have children or a suicide call if your father killed
> himself when you were growing up).
>
> 2\. **Vulnerability** is the recognition that "it could have been me."
>
> 3\. **Personal significance** occurs when the responder can relate
> emotionally to the incident (e.g., the responder is called to a DWI
> accident and his spouse was killed by a drunk driver).
>
> 4\. **Pile-up effect** is when the recurring disturbing events wear
> one down over time (e.g., repeated deaths of infants).
>
> 5\. **Accidental crisis** events are those trials in life that often
> carry over to the workplace (e.g., the loss of one's mother may make
> death at work more difficult to accept).
>
> 6\. **Role conflict** takes place when one cannot fulfill obligations
> of work (e.g., a victim cannot be rescued due to the imperative of
> protecting one's safety)" (Harris 1989, 17-18).
>
> C. It has also been shown that **". . . the degree of their recovery
> depends on the interaction of several factors: the nature of the event
> itself and a person's action or lack of action during it; the
> cumulative effect of any previous trauma; other current life
> stressors, such as illness, divorce or financial problems; person's
> personality traits; the actions and statements of others during and
> after the event"** (Doepel 1991, 180).

**Objective 23.3** **Identify the common signs of PTSD/CIS.**

**Requirements:**

**Have the students participate the following class exercise.**

I. **Divide the students into five groups.**

II\. **Assign each group one of the following topics: physical,
cognitive, emotional, behavioral and spiritual.**

III\. Ask each group to develop **a list of PTSD/CIS signs and
symptoms** for their particular category.

IV\. After the students have had sufficient time to develop their lists,
**ask each group to present their findings to the class.**

V. **After the presentations, the professor may want to utilize the
following information as needed.** People suffering from PTSD/CIS may
show **symptoms, which** **may include** **physical, cognitive,
emotional, behavioral and spiritual manifestations** (ICISF 2004).

> A. "The following lists the behaviors typical of a critical incident
> stress reaction: **sleep disturbances, nightmares, startle response,
> hyper-vigilance, loss of appetite, weight loss, digestive disorders,
> excessive anger, increased instability, difficulty making decisions,
> increased alcohol/drug use, depression, withdrawal from family,
> friends and colleagues, chronic fatigue, heart pounding, chest pains,
> dizzy spells, restlessness, frequent headaches, absentmindedness,
> increased smoking, unusual sense of vulnerability, guilt"** (Corneil
> 1989, 25).
>
> B. "Danger signs include: **increased alcohol abuse, suicidal
> thoughts, nightmares/intrusive images, sleep/appetite disturbance,
> severe relationship disturbances (e.g., domestic violence), persistent
> severe stress symptoms (physical, cognitive, emotional, behavioral)"**
> (Harris 1989, 18).
>
> C. Other possible symptoms include: **mood swings, loss of enthusiasm,
> feeling detached, poor judgment, inability to prioritize, crying, loss
> of creativity, bothered by publicity, decreased sexual desire,
> absenteeism, menstrual changes"** (Fox and Bowlus 1996, 43).
>
> D. "Typically, people report **numbness, denial, avoidance of places
> or things that remind them of the trauma, withdrawal from social
> interaction, depression, inability to concentrate or think clearly,
> and difficulty connecting with others**. People in the acute
> post-trauma period also experience **fearfulness, irritability,
> intrusive imagery, sleeplessness and nightmares, heightened
> sensitivity to external stimuli, and flashbacks to the traumatic
> event**" (Doepel 1991, 179).

VI\. Some **symptoms** may be **age specific**:

> A. Young children "will tend to return to younger behavior such as
> resumption of **bedwetting, thumbsucking, fear of the darkness, fear
> of animals, fear of 'monsters,' and fear of strangers**" (Jocius 1994,
> 164).
>
> B. Older children may exhibit **aggression, rebellion or
> attention-seeking behavior, poor school performance** (Jocius 1994,
> 164-165).

VII\. Many symptoms are **not readily apparent** but may **endure for
long periods of time**.

> A. "The **first signs** and symptoms of stress **are often internal**
> and therefore not clearly apparent to command officers and fellow
> workers. **Minor tremors, nausea, loss of concentration, difficulty
> thinking and problems with memory appear**" (Mitchell 1987, 3).
>
> B. "Most often, these reactions **last for a few weeks** after the
> event. For a few, **they last for months, sometimes years,** affecting
> the firefighter's personal and professional life" (Corneil 1989, 25).
>
> C. "With continued exposure to stressful conditions, **fatigue,
> irritability, frustration, tactical errors, shakes, headaches, stomach
> cramps, intense nausea, visual distortion, and loss of emotional
> control may appear"** (Mitchell 1987, 3).
>
> D. "There's some data to suggest that **if someone's still suffering
> two to three months later, they may end up suffering 12 months down
> the road** as well" (Keane in Patterson 2002, 5C).
>
> E. "**If there is such a 'walling off,' long-term 'post-traumatic
> decline' can occur,** leading to **depression, development of chronic
> medical problems, extreme social isolation, and the loss of ability to
> work and maintain relationships**" (Doepel 1991, 180).
>
> F. "If the stressful events pushing on them do not subside, and if
> they are not relieved, **the reactions to stress may then disrupt
> their abilities so seriously that they become partially or fully
> dysfunctional at the scene**. What is even more unfortunate is that
> the aftereffects of stress may not end when the scene is cleaned up.
> **Some personnel may suffer long range effects which affect their
> lives on the job and at home**" (Mitchell 1987, 3).

**Objective 23.4 Explore why it is necessary to address PTSD and what
can be done to effectively overcome it.**

**Requirements:**

**Present the following information as a lecture.**

I. In light of the psychological problems that result from major
emergencies and disasters, it is recommended that **post-traumatic
stress debriefing/critical incident stress debriefing/critical incident
stress management be implemented** by mental health professionals and
peer counselors.

> A. According to Jeffrey T. Mitchell, "**The two main goals of the
> Critical Incident Stress Debriefing (CISD) are to**:
>
> 1\. **lessen the impact of distressing critical incidents** on the
> personnel exposed to them; and,
>
> 2\. **accelerate recovery from those events** before harmful stress
> reactions have a chance to damage the performance, careers, health and
> families of emergency services personnel" (1988a, 47).
>
> B. Such "**cognitive behavioral therapies take aim at someone's
> thought processes and behavior**. The treatments typically involve
> multiple one-on-one sessions, a few weeks after the trauma.
> **Survivors focus on things such as normal reactions to the event,
> relaxation exercises and coping strategies**. The patients also
> recount the trauma and therapists try to redirect any harmful thinking
> (for instance, if someone believes he was responsible for the
> tragedy)" (Patterson 2002, 5C).

II\. **Critical incident stress debriefing** has **emanated from
military experiences** (combat stress), **police psychology, emergency
medical services and disasters** (Mitchell 1988a, 47).

> A. It has been shown that **"approximately 65 percent of those who
> received immediate psychological treatment for stress were able to
> return to combat duties, but less than 40 percent of those who were
> given delayed treatment in distant areas were able to return to
> combat"** (Mitchell 1988a, 48).
>
> B. Police psychologists have uncovered the **value of "family support
> services, educational programs, post-shooting trauma teams, peer
> support officers and group debriefings"** (Mitchell 1988a, 48).
>
> C. **"Emergency medical services organizations began developing
> psychological support services for staff members in 1972.** The first
> programs were **based in large hospitals and trauma centers**.
> **Services for staff members arose as an off-shoot of services for
> traumatized victims and their families"** (Mitchell 1988a, 48).
>
> D. "One person who felt strongly that group **debriefings were
> important to alleviate stress in emergency personnel** was Captain
> Chip Theodore of the Arlington County (Va.) Fire Department. In 1982,
> he worked at the scene of the Air Florida Airlines crash in
> Washington, D.C. He and his personnel were extremely stressed by that
> incident and Capt. **Theodore pushed for the development of the first
> Critical Incident Stress Debriefing team in the United States**"
> (Mitchell 1988a, 48).

III\. Because **post-traumatic stress debriefing/critical incident
stress debriefing are relatively new techniques** to dealing with
psychological problems, **there are inconsistencies** about the
effectiveness of these treatments.

> A. **Some studies show** **no relation between critical incident
> stress management and psychological recovery**.
>
> 1\. For instance, **Gibbs et. al. study** of the AVIANCA aircrash
> illustrates that **pre-disaster training on disturbing disaster
> conditions had no effect on post-disaster symptoms** (1996).
>
> B. **Research by others shows** **the importance of debriefing**.
>
> 1\. "That National Institute of Mental Health has sponsored numerous
> **studies** on American disasters and has supported the development of
> several important documents that **clearly point out the need for
> psychological support services, especially debriefings for police,
> fire and emergency medical personnel.** But even before these
> documents were published, disasters were showing themselves to be so
> extraordinarily powerful that few emergency workers escaped without
> significant stress reactions" (Mitchell 1988a, 48).
>
> 2\. "The first evaluation studies have been undertaken by a very
> credible researcher, Dr. Robyn Robinson of Melbourne, Australia (who
> in 1986 conducted the largest stress-related study of emergency
> services ever). Her preliminary data in the current study indicate
> that **the majority of emergency personnel (fire, police and
> ambulance) who attended debriefings in Melbourne, Australia during the
> last year felt that the sessions were helpful**. In fact, the more
> serious the incident, the more helpful were the debriefings perceived"
> (Mitchell 1988a, 50).
>
> 3\. "Seventy-five percent of those who participated in her recent
> preliminary **study** **cited three main values of a CISD**. They are:
> **the opportunity to express oneself and be assured that one's
> reactions are normal; the chance to learn from others and mobilize
> one's own coping behaviors; and the ability to gain a greater
> understanding of Critical Incident Stress**" (Mitchell 1988a, 50).
>
> 4\. Research has shown the importance of **addressing PTSD/CIS quickly
> and effectively**.
>
> a\. "**If psychological effects are left unresolved, they can lead to
> job burnout, alcohol and drug dependency**. All of which means you can
> lose a good firefighter in the prime of his career" (Garrity 1989,
> 14).
>
> b\. **"The longer you wait to get help, the longer it takes to get
> better"** (Harris 1989, 18).
>
> c\. "Dr. Everly points out that in cases **where help for extremely
> traumatic events was provided within three weeks, the costs for
> treatment of a severely traumatized person were about \$5,000**. **If
> help was delayed** beyond three or four weeks, **a severely
> traumatized person or his organization might be faced with bills of
> approximately \$200,000 to achieve recovery**" (Mitchell 1988a, 50).
>
> C. **Others question the value of critical incident stress
> management** (Patterson 2002).
>
> 1\. Barnett-Queen and Bergmann have illustrated the problems
> associated with one-on-one counseling. **"There are at least four
> major difficulties with individual counseling after traumatic
> events:**
>
> a\. **There may be a stigma attached to seeking mental health services
> in many departments.** Firefighters who participate in counseling may
> be viewed as weak or even crazy, and may be denied promotions or
> choice assignments. Where such obvious discrimination does not exist,
> the feeling among other personnel may be that they are somehow less
> trustworthy or reliable.
>
> b\. **Firefighters who are referred to counseling may believe that
> they are being singled out for their post-traumatic symptoms and that
> these feelings are not normal and to be expected.** Such thoughts may
> increase the probability of severe post-trauma consequences.
>
> c\. **Counseling participation is costly.** One hour of individual
> counseling will vary in cost from \$40.00 to \$120.00 depending on the
> experience and expertise of the mental health provider. Psychological
> debriefing sessions may include as many as 20 firefighters, and, as a
> result, are much more economical.
>
> d\. **Some firefighters who need post-trauma services will not be
> identified by the normal referral process.** In order to make a
> referral for counseling, the person making the referral must have
> noticed a change or seen a need in that individual. However, those
> impacted by duty-related trauma may not show such changes, or will be
> able to hide their feelings. In these cases, a person needing
> assistance may not receive it.
>
> e\. **Traumatized firefighters need the support of those who have been
> involved in the same and/or similar incidents.** Counseling with a
> mental health professional may not provide this support"
> (Barnett-Queen and Bergmann 1989, 15).
>
> 2\. **"Debriefing may also encourage survivors to focus too much on
> their symptoms -- and worry about them in the long run"** (Foa in
> Patterson 2002, 5C).
>
> 3\. "The problem is that even though . . . those early psychological
> interventions have become an industry**, there were not really good
> studies about them**,' says Edna Foa, of the University of
> Pennsylvania. **'So now that the studies have started to come, in the
> last six, seven years, none has shown that it works. And two or three
> are showing that it may even impede the recovery'"** (in Patterson
> 2002, 1C).
>
> D. Most scholars therefore agree that **critical incident stress
> management is a complicated matter and that we need more research on
> the topic.**
>
> 1\. "The few **negative comments** provided by people in the study who
> were debriefed after critical incidents **did not indicate that the
> debriefings were not helpful**. Instead**, they made suggestions for
> improving the process of the debriefing** and the communications
> between the CISD team and those being debriefed" (Mitchell 1988a, 50).
>
> 2\. We have made some **assumptions that require further
> investigation**: "that **all stressful experiences call for crisis
> intervention; that the earlier done, the better; and that recounting
> the incident is beneficial**" (Foa in Patterson 2002, 5C).
>
> 3\. Dr. Pennebaker states "It's not reasonable to assume that you can
> work through all those issues in five minutes, a day, some kind of
> debriefing session, or any kind of therapy session. **The bigger the
> event, the longer it's going to take**" (in Patterson 2002, 5C).
>
> 4\. "Dr. Keane wonders whether survivors behave differently after a
> small-scale event, such as a plant explosion, vs. a tragedy of the
> magnitude of Sept. 11. And, he notes, **researchers need to address
> cultural differences** -- to understand, for instance, why **Hispanics
> as a group were more likely to have symptoms of PTSD after the World
> Trade Center disaster than other New Yorkers were**." (Patterson 2002,
> 5C).
>
> 5\. "I think **we've come a great distance** since the disorder was
> identified,' he says, citing advances in treatments, diagnosis, and
> understanding of the biology and course of PTSD. 'That being said,
> **there's more to be learned'**" (Keane in Patterson 2002, 5C).

IV\. Regardless of the inconclusive nature of research, there are many
**steps that can be taken to effectively deal with PTSD/CIS**.

> A. **Citizens and emergency personnel** should be **educated and
> trained** about **PTSD and CIS**.
>
> 1\. "**The first and most important issue** is a continued emphasis on
> **pre-incident stress education**. This has always been a mainstay of
> the CISD process" (Mitchell 1988a, 51).
>
> 2\. "One of the first things officers should do to assist themselves
> in preventing stress reactions in their personnel is to **attend
> training programs or read material which give them the cues so that
> they might recognize stress reactions in their personnel**.
> **Recognition can be one of the most important steps** to take to deal
> with stress at an incident" (Mitchell 1987, 3).
>
> 3\. Corneil has also asserted the need for "**awareness and
> acknowledgement of CIS, training and education in recognizing the
> signs of CIS, and preplanned responses to minimize the incapability
> caused by CIS**" (1989, 25).
>
> B. **CIS Teams can be created** **and operated carefully** to help
> first responders deal with stress.
>
> 1\. "**CISD teams are made up of** dedicated and trained
> **mental-health professional**s who combine their expert knowledge and
> talents with specially trained peer support personnel drawn from the
> emergency service's ranks. The CISD team is essentially a
> **partnership** between the two groups with a common goal -- the
> reduction of critical incident stress in emergency personnel"
> (Mitchell 1988b, 44; see also Neely and Spitzer 1997, 114).
>
> 2\. "The makeup of a team is roughly **one-third mental-health
> professionals and two-thirds peer-support personnel**" (Mitchell
> 1988b, 44).
>
> 3\. "**A CISD team without mental-health professionals is not only
> ineffective, but dangerous** because mental-health professionals are
> necessary to provide leadership and supervision. They also possess
> diagnostic skills to recognize those issues more serious than stress
> alone. **Missed symptoms may cause an emergency worker to commit
> suicide**" (Mitchell 1988b, 46; Neely and Spitzer 1997, 114).
>
> 4\. "**It takes a special task force at least six months to one year
> to properly organize a CISD team** in most communities" (Mitchell
> 1988b, 46).
>
> 5\. "Another challenge for CISD teams is to **maintain the middle
> position, or even better, a neutral outside position to all of the
> political factions which exist within emergency services
> organizations**. CISD teams must avoid becoming the political
> footballs of unions, management, government and special interest
> groups" (Mitchell 1988a, 51).
>
> 6\. "They must **be cautious in their efforts to help every group that
> approaches them with a need**. Attempting to help too broad a spectrum
> of people will dilute the ability of the teams to provide effective
> services, leaving them fragmented and exhausted with little energy
> left for the people they were designed to help -- the emergency
> services personnel" (Mitchell 1988a, 51).
>
> 7\. "Another point to keep in mind when establishing a team is the
> size of the area served. Since mental-health resources are limited, it
> is recommended that a team serve a region encompassing several
> jurisdictions. . . . **Serving a large area is important for several
> reasons**. **First, it is not a good idea to formally debrief your
> friends and fellow workers because it is too emotionally draining.
> Second, supervisory staff members may join the team and are always
> more helpful to people outside their own organizations because of
> management issues that may arise. Third, the debriefing attendees feel
> more comfortable when receiving services from people they do not see
> or work with on a regular basis"** (Mitchell 1988, 44).
>
> C. **Seek support from key administrators**.
>
> 1\. "The next important issue to be emphasized is administrative
> support for emergency personnel. **Even the best CISD teams**, that
> have provided the very best pre-incident stress training and the best
> post-incident debriefings, **will be frustrated and ineffective if
> they are forced to work in an environment where administrators do not
> acknowledge a need to support their most valued resource** **-- their
> personnel**" (Mitchell 1988a, 51).
>
> D. **Address trauma during response.**
>
> 1\. "Except for the first arriving crews, which are heavily involved
> in operations, **all new arriving crews should be given a briefing
> about the operation** and the things they will see and hear.
> **Surprise can be a dangerous psychological element** in a field
> situation and every effort should be made to cut down on
> surprises**"** (Mitchell 1987, 3).
>
> 2\. "One of the most important things which lessens stress in the
> field is **frequent breaks**. Most people can work under intense
> stress for about an hour before some of the effects of stress are
> felt" (Mitchell 1987, 3).
>
> 3\. "**Emergency workers need a considerable amount of fluid to
> prevent dehydration**. Water, juices, coffee, tea and hot cocoa are
> certainly welcome and necessary refreshments at a scene. But emergency
> personnel should be cautioned that **excessive caffeine and sugar can
> enhance a stress reaction**. **They should therefore limit their
> intake of caffeine and sugar.** **Obviously an adequate supply of food
> should be provided at the scene to assure that personnel have
> sufficient energy to perform their work**" (Mitchell 1987, 3).
>
> 4\. "An important key to stress control is to recognize change in the
> personnel. When people act very differently than what the commander is
> used to, it is usually an indication of stress reactions.
> **Significant change in the behavior of one's personnel should be an
> alarm to the commander that the event has had a significant
> psychological impact on them**" (Mitchell 1987, 3).
>
> 5\. "Decisions on whether a distressed person needs to be removed from
> service at the scene are usually difficult to make. **Hasty decisions
> will usually not be good ones.** **First try an extended rest break.**
> If the person improves, he or she might be placed back in service at
> the scene, but **it is usually preferable to change their work site
> and duties so that they will not be retraumatized**. If no improvement
> is noted, **the next option might be keeping the person at the scene
> but not assigning them to work crews. If the serious distress
> continues, the individual probably needs to be removed to home or a
> fire station**" (Mitchell 1987, 6).
>
> 6\. "**If a crew is only a few minutes from completion of a task, they
> should be allowed to complete it**. If they are changed when the task
> is close to completion, they will be quite angered and demoralized by
> the change" (Mitchell 1987, 3).
>
> 7\. "**If mental health personnel are called to the scene because the
> magnitude of the event warrants on-scene support, they should report
> to the command post** and be given a briefing about the incident. **It
> is best that mental health personnel function as observers** and
> advisors and **keep a generally low profile** around the scene"
> (Mitchell 1987, 6).
>
> 8\. "Mental health professionals at a scene would be best to **render
> crisis intervention only to those emergency workers who are showing
> obvious signs of emotional distress**" (Mitchell 1987, 6).
>
> 9\. "**Under no circumstances should they \[the disturbed responders\]
> be sent away** to a place where they will be completely **alone**.
> They do not need anyone to be clinging to them, but **someone should
> be in the vicinity in case they decide that they need to talk about
> the experience**" (Mitchell 1987, 6).
>
> 10\. Ensure that responders know the value of expressing concerns:
> "**The natural course of trauma is that people turn to others, they
> talk to others, they listen to others . . . . I think these are the
> natural resources that most of us have when we deal with something
> upsetting**" (Pennebaker in Patterson 2002, 5C).

E. **Follow up** with PTSD/CIS **after the incident**.

> 1\. "**Before a debriefing** is held, **all of the coordination
> associated with the debriefing is done**, including the **announcement
> to those involved and the setup of the room**. Also, the **CISD team**
> **reviews the incident** by reading the reports and newspaper
> clippings and by viewing photographs or video tapes of the incident.
> Many CISD teams **visit the scene** before conducting a debriefing"
> (Mitchell 1988b, 45).
>
> 2\. "If the critical incident affected various types of emergency
> personnel at the scene, a joint multi-agency debriefing is often held.
> It is important then to pick **peer-support personnel from each of the
> services for the CISD team**. **If an incident involves only EMS
> personnel, it is important to choose EMS peers** since EMS people are
> more likely to trust fellow workers**. The same concept holds true for
> police and fire personnel**" (Mitchell 1988b, 45).
>
> 3\. "During the debriefing, **personnel should not be required to
> respond to calls;** others in the system need to fill in for them"
> (Mitchell 1988b, 45).
>
> 4\. "**Family members may not only benefit from participating in the
> counseling process**, as it may help increase their understanding of
> you and your job, **they are an invaluable source of support** that is
> often ignored by firefighters." (Harris 1989, 18).
>
> 5\. Follow the **components of critical incident stress debriefings**:
>
> a\. "The CISD begins with an ***introduction*** from the CISD team
> members at which point **they state that the material to be discussed
> is strictly confidential**. It should also be emphasized that the CISD
> is **not an operations critique**. Attendees are then told what to
> expect during the debriefing and assured that the major concern of the
> CISD team is to restore people to their routine lives as soon as
> possible with minimal personal damage to the emergency services
> worker" (Mitchell 1988b, 45).
>
> b\. "The second phase of the CISD is the ***fact phase*** in which
> people **are asked to describe what happened at the scene**. This is a
> relatively easy phase for emergency personnel used to talking about
> the operational aspects of the incident" (Mitchell 1988b, 45).
>
> c\. "Once the incident is described, the debriefing team leader will
> lead the discussion into the ***thought phase*** of the process. The
> usual question asked in this phase is, **'Can you recall your first
> thoughts once you stopped functioning in an automatic mode at the
> scene?'** This helps people to 'personalize' their experiences"
> (Mitchell 1988b, 45).
>
> d\. "The fourth phase of a debriefing is the ***reaction phase***, the
> point at which **people can describe the worst part of the event for
> them and why it bothered them**. If a critical incident has any
> significant emotional content attached to it, it will usually be
> discussed during this phase. It can occasionally become a heavy
> emotional phase of the debriefing but is not necessarily intense"
> (Mitchell 1988b, 46).
>
> e\. "The fifth phase of the CISD process is the ***symptom phase***.
> The group is asked to **describe stress symptoms felt at three
> different times**: The first being those symptoms experienced during
> the incident; the second are those that appeared three to five days
> after the incident; and the last being symptoms that might still
> remain at the time of the debriefing. Changes, increased and decreases
> of symptoms are good indicators for the mental-health of the person of
> the need for additional help for some attendees" (Mitchell 1988b, 46).
>
> f\. "The next phase of the CISD process is the ***teaching phase***.
> The CISD team members **furnish a great deal of useful
> stress-reduction information to the group**. They also incorporate
> other information, such as the **grief process, promoting
> communication with spouses and suggesting how to help one another
> through the stress**" (Mitchell 1988b, 46).
>
> g\. "The seventh phase of the debriefing process is called the
> ***re-entry phase***, when personnel may **ask whatever questions they
> have**. A summary is given by the team and the CISD is concluded"
> (Mitchell 1988b, 46).
>
> 6\. Help victims understand c**oping strategies which may include:
> "concentrating on other things, exercise, talk about incident to
> coworkers, think about humorous aspects, discuss with family and
> friends, try to be more helpful to others, devote self to work, try to
> find new interests, contemplate the meaning of life, turn to
> religion"** (Fox and Bowlus 1996, 44).
>
> 7\. "**All defusing, demobilizations and debriefings must receive
> follow-up services. Follow-ups usually begin 24 hours after the
> debriefing.** The many ways that follow-up can be achieved include:
> **telephone calls** to individuals, **discussions** with commanders,
> **visits** to stations, **sending** **peers** **to** **see** that
> **personnel** are doing all right, **educational** **programs**,
> **individual** **counseling** sessions, **spousal** **support**
> **services**, others activities as the needs arise" (Mitchell 1988b,
> 46).
>
> F. **Mitchell has summarized many of these CISD functions**.
>
> 1\. **"Pre-incident CISD Functions:**
>
> a\. **Educating line personnel about stress, stress recognition and
> stress reduction**.

-   Education should include **material on critical incident stress, how
    it differs from non-emergency stress, a description of the CISD team
    and how to utilize it** if the need arises.

> b\. **Educating the command staff about stress and its effects on
> themselves and their personnel**.

-   This segment should include specific information on **field
    strategies for stress control** during a crisis.

-   Commanders should also **know the capabilities and limitations of
    the CISD team and how to initiate services** during and after a
    critical incident.

> c\. **Developing stress management protocols for field use**.

-   It is well-established that if the **guidelines are written down and
    practiced**, they are most likely to be followed.

-   The protocols should list guidelines for commanders on items such as
    the **optimal length of work time, frequency of rest periods,
    maximal time at the scene, food, shelter, replacement of gloves and
    use of the CISD team members** during major events.

> d\. **Providing significant other or spouse and family education
> programs** to enhance the quality of life for emergency personnel and
> the people important to them.
>
> e\. **Organizing individual counseling programs, employee assistance
> programs, chaplain services and disaster intervention plans** as well
> as other programs helpful to emergency responders" (Mitchell 1988b,
> 44-45).
>
> 2\. **CISD Functions During an Incident**:
>
> a\. **On-scene support services**

-   During the incident, a debriefing team is involved with **providing
    on-scene support services** that assist obviously distressed
    personnel.

-   It **advises and counsels command staff and gives direct and
    indirect support to the victims** until other appropriate agencies
    can be mobilized to provide services.

b\. **Defusings**

-   These are **shorter, unstructured debriefings that encourage a brief
    discussion of the events** and significantly reduce acute stress.

-   Defusings are **done anywhere from one to three hours following the
    incident**, often at the station, and generally last from 30 minutes
    to an hour.

-   **Only those crews most affected are involved**; not all workers
    from the scene attend, as would be the case in debriefings.

-   **If the defusings are not accomplished within 12 hours, a full
    formal debriefing is the next alternative** **approximately three
    days after the incident**.

-   **A well-run defusing often eliminates the need for a full formal
    debriefing**.

-   Even if both are still necessary, **a debriefing held three days to
    a week after a defusing usually is more beneficial**.

-   **People are more willing to talk during a debriefing when first
    presented with a supportive defusing shortly after the incident**.

> c\. **Demobilizations**

-   These are **reserved for large-scale incidents only** and take the
    place of a defusing.

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-   Immediately after emergency units cease and disengage from
    operations at a major incident, **units are sent to a large meeting
    facility where they are met by mental-health professional**.

-   Unlike the defusing or debriefing, **personnel are not requested to
    discuss the incident**.

-   Instead, **the mental-health professional assigned to their unit
    provides a 10-minute presentation on the typical effects of critical
    incident stress** and the signs and symptoms that may appear.

-   The **personnel are given as many practical suggestions for stress
    management** as possible along with an opportunity to ask questions
    and make comments.

-   The **mental-health person assigned to their group remains available
    to privately discuss the situation or their reactions**.

-   **Talking to the other mental-health professionals at the debriefing
    center is also an option**.

-   **Chaplains may be present** at the debriefing center and **are
    available** if an emergency person would prefer to discuss something
    with them.

-   **No one is required to talk unless they choose to**.

-   All of the personnel being demobilized are **given an opportunity to
    get something to eat and relax** before returning to duty or home.

-   They are **encouraged to rest during the transition from a major
    event back to routine duties**.

-   **The entire demobilization process should be completed within 30
    minutes**, and two-thirds of that time should be allotted to rest
    and eating.

> 3\. **Post-incident CISD Team Functions**
>
> a\. Once an incident is over and defusings or demobilizations
> complete, **emergency personnel enter a phase lasting about 24 hours
> where they generally prefer not to discuss the situation** with
> outsiders.

-   Many **private thoughts emerge** as crew members attempt to sift
    through all the details of the incident.

-   Many times **they are concerned with whether protocols and
    procedures were followed exactly**.

-   It may be required that they **write reports or go through the
    preliminary investigations**.

-   They are usually **not ready to deal with whatever feelings may have
    been generated** during the incident.

-   **Emergency responders usually do not benefit from CISDs during that
    24-hour period because their reactions are too intense to absorb the
    important messages presented in a debriefing**.

> b\. What is usually more important is to **provide individual support
> to those people showing the greatest need and to provide advice to
> command staff** trying to plan for the support services required.

-   Following a crisis, **emergency workers are likely to close ranks,
    preferring to talk with individuals in the unit or participate in
    small group conversations** related to the event.

-   This conversation is called the **'initial discussion'** and CISD
    teams usually have little involvement in it.

-   However, **peer support personnel, including those involved in the
    incident, are trained to watch for telltale signs of distress in
    their fellow workers: irritability, excessive humor, increased
    derogatory remarks against one another, significant changes in
    behavior and withdrawal from others**.

-   When these sign of distress become apparent in their coworkers,
    **peer support personnel contact the CISD team coordinator who may
    initiate the setup of formal CISD"** (Mitchell 1988b, 44-45).

> G. **Barnett-Queen and Bergmann have identified similar steps for
> CISD** (1989, 16).
>
> 1\. "**Trauma Preparation Training**.
>
> a\. **Each firefighter and officer should receive basic information
> concerning duty-related trauma** to assist in understanding the
> department's program and the psychological risks associated with the
> fire service.
>
> b\. The **goals of this training** are to:

-   **prepare personnel for the normal psychological consequences of
    exposure to potentially traumatic incidents**;

-   **teach basic recovery coping skills** to be used after an incident;

-   assist in **creating a supportive environment throughout the
    organization**; and

-   **describe the components, procedures and regulations associated
    with the post-trauma program**.

> 2\. **Peer Support Programs**.
>
> a\. The purpose of the peer support component of the Continuum is to
> **insure that each person involved in potentially traumatic incidents
> will receive the support and services** necessary to make a successful
> recovery.

-   **Without the availability of peers** within the organization to
    monitor potentially traumatic incidents, **some will certainly be
    overlooked**.

> b\. **Peer supporters are not counselors**.

-   **Their tasks include: contacting co-workers to remind them that
    others in the organization are concerned about their welfare,
    allowing the opportunity to discuss the incident, assessing for the
    need for further post-trauma services, reinforcing the use of
    productive post-trauma coping skills taught in the training session
    and following up with each person through the recovery process**.

-   **Peer supporters may also participate in debriefings** by assisting
    mental health professionals.

> 3\. **Debriefings**.
>
> a\. Debriefings are **carefully structured meetings which occur after
> a potentially traumatic incident**.
>
> b\. There are **two main types of debriefings**, **didactic and
> psychological**.
>
> c\. **Didactic debriefings** may include **large numbers of personnel,
> and focus on educating participants concerning post-trauma
> consequences and effective coping skills**.
>
> d\. **Psychological debriefings** **are designed for smaller groups of
> personnel** (15-20 maximum), and focus on **preventing long-term
> post-trauma consequences** and the need for additional services.

-   It is our experience that **psychological debriefings are most
    effective**, especially when they are part of a planned and
    coordinated post-trauma program.

-   Only this type of debriefing **includes all of the critical elements
    of recovery, and provides the individual attention and supervision
    that best insures the safety of participants**.

> 4\. **Post-trauma Counseling**.
>
> a\. **Only a small percentage of those involved in a traumatic
> incident require counseling**.
>
> b\. A **recommendation for this service** is usually **made at the
> debriefing** for the following reasons:

-   **severe post-trauma consequences** are reported;

-   there is **evidence of serious levels of depression or suicidal
    ideas**; or

-   **some aspect of an individual's participation in the debriefing has
    indicated that counseling would be helpful**.

-   **Counseling sessions** are extensions of debriefings, and include
    **continued discussion of the traumatic events and post-trauma
    consequences**, as well as a **heavy focus on coping skills** for
    reducing the probability of long-term post-trauma consequences.

-   Post-trauma counseling sessions are **different from many other
    kinds of counseling and psychotherapy** in that they are almost
    exclusively oriented to the '**here and now**.'

-   While some mental health professionals spend considerable time with
    clients discussing events in the distant past, **those working with
    trauma individuals are more likely to focus on the traumatic event
    and efforts toward recovery**.

-   **Counseling** provided as part of an overall program and with the
    incident as the focus of the services **can be an important part of
    a firefighter's recovery**" (Barnett-Queen and Bergmann 1989, 16).

> H. According to Barnett-Queen and Bergmann, "**Effective post-trauma
> programs seem to require the following four components**:
>
> 1\. **Information**.
>
> a\. Personnel who have **accurate information** about trauma,
> post-trauma consequences and productive post-trauma coping skills
> **seem to make more successful recoveries**.
>
> b\. Those who are the victims of duty-related trauma and **do not have
> recovery information** sometimes believe that they are **never going
> to recover** and that they should not be experiencing any emotional
> changes.
>
> c\. In addition, **they tend to use inappropriate coping skills** to
> numb or manage their post-trauma consequences.

2\. **Support**.

> a\. Survivors of trauma tend to **feel isolated, distrustful and
> detached**.
>
> b\. Where survivors **receive consistent support from their peers and
> families**, they feel more positive about themselves, their efforts to
> recover and their prognosis.

3\. **Ventilation**.

> a\. Detailed **discussion of the incident with others is an important
> element** of post-trauma recovery.
>
> b\. **Individuals who can talk about their experiences are more likely
> to feel supported** by the listeners and others involved in the
> incident.
>
> c\. **They may learn important details of the event from others or may
> recall more of their own experiences during the incident, which
> promotes recovery**.
>
> d\. Finally, **survivors who are able to articulate their experiences
> are more likely to understand what has happened and the changes in
> their lives**.
>
> 4\. **Coping Skills**.
>
> a\. **The coping skills required for day-to-day living may not be
> those most helpful for a successful recovery**.
>
> b\. The use of appropriate **coping skills enhances the probability of
> recovery after a traumatic event**" (Bergmann and Barnett-Queen 1989,
> 15).
>
> 5\. In short, **"an effective post-trauma program includes a large
> organizational shift; administration and personnel come to accept the
> validity of the impact of psychological trauma and the critical nature
> of the program"** (Barnett-Queen and Bergmann 1989, 15).

**Questions to be asked:**

**1. What is Post-traumatic Stress Disorder/Critical Incident Stress?**

**2. Who can be affected by PTSD/CIS?**

**3. Why are people adversely impacted after a disaster?**

**4. What are the common signs and symptoms of PTSD?**

**5. Why does PTSD/CIS need to be addressed quickly after a disaster?**

**6. What is the make up and benefit of a PTSD/CIS team?**

**7. What can be done to correct PTSD/CIS?**

**8. What are the traits of successful PTSD/CIS programs?**

**Definitions of PTSD/CIS**

**"Post trauma stress disorder (PTSD) is the clinical diagnosis given by
psychiatrists to the development of specific symptoms following a
psychologically traumatic event not generally encountered in human
experience"** (Corneil 1989, 24).

**Critical incident stress (CIS) is defined as unusual work stress
resulting from any trauma, crisis, or event that overwhelms available
coping mechanisms and potentially interferes with normal functioning of
emergency service personnel"** (Mitchell in Fox and Bowlus 1996, 41).

**Events that Produce PTSD/CIS**

**"Any event that has significant emotional power to overwhelm usual
coping mechanisms:**

-   **line-of-duty deaths**

-   **serious line-of-duty injuries**

-   **emergency-worker suicide**

-   **disasters, unusually tragic deaths to children**

-   **significant events where the victims are relatives or friends of
    emergency personnel**

-   **events that attract excessive media attention**

-   **events that seriously threaten the lives of the responders"**
    (Mitchell 1988, 45).

**Other Factors that Lead to PTSD/CIS**

**"Psychosocial development**, or your life situation and past
experiences, may influence susceptibility (e.g., responding to a SIDS
call if you have children or a suicide call if your father killed
himself when you were growing up).

**Vulnerability** is the recognition that "it could have been me."

**Personal significance** occurs when the responder can relate
emotionally to the incident (e.g., the responder is called to a DWI
accident and his spouse was killed by a drunk driver).

**Pile-up effect** is when the recurring disturbing events wear one down
over time (e.g., repeated deaths of infants).

**Accidental crisis** events are those trials in life that often carry
over to the workplace (e.g., the loss of one's mother may make death at
work more difficult to accept).

**Role conflict** takes place when one cannot fulfill obligations of
work (e.g., a victim cannot be rescued due to the imperative of
protecting one's safety)" (Harris 1989, 17-18).

**Symptoms of PTSD/CIS**

(ICISF 2004)

-   **Physical**

-   **Cognitive**

-   **Emotional**

-   **Behavioral**

-   **Spiritual**

**Where Debriefings Came From**

(Mitchell 1988a, 47)

-   **Military experiences** **(combat stress)**

-   **Police psychology**

-   **Emergency medical services**

-   **Disasters**

**Steps to Deal with PTSD/CIS**

-   **Train and educate response personnel**

-   **Create CIS Teams**

-   **Seek support from administrators**

-   **Address trauma during response**

-   **Follow up after the event**

**Components of CIS Debriefing**

(Mitchell 1988b, 46)

-   **Introduction**

-   **Fact Phase**

-   **Thought Phase**

-   **Reaction Phase**

-   **Symptom Phase**

-   **Teaching Phase**

-   **Re-entry Phase**

**Characteristics of Effective Programs**

(Bergmann and Barnett-Queen 1989, 15)

-   **Information**

-   **Support**

-   **Ventilation**

-   **Coping Skills**

**Sample PTSD/CIS Program**

The following information was provided by a fire chief in Hudson,
Massachusetts:

"On May 5, 1989, at 0145 a.m. my men responded to a reported dwelling
fire. Upon arrival, the first engine company reported that they had a
fully involved second floor, extending to the third floor in a 2 ½-story
wooden, balloon-type-constructed building. They were met by cries of the
father and mother who were both severely burned, and a brother who lived
downstairs, who was not burned. He hysterically relayed to the fire
fighters that his two brothers and one sister were still trapped in the
building.

Natural access up the front stairwell was not possible because of the
tremendous volume of fire encountered. Fire fighters put up a ground
ladder and advanced a line to the bedroom of the two boys. This room was
burning and the firefighter went into the room while the other
firefighters kept the fire from engulfing the room. The two boys were
found and removed by firefighters over ladders. The same type of rescue
was attempted over an aerial ladder on the third floor with 1 ¾-inch
line to try and drive the fire out. This attempt was unsuccessful
because of the large amount of fire, and the little girl was not
rescued. Her body was not recovered for approximately one hour, not
until the internal attack had knocked down the fire. Concerning the two
boys that firefighters rescued: one died, and the other is today out of
the hospital and doing well.

After the fire, I spoke with all fire department personnel who were
involved, and commended their efforts. I could see that the two deaths
had taken their toll on the firefighters, and they were not speaking
freely about the incident.

I contacted Dr. Gerry Lewis for his help with the psychological
counseling needs of my men. I called a department meeting and invited
all firefighters to come. At the meeting, which was attended by
four-fifths of the department, we discussed what had taken place four
days earlier. By using our radio tape recorder I was able to put
together a sequential order of events, and the times they had taken
place. I found this to be extremely helpful to the overall effectives of
the critique because it showed the firefighters how quickly things were
done. With the help of Dr. Lewis, each firefighter spoke of the actions
they had performed at each stage of the fire. By the end of the critique
the firefighters were openly talking, which made the effects of the
incident at least livable. In this entire fire, the thing which affected
my men the most was that they were unable to immediately remove the girl
from the building" (Garrity 1989, 14).