Critical incident stress debriefing (CISD) uses a structured, small group format to discuss a distressing crisis event. It is the best known and most widely used debriefing model. Critical incident stress management (CISM) refers to a system of interventions that includes CISD as well as other interventions, such as one-on-one crisis intervention, support groups for family and significant others, stress management education programs, and follow up programs. It was originally designed to be used with high-risk professional groups, such as emergency services, public safety, disaster response, and military personnel. It can be used with any population, including children. A trained personnel team conducts this intervention. The team usually includes professional support personnel, such as mental health professionals and clergy. In some settings, peer support personnel, such as emergency services workers, will be part of the debriefing team. It is recommended that a debriefing occur after the first 24 hours following a crisis event, but before 72 hours have passed since the incident.
Purpose
This process aims to prevent excessive emotional, mental, physical, and behavioral reactions and post-traumatic stress disorder (PTSD) from developing in response to a crisis. Its goal is to help individuals recover as quickly as possible from the stress associated with a crisis.
Description
Individuals are more open to receiving help during crises. A person may have experienced the crisis within the last 24 hours or within a few weeks before seeking help. Crisis intervention is conducted in a supportive manner. The length of time for crisis intervention may
range from one session to several weeks, with the average being four weeks. Crisis intervention is not sufficient for individuals with long-standing problems. Session length may range from 20 minutes to two or more hours. Crisis intervention is appropriate for children, adolescents, and younger and older adults. It can take place in a range of settings, such as hospital emergency rooms, crisis centers, counseling centers, mental health clinics, schools, correctional facilities, and other social service agencies. Local and national telephone hotlines are available to address crises related to suicide, domestic violence, sexual assault, and other concerns. They are usually available 24 hours a day, seven days a week.
Responses to crisis
A typical crisis intervention progresses through several phases. It begins with an assessment of what happened during the crisis and the individual's responses to it. There are certain common patterns of response to most crises. An individual's reaction to a crisis can include emotional reactions (fear, anger, guilt, grief), mental reactions (difficulty concentrating, confusion, nightmares), physical reactions (headaches, dizziness, fatigue, stomach problems), and behavioral reactions (sleep and appetite problems, isolation, restlessness). Assessment of the individual's potential for suicide and/or homicide is also conducted. Also, information about the individual's strengths, coping skills, and social support networks is obtained.
Education
There is an educational component to crisis intervention. It is critical for the individual to be informed about various responses to crisis and informed that he or she is having normal reactions to an abnormal situation. The individual will also be told that the responses are temporary. Although there is not a specific time that a person can expect to recover from a crisis, an individual can help recovery by engaging in the coping and problem-solving skills described below.
Coping and problem solving
Other elements of crisis intervention include helping the individual understand the crisis and their response to it as well as becoming aware of and expressing feelings, such as anger and guilt. A major focus of crisis intervention
is exploring coping strategies. Strategies that the individual previously used but that have not been used to deal with the current crisis may be enhanced or bolstered. Also, new coping skills may be developed. Coping skills may include relaxation techniques and exercise to reduce body tension and stress as well as putting thoughts and feelings on paper through journal writing instead of keeping them inside. In addition, options for social support or spending time with people who provide a feeling of comfort and caring are addressed. Another central focus of crisis intervention is problem solving. This process involves thoroughly understanding the problem and the desired changes, considering alternatives for solving the problem, discussing the pros and cons of alternative solutions, selecting a solution and developing a plan to try it out, and evaluating the outcome. Cognitive therapy, which is based on the notion that thoughts can influence feelings and behavior, can be used in crisis intervention.
In the final phase of crisis intervention, the professional will review changes the individual made in order to point out that it is possible to cope with difficult life events. Continued use of the effective coping strategies that reduced distress will be encouraged. Also, assistance will be provided in making realistic plans for the future, particularly in terms of dealing with potential future crises. Signs that the individual's condition is getting worse or "red flags" will be discussed. Information will be provided about resources for additional help should the need arise. A telephone follow-up may be arranged at some agreed-upon time in the future.
Assessment
Suicideintervention begins with an assessment of how likely it is that the individual will kill himself or herself in the immediate future. This assessment has various components. The professional will evaluate whether or not the individual has a plan for how the act would be committed, how deadly the method is (shooting, overdosing), if means are available (access to weapons), and if the plan is detailed and specific versus vague. The professional will also assess the individual's emotions, such as depression, hopelessness, hostility and anxiety. Past suicide attempts as well as completed suicides among family and friends will be assessed. The nature of any current crisis event or circumstance will be evaluated, such as loss of physical abilities because of illness or accident, unemployment, and loss of an important relationship.
Treatment plan
A written safekeeping contract may be obtained. This is a statement signed by the individual that he or she will not commit suicide, and agrees to various actions, such as notifying their clinician, family, friends, or emergency personnel, should thoughts of committing suicide again arise. This contract may also include coping strategies that the individual agrees to engage in to reduce distress. If the individual states that he or she is not able to do this, then it may be determined that medical assistance is required and voluntary or involuntary psychiatric hospitalization may be implemented. Most individuals with thoughts of suicide do not require hospitalization and respond well to outpatient treatment. Educating family and friends and seeking their support is an important aspect of suicide intervention. Individual therapy, family therapy, substance abuse treatment, and/or psychiatric medication may be recommended.
Phases of CISD
There are seven phases to a formal CISD.
1. Introductory remarks: team sets the tone and rules for the discussion, encourages participant cooperation.
2. Fact phase: participants describe what happened during the incident.
3. Thought phase: participants state the first or main thoughts while going through the incident.
4. Reaction phase: participants discuss the elements of the situation that were worst.
5. Symptom phase: participants describe the symptoms of distress experienced during or after the incident.
6. Teaching phase: team provides information and suggestions that can be used to reduce the impact of stress.
7. Re-entry phase: team answers participants' questions and makes summary comments.
Precautions
Some concern has been expressed in the research literature about the effectiveness of CISD. It is thought that as long as the provider(s) of CISD have been properly trained, the process should be helpful to individuals in distress. If untrained personnel conduct CISD, then it may result in harm to the participants. CISD is not psychotherapy or a substitute for it. It is not designed to solve all problems presented during the meeting. In some cases, a referral for follow-up assessment and/or treatment is recommended to individuals after a debriefing.
Medical crisis counseling
Medical crisis counseling is a brief intervention used to address psychological (anxiety, fear and depression) and social (family conflicts) problems related to chronic illness in the health care setting. It uses coping techniques and building social support to help patients manage the stress of being newly diagnosed with a chronic illness or suffering a worsening medical condition. It aims to help patients understand their reactions as normal responses to a stressful circumstance and to help them function better. Preliminary studies of medical crisis counseling indicate that one to four sessions may be needed. Research is also promising in terms of its effectiveness at decreasing patients' level of distress and improving their functioning.
BOOKS
Aguilera, Donna C. Crisis Intervention: Theory andMethodology. 8th ed. New York: Mosby, 1998.
Dattilio, Frank M. and Arthur Freeman, eds. Cognitive-Behavioral Strategies in Crisis Intervention. New York: Guilford, 1994.
France, Kenneth. Crisis Intervention: A Handbook ofImmediate Person-to-Person Help. 3rd ed. Springfield, IL: Charles C. Thomas, 1996.
Johnson, Sharon L. Therapist's Guide to Clinical Intervention:The 1-2-3s of Treatment Planning. New York: Academic Press, 1997.
Mitchell, Jeffrey T. and George S. Everly, Jr. "Fundamentals of Critical Incident Stress Debriefings (CISD)." In Critical Incident Stress Debriefing: An Operations Manual for the Prevention of Traumatic Stress Among Emergency Services and Disaster Workers. 2nd ed revised. Ellicott City, MD: Chevron, 1996.
Slaby, Andrew E. "Outpatient Management of Suicidal Patients." In Risk Management with Suicidal Patients, edited by J. B. Bongar, A. L. Berman, R. W. Maris, M. M. Silverman, E. A. Harris, and W. L. Packman. New York: Guilford, 1998.
PERIODICALS
Koocher, Gerald P., Erin K. Curtiss, and Krista E. Patton. "Medical Crisis Counseling in a Health Maintenance Organization: Preventive Intervention." Professional Psychology: Research and Practice 32, no. 1 (2001): 52–58.
ORGANIZATIONS
American Association of Suicidology. 4201 Connecticut Avenue, NW, Suite 408, Washington D.C. 20008. (202) 237-2280. <http://www.suicidology.org>.
American Foundation for Suicide Prevention. 120 Wall Street, 22nd Floor, New York, New York, 10005. (212) 363-3500, or 888-333-AFSP. <http://www.afsp.org>.
International Critical Incident Stress Foundation. 10176 Baltimore National Pike, Unit 201, Ellicott City, MD 21042. (410) 750-9600. <http://www.icisf.org>.
