In this chapter, from the various methods available for crisis intervention, the focus will be laid on the comprehensive system of Critical Incident Stress Management (CISM[R1] ). This is an integrated combination of methods developed in the USA in the 1980s (1). It was first applied to emergency medical service (EMS) personnel. Today, it is the system with the highest application rate in institutions all over the US, such as emergency and fire services, US Navy, US Army, US Air Force, Coast Guard and many others. It has been adopted (sometimes in a somewhat modified manner) into many services in Europe and Asia, especially into the military and the United Nations (2, 3, 4, 6).
The highly structured CISM methods may be used to help the individual during and after stressful events. The process of using these methods is confidential, voluntary and educative.
The general goal of CISM is the prevention of acute, disabling psychological discord and the rapid restoration of adaptive functioning in the wake of a critical incident. In particular, CISM aims at reducing the incidence, duration, severity of traumatic stress and of impairment arising from crisis situations. Furthermore, it is applied to facilitate advanced follow-up mental health interventions, if necessary.
Components of CISM (1)
- Pre-incident preparation
- Individual crisis intervention (One-on-One)
- Large scale intervention programs (demobilization, staff advisement, crisis management briefings (CMB)
- Critical Incident Stress Debriefing
- Pastoral crisis intervention
- Family crisis intervention, organizational consultation
- Follow-up; Referral mechanism for assessment and treatment
Pre-incident preparation has two goals. One is to set the appropriate expectancies for personnel as to the nature of the crisis and trauma risk factors they face. This includes establishment and maintenance of incident awareness, i.e. to achieve the attitude that a critical incident may happen. This activity is accompanied by teaching basic crisis coping skills in a proactive manner. The other goal is to teach skills for psychological first aid (self help and buddy help).
Pre-incident preparation is usually carried out by superiors, e.g. nautical officers or personnel from the shipping company. Frequently it is conducted in cooperation with psychologists. The appropriate time is before entering the professional field of seafaring. Periodic refreshing and adaptation to new situations should be provided.
Individual crisis intervention
On-scene and directly after the event, self and buddy help will be applied, thus carrying out supporting measures for stabilizing affected individuals.
Most crisis response interventions are done individually. On scene or immediately after the event the SAFER model may be used for an individual who is in crisis. Its goal is to mitigate the acute distress and to facilitate access to follow-up mental health assessment and treatment, if needed. In addition, this type of intervention serves to avoid infection. The five stages of the model are
Stabilization of the situation: removal of the person in crisis from provocative stressors, thereby mitigating further escalation and constituting the possibility for assessing the mental status of the person.
- Acknowledgement of the crisis: letting the person describe what happened and in which way he or she reacted, thereby giving way for ventilation and for reduction of arousal.
- Facilitating of understanding: explaining symptoms in context of traumatic stress symptoms, thereby conveying the impression that the reactions are normal, although problematic for the person.
- Encouragement of adaptive coping: teaching basic stress/crisis management techniques, thereby improving immediate and short-term coping.
- Restoration of independent functioning, or referral for continued care: assessing current adaptive functioning as adequate or seeking further assistance, thereby re-establishing psychological equilibrium and creating the possibility of continued care.
Activities of SAFER belong to the one-on-one techniques (one individual support person assisting one, or perhaps two, individual(s) in crisis). It is important to note that these activities give the opportunity for assessment of mental status, for improving motivation for accepting further assistance, for deciding whether further monitoring is needed and/or whether additional help must be called in, e.g. a crisis intervention team.
SAFER activities may be carried out on-scene or after the event whenever necessary (and possible) by superiors preferably with peer support personnel training.
One-on-one (or individual crisis intervention) may be carried out all over the range of crisis intervention after a critical incident. As necessary, there may be more than one contact. In this application it may have a format similar to the defusing, i.e. peer support or mental health personnel may follow the general line of defusing. Individual crisis intervention lacks in giving the individual the feeling of “normal reaction to a not normal situation”. This is easier to accomplish in group programs.
Large scale intervention programs
Demobilization can be used with large numbers of affected individuals immediately after the event has ended or the personnel are disengaged from the scene. The goal is to bring the personnel back to normality, to take the stress from the persons, to set realistic expectations for the psychological consequences of the crisis event, to provide education concerning practical stress management techniques, and to give some advice with reference to other psychological and/or physical support systems. Normally, in a safe area an informational briefing about stress, trauma and coping techniques takes place. It usually takes 20 - 30 minutes.
Demobilization should be carried out by peers or mental health professionals.
Crisis Management Briefing (CMB)
The group informational briefing is a technique which is used with large groups that have been affected by a critical incident. It aims at providing relevant information pertaining to the event, at reducing subsequent rumours and misinformation, and at facilitating access for follow-up resources, if necessary. It reviews the relevant facts surrounding the incident, presents the psychological dynamics of the incident, and introduces professional resources which can be used for follow-ups.
CMB may be carried out by peers or mental health professionals up to several days after the event.
Defusing may be done at the crisis venue after disengagement from the crisis activity or anywhere in the post-crisis phase within 12 hours after a crisis. Defusing is a 20 - 45 minute group discussion of the crisis event designed to reduce acute stress and tension levels. Defusing has three phases:
- Introduction: introduction of the intervention team, explanation of the reason and the goals of the intervention, and setting expectations as to the goals.
- Exploration: exploration of the nature and impact of the crisis, asking about the facts and asking about the individual reactions to the crisis.
- Information: educational phase as to the normal nature of the symptoms and to practical coping strategies.
Defusing is an intervention that is a shorter, less formal version of a Critical Incident Stress Debriefing. It should be done within 12 hours of the crisis by peers, mental health professionals, or a crisis intervention team.
Critical Incident Stress Debriefing (CISD)
Critical incident Stress Debriefing (CISD) is used with a homogeneous (!) group of individuals who have experienced a crisis or a traumatic event. As with defusing, the goal is to mitigate the adverse impact of a traumatic event by reducing the intensity and chronicity of symptoms related to the trauma. It differs from defusing in several aspects: 1) it is carried out later than a defusing; 2) it is more detailed and more structured than defusing; 3) it is designed to bring psychological closure to a traumatic event.
CISD has seven phases:
- Introduction: introduction of the crisis intervention team, explanation of the process.
- Fact phase: participants are encouraged to describe the traumatic event from his/her perspective.
- Thought phase: participants describe their cognitive reactions to the event; and start to transition to the affective domain.
- Reaction phase: identification of the most traumatic aspect of the event and thus giving the opportunity of ventilation.
- Symptom phase: identification of symptoms of distress or psychological discord, transition back to the cognitive domain.
- Teaching phase: supporting the return to the cognitive domain by normalization and psychological education.
- Re-Entry phase: provision of closure to the CISD process.
CISD is usually most effective if done two to ten days after the crisis has concluded. In some cases, CISD may be effectively done three to four weeks after the event. It usually takes one to three hours to complete. It is provided by a crisis intervention team.
Pastoral crisis intervention
Mitschell and Everly integrated this method into CISM in one of the later editions of their book.
It is the integration of crisis intervention with pastoral-based support services. There may be more parts than the traditional crisis intervention tools, such as scriptural education, rituals, and sacraments. This intervention may not be appropriate for all individuals concerned. Nevertheless, it should be offered where possible. Often individuals find a “closing point” of the event through participation in a pastoral service.
Pastoral crisis intervention should be carried out several days after the event. For seamen Christian Centres, Chaplaincies and other Seamen’s Welfare Agencies could assist with this intervention.
Family crisis intervention, organizational consultation
Support services are provided for families and/or organizations of which the affected individual is part. The goal is to convey information how to deal with the affected individual and, in case of organizations, to which degree the individual’s work capacity may be reduced and what the organization can do to facilitate the return to normal functioning.
These activities may be carried out by mental health professionals, crisis intervention teams or chaplaincy any time after the event whenever required.
Follow-up, Referral mechanism for assessment and treatment
After conclusion of the intervention activities it is necessary to check whether the activities were successful or not. On the basis of the individual and group intervention activities, and following assessment of the mental status individuals may be referred to additional professional psychological or psychiatric help. This should be done by mental health professionals after the conclusion of the activities or later, whenever needed
Aspects to consider
Emergency medical measures
Sedatives should be used only in cases of acute crisis. The Medical Guide for Ships (5) recommends for the treatment of Trauma (C.1.6.3) stronger sedativa and suggests making use of the Radio Medical Advice.
Special care has to be provided to affected individuals who show risk of suicide. They have to be observed carefully.
In order to prevent suicide fixation may be recommended.
General advice for applying crisis intervention methods
All crisis intervention activities should be carried out without being intrusive. Nobody should be forced to speak about his feelings. Affected individuals may not admit that they need help. They may be afraid that this could interfere with their job security or career opportunities. Persons doing crisis intervention should assure the affected individuals that their reactions are normal after an extraordinary situation. They should make an effort to convince the individuals of the benefit of the methods, and they shall ensure them confidentiality of the intervention.
It is important that crisis intervention is offered to all the persons who experienced the critical incident in one way or the other.