Conflict & crisis communication: methods of crisis intervention and stress management.
Subject: Stress management (Methods)
Post-traumatic stress disorder (Care and treatment)
Stress (Psychology) (Risk factors)
Stress (Psychology) (Care and treatment)
Author: Vecchi, Gregory M.
Pub Date: 12/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Winter, 2009 Source Volume: 12 Source Issue: 4
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 216961291
Full Text: [ILLUSTRATION OMITTED]

Barricaded hostage and crisis situations, kidnappings, transportation and natural disasters, and terrorist events comprise some of the most difficult critical incidents that communities must be ready to respond to, manage, and resolve. Like all critical incidents, these situations can bring on feelings of fear, hopelessness, and helplessness. Individual responses to these events fall along a broad continuum, from being paralyzed with trauma to being dismissive of the entire event. The reaction of an individual to a critical incident can never be predicted with 100% accuracy, but must rather be dealt with on a case-by-case basis. This is because an intervener can never know for sure the entire background and experiences of an individual and the baggage that he or she brings to the table. For those who experience psychological trauma associated with critical incidents, individual crisis intervention and Critical Incident Stress Management (CISM) are methods that can be used to restore a person's ability to cope and prevent long-term psychological ailments such as Post-Traumatic Stress Disorder (PTSD). This article will discuss individual crisis intervention with emphasis on bereavement and grief and CISM with emphasis on Critical Incident Stress Debriefings (CISD) as they relate to line-of-duty deaths, children, and the debriefers themselves.

Human Stress

Stress is a natural part of life. In fact, the human body needs stress in order to grow; otherwise, the mind and body atrophy. There is good stress and bad stress. Good stress, otherwise known as eustress, concerns positive daily routines and challenges that keep our mind and body sharp. Bad stress, also known as distress, involves negative situations and challenges that drag us down mentally and physically. Whether or not stress affects us negatively or positively depends on individual coping mechanisms and attitude.

Distress is a state that occurs when people are faced with events they perceive as endangering their physical or emotional well-being coupled with the uncertainty of their ability to deal with these events. Distress can also result from burnout, which is cumulative stress that results in a state of mental and physical exhaustion. The burnout process has three phases:

1. Stress Arousal Phase, which may include anxiety, panic, difficulty concentrating, feeling out of control or overwhelmed, and physical symptoms of headaches and high blood pressure;

2. Energy Conservation Phase, which includes procrastination, lateness, absenteeism, increased caffeine or tobacco consumption, or withdrawal and avoidance; and

3. Exhaustion Phase, which consists of feelings of hopelessness/helplessness, depression, serious consideration of changing jobs or personal living situation, desire to withdraw, self destructive behavior, or substance abuse.

Stressors are factors with the potential to cause stress. Acute stressors are short-term specific changes, disruptions, or events that directly cause the stress reaction. Chronic stressors are long-term or persistent conditions that indirectly cause the stress reaction.

Each person handles stress differently. Some people seek out situations that may appear stressful to others. For example, moving out of state, changing careers, or jumping out of an airplane with a parachute might be overwhelming for some people, while others would welcome the change and challenge. The key rests in determining personal tolerance levels for stressful situations (National Mental Health Association, 2009).

Controlling stress takes practice, determination, persistence, and time. Some suggestions may help immediately, whereas chronic stress requires more attention and some lifestyle changes. The following are a few suggestions for controlling and dealing with stress:

* Be realistic (learn to say no)

* Shed the "superman" or "superwoman" urge (don't expect perfection from yourself or others)

* Meditate (take 10 minutes to reflect and center yourself)

* Visualize (use your imagination to picture how you can manage a stressful situation more successfully)

* Take one thing at a time (when feeling overwhelmed, prioritize and accomplish your tasks one at a time)

* Exercise (20-30 minutes of moderately strenuous exercise reduces stress)

* Hobbies (take a break and do something you enjoy, as the distraction will revitalize you)

* Healthy lifestyle (good nutrition and moderate caffeine and alcohol keep your physical stress coping mechanisms sharp)

* Share you feelings (don't cope alone; share you feelings and discover you are not the only one)

* Give in occasionally (if you are meeting constant opposition, rethink your position, as arguing intensifies stress)

* Go easy on criticism (everyone has their own virtues, shortcomings, and the right to develop as an individual)

Traumatic stress is caused by any event outside the usual realm of human experience that is markedly distressing and which evokes reactions of intense fear, helplessness, and horror. These events usually involve the perceived threat to one's physical or psychological integrity. A critical incident is a high-conflict or crisis event that has a stressful impact that is sufficient enough to cause traumatic stress. Critical incident stress is the reaction a person or group has to a critical incident. Events such as terrorism, disasters, and crime are among the many stressors that cause traumatic stress.

Post-traumatic stress is very intense arousal subsequent to a traumatic stressor (APA, 2000). If the critical incident is extreme in nature, it may serve as the starting point for the psychiatric disorder known as PTSD, which may result from exposure to a critical incident or traumatic event. Stressors producing this syndrome normally evoke symptoms of distress in most people, which can be acute, chronic, or delayed. In addition, the symptoms often worsen when the individual is exposed to situations that resemble the original trauma. PTSD exhibits the following characteristics (APA, 2000):

* Excessive excitability and arousal

* Numbing, withdrawal, and avoidance

* Repetitive, intrusive memories or recollections of the trauma and/or events related to the trauma

* Significant distress/dysfunction

* Lasts at least one month

Possible early warning signs of PTSD include (APA, 2000):

* Dissociation

* Traumatic dreams

* Memory disturbances

* Persistent intrusive recollections of the trauma

* Self medication

* Anger, irritability, hostility

* Persistent depression, withdrawal

* A "dazed" or "numb" appearance

* Panic attacks

* Phobia formation

Concepts of Crisis Intervention, CISM, and CISD

Crisis intervention includes techniques and approaches used to immediately assist others who have slipped into crisis and who have exceeded their ability to cope, as a result of experiencing a critical incident (Datrilio & Freeman, 2000; Hendricks & Byers, 2002; James & Gilliland, 2001; Roberts, 2000; Wiger & Harowski, 2003). These techniques include active listening, empathy, rapport, and influence and are applied via the Behavioral Influence Stairway Model (BISM), which was previously examined in this series of articles on conflict and crisis communication (Vecchi, 2009a, 2009b, 2009c). In other words, the focus of crisis intervention is to return the person in crisis to their pre-crisis state. CISM includes crisis intervention techniques but goes beyond the initial crisis state by taking a strategic and systematic approach to dealing with the residual effects of crisis. CISD is the tactical tool of CISM that is used to deal directly with the residual effects of crises. PTSD occurs in some individuals when CISM Fails or is not used.

Crises

Crises situations place demands on persons to act in furtherance of resolving the crisis. Depending on the action taken, the behavior can be adaptive or maladaptive (Rosenbluh, 2001). Adaptive behavior results in positive crisis resolution and maladaptive behavior results in negative resolution. For example, a situation involving a man discovering that his wife has cheated on him has the potential to incite a crisis. How the man deals with the situation can be either adaptive or maladaptive, depending on his coping skills. An example of an adaptive strategy would be for the man to gather all information possible and constructively confront his wife about the situation and pursue marital counseling. An example of maladaptive behavior would be for the husband to take his wife captive with the intent to kill her for cheating on him. In both examples, the man is attempting to resolve the crisis; however, in the former example, the crisis responder would encourage the adaptive behavior, whereas in the latter example, it would be discouraged by implementing the strategies and tactics of the BISM to assist in ending the crisis in a more adaptive manner (Vecchi, 2009b).

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When a person slips into crisis, he or she attempts to deal with it through existing (or nonexistent) coping methods, which affects whether or not the resolution of the crisis is based on adaptive or maladaptive actions. For the crisis responder, the key to implementing the BISM towards adaptive resolution is to focus on understanding the needs of the person in crisis, which is oftentimes hidden behind more seemingly substantive concerns (Connor, 2002, Vecchi, 2009b). For example, an elderly man who takes his daughter captive and threatens to harm her may appear to be mentally ill, but in reality, he doesn't want her to place him in a nursing home because he feels he will lose control of his life. In this example, the crisis responder would attempt to unveil this "hidden" need and use it as a "hook" to develop a theme in furtherance of resolving the crisis in an adaptive manner. Therefore, it is important to note that people don't always say what they mean, so it is important to attempt to listen for the meaning behind the words in order to reveal the needs of the person in crisis. Remember, interveners don't meet demands, but they do satisfy needs. Some of the common needs that often surface during crisis intervention and problem-solving include (Vecchi, 2009b):

* Security needs (physical/emotional)

* Recognition needs (person's view is understood and acknowledged)

* Control needs (ownership in the process, having some say in the matter)

* Dignity needs (saving face)

* Accomplishment needs (achieving something)

When dealing with a person in crisis, the crisis responder gives the person a "hearing." This is because people want their needs and values to be understood; thus, listening is the cheapest, yet most effective concession a crisis responder can make and it demonstrates respect. Being right is not the issue; making the attempt to get it right is what counts. Tone speaks louder than words and indicates your attitude, as a calm controlled demeanor is more effective than a brilliant argument (Vecchi, 2009a, 2009b).

Critical Incidents and Critical Incident Stress

A critical incident is a high conflict or crisis event that has a stressful impact sufficient enough to cause critical incident stress. Critical incident stress is the reaction a person or group has to a critical incident. Events such as terrorism, disasters, and crime are among the many stressors that cause traumatic stress. The following are some critical incidents that may affect criminal justice professionals:

* Line of duty death

* Suicide of a co-worker

* Multi-casualty incident/disaster

* Significant event involving children

* Knowing the victim of the event

* Serious line of duty injury

* Police shooting

* Excessive media interest

* Prolonged incident with loss

If the critical incident is extreme in nature, it may serve as the starting point for PTSD. PTSD is caused by a psychologically traumatic event that is generally outside the range of usual human experiences. Stressors producing this syndrome normally evoke symptoms of distress in most people, which can be acute, chronic, or delayed. In addition, the symptoms often worsen when the individual is exposed to situations that resemble the original trauma. For example, during a suicide crisis intervention where a person is sitting under a tree with a shotgun in his mouth, a negotiator tries in vain to influence the person in crisis to not commit suicide. Upon the person shooting himself in the head with the shotgun and dying, doves that were perched in the tree fly frantically away from the scene. As a result, every time the negotiator hears the flutter of wings, he is reminded of the suicide event, even years later (NCNC, 2002). The following are some symptoms of PTSD:

* Problems with concentration and memory

* Inability to relax

* Impulsiveness

* Tendency to be easily startled

* Sleep disturbances

* Anxiety

* Depression

* Psychic numbing

* Nightmares, dreams, and "flashbacks"

Critical incident stress affects not only the criminal justice and first responder professions, but also their families with respect to marital difficulties, parent-child trouble, and mental and physical health problems. The following are some warning signs:

* Change of personality (becoming more withdrawn or aggressive)

* Change in personal appearance

* Excessive use of sick time

* Getting sick during a tour of duty

* Calling in sick after days off

* Late for roll call

* Civilian complaints

* Rapid mood changes

* Excessive use of alcohol or other drugs

* Extreme defensiveness

* Excessive nervous habits

* Sleep disturbances

* Decrease in work performance

* Frequent accidents

* Taking unnecessary chances

* Obsession about working

* Depression

* Use of excessive violence

Overview of Strategies and Techniques

When intervening in crisis situations, it is important to remember that buying time, projecting understanding, being non-threatening and nonjudgmental are the keys to effectively implementing the BISM and effectively influencing the person to end the crisis in a positive manner. In doing so, the crisis responder attempts to lower volatile emotions, increase rationality, build trust and rapport, and introduce nonviolent problem-solving alternatives.

All actions by the crisis responder should be considered on the basis of their impact upon the person in crisis; their perception is what counts as their reality in the situation, rather or not it is grounded in fact. Therefore all actions should be made on the basis of what the person in crisis believes the crisis responder is trying to do.

Crisis Intervention Stages

Regardless of the model being employed, crisis intervention encompasses the following stages (Vecchi, 2009a, 2009b):

* Establishing Communication

* Dealing with emotions

* Identifying the precipitating event(s)

* Problem solving

Establishing Communication

Establishing communication is the vehicle for the delivery of crisis intervention strategies and tactics as described in the various models. When speaking to the person in crisis, it is important to speak slowly and calmly and to choose your words, tone, and manner with care. Remember that how the crisis responder says something is much more important than what is said; in that, content can be easily adjusted by telling the person in crisis that you simply are trying to understand; however, it is much more difficult to fix an attitude that is perceived by the person in crisis as being "bad." In addition, your communication delivery should be deliberate, methodical, and, most importantly, non-judgmental (Vecchi, 2009a, 2009b).

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A non-judgmental attitude is one that can be described as accepting and one where the person in crisis perceives that his or her feelings, values, thoughts, and opinions are what are most important. It is important for the crisis responder not to inject his or her own values into the situation; however, this does not mean that the crisis responder has to agree with the values or morals (or lack thereof) of the person in crisis. This disagreement can be relayed to the person in crisis by saying something like: "From what you're saying, I can imagine how your wife could have made you angry enough to kill her ... that would have made me angry too but I don't think I could have done what you did" (Vecchi, 2009a, 2009b).

Dealing with Emotions

Dealing with emotions is a base-line skill that every crisis responder must learn because intense emotions are a hallmark of crisis situations. Although emotions are universal, experiences are not. Making assumptions about a person's emotions based upon the circumstances can stall crisis intervention. For example, during a situation where a man has barricaded himself and is threatening to commit suicide, the crisis responder attempts to demonstrate empathy by saying: "I know how you feel." The person in crisis responds by saying "You don't know how I feel ... just go away." In this case, the crisis responder's attempt at empathy is counterproductive because the person in crisis does not believe the crisis responder has ever tried to commit suicide before, and, regardless of whether or not this is true, the perception of the person in crisis is their reality; therefore, arguing or trying to be rational with the person in crisis is pointless. An alternate approach would be for the crisis responder to say: "I've never been in your situation before, but I imagine you must be feeling very depressed and lonely." By saying this, the crisis responder is demonstrating that he or she is trying to understand the situation from the perspective of the person in crisis without leaping to conclusions (Vecchi, 2009a, 2009b).

Identifying the Precipitating Event(s)

A precipitating event is the "last straw" or trigger that puts a person into crisis. The precipitating event is usually associated with some sort of loss, which could be the result of losing a job, losing a significant other, or losing money. Identifying the precipitating event is crucial in laying the groundwork for problem- solving because it identifies the problem that needs to be solved (Vecchi, 2009a, 2009b).

Sometimes, the person in crisis is unaware of or confused about the nature of the precipitating event, as the crisis may involve a conflict of values (Vecchi, 2009b). Values are what people believe are important and cherish and they are the "hooks" used by crisis responders to assist in alleviating the crisis. For example, a religious person who values nonviolence is robbed and attacked, resulting in the death of the robber. This results in conflict between his convictions of nonviolence and his violent actions (even though justified), which trigger a crisis. In this situation, it is necessary for the crisis responder to assist the person in clarifying his values. For instance, the crisis responder could point out that the death of the robber was unintended and in blind reaction to the actions of the robber. By attaching "intent" as a requirement to defining something as violent, the action of the person can be reframed as not violating the value of nonviolence, thus, alleviating the internal conflict and setting the stage for problem-solving.

Problem-Solving

Once emotions are under control, communication has been established, and the triggering event has been identified and dealt with, the person in crisis is in a position to problem-solve (Vecchi, 2009a, 2009b). Problem-solving is the process by which the crisis responder helps the person in crisis explore other alternatives and solutions to the crisis.

Part of effective problem-solving involves listening for distorted thinking on the part of the person in crisis. As a result of life experiences, individuals develop different patterns of thinking. These thinking patterns influence how an individual perceives himself and how others perceive the individual. This can be viewed as a "filter" through which the world is viewed, which may influence a person's reaction to events and lead to emotional distress and to crisis. Sometimes these distortions affect the potential for problem-solving and must be addressed by the crisis responder (Vecchi, 2009a, 2009b, 2009c). For example, a drug abuser tries to steal a prescription drug in a pharmacy and is caught. The police are notified and surround the building before the person can escape. As a result, the man becomes depressed and demands to be set free or he will kill himself because going to jail is not an option in his mind. In this case the distorted thinking surrounds the assumption of only two options: going free or going to jail. In response, the crisis responder offers another choice: being sent to a drug rehabilitation center for treatment rather than jail. After several hours, the person surrenders without incident. This suggestion by the crisis responder refocuses the thinking of the person, who now sees another option beyond his previous distorted perception.

Bereavement and Grief

Everyone is affected by death and loss, as they are inevitable and are ever present in our lives. The ability of people to cope with death and loss determines the degree of difficulty with which they pass through the stages of grief. It is important to be able to use the concepts of crisis intervention to assist individuals in coping with the loss of a life.

Although bereavement and grief are closely related, they are two different concepts. Bereavement usually relates specifically to death, such as the death of a spouse or the death of a pet. The characteristics of bereavement are similar to major depression; however, there are other differences as well. According to APA (2000), bereavement differs from major depression in accordance with the following characteristics:

* Guilt about things other than the actions taken or not taken by the survivor at the time of death

* Thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person

* Morbid preoccupation with worthlessness

* Marked psychomotor retardation

* Prolonged and marked functional impairment

* Hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person

Grief is usually associated with bereavement, but it can also be associated with other things as well. A person would almost certainly experience grief at the loss of their spouse, but there are also some people who would experience grief at the loss of a football game. The key for communicators is to address the mental anguish associated with grief, regardless of the triggering event.

Stages of Grief and the Crisis Intervention Process

According to Weide (2009), grief occurs in five stages: denial, anger, bargaining, depression, and acceptance. During the denial stage, the person refuses to believe what has happened and he or she may carry this denial to extremes by, for example, making an extra cup of tea for the loved one who is no longer there. In the anger stage, anger can manifest itself in several ways, such as blaming others for the loss, having emotional outbursts, or even getting angry with oneself. In the bargaining stage, the aggrieved person desires to have things as they were, so they promise to do something in return. During the depression stage, feelings of having no purpose, tiredness, and even suicidal thoughts engulf the grieving person. Finally, the acceptance stage is when the grieving person realizes that life must go on, thereby accepting the loss and, in doing so, regains energy and goals for the future.

Certain stages within the grief process have the potential to escalate to the point that necessitates a crisis negotiation response. Of the five stages, the anger and depression stages have the most potential to do so (Weide, 2009; Vecchi, 2009a, 2009b). During the anger stage, the person in crisis (P) is dealing with potentially explosive emotions as he or she leaves the denial stage and begins to deal with the event. When faced with the anger stage of grief, the communicator (C) should focus on reducing the emotionality of the situation by letting the person vent, as releasing the anger moves the person along through the remaining stages of grief (Vecchi, 2009b). For example:

P: It's his fault that my baby is dead!

C: Your baby is dead?

P: Yes because HE was too busy watching TV to know that she had gotten into rat poison.

C: It sounds like you are angry.

P: I hate him, and I want him dead.

C: You hate him?

P: Wouldn't you? He let my baby girl die! Why is this happening to me?

C: It sounds like you are angry with him because he wasn't paying attention.

P: He wasn't ...

C: It also sounds like he didn't mean for this to happen.

P: I don't think he meant to ...

C: Tell me more about it.

From here, the communicator would continue to let the person vent, thus reducing emotionality and increasing rationality (Vecchi, 2009b). The communicator would also simultaneously mitigate the circumstances in order to prevent the person from further demonizing the man, which acts as insurance against a violent response from the person.

During the depression stage, the person in crisis has acknowledged the event and becomes lethargic. Depending on their ability to cope, some people slip so deep into depression that they become suicidal. When faced with the depression stage of grief, the communicator should focus on assessing lethality (Vecchi, 2009b). For example:

P: I can't take this anymore.

C: You can't take it?

P: It's not worth it.

C: Are you okay?

P: Forget about it.

C: Are you having thoughts about killing yourself?.

P: Yes, because I can't go on like this.

C: Could you tell me more about what you're feeling?

From here, the communicator would employ strategies and tactics aimed at trying to get the person in crisis to see that his or her depression is only temporary and that this is a normal response to death. The communicator would also help the person move onto the final stage of grief (acceptance) by laying out positive images of moving on with life (Vecchi, 2009b).

Managing Critical Incident Stress

According to Mitchell & Everly (2001b), the need for CISM is great:

* 90% of United States Citizens will be exposed to a traumatic event during their lifetime

* The conditional risk of posttraumatic stress disorder (PTSD) was found to be 13% for females and 6% for males

* Suicide rates have been seen to increase as much as 63% in the first year after an earthquake; increase 31% in the first two years after a hurricane; and increase 14% four years following a flood

* Millions of people experience crimes on interpersonal and other violence

CISM is a system of emergency mental health that addresses three goals:

1. Reducing the risk of acute and intense psychological crises or traumas,

2. Stabilizing and reducing the immediate severity of a crisis or traumatic situation, and

3. Facilitating recovery from a crisis or traumatic episode (Dyregrov, 2003; Everly & Mitchell, 2008; Everly & Mitchell, 2000; Everly & Mitchell, 1999; Mitchell & Everly, 2001a, 2001b; Mitchell & Everly, 1994).

CISM consists of 10 major components:

* Pre-crisis planning/education

* Individual crisis intervention (one-on-one)

* Small group crisis intervention-Defusing

* Small group crisis intervention-Critical Incident Stress Debriefing (CISD)

* Large group crisis intervention-Demobilizations (Public Safety/Disaster Personnel)

* Large group crisis intervention-Crisis Management Briefing (Civilian Populations)

* Organizational consultation

* Family crisis intervention

* Pastoral crisis intervention

* Mechanisms for follow up and referral

CISM Versus Psychotherapy

It is important to understand that CISM is not psychotherapy, but crisis intervention designed to be used as "emotional first aid" to aid in stabilizing and returning the person to his or her functioning level (Dyregrov, 2003; Everly & Mitchell, 2008; Everly & Mitchell, 2000; Everly & Mitchell, 1999; Mitchell & Everly, 2001a, 2001b; Mitchell & Everly, 1994). Mitchell & Everly (2001b) summarize the differences between psychotherapy and CISM (See Figure 1).

Applications of CISD

Among the most effective interventions for emotional first aid is CISD, which was originally developed by Dr. Jeffrey Mitchell of the International Critical Incident Stress Foundation. The goals of CISD are to 1) lessen the impact of the critical incident, 2) accelerate recovery from those events before the onset of damaging stress reactions, and 3) facilitating the return to a previous level of functioning (Mitchell & Everly, 2001a). CISD, which is a psycho-educational group intervention technique, is administered to homogenous groups who have all experienced the same traumatic or critical incident. The groups are facilitated by mental health professionals, chaplains, and trained peers. These debriefings emphasize ventilation of emotions, educational and informational material concerning stress from the event, and confidentiality of discussions. Over the years, CISD has proved to be an effective intervention in instances where several individuals have experienced traumatic and critical incidents simultaneously (Dyregrov, 2003; Everly & Mitchell, 2008; Everly & Mitchell, 2000; Everly & Mitchell, 1999; Mitchell & Everly, 2001a, 2001b; Mitchell & Everly, 1994).

CISDs are facilitated discussions about a traumatic event(s) used to mitigate the psychological impact of a traumatic, prevent the subsequent development of PTSD, and serve as an early identification mechanism for individuals who will require professional mental health follow up. CISD is provided one to 10 days post event with the exception of disasters, which is three to six weeks post disaster. CISD lasts one to three hours. CISD is usually reserved for small groups of emergency workers (police officers, paramedics, nurses, firefighters, etc.). CISD has seven stages (Mitchell & Everly, 2001a):

* Introduction

* Fact

* Thought

* Reaction

* Symptom

* Teaching

* Re-entry

A defusing is a shortened debriefing that is provided within eight hours of an incident (Mitchell & Everly, 2001a). The target groups are small groups of emergency workers, but may consist of multiple defusings for different groups. The goals of defusings are to

1. Mitigate the impact of the event,

2. Accelerate the recovery process,

3. Assess of the need for debriefings and other services, and

4. Reduce cognitive, emotional, and psychological symptoms.

The defusing process involves:

* Establish a non-threatening social environment

* Allow rapid ventilation of the stressful experience

* Equalize the information cells

* Restore cognitive processing of the event

* Provide information for stress survival

* Affirm the value of the personnel

* Establish linkages for additional support

* Develop expectancies for the future

Demobilization is a quick informal rest session applied when operations units have been released from service at a major incident that requires over 100 personnel (Mitchell & Everly, 2001a). Demobilizations are best applied after being released from a major incident and before returning to normal duties. The target groups are teams of workers (ambulance units, police squads, etc.). The goal of demobilization are 1) assess the well-being of personnel after major incident, 2) mitigate the impact of the event, 3) provide stress management information to personnel, 4) provide and opportunity for rest and food before returning to normal duties, and 5) assess the need for debriefing and other services. The demobilization process involves:

* Establishing an appropriate demobilization center

* Checking in units as they arrive

* Keeping work teams together for demobilization

* Assigning a trained team member to provide information to the group

* Limiting the information section to ten minutes

* Providing 20 minutes to rest and eat

* Letting participants know if a debriefing is planned

* Providing handouts on stress survival suggestions

Crisis Management Briefings (CMB) are large group intervention techniques designed for up to 300 primary victims (Mitchell & Everly, 2001 a). CMB may be applied to civilians after terrorism events, mass disasters, school and workplace violence incidents, or military crises. The goals of CMB

1. Provide information,

2. Rumor control,

3. Reduce sense of chaos,

4. Provide coping resources,

5. Facilitate follow-up care,

6. Engender increased cohesion and morale,

7. Assess further needs of the group, and

8. Restore personnel to adaptive functions.

The CMB process involves:

* Assembling participants

* Providing facts regarding crisis

* Discuss and normalize common behavioral/psychological reactions

* Discuss personal and community stress management and resources

CISD and Line-of-Duty Deaths

One of the most traumatic psychological events occurs in line of duty deaths (LODD). These deaths involve the single death in the performance of one's duties, multiple deaths in the performance of duties, or "friendly fire" incidents involving the accidental killing of a colleague. LODD requires a two-part CISD approach (Everly & Mitchell, 2000). The first intervention occurs on the day of death and the second intervention occurs three to seven days after the funeral. Subsequent one-on-one counseling and family support services may also be required.

The first CISD on the day of death should last about one hour. Its goals are to

1. Equalize information,

2. Prepare participants for the impact of the funeral, and

3. Identify those who are actually distressed (Everly & Mitchell, 2000).

This debriefing consists of five phases: introduction, fact, reaction, teaching, and re-entry. The introduction phase sets the tone and should only include the essentials. The fact phase equalizes the information concerning the death. The reaction phase examines the worst part at the present moment. The teaching phase prepares the group for the funeral and early grief processes. The re-entry phase is a question-answer-session with an emphasis on continuous CISM services. Notice that this CISD differs from the normal seven phase CISD by eliminating the thought and symptoms phases. These phases are eliminated because participants are in a state of shock, denial, and are overwhelmed.

CISD and Children

Although CISD was initially developed for use with first responders, adjustments can be made in order to make it useful for alleviating psychological trauma experienced by children as a result of disasters, terrorism, and domestic violence. The best approach is to divide them by age groups (below six years of age, six to 12 years of age, and 13 years old and older), homogenous groups (e.g., homeroom classes), and making adjustments to the CISD model (Everly & Mitchell, 2000).

Children under six years of age ordinarily lack the sophisticated verbal and social interaction skills necessary to participate actively in typical CISD processes (Everly & Mitchell, 2000). As such, a form of CMB is used that focuses on general information, reassurance, guidance, and emotional support. The effectiveness of the CMB is dependent on the level of trust and rapport the children have with the facilitator; therefore, he or she should be a familiar person, such as a teacher. The CISD session should be about 45 minutes in length, which is consistent with the limited attention span of young children (Everly & Mitchell, 2000).

Children six to 12 years of age usually respond well to CISD. A five-phase CISD model similar to the first day LODD CISD is utilized, eliminating the thought and symptom phases from the standard seven-phase model (Everly & Mitchell, 2000). This is because young children have a difficult time sorting out their specific thoughts about the incident and they do not usually relate to the concept of "symptoms." This CISD process should also last about 45 minutes in length. Everly & Mitchell (2000) provide several factors to keep in mind when working with this age group:

* The use of age appropriate language is vital.

* Children should not feel forced or coerced to speak.

* Support team members need to be very interactive with children. For example, "Thank you Joey. And what did you see, Marsha? Thank you for sharing that with us, Wade."

* Some young children will move toward group leaders in a group because they are frightened and need hugs and reassurance. Appropriate support should be provided within the group.

* Efforts should be made to bring a quiet child into the discussion. For example, "Joey, would you like to tell the group what you went through during the situation?" Then ask, "How many of you went through the same thing?"

* Unlike working with adults, a more active role of exploring emotions is utilized. For example, "Were you frightened? I know I would have been. How many others were frightened? Raise you hands."

* Encourage outside contact and support with young children. For example, "You know your morns and dads love you very much and they would like to hear what we have talked about today."

* A brief follow-up meeting is very helpful a few days after the debriefing to ensure the children are recovering.

* Children who were withdrawn or show significant distress should be supported in one-on-one sessions immediately following the CISD.

For children 13 years of age and older, the full seven-phase CISD process can be used (Everly & Mitchell, 2000). Although structure and process is the same as for adults, the question delivery is tailored to fit the situation. For example, adults may be asked, "who are you and what was your job during the incident?" For teens, the questions may be changed to, "so, who was involved most? How were you involved?" Keep in mind that information, guidance, and practical suggestions should be emphasized in the teaching phase, which can be immediately useful for the teen as they try and recover from the crisis.

Debriefing the Debriefers

One of the most important, but often forgotten, aspects of crisis intervention and CISM in particular is the cumulative effect of trauma on the interveners themselves (Everly & Mitchell, 2000). Burnout and feelings of being overwhelmed are common among interveners who are not monitored for such eventualities. It is important to note that interveners who have spent several hours being exposed to the pain and trauma of the individuals they debriefed have become participants in it. This is why it is important to have a system for debriefing the debriefers so that vicarious traumatization can be avoided or assisted.

Debriefer Debriefings work towards achieving three goals:

1. Preventing negative reactions such as vicarious traumatization, cumulative stress, and the effects of negative self-judgment;

2. Using an opportunity to reinforce skills demonstrated during the debriefing; and

3. Practicing what you preach to members of the team (Everly & Mitchell, 2000).

By assuring intervener debriefings are built into the CISM system, their effectiveness and longevity are increased. In addition, the odds of negative personal reactions by members of the team are decreased, as well as preparing the debriefers for re-entry into the world. Debriefer debriefings should be done soon after they finish work and before they go home (Everly & Mitchell, 2000).

If the debriefers have been involved in a prolonged series of defusings, debriefings, and demobilizations over a prolonged event response, the debriefing might be better accomplished within a few days, which will allow the interveners to process some of what they experienced on their own. The length of time for this process is usually 15 to 30 minutes or even longer in the event of particularly long or difficult debriefings (Everly & Mitchell, 2000). The location for the debriefers debriefing should be neutral with appropriate privacy. Keep in mind that the more difficult the CISM responses were, the more privacy needed.

A team leader or experienced peer should lead the process (Everly & Mitchell, 2000). The leader should also not have been part of the debriefings conducted by the interveners undergoing the debriefers debriefing. This allows all team members to participate in the full debriefers debriefing and promotes unbiased feedback to the team.

The debriefers debriefing process consists of three phases:

1. Review,

2. Respond, and

3. Remind (Everly & Mitchell, 2000).

The Review Phase is a combination of the Introduction/Fact/Thought phase of a regular CISD debriefing. It uses questions designed to have members think about and discuss the debriefing and their participation in it. Everly & Mitchell (2000) provide some suggested questions for this phase:

* How did it go?

* How do you think you did?

* What could you have done better?

* What themes emerged?

* What was the participation level of the group?

* Is there anything you are worried about?

The Response Phase is a condensation of the Reaction/Symptom phase of a regular CISD debriefing. It works to elicit comments on the self-perception of the team members and any concerns they may have about their performance. Everly & Mitchell (2000) provide examples of some questions that may be asked during this phase:

* What did you day that you wish you hadn't?

* What didn't you say that you wish you had?

* How has this debriefing affected you?

* What is the hardest part of this debriefing for you?

If a person is blaming themselves or worried that he or she did something wrong, it is important for the facilitator reassure everyone that each contributed to the process and offer methods for handling problem issues. This phase is also used to teach new techniques and reinforce what the team did well.

The Remind Phase combines the Teaching/Re-Entry phases of the basic CISD model. Everly & Mitchell (2000) provide suggested questions for this phase:

* Is there any follow-up to be done?

* What are you going to do to take care of yourself in the next 24 hours?

* What will it take for you to "let go" of this debriefing?

Debriefer debriefings are structured approaches to minimizing any self-doubt exhibited by team members and maximizing reassurance that team members are valuable assets. "If we believe in what we are doing for the individuals we serve, we should believe in what we are doing for the individuals providing the services!" (Everly & Mitchell, 2000, p. 121).

Criminal justice and first responder professionals need to know that there is nothing wrong with seeking professional help if they find they are having difficulty coping with stress or a critical incident. Just as they refer others to mental health professionals, they should also know that, at times, they need help too. The National Association of Mental Health (2009) suggests the following ideas to consider when talking with a mental health professional about stress or critical incidents:

* List the things that cause stress and tension in your life.

* How does this stress and tension affect you, your family, and your job?

* Can you identify the stress and tensions in your life as short or long term?

* Do you have a support system of friends or family that will help you make positive changes?

* What are your biggest obstacles to reducing stress?

* What are you willing to change or give up for a less stressful and tension-filled life?

* What have you tried already that didn't work for you?

* If you do not have control of a situation, can you accept it and get on with your life?

As human beings, criminal justice and first responder professionals are just as susceptible to the effects of stress and critical incidents as are the people they serve. Averting personal crises for these professionals keeps their abilities intact and available to those they serve.

Conclusion

Critical incidents have the potential to cause significant psychological trauma to those who experience them; however, there is no way to positively determine who or when someone will lapse into crisis. Critical incident stress, in whatever form, affects not only the people who are served by the criminal justice and first responder professions, but the service providers as well, to include their family with respect to marital difficulties, parent-child trouble, and mental and physical health problems.

Crisis intervention comprises interventions aimed at returning individuals to their pre-crisis state by re-establishing support and coping methods. This is accomplished by understanding and dealing effectively with each stage of crisis. CISM is a systematic approach to crisis intervention relating to critical incident stress and involves a deliberate process of intervention techniques and approaches aimed at stabilization, a return to functioning, and prevention of further trauma.

Empirical and other anecdotal evidence suggests that CISD is an effective crisis intervention process for assisting individuals with psychological trauma experienced as a result of exposure to critical incidents such as terrorism and disasters. CISD can also be effective when properly adjusted to deal with the special trauma experienced in LODD, children, and the CISM team members themselves.

References

American Psychiatric Association [APA]. (2000). Diagnostic and statistical manual of mental disorders-text revision (4th ed.). Washington, DC: Author.

Connor, M. G. (2002). Abuse violence. Retrieved January 3, 2003, from http://www.crisiscounseling.com.

Dattilio, F. M., & Freeman, A. (Eds.). (2000). Cognitive-behavioral strategies in crisis intervention (2nd ed.). New York: The Guilford Press.

Dyregrov, A. (2003). Psychological debriefing: A leader's guide for small group crisis intervention. Ellicott, MD: Chevron Publishing.

Everly, G. S., & Mitchell, J. T. (2008). Integrative crisis intervention and disaster mental health.

Ellicott, MD: Chevron Publishing.

Everly, G. S., & Mitchell, J. T. (2000). Critical incident stress management: Advanced group crisis interventions. A workbook (2nd ed.). Ellicott City, MD: ICISF, Inc.

Everly, G. S., & Mitchell, J. T. (1999). Critical incident stress management: A new era and standards of care in crisis intervention (2nd ed.). Ellicott, MD: Chevron Publishing.

Hendricks, J. E., & Byers, B. D. (Eds.). (2002). Crisis intervention in criminal justice/social service (3rd ed.). Springfield, IL: Hendricks and Byers.

James, R. K., & Gilliland, B. E. (2001). Crisis intervention strategies (4th ed.). Stamford, CT: Brooks/ Cole.

Mitchell, J. T., & Everly, G. S. (2001a). Critical-incident stress debriefing: An operations manual for CISD, defusing and other group crisis intervention services rvention (3rd ed.). Ellicott, City, MD: Chevron Publishing. Inc.

Mitchell, J. T., & Everly, G. S. (2001b). The basic critical incident stress management course: Basic group crisis intervention (3rd ed.). Ellicott, City, MD: ICISF, Inc.

Mitchell, J. T., & Everly, G. S. (1994). Human elements training for emergency services, public safety and disaster personnel." An instructional guide to teaching debriefing, crisis intervention and stress management programs. Ellicott City, MD: Chevron Publishing.

National Crisis Negotiation Course [NCNC]. (2002). Quantico, VA: FBI Academy.

National Mental Health Association. (2009). Retrieved October 23, 2009, from www.nmha.org.

Roberts, A. R. (Ed.). (2000). Crisis intervention handbook (2nd ed.). New York: Oxford University Press.

Robinson, R., & Murdoch, P. (2003). Establishing and maintaining peer support programs in the workplace (yd ed.). Ellicott, MD: Chevron Publishing.

Rosenbluh, E. S. (2001). Police crisis intervention: A dilemma in the aftermath of Columbine High School. Journal of Police Crisis Negotiations, 1 (1), 35-46.

Vecchi, G. M. (2009a). Conflict and crisis communication: A methodology for influencing and persuading behavioral change. Annals of American Psychotherapy 12(1), 34-42.

Vecchi, G. M. (2009b). Conflict and crisis communication: The behavioral influence stairway model and suicide intervention. Annals of American Psychotherapy 12(2), 32-39.

Vecchi, G. M. (2009c). Conflict and crisis communication: Workplace and school violence,

Stockholm Syndrome, and abnormal psychology. Annals of American Psychotherapy 12(3), 30-39.

Weide, U. (2009). Coping with loss and grief Retrieved October 23, 2009, from www.coping-with-loss-and-grief.com.

Wiger, D. E., & Harowski, K. J. (2003). Essentials of crisis counseling and intervention. Hoboken, N J: John Wiley & Sons.

This article by Gregory M. Vecchi, PhD, is the last in a four-part series about conflict and crisis communications. If you would like to read the first three parts of the series, please visit the journal archives posted on the Annals of the American Psychotherapy Web site, which are located at www.annalsofpsychotherapy.com/archives.php.

By Gregory M. Vecchi, PhD, CFC, CHS-V, DABCIP, DABLEE

Gregory M. Vecchi, PhD, CFC, CHS-V, DABCIP, DABLEE, is the unit chief of the Behavioral Science Unit (BSU), Federal Bureau of Investigation (FBI). Dr. Vecchi conducts research training and consultation activities in behavior-based conflict analysis and resolution. crisis management, conflict and crisis communication, and global hostage-taking.
* Figure 1

                       Crisis Intervention
                              (CISM)               Psychotherapy

Context               Prevention               Reparation

Timing                Immediate to stressor    Delayed to stressor

Location              Close proximity to       Safe, secure
                      stressor                 environment

Duration              1-3 contacts             As long as needed/
                                               desired

Provider's Role       Active, directive        Guiding, consultative

Strategic loci        Conscious processes      Conscious and
                      and environmental        unconscious pathology
                      factors

Temporal focus        Here and now             Present and past

Patient Expectation   Directive, stress        Symptom reduction,
                      reduction, reduction     reduction of
                      of  impairment           impairment, personal
                      directive support        growth, guidance and
                                               collaboration.

Goals                 Stabilize, reduce        Symptom reduction,
                      impairment, return to    reduction of
                      function, or move onto   impairment, correction
                      next level of care       of pathogenesis,
                                               personal growth,
                                               personal
                                               reconstruction
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