Critical Incident Stress Management (CISM): A Practical Review

FIRSTE D I T I ONREVIEW COURSECritical Incident Stress Management (CISM):A PRACTICAL REVIEWInternational Critical Incident Stress Foundation, Inc.George S. Everly, Jr., PhD, ABPP, CCISMThe Johns Hopkins University, Loyola University, MarylandJeffrey T. Mitchell, PhD, CCISMThe University of Maryland Baltimore County

CRITICALINCIDENT STRESSMANAGEMENT(CISM):A Practical ReviewGeorge S. Everly, Jr., PhD, ABPP, CCISM&Jeffrey T. Mitchell, PhD, CCISM 2016 George S. Everly, Jr. and Jeffrey T. MitchellAll rights reserved. Duplication of any of thesematerials is strictly prohibited.

About the AuthorsGeorge S. Everly, Jr.George S. Everly, Jr., PhD, ABPP, FAPA, FAPM,CCISM is an award-winning author and researcher. In2016, he was ranked #1 published author in the world byPub-Med Finder in the field of crisis intervention. Hispaper on resilient organizational cultures was ranked #1in it content domain by Bio-Med Library. Dr. Everly isco-Founder and Chairman Emeritus of the InternationalCritical Incident Stress Foundation. He holdsappointments as Associate Professor (part time) inPsychiatry at the Johns Hopkins School of Medicine,Professor in the Department of International Health(adjunct) at the Johns Hopkins Bloomberg School ofPublic Health, and Professor of Psychology at LoyolaUniversity in Maryland (core faculty).In addition, he has served on the adjunct facultyof the Federal Emergency Management Agency and theFBI’s National Academy at Quantico, Virginia. He wasa member of the CDC Mental Health CollaborationCommittee (having chaired the mental structure Expert Team within the US Department ofHomeland Security, and the NVOAD Emotional &Spiritual Care Committee, as well as the NVOAD EarlyPsychological Intervention sub-committee. He wasSenior Research Advisor, Social Development Office,i

Office of His Highness, the Amir of Kuwait, State ofKuwait. Prior to these appointments, Dr. Everly was theChief Psychologist and the Director of BehavioralMedicine for the Johns Hopkins' Homewood HospitalCenter. He was a Harvard Scholar visiting inPsychology, Harvard College and a Visiting Professor atthe University of Hong Kong.Dr. Everly is a Fellow of the American PsychologicalAssociation and a Fellow of the American Institute ofStress, in addition, he has been awarded the Fellow'sMedal of the Academy of Psychosomatic Medicine andthe Professor's Medal of the Universidad de Weiner(Peru). He was elected a “Pioneer in Traumatology” byFlorida State University and received the LeadershipAward from the American Red Cross.Jeffrey T. MitchellJeffrey T. Mitchell, PhD, CCISM is Clinical Professor ofEmergency Health Services at the University ofMaryland in Baltimore County, Maryland. He is amember of the Graduate Faculty of the University ofMaryland. He is a co-founder and President Emeritus ofthe International Critical Incident Stress Foundation. Heearned his Ph.D. in Human Development from theUniversity of Maryland. He served for six years as aregional coordinator of Emergency Medical Services forthe Maryland Institute for Emergency Medical ServicesSystems. He was responsible for the development of theEmergency Medical Services System in five southernii

Maryland counties. After serving as volunteer paramedic/ firefighter for ten years, he developed acomprehensive, integrated, systematic, and multicomponent crisis intervention program called “CriticalIncident Stress Management.” Today, that programreduces traumatic stress in many countries.He has authored more than 275 articles and 19books in the stress and crisis intervention fields. Heserves as an adjunct faculty member of the EmergencyManagement Institute of the Federal EmergencyManagement Agency. He is a faculty member of FloridaInstitute of Technology and teaches a course on thepsychology of disasters. Dr. Mitchell is a facultymember in the school of education, Johns HopkinsUniversity. He is a reviewer for the Journal of theAmerican Medical Association (JAMA), DisasterMedicine, the Journal of Emergency Medical Services(JEMS) and the International Journal of EmergencyMental Health. He received the Austrian Red CrossBronze Medal for his work in Crisis Intervention in theaftermath of the Kaprum, Austria train tunnel fire. TheAssociation of Traumatic Stress Specialists approved Dr.Mitchell as a Certified Trauma Specialist.The United Nations appointed him to the UnitedNations Department of Safety and Security WorkingGroup on Stress. He has consulted on stress, crisis, andtrauma topics in 28 nations and in every one of the 50United States.iii

CONTENTSIntroduction . 1Chapter One: Foundations of CISM . 3Critical Incident . 3Terrorism as a Critical Incident . 6Psychological Toxicity. 8The Effects of Terrorism . 9Psychological Efforts to Mitigate theAdverse Impact of Terrorism .16Psychological Crisis .17Crisis Intervention .22PIE.22Effectiveness of Crisis Intervention .24Pastoral Crisis Intervention (PCI) .29Functional Elements of PCI .30Peer Support Approach .32Disaster Mental Health .33Continuum of Care.33A New Paradigm: The Johns Hopkins’Resiliency Model (RRR).34Critical Incident Stress Management(CISM).37Strategic Planning and CISM: ThreeTools .46Effectiveness of CISM .52Controversy .59Chapter Two: Crisis Communications .65iv

Rapport and Empathy .65Questions.69The Diamond Technique.70Action Directives .72Body Language .7419 Important Crisis CommunicationsConcepts .74Chapter Three: The Nature of the Crisis Response .79Five Categories of the Crisis Response .79Surveillance and Psychological Triage .85The Sea-3 Mental Status Assessment .88Chapter Four: Assisting Individuals in Crisis .89SAFER-R .90SAFER-R and Suicide Intervention . 100CCDR Model . 100Chapter Five: Informational Group Crisis InterventionRest Information Transition Services (RITS) . 103Crisis Management Briefings (CMB) . 104Chapter Six: Interactional Group CrisisIntervention . 111Interactive Group Crisis Intervention . 111Defusing . 113Critical Incident Stress Debriefing(CISD) . 129Strategic Planning: Groups . 162Chapter Seven: The Rules of Engagement . 167National Incident Management System(NIMS) . 167v

(NIMS) Components . 170Emergency Operations Center (EOC) . 172Incident Command System (ICS) . 173Placement of Psychological CrisisIntervention Teams . 175Principles of Operation in Large-ScaleIncidents . 176Chapter Eight: Supporting Crisis Interventionistsand Self-Care . 181Physical Challenges . 181Cultural Challenges . 183Role Ambiguity. 183Role Conflict . 184Role Overload . 184Existential Challenges . 185Coping and Support Interventions . 185Chapter Nine: The CISM Team-General Guidelinesfor Team Development and Leadership . 195Basic Organizational Considerations . 195Thoughts on the Use of Peer Support . 198Crisis Leadership . 200Appendix 1: Sample Review Questions on CISM . 205Appendix 2: Sample CISM Questions withAnswers. 219Appendix 3: A Guide to Relevant Resources . 229References . 243Index . 261vi

Figure 1.1: The CISM Amalgam of Interventions .41Figure 1.2: Circles of Impact .48Figure 1.3: The Funnel Technique .50Figure 1.4: A Planning Matrix .52Figure 2.1: The Empathy Cascade .67Figure 2.2: The Diamond Technique .70Figure 6.1: Cognitive & Affective Phases of CISD 142Figure 7.1: ICS Structure . 174Table 1.1: Pastoral Crisis Intervention.31Table 1.2: Six Core Factors of Critical Incident StressManagement (CISM) .43Table 3.1: Cognitive Indicia .80Table 3.2: Emotional Indicia.80Table 3.3: Behavioral Indicia.81Table 3.4: Spiritual/Faith Indicia .81Table 3.5: Physical Indicia.82Table 6.1: Group Planning Matrix . 163Table 7.1: Administrative Positions. 175vii

INTRODUCTIONIt has been over a decade and a half since we lastwrote a comprehensive review of Critical Incident StressManagement (CISM) (Everly & Mitchell, 1999). Thisvolume represents the latest available review of the coreconcepts, intervention tactics, and research on CriticalIncident Stress Management (CISM), albeit in digestform.Since the last review of CISM was written, manychanges have taken place in the fields of critical incidentstress and disaster mental health. The recognition thatfirst responders and the military are at extraordinary riskfor developing acute and posttraumatic stress injuriesand disorders, continues to grow, though still notuniversally recognized. With such recognition of thehigh intensity and high risk of these professions isacknowledged, there comes an ethical, if not legal,obligation to protect those personnel; an obligation tocreate the most reasonable and ‘safest workplace’possible. While some environments may be inherentlyhigh risk, if not toxic, and thus immutable topsychological detoxification (e.g., combat), theobligation would seem to extend to reactive prophylaxissuch as crisis intervention and resiliency fosteringinitiatives. This is the essence of CISM. Given thehindsight of four decades we have come to understand1

that CISM is, at its core, a program designed to fosterhuman resilience.Though originally formulated for emergencyservices personnel, CISM with some modification, maybe useful when applied to other populations at high riskfor psychological injury or posttraumatic stress. Thiswould include the military, disaster response agencies,relief workers, and humanitarian aid personnel including:public health agencies, hospital personnel, lains,transportation workers, and civilians in workplacesvulnerable to violence, accidents, and criminality.Although formulated over four decades ago,CISM has endured perhaps largely because of itsflexibility to adaptation to numerous and diversesituations, populations, and venues. By definition, CISMis a comprehensive, integrated, systematic and multicomponent intervention system. The skills involved insuccessful application are: 1) tactical competency usingthe specific interventions across the CISM continuum,and 2) choosing the best intervention at the right timefor the right target group.2

wrote a comprehensive review of Critical Incident Stress Management (CISM) (Everly & Mitchell, 1999). This volume represents the latest available review of the core concepts, intervention tactics, and research on Critical Incident Stress Management (CISM), albeit in digest form. Since the last review of CISM was written, many