Critical Incident Stress Management
Program (CISM)
Critical Incident Stress Management Program (CISM)

Critical Incidents

What is a Critical Incident?

Any incident that causes an individual to experience unusually strong emotional involvement whose reactions to
it has the potential to interfere with that individual's ability to function during or after the incident may qualify for
a Critical Incident Stress Debriefing. The following are some examples of incidents that may be selected for a
debriefing:

* Serious injury or death of an emergency services personnel at an incident
* Mass casualty incidents
* Suicide of a co-worker
* School-related crisis
* Death or violence to a child
* Natural disasters
* Incidents that attract extremely unusual or critical media coverage
* Any incident that is charged with profound emotion, and is deemed critical by the officer or person in authority

A critical incident is not limited to the above examples.

Critical Incident Stress

Recognizing Critical Incident Stress

The lists below represent some of the symptoms a person may experience following a critical incident (CI).
These symptoms are temporary and may last from several days up to a couple weeks. However, if the symptoms
persist longer than several months, it is important to seek professional help. Symptoms of CI stress include, but
are not limited to, the following:

* Physical Symptoms
*  Fatigue
* Difficulty sleeping or developing insomnia
* Easily startled
* Chest pain
* Headaches
* Elevated blood pressure
* Rapid heart rate
* Teeth grinding

Any of these symptoms may indicate the need for medical evaluation. When in doubt, consult a physician.

Behavioral Symptoms  
* Hyperarousal — increased arousal: the person continues to anticipate an overwhelming threat. It may cause
difficulties with attention and concentration.
* Avoidance — withdrawal: avoids close emotional ties with family, colleagues, and friends. Other changes in
social activity, including isolation (being distant).
* Inability to rest.
* Intensified pacing.
* Erratic movement.
* Loss of or increase in appetite.
* Increased alcohol consumption: abusing alcohol or other drugs as a form of self-medication.
* Change in usual communications.
* Completes only routine mechanical activities.

Emotional Symptoms  
* Fear
* Grief
* Panic
* Denial
* Anxiety
* Agitation
* Irritability
* Depression
* Intense anger
* Apprehension
* Guilt because he or she survived while others did not
* Emotional outbursts — suddenly irritable or explosive, whether provoked or not
* Feeling overwhelmed
* Loss of emotional control
* Inappropriate emotional response
* Inability to feel or express emotions
* Emotional numbness (difficulty feeling love and intimacy, or in taking interest and pleasure in day-to-day
activities)

Cognitive Symptoms  
* Confusion
* Nightmares
* Uncertainty
* Suspiciousness
* Intrusive images — the unwanted memories so strong he or she feels the critical incident is actually occurring
again
* Blaming others
* Poor problem solving
* Poor abstract thinking
* Shortened attention span or indecisiveness
* Poor concentration or memory
* Difficulty identifying objects or people
* Heightened or lowered alertness
* Increase or decrease awareness of surroundings
* Memory loss
* Self-blame
The CISM program utilizes the following approach in accordance with
the International Critical Incident Stress Foundation model


* Individual Crisis Intervention & Peer Support

Crisis intervention is sometimes called "emotional first-aid." Interventions are typically done
individually (one-on-one) or in groups. This program is designed to teach participants the
fundamentals of individual intervention and the protocol specific to it. The audience for this class
includes both emergency services, military, and business/industrial peer support personnel without
formal training in mental health, as well as mental health professionals, who desire to increase their
knowledge of one-on-one crisis intervention techniques.

* Group Crisis Intervention

The Group Crisis Intervention training program is designed to present the core elements of a
comprehensive, systematic and multicomponent crisis intervention curriculum. The two day course
prepares participants to understand a wide range of crisis intervention services including pre- and
post-incident crisis education, significant-other support services, on-scene support services, crisis
intervention for individuals, demobilizations after large scale traumatic incidents, small group
defusings and the group intervention known as Critical Incident Stress Debriefing (CISD).

* Advanced Group Crisis Intervention

The Advanced Group Crisis Intervention training program has been designed to provide participants
with the latest information on critical incident stress management techniques and post-trauma
syndromes. The program emphasizes a broadening of the knowledge base concerning critical incident
stress interventions as well as Post-Traumatic Stress Disorder. The emphasis will be on advanced
defusings and debriefings in complex situations. This training has been developed for EAP, human
resources and public safety personnel, mental health professionals, chaplains, paramedics,
firefighters, physicians, police officers, nurses, dispatchers, airline personnel and disaster workers
who are already trained in the critical incident stress debriefing format.

* Grief Following Trauma

This course is designed to help both professional and lay people identify characteristics of trauma
and traumatic events, the normalcy of traumatic grief reactions, learn good death notification and
body identification techniques, become skilled at identifying warning signs of complications, and learn
the importance of early interventions and support utilizing the SAFER-R model.

* Stress Management for the Trauma Provider

This course explores the "Stress Continuum," the levels of stress including eustress (beneficial,
motivating stress), traumatic stress, burnout, countertransference, compassion fatigue or secondary
PTSD, and vicarious traumatization which may occur as a result of helping others. A discussion of
coping strategies for those who work with traumatized children will also be offered. This course is
appropriate for all mental health professionals, emergency services personnel, and peer counselors.

* Strategic Response to Crisis

This course presents essential information for the assessment of both crisis situations and the
effects of critical incidents on people involved in those situations. Participants will learn to create an
effective plan of action to assist those in crisis. Strategic planning and tactical decision making are
emphasized, as are rationales for choosing one set of crisis intervention processes over another.

* Pastoral Crisis Intervention

Pastoral Crisis Intervention may be thought of as the combination of faith-based resources with
traditional techniques of crisis intervention. The purpose of this two-day workshop is to assist the
participants in learning how pastoral interventions and traditional psychological crisis interventions
may be effectively integrated. Chaplains, pastoral counselors, mental health professionals, ministers,
and anyone interested in the use of faith-based resources in healing should find this course of
interest.
The Intervention Process

The CISM program utilizes the following approach in accordance
with the International Critical Incident Stress Foundation Model

* Pre-incident Education: Pre-incident traumatic stress education is the most important
component of CISM. The primary aim of stress education is to establish a protective barrier
against traumatic stress and to teach stress management strategies so individuals can quickly
reduce and eliminate significant stress generated by traumatic events.

* Defusing: This intervention typically occurs in the range of 3-12 hours post incident for those
who were on the front lines. It offers an opportunity for ventilation, normalization, and
education.

* Crisis Management Briefing: Using community leaders and others, this intervention has many
applications to help mitigate stress reactions, assist in recovery, and provide local resources.

* Individual "1-on-1's": These are the most common intervention services we provide. These
are often conducted by team members shortly after a critical incident, but occur at other times,
as well. Individuals needing on-going psychological support will be referred for assessment to
appropriate local mental health professionals.

* Psychological Debriefing: The formal seven-stage debriefing is utilized based upon
assessment of need and usually held within 1-10 days after the conclusion of the incident.

* Follow-up and Family Services: This is a means by which we "touch base" to see if things are
going well. This is another area where we rely heavily on our trained mental health professionals
and seek to find local resources that will allow them to return to effective functioning or the "new
normal."
www.MickMaurer.com
The Critical Incident Stress Debriefing (CISD), CISDdeveloped by Jeffrey T. Mitchell, Ph.D., is a group meeting or discussion about a distressing critical incident. A critical
incident is any event which has a stressful impact sufficient enough to overwhelm the usually effective coping skills of either an individual or a group. Providing crisis
intervention and education, the CISD meeting (lasting approximately one-to-three hours) may reduce the impact of a critical incident

Critical Incident Stress Debriefing:

* is not therapy or substitute for therapy

* should be applied only by those who have been specifically trained in its uses

* is a group process, group meeting, or discussion designed to reduce stress and enhance recovery from stress. It is
based on principles of crisis intervention and education.

* may not solve all the problems presented during the brief time-frame available.

Sometimes it may be necessary to refer individuals for treatment after a debriefing.

* may accelerate the rate of "normal recovery, in normal people, who are having normal reactions to abnormal events."

Mitchell, J.T. & Everly, G.S. (1995). Critical incident stress debriefing: An operations manual for the prevention of trauma among emergency service and disaster workers.
(2nd ed.). Baltimore, MD: Chevron.
A Critical View on Debriefing
by Richard Gist, PhD

This contribution is excerpted from a May 1996 post to the traumatic-stress list by Richard Gist, concerning the effectiveness of debriefings following natural or man-made disasters. It is reproduced here
with the author's permission.

It is important (though always treated as some form of sacrilege) to note one more time that "debriefing" fails to emerge in a range of empirical studies as any sort of "a most important first step in a
disaster" (sic), and many studies seem to be suggesting an oddly paradoxical negative effect for at least some of those most at risk. The "debriefing" movement is a truly classical example of how powerful
the "Barnum effect" can become, even among folks ostensibly trained in critical empirical paradigms. It seems like a good thing to do, and we've told one another (and the world) repeatedly that it is; we ask
people if it helped, and they say they felt better--that's enough, isn't it?

Not really . . . we ask people if they'd like a doughnut, and most say yes; we ask if their doughnut was tasty; most agree. So do we now conclude that doughnuts are important elements of nutrition? Do we
rush to stuff doughnuts into any open mouth? High concentrations of sugar and fat make the fare desirable on the surface, but also render it less than healthy beneath.

There's a significant literature on this . . . in a couple of places:

There's piece after piece of "show and tell" in trade magazines, newsletters, and such, plus any number of proprietary seminars and conferences chock full of allusions to "scientific" information--here we find
quite intemperate claims of "proven approaches" to "the right kind of help," and even aspersions that any other approach can somehow prove harmful! We've even seen claims of "data" and allusions to
"studies" touted to "prove" the efficacy and criticality of this simplistic but labyrinthically aggrandized intervention system, but these evaporate like a bottle of Evian spilled on the desert floor when we go in
search of the data themselves.

The principal purveyors, as happens in so many of these "movements," often hold credentials that respond to even light scrutiny much like that silvery stuff on a rub-off lottery ticket; exaggeration and
misstatement go unchallenged in the revival tent atmosphere of the faithful, and are treated like heresy when heard from "outsiders." Serious researchers may pass through such environs, but quickly come to
eschew the transparently disingenuous machinations pretending as science and set about the slow and thankless process of sifting through the silt. That's been taking place for several years now around this
topic, and in the refereed academic journals of our discipline we find a growing chain of structured, reasonably partitioned empirical studies which report with an eerie consistency:

1. No preventative effect from debriefing;
2. No differential ill-effect from its absence;
3. An equally consistent (but generally discounted) finding which seems to suggest that those who most seek this intervention show poorer longer-term resolutions.

But the bandwagon rolls and rolls and rolls . . . it's fun and affirming, I guess, to ride it, even if the trip is for nought (at least from the client perspective). But watch where the vehicle goes . . . additional traffic
in a disaster zone is not exactly a welcome sight.

A Short Reference List
(not at all exhaustive; simply copied from a recent manuscript)

Alexander, D. A., & Wells, A. (1991). Reactions of police officers to body handling after a major disaster: A before and after comparison. British Journal of Psychiatry, 159, 547-555.

Bisson, J. I., & Deahl, M. P. (1994). Psychological debriefing and prevention of post-traumatic stress: More research is needed. British Journal of Psychiatry, 165, 717-720.

Deahl, M. P., Gillham, A. B., Thomas, J., Searle, M. M., & Strinivasan, M. (1994). Psychological sequelae following the Gulf war: Factors associated with subsequent morbidity and the effectiveness of
psychological debriefing. British Journal of Psychiatry, 165, 60-65.

Gist, R., & Taylor, V. H. (1996). Line-of-duty deaths and their effect on co-workers and their families. Police Chief, 63(5), 34-37.

Gist, R. (1995, August). Who cares about firefighter health and safety? In J. M. Melius (Chair), Who does care? Symposium conducted at 13th Symposium on Occupational Health and Hazards of the Fire
Service, John P. Redmond Foundation/International Association of Fire Fighters, San Francisco, CA.

Gist, R., & Woodall, S. J. (1995). Occupational stress in contemporary fire service. Occupational Medicine: State of the Art Review, 10, 763-787.

Gist, R. & Woodall, S. J. (In review). And then you do the hokey-pokey and you turn yourself about. Manuscript for conference symposium.

Hytten, K., & Hasle, A. (1989). Firefighters: A study of stress and coping. Acta Psychiatrica Scandinavia, 355(supp.), 50-55.

Kernardy, J. A., Webster, R. A. , Lewin, T. J., Carr, V. J., Hazell, P. L., & Carter, G. L. (1996). Stress debriefing and patterns of recovery following a natural disaster. Journal of Traumatic Stress, 9, 37-49.

McFarlane, A. C. (1988) The longitudinal course of posttraumatic morbidity: The range of outcomes and their predictors. Journal of Nervous and Mental Disease, 176, 30-39.

Raphael, B., Meldrum, L., & McFarlane, A. C. (1995). Does debriefing after psychological trauma work? Time for randomized controlled trials. British Medical Journal, 310, 1479-1480.

Redburn, B. G. (1992). Disaster and rescue: Worker effects and coping strategies. Doctoral dissertation (community psychology), University of Missouri-Kansas City. [University Microfilms No. AAD93-12267;
Dissertation Abstracts International, 54(01-B), 447.]

Redburn, B. G., Gensheimer, L. K., & Gist, R. (1993, June). Disaster aftermath: Social support among resilient rescue workers. Paper presented at the Fourth Biennial Conference on Community Research and
Action, Society for Community Research and Action (Division 27, American Psychological Association), Williamsburg, VA.

Simmons, T. (1995). What makes them winners . . . Phoenix FireWorks, 19(5), 1; 4-5; 8.

Woodall, S. J. (1994). Personal, organizational, and agency development: The psychological dimension--A closer examination of critical incident stress management. Applied research project, Strategic Analysis
of Fire Department Operations, Executive Fire Officer program, National Fire Academy. (Available from Learning Resource Center, National Emergency Training Center, Emmitsburg, MD.)

Richard Gist, Ph.D.
Consulting Community Psychologist:
Kansas City (MO) Fire Department
South Metro Fire Protection District
Kansas City (MO) Health Department

Director, Social Sciences and Social Services
Johnson County Community College
12345 College Boulevard
Overland Park, Kansas 66210-1299
Page: (816) 989-8741 Mobile: (816) 223-8240 Voice: (913) 469-8500, Extension 3933 Fax: (913) 469-2585
CENTER FOR POST-TRAUMA THERAPY AND TRAUMA EDUCATION

Jeffrey T. Mitchell, Ph.D., works as an assistant professor at the University of Maryland, Emergency Health Services. He is also
on the staff of The Emergency Management Institute of the National Emergency Training Center in Emmitsburg, Maryland, U.S. He
is the founder of The International Critical Incident Stress Foundation Inc. and has authored many publications on crisis
intervention, critical incident stress, disaster psychology, and Critical Incident Sress Management.

Dr Mitchell has served the center as an expert in issues related to helping the helpers. He has also acted as a trainer at the
following seminars organized in 1996 by the Crisis Consultation and Education Center: Critical Incident Stress Management and
Organizing Disasterr Emergency Work.
The Debriefing Debate

"A single session debriefing along with everything else [that] happens in an individual's life after an accident may or may not produce an effect, either positive or negative," said Dr. Ritchie. "But there were
enough indications that some people did worse after debriefing to make us worry about it. What often happens in an accident scenario or a disaster scenario, and this is what we're trying to change, is you've got a
traumatized population that's just seen or heard some pretty horrendous stuff. And you have a troop of folks who come in from the outside and says, 'Okay, let's form a group. Now I want you to go through and
tell me what's happened, tell me what you saw, what you felt, what you smelled, what you imagined.' And the intent of some of this has been good, in terms of talking about your normal reaction, but some
people aren't ready to go back and re-experience the sights and smells of what just happened, especially if they're still feeling unsafe themselves."

Dr. Ritchie said if there are still shootings occurring, for example, people may still feel unsafe, so sometimes the best reaction for somebody is to try to suppress what happened to get through until they are in a
safer place, and even then they may not want to talk about the event. "The other big problem is a lot of times people would like to go in and do the single session debriefing and then say, 'Okay, they are
debriefed and we don't need to do anymore.' You lose the ability to do a whole lot of other interventions," she added.

However, Jeffrey Mitchell, PhD, a psychologist who formalized CISD, has established the International Critical Incident Stress Foundation to provide training for emergency services professionals. According to Dr.
Mitchell and George S. Everly, Jr., PhD, Critical Incident Stress Management (CISM) is often misrepresented and misunderstood. They say it is a comprehensive, integrative, multi-component crisis intervention
system that covers the pre-crisis, acute crisis and post-crisis phases and may be applied to individuals, small or large groups, families, organizations, and even communities. CISD, the seven-step group
discussion, is one of its core components and is conducted one to 10 days post-crisis to mitigate acute symptoms, assess the need for follow-up, and if possible provide a sense of post-crisis psychological
closure. Other key components of CISM are one-on-one crisis intervention, counseling or psychological support throughout the crisis spectrum and follow-up and referral mechanisms for assessment and
treatment, if necessary.

Among those trained by Dr. Mitchell was Cdr. Bryce LeFever, PhD, MSC, USN, department head of the substance abuse rehabilitation program at the Naval Medical Center in Portsmouth, Va., who conducted
debriefings as a psychologist attached to a Special Forces unit during the Afghanistan conflict for three months in the summer of 2002. Unless a particularly traumatic firefight or event occurs that requires an
immediate debriefing, debriefers in the field often will not carry out full sessions until combat operations have ended and in the meantime will focus more on being supportive. The full debriefings are aimed at
helping provide soldiers a smooth transition to home life from the "insane world" of combat, which was not done with Vietnam, Cdr. LeFever advised.

Cdr. LeFever also said there is some research that indicates debriefing sessions conducted within 72 hours of a traumatic event are likely to prevent PTSD. The object is for the individual to face their trauma and
process it, so that they don't have to avoid memory triggers, he advised.

But Dr. Ritchie said her main concern with debriefings is bringing somebody back to imagining the traumatic situation when they may not be ready for it. "By reliving the trauma, that may make the trauma worse,"
she advised.

Dr. Ursano said "prudent medical care requires evidence-based interventions and evaluations, particularly for interventions proposed to be applied widely and to many who are not at risk of long-term
consequences."

Dr. Ursano also advised that the new aspects of war, such as terrorism, ongoing threats and sustained low level exposures, will require new considerations of stress casualties and how best to identify and treat
them. "The need to assure that those who are injured received good psychiatric evaluation and care has been highlighted by the success of the new [Interceptor] body armor," he said. "Those who are injured are
a high risk group for PTSD. After the first Gulf War, in one study, about 34 per cent of those who were injured required some type of psychiatric intervention."

According to a paper titled 'The Debriefing Debate' from the Center for the Study of Traumatic Stress at USUHS, maintaining rest, food, water and natural recovery processes such as talking to fellow workers,
spouses and friends, should be considered when including debriefing in an intervention. It says debriefing has not been shown to prevent PTSD but for some may relieve pain, restore some function and limit
disability, although further study is needed. Talking in groups of people who are familiar with each other may be more helpful than in those that are not. Furthermore individuals dealing with the death of a loved
one may have difficulty if placed in a group with others who are not, and debriefing groups with individuals having different levels and types of exposures may 'spread' exposure from those with high trauma
exposure to those with low trauma exposure.

The November 2003 issue of Psychological Science in the Public Interest featured an article that said although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence
that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. But it also says that methodological limitations have complicated
interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma. "Evidence to date shows it does not make a difference," said Richard J.
McNally, PhD, a psychology professor at Harvard University and one of the article's authors. "In some, the debriefed end up doing worse, which shows the need to test these things first. Studies overwhelmingly
show that people who participate in them appreciate them [but] it's difficult to interpret statements that show gratitude to people who want to help."

According to the article, recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer
support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. "The single most important indicator of subsequent risk for chronic PTSD appears to be the severity
or number of post-trauma symptoms from about 1 to 2 weeks after the event onward," the article stated.

Dr. McNally said the vast majority of people are quite resilient and recover quickly from stressful events, but there are some people who 1-3 months after, have symptoms, such as nightmares. "So, we want to
target our resources toward them, rather than debrief everyone, focus on them, cognitive behavioral treatment for 4-6 weeks. Some have developed brief questionnaires to identify who's at risk for having
problems. That's very different than having them relive events. People are often too raw to deal with it and not everyone wishes to expose themselves in a public forum like that, especially so close to the event."

However Cdr. LeFever believes CISD debriefings are effective. "I am aware of the debate," he said. "For the most part, the studies criticizing Critical Incident Stress Management have been very flawed. For
example, examining trauma interventions that are not actual Critical Incident Stress Debriefings, or, the research has been done in cases where the technique has been grossly misapplied. There are specific
guidelines (therapeutic windows) on when to intervene and on which technique to apply. When these are violated, then I am certain that harm can be done. And, it is quite probable that some debriefers are more
skillful than others. I am not in a position where I can research this question and I do feel that bona fide research is important. The research should be done fairly. Too often it is done by those with an agenda to
tear down what I feel is one of the most important and effective psychological innovations of the 20th century. The bottom line is that, in my opinion and in my observation, CISD works because the 'guided
conversation' prevents avoidance of the trauma. Chronic avoidance of trauma [or any pain] is central to post-traumatic stress disorder and to every anxiety disorder ."

Dr. Ritchie said there are some people in the field who say group debriefings have helped their patients or allowed them to recognize those who needed further care. However she said in the past that she might
be called in to do a debriefing without knowing much of the background of the situation. "Sometimes it seemed to work well, and sometimes there was so much anger and hostility in the room and anger at each
other and the commander and at me for the outsider coming in and I'd leave feeling, 'Well, that's what the doctrine said to do, but was that the right thing to do in the situation?' And in the past what we've been
told is to do it very quickly, 24-72 hours after the traumatic event. [But] we don't really know [the best timing yet]. The British Royal Marines have a model that they're practicing where they do it at seven days
afterwards and 30 days afterwards. The field is changing right now very rapidly."

PTSD Risk
Lt. Col. Charles C. Engel Jr., MC, USA, a member of the VA/DoD joint PTSD clinical practice guidelines (CPG) work group, also said that poorly understood physical illnesses should not be written off as PTSD. A key
component of the new PTSD guideline is assessing environmental risks and possible illness links to exposures. Cognitive behavioral therapy and/or exercise have shown that they can provide modest relief of
symptoms for Gulf War illness, he added.

Dr. Ritchie said PTSD prevention should begin with a needs assessment. "In the military, you often do that by talking to the first sergeant, the commander, the chaplain, somebody who knows the unit," she said.

Dr. Ritchie added that most civilians do not want to talk to a group of strangers right after a disaster and just want to know if their family is safe. "They want to know where are they going to sleep that night, if say,
their house has been flooded out," she said. "And then if you go down after the immediate needs are met, one of the things that comes up over and over again is are environmental hazards there? How do I
know that the air that I breathe and water I drink [are safe]?"

Dr. Ritchie said monitoring the air and water is important, because a constellation of medical and psychological symptoms appear after a disaster. "What we like to have in health risk communication is clear
information coming out and being consistent from source to source, from a source you can trust," she said. "The idea is that you talk to the public in an honest fashion, you acknowledge what you don't know, you
also listen to the public so it's not just you preaching."

Mental health professionals should also make sure inappropriate mental health interventions are not coming in, Dr. Ritchie advised, "to allow the person to regain a sense of control over where they are, and part
of that is being able to tell media or counselors or whoever to hold off for a moment."

Dr. Ritchie said differences in populations being treated should be considered in the needs assessment piece. "What is your population, is the stress rapid, expected, unexpected, have they been trained for it or
not, are they wounded or not, and really until you know that, you can't make an appropriate [intervention] unless you know who is it that you're working with," she said.

Dr. Ritchie said she believes that in some circumstances debriefing can be useful, but that you have to be careful. Dr. Engel, speaking at the annual meeting of the Association of Military Surgeons U.S. in
November, said that although there is increasing recognition that debriefing strategies are less than effective and can be even harmful, "there is a tremendous pull to do them, certainly in absence of alternative
strategies. More studies need to be done."

Dr. Ritchie said it is important to screen individuals before you conduct a CISD. "If you have somebody with a history of mental illness, you should probably approach them very differently than a Special Forces
soldier in terms of asking them to tell what happened," she said. "The soldier is somebody who is liable to have a stiff upper lip and they may need some encouragement to talk, while somebody who is very
emotionally distraught who is already crying on somebody's shoulder, talking may not be what they need. They may need somebody to help give them support, help them calm down. The problem with debriefings
is you have one hammer and you're hitting all the nails and screws and staples with the one hammer. Some are going to work well and some you're going to cause further damage."

Dr. Ritchie said it is also important to distinguish whether a debriefing would best be served in a group or individual setting. If it is a platoon that has been together for several months, as opposed to a group of
strangers, then it may be more appropriate to conduct it in that group situation. It is also important to look for those who seem to be having more intense symptoms than others. "Because they are going to be
more at risk for developing the long-term symptoms," she said. "Often people think just PTSD is a long-term symptom, but we know there is a range, there is depression, there is anxiety, there is substance
abuse, in children there can be delayed development and possibly regression. And, some people grow with trauma. If somebody has something to do after a traumatic or a difficult situation, they do much better,
and they can incorporate that experience, and feel stronger."

New CPG For PTSD
Dr. Harold Kudler, VA's VISN 6 mental health coordinator and a member of the VA/DoD joint PTSD CPG work group, said there are many people who jumped on the bandwagon to use CISD as a fit for everybody.
He said there are people who use them and like them, but there is no good evidence that it actually improves clinical outcomes. He said CISD was never intended as a substitution for therapy. "It was designed for
a group and critical stress management, as well as for pre-crisis situations, family interventions, and [Dr.] Mitchell stands behind critical stress management, pre-crisis intervention, and a good deal of preparation
and education. The work group recommended against individual psychological debriefings to reduce acute PTSD or prevent PTSD. Within [settings of] groups, there isn't evidence to recommend for or against
structured group debriefings," Dr. Kudler said, adding that forcing people who are not ready to relive their memories can do harm, whether in a group or individual setting, and can retraumatize them.

Dr. Kudler said that maybe 9 out of 10 people who have been through a trauma, whether soldiers or other victims, may be ready for a debriefing within 24-72 hours and will leave thinking, "I better understand it,
I feel supported, but not broken and not hurting." But people might not be ready to allow themselves to feel and they actually may be more likely to develop PTSD if they are retraumatized. Although the military
uses trained psychotherapists in some settings to carry out debriefings, Dr. Kudler said there might also be situations where members of a company are assigned to conduct debriefings and receive little training
for them. "This is one of my concerns about debriefing," he said. "It's a movement."

Debriefings should be done by psychotherapists because they are better at talking in a sensitive way and more likely to recognize problems and triage patients to the right level of care. Before the new guideline
can be revised to endorse debriefings, Dr. Kudler said more evidence needs to be provided. There is much to salvage in debriefings, he added. "Many military units use CISD," he said. "We'd be wise not to apply
debriefing in a routine way, but apply thoughtful elements and link it to continuity of care."

The new CPG was created by VA and DoD mental health personnel, other providers and chaplains. "We recommend early identification of people having problems, early education and support, careful use of
medication early on, prompt use once identified, and education of soldiers, [squad] leaders, families [and primary care providers], so these things are recognized early," Dr. Kudler advised.

Dr. Kudler said there is a good chance a soldier will be all right if he can get the support he needs. Nightmares are a normal response to traumatic events. "We hope by normalizing behavior, identifying people
early on and gradual levels of treatment...we'd like to build education and graded responses into caring and continuity of VA and DoD. We'd like the problem identified and to be part of a comprehensive plan. We
recommend nearly all returning veterans be screened for PTSD. It's important to try to change the culture," Dr. Kudler said. "We believe it is the clinically responsible thing to do, and we will be clocking this."

Several of the work group members were deployed to Iraq, and brought early drafts of the CPG to use as treatment guidelines in the field. "We can catch a whole generation of combat vets at the beginning
before they develop chronic problems, like depression, substance abuse that can mask PTSD, drinking to avoid nightmares to sleep," Dr. Kudler said. "Ten per cent of Gulf War I vets currently have PTSD. Fifteen
per cent of all Vietnam vets had it in the late '80s and 30 per cent sometime in their lifetime. One in five World War II casualties was psychiatric. We know it has a profound effect, and if we get it early we can
prevent chronic problems, joblessness, homelessness. If people have early signs, there is a high percentage they will go on to develop it."

In a letter sent in mid-January to VA under secretary for health Dr. Robert Roswell, Rep. Lane Evans (D., Ill.), ranking member on the House committee on Veterans Affairs, urged immediate improvements and
enhancements in VA programs for veterans with PTSD to prepare for servicemembers returning from Iraq and Afghanistan. "Clinicians tell me that these veterans will be coming home to a system that in many
cases is barely treading water to meet the chronic needs of veterans already in the system," he said.

Rep. Evans' letter commended the new joint VA/DoD PTSD guideline, but also expressed concern that it might not be fully implemented. Susan Edgerton, minority staff director of the House VA subcommittee on
health, said the hope is the new guidelines be put into everyday use. "The main thing we're worried about is you can't just release them into the ether," she said. "You have to sit down and educate, so they are
not just reports sitting on a shelf."

Rep. Evans stressed the importance of strong readjustment counseling for veterans. He said the VA/DoD working group recommended that VA make substantial enhancements in services to treat veterans with
PTSD and that there be resources such as network coordinators and informatics available.

Rep. Evans also urged VA to collaborate with DoD to obtain information and timely patient data transfers to help VA adequately plan and prepare for addressing new veterans' needs for PTSD treatment. "I think
we have some concerns about how the military is conducting pre- and post-deployment surveys," Edgerton added. "They don't seem to be done completely or routinely."

Furthermore Congress had requested a clinical evaluation of returning soldiers and DoD instead is administering a four-question PTSD risk assessment, but is not sharing that information with VA on a regular
basis, Edgerton advised. If a soldier answers 2 of 4 four questions yes, he is supposed to be referred for further examination and possible treatment. A concern is that referrals are not happening on a routine
basis because soldiers are on their way home anyway. "VA wants to be able to pick them up," Edgerton said. "We were hoping for a lifetime trail [of a complete patient record]. I think the main problem, to me, is
that the onus is on the military to get the record transfer straightened out. There is an informal data exchange that happens, but I don't know if it's routine and it's not systemwide. They will transfer the soldier's
medical records, which probably include the [post-deployment] surveys, when the patient is discharged. VA would like to be more proactive in being able to identify folks and not just have a look at these folders
after the fact. They would like to be planning for medical needs."

"We probably need to step up resources to PTSD, given that troops are in the field and are experiencing combat," she added. "They are constantly under stress and seeing a lot of action."

Changing Doctrine
Dr. Ritchie said she thinks in practice people are changing the way debriefings are conducted in the field. "The challenge is the commanders now expect a debriefing," she said. "It's part of what happens, and
they're often like, 'okay there has been a Blackhawk down, well let's get the combat stress control folks in to do a debriefing,' and so it took folks a while to get the commanders to realize that mental health is
important."

Dr. Ritchie said she spoke with a group of Coast Guard chaplains and commanders who had been administering debriefings to returning guardsmen after they had been at sea. "Nobody wants to stay there and be
debriefed," she said. "They want to go home and see their loved ones. So, this publication has allowed them now to say, 'okay, we don't have to do that anymore. I'm still going to say hello to everybody as they
get off the boat, but then I can work with who I need to on a more individualized basis.' "

Dr. Ritchie reiterated that she's not saying never do debriefings, but rather make sure it is appropriate when you do them. "Probably the most appropriate group is personnel who have worked together, such as
first responders, firefighters, medics, Special Forces. A debriefing may very well be useful in that setting if it's something people want," she advised. "Some people have also found that hearing of other people's
experiences may actually make their own worse because they are not ready to hear the stories or to tell their story. So much of it comes down to what is the need. We don't have the best or final answer right now."

A Repeat Of Vietnam Vets' PTSD?
"I think nobody knows what the psychological reactions of the [Iraq War] soldiers will be, but we're certainly concerned about them," Dr. Ritchie said. "There has been all the sights and sounds, and atrocities and
bombings, and suicide bombers and deaths. I really don't know the answer. After every conflict it's always a little bit different. But I'm sure there will be psychological casualties and I'm also sure there will be
some kind of physical manifestation of the stress because we've seen that in every conflict, too, such as Gulf War illness. And I think that's really hard to know because it is such a nasty war. One of the problems
of Vietnam is that people rotated in and out as individuals, so you began to count your time down to when you could go home, which wasn't good for unit cohesion. Now the units, in general, go in and out
together. And we've learned about the importance of good unit morale and cohesion and discipline. World War I and II units went over together and they came back together, and they had three weeks [in the
ship] to talk about it to process. You couldn't call it debriefing, but they had time to get ready to come home together as a group."

Another way the military is attempting to make the transition back to home life smoother for returning soldiers is through the Deployment Cycle Support Program, which includes the post-deployment health
assessment, as well as programs to help the soldier and his family readjust. "A place where that is unavoidably unable to be done is where the wounded get flown out of there very quickly, and then to Landstuhl
[Army hospital in Germany] and they come back to Walter Reed [hospital in D.C.]," Dr. Ritchie said. "One of the things that they're trying to do with the wounded there is recreate a sense of cohesion and morale
among the wounded, realizing they've all been torn from their units. We got a high rate of amputees, unfortunately, and they all get physical therapy, they all get ortho and they all get mental health
assessments. We know wounded are at a higher risk for PTSD. Traditionally one of the problems is they come home, people say, 'it's great, you're home, well you've lost your leg, but at least you're alive.' The
cheerleaders come and visit them, and they get a purple heart from leaders, and then they go home and they're a 19-year old kid who has lost a leg and they have got to deal with issues about dependency on
parents, and perhaps colostomies, and self-image and traditionally there is a very high risk for depression, and not rehabbing as well if you're depressed. Folks are trying very hard to prepare them for that time
at home, to keep up their sense of community and rehab, and the fortunate thing is here there is a lot of support back in the community. We are also trying to work with the VA in terms of the transition from our
system to the VA system. It's on the higher level in terms of planning, and it's on the local level in terms of how to make sure this patient receives all the care that they need."

Dr. Ritchie said the military has learned the importance of having far forward mental health treatment, and following symptoms over the long term. "We have a number of psychiatrists, psychologists, social
workers in Baghdad, in Tikrit, and I think we have recognition about the long-term needs," she said. "Whether that will be enough, time will tell. We're doing far more than we've ever done before. I always think
that we can do more."

In a November 2003 article in the Psychiatric Annals, Dr. Ritchie wrote that in the Army, combat stress control teams deploy overseas and stress response teams operate out of the major hospitals for events
located within the U.S. "The Navy's Specialized Rapid Intervention teams deploy to a ship after a traumatic event," she wrote. "The Air Force maintains Critical Incident Stress Management teams. The strategy of
the Marines is similar to that of the Army, using Operational Stress and Combat Response units."

Furthermore each Army and Marine division is assigned a mental health section with teams comprising a mixture of mental health disciplines, including psychiatrists, psychologists, social workers, psychiatric nurses
and occupational therapists.

Dr. Ritchie wrote that initially soldiers with psychological symptoms in the first two world wars were evacuated out of theater and did not fare well. It was learned that treating them close to the front lines led to a
much higher return to duty rate and these principles were later codified as "proximity, immediacy, expectancy and simplicity," directing simple, immediate treatment on the front lines with the expectation of return
to duty.

In terms of identifying folks who need follow-up mental health care, Dr. Ritchie said it depends on the situation. "In a unit, people know each other, work with each other, if you're the chaplain of the unit, you'll be
able to identify those people yourself or the first sergeant will identify them," she said. "If you're in the school, again you'll have counselors who will be able to hopefully say, 'hey, this kid is having problems. Let's
work with these kids, definitely follow them over time.' Unfortunately, in many communities they're not cohesive enough that somebody is watching out for somebody else. And in those cases, often we don't have
a good way to identify folks who need interventions. And unfortunately, in our current method of paying for health care, it's often the socially disadvantaged, the unemployed, the mentally ill who are the ones that
are going to need more complicated interventions and they may or may not have access to care."

That is a concern with some veterans who may be having problems and are at risk to end up indigent with no one really following them. "I think there is a real potential for a problem there, especially if they leave
the military where they are closely watched, because they have to go of their own free will to seek treatment in the VA, and bridging that gap is really important," Dr. Ritchie said.

Staying Busy
Dr. Ritchie said she thinks the military folks at the Pentagon had a lesser incidence of PTSD after 9/11 than people who survived the NYC attack. "It may be because they were military in advance, they had better
unit cohesion, the disaster wasn't as great, but I believe that a big part of the reason they felt better afterwards is they had something to do," she said. "They had a mission, they had a job. We went to war, as
opposed to sitting at home or in a hotel room, stuck because your flight isn't going for seven days where you have nothing to do and all you can do is kind of worry and be anxious," she said.

A lot of people wanted to give blood after the disasters to just be able to do something. "We know the things that improve resiliency are things like being in good physical shape, having a cohesive community like
unit cohesion, but maybe your neighbor or your work place and a sense of mission and purpose," Dr. Ritchie said.

After the Pentagon disaster, Dr. Ritchie said survivors were told that they should expect to experience symptoms. "It's very common to have nightmares, insomnia, irritability, but if those symptoms are continuing
so that they interfere with your functioning at your job or at your home, then you should come in and talk to somebody about it," she said. "What the Army, Navy and Air Force did at the Pentagon after 9/11 is
they sent in teams of mental health folks and they basically fanned out through the building, and they knocked on everybody's door and said, 'hey, how are you? We just want to know that if you want help, this is
where we are.' We left a card, and if people were concerned about their kids, this is where they could go. Some people said, 'go away, get out of my face, I'm busy.' And some people said, 'you know, I'm busy
right now but I'd like to come down and talk to you later' and then people talk for two hours. In some places, group meetings were done, and in some cases people came individually. The chaplains did a great
job, a lot of the work was done at funerals. That's where a lot of people get their spiritual support."

Offering emotional support after a disaster is something that is needed for the long term. "I was at that work for about a month [at the Pentagon] following [9/11], and there were probably 150 mental health
folks who were working in and around the building and now it's down to a handful, but they're still there for people," Dr. Ritchie said. "We found that over and over if we offered a group debriefing down in the clinic,
nobody would come. But if you went and talked to people at lunch or had coffee with them, or if you went into the workplace and did more of what we call a classical debriefing, that could be very helpful. But I said
only talk if you're comfortable. What I really focused on is how can you reestablish the sense of cohesion and morale around here. Often people had been working nonstop for three weeks and hadn't done any of
their normal chatting or potluck [get-togethers]. They go home at 10 at night and their family would have gone to bed, and they feel isolated from their family, too."

Dr. Ritchie said casualty assistance officers are assigned to each soldier's family. Furthermore after 9/11 a family assistance center was set up nearby that allowed families of both the Pentagon and airline victims
to go to one place for all their needs. "That worked very well because the families could get a sense of being together," she said.
Dr. Cameron Ritchie
April 2004

PTSD Prevention, Care Techniques Debated - Matt Pueschel

U.S. Medicine Information Central
Cdr. Bryce LeFever