Critical incidents… events that endanger lives and evoke intense fear and shock. Unmitigated, such incidents have potential to interfere with emergency responder functioning and to shorten careers by stress disability. Most emergency responders do not develop post-traumatic disorders. For those who do, the effects can change lives. However, most emergency responders do experience some stress that can compromise health post-event and manifest in absenteeism, diminished morale, substance use, or family and interpersonal conflicts, if left unnoticed.

On September 28th and 29th, Dr. Jeffrey Mitchell, President of the International Critical Incident Stress Foundation (ICISF), trained over 100 public safety and business emergency services personnel in a crisis intervention model called Critical Incident Stress Management (CISM). This event was sponsored by BICEPP with Amgen Inc., Southern California Edison, City of Santa Fe Springs and Santa Fe Springs Chamber of Commerce & Industrial League Inc. as contributing partners.

Why Is Critical Incident Stress Important?
Over the past 150 years, behavioral scientists have grappled with the effects of catastrophic experiences upon health. Most often, modern warfare has been the engine behind the need for this to be understood. The fury of the Civil War resulted in soldier "melancholia." Weapon enhancements during World War I was followed by the study and treatment of veterans who returned with "shell shock."

During World War II military psychiatrists discovered that immediate psychological support for soldiers after firefights helped units return to combat. This finding became known as the "immediacy, proximity, and expectancy (of return to full functioning) guidelines." Following the Vietnam War, the American Psychiatric Association designated "Post Traumatic Stress Disorder" to describe a syndrome of frozen reaction for many of these vets.

Crisis Intervention has taken hold during the past 40 years as the approach to critical incidents beyond the scope of war. One of the most pivotal developments occurred in 1983 when Dr. Mitchell designed a structured crisis intervention method to respond to emergency worker stress. Since then, Mitchell's model has been adapted for professional emergency response organizations, military units, and others. It is currently utilized internationally in over 350 settings, and has become the recognized standard of care among professional emergency responders.

According to Mitchell, the human stress response is a "combination of neurologic, neuroendocrine, and endocrine arousal response mechanisms that can affect and alter every organ and function of the human body" (CISM: The Basic Course Workbook 2nd Ed., p. 17). In post-traumatic stress, one's coping mechanisms are overwhelmed by stress. The affected person feels out of control and helpless.

A community wide disaster is a potentially traumatizing event. Participants at Dr. Mitchell's training, including those from Amgen, The Capital Group Companies, El Camino Community College District, Pacific Clinics, the American Red Cross, Santa Fe Springs Fire Department, Southern California Edison, Universal Studios, and Warner Bros. Studios, want to be ready. BICEPP sponsored an introductory lecture by Dr. Mitchell last December.

Critical Incident Stress Management Training.
Mitchell describes the core components of Critical Incident Stress Management (CISM) as a series of interventions that occur within phases of activation, with a specified goal and format for each intervention. During the pre-crisis phase CISM includes pre-incident preparation services of training and pre-deployment. During the acute crisis phase CISM consists of on-scene services such as individual and family support and demobilization. During the post-crisis phase CISM is composed of off-scene support services of defusing and critical incident stress debriefing (CISD).

The Pre-Crisis Phase

Pre-incident preparation, during the pre-crisis phase, includes the following

1. Determining that a CISM team is needed if several critical incidents a year produce serious emotional impact on personnel;
2. Gaining support from administration to gather a task force of peer support personnel and mental health professionals to develop the CISM team;
3. Providing a minimum of two days training for the CISM team in ICISF-approved courses, with an additional two days training for entry level team members;
4. Establishing the leadership and developing written operating procedures for the CISM team;
5. Reviewing critical incidents, as they occur, to evaluate CISM team improvements.

The Acute-Crisis Phase

During the acute-crisis phase the trained CISM team provides on-scene services of individual and family support and demobilization. Demobilization is a 30-minute information and rest session for incident response of 100 or more personnel. The goals of demobilization are to assess the well-being of personnel and the need for debriefing or other services, and to provide stress management information and the opportunity for rest before returning to routine work.

The Post-Crisis Phase

In the post-crisis phase, the formats for intervention consist of critical incident debriefing and critical incident stress defusing. Defusing is a shortened version of CISD, 20-45 minutes in length, conducted by trained CISM team members only. The goals of defusing are to mitigate the impact of the incident, to accelerate the recovery process, and to reduce cognitive, emotional, and psychological symptoms of critical incident stress. This is accomplished through rapid ventilation of the stressful experience and restoration of cognitive processing of the event. The defusing process provides information for stress survival, affirms the value of personnel, establishes linkages for additional support, and develops expectancies for the future.

Mitchell zeroed in on off-scene support services of defusing and CISD, using experiential learning in addition to didactic material to teach the model. Day Two of the training began with a defusing demonstration. The defusing dealt with a multiple-stressor critical incident in which police and emergency medical technicians (EMTs) responded to a confusing and terrifying suicide rescue situation. Volunteers for the mock defusing demonstration included a number of officers representing a range of Southern California public safety agencies. Reactions to the hypothetical suicide were voiced in the defusing meeting as shock, fear, or outrage.
Later that morning, the class was invited to take part in practicing the format for critical incident stress defusing. Divided into small groups, participants role-played both the survivors of a business meeting held hostage for 15 minutes by an agitated man brandishing a gun, and the two CISM team members sent in to defuse them.

At the conclusion of this role-play the takeover survivors and the CISM team members of the hypothetical incident told each other what the defusing meeting had meant to them. A number of the small groups were impressed by how quickly a situation of unexpected fearfulness had become marked by interpersonal conflict and blame. Other participants expressed how clearly they had witnessed the necessity of staffing CISM teams with both peers and mental health practitioners trained in the model, as Dr. Mitchell has always recommended.

Reactions To The Training
Some attendees asked the question, "What should be done if a debriefing or defusing erupts into lots of angry blaming?" Mitchell answered that anger is expectable and should be addressed openly and with neutrality. During debriefings and defusings, CISM team members point out that anger is one way people channel their stress reactions.

Others anticipated, "Who will debrief me after I debrief our employees?" As Mitchell stated, emergency response personnel who respond together should not debrief each other, nor should an employee debrief other employees with whom they routinely work.

Participants interviewed during Day One of the BICEPP-sponsored two-day training by Mitchell were impressed with the utility of the CISM model for their own emergency response organizations. They felt that they could identify the situations in their emergency work that produce critical incident stress, and they understood why support services would be needed. Others were convinced of the value of CISM by the documentation, presented by Dr. Mitchell, of short- and long-term costs to business when critical incidents are not properly mitigated.

Implementation of CISM services posed a number of questions for trainees interviewed on the second day of training. Given that the model was developed within police, fire, and EMT agencies, the provision of multi-component CISM services has been most often replicated within those settings. Typically, public safety personnel such as these have ongoing staffing procedures for their CISM teams, involving on-site peers with off-site mental health professionals.

Participants considered how to integrate trained peers and mental health professionals into CISM programs. Representatives from a number of business settings felt that they wanted to use Mitchell's training to implement their own CISM teams capable of debriefing employees on-site shortly after critical incidents. Anticipating Southern California's next +7.0 earthquake, BICEPP members considered the difficult logistical issues involved in relying on any off-site personnel to fulfill essential functions.

Some participants interviewed suggested that Mitchell's approach could be set up in their business and industry settings with a couple of caveats. One way to address the mental health professionals' involvement, recommended in CISM, is to include them in the early stages of preparedness planning. Historically, this has not been a focus for business, or mental health for that matter, because it rests upon a shift in thinking about intervention to thinking about prevention. Another way to address the mental health professionals' involvement, recommended in CISM, is to include them in developing systems to support business resiliency during emergency response. The value of a preventive approach to critical incident stress in emergency operations, through systemic interventions to delimit psychological hazards during the acute-crisis phase, is an important avenue to implementation of the CISM programs that business and industry now seek.

What's Next?
Participants representing BICEPP members voiced a range of thoughts about how to utilize the training at their workplaces. Some stated that they intend to evaluate the training's potential implementation at their companies, after considering the input of other departments. Some of the BICEPP participants clearly expressed their intent to establish internal CISM teams, composed of themselves and others who will also take the Basic CISM training, in order to provide rapid response to employees who have witnessed critical incidents.
BICEPP is considering hosting an advanced training by Dr. Jeffrey Mitchell to assist Southern California business and industry in developing CISM programs. BICEPP President Chris Wright and BICEPP Programs Director Nina Johnson have underscored the importance of managing human risks to business. Jeffrey Mitchell, fire fighter and psychologist, and proponent of CISM, has launched business and industry on the path of implementing company emergency response services to protect employees.

1st Annual BICEPP E.R.T. Challenge
Let the Games Begin! Brush off your training program and prepare your company's Emergency Response Team (E.R.T.) for the 1st Annual BICEPP E.R.T. Challenge. The competitions will be held on Saturday, May 5, 2001.
BICEPP member company teams will compete against each other in a demonstration of their abilities to respond to multiple categories of emergencies. The event will have two divisions/categories. Companies will be able to register their team in either the Floor Warden or the Emergency Response Team category, depending upon the experience and skill level of their team. Save the date and look forward to more information on registration and competition venues.

Gifts of Life
Show you care! Why not give a survival gift to everyone on your gift list this year? Items such as portable radios, batteries, flashlights, first aid kits, fire extinguishers and lightsticks for children are great and inexpensive gift-giving ideas. Or, put together complete quake kits for the people you care about.
This message was brought to you by ESP the Earthquake Survival Program. For more information on ESP, contact Joyce Harris, Los Angeles County Office of Emergency Management, ESP Hotline (213) 974-1166.

Dr. Monty Clouse of Trauma Intervention Specialists is a consulting and clinical psychologist. As a member of BICEPP and the International Critical Incident Stress Foundation, Dr. Clouse is actively involved in designing and training corporate emergency response programs and regularly speaks on strategic issues of human performance during emergencies.

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