Critical Incident Stress Mgmt
What is Critical Incident Stress Management?
The International Lifeguard Critical Incident Response Alliance (ILCIRA) follows the International Critical Incident Stress Foundation (ICISF) Model developed by Dr. Jeffrey T. Mitchell. Dr. Mitchell & his colleague, Dr. George S. Everly have conceived a comprehensive, integrated, systematic, and multi-component response program designed to provide crisis intervention to those impacted by traumatic events, called Critical Incident Stress Management (CISM). CISM includes crisis intervention techniques shown to be effective for those seeking support after being impacted by a critical incident or traumatic event. A peer relationship, and the delivery of the specific CISM technique is used to provide; a sense of normalization, foster a sense of affiliation, as well as assist an impacted individual to reestablish their disrupted natural coping strategies.
A critical incident is any unusual event that has the power to overwhelm one’s usual coping strategies and elicit a psychological crisis where thoughts are impacted, and emotions become dominant. This disruption can create a state of emotional turmoil causing significant human distress.
As outlined on ICISF Canada’s website, Critical Incident Stress are the normal and common reactions in response to any stressful event. These events can be critical, or normal life events. The key to understanding the concept is that it is not the nature of the event that is the focus of determining if it is a “critical incident”, but the impact on those who experienced it.
These common reactions manifest in the 5 Domains of Stress Reactions:
Physical Domain
Where one’s sympathetic nervous system activates in response to adversity releasing stress chemicals designed to promote survival of the organism, known as the fight-or-flight response. Common stress reactions manifest in the body such as a sudden change in heart rate, psychogenic sweating, dry mouth, headaches, GI distress, fatigue, and muscle aches or pains.
Emotional Domain
After a crisis our emotions tend to increase and dominate over our thinking. Emotional states perpetuate the secretion of stress chemicals that are designed to protect the brain and promote the body and brain’s ability to learn from experiences. This is why experiencing adversity can cause states of emotional turmoil. However uncomfortable, these high states of emotional turmoil are natural and normal reactions of a healthy nervous system responding to adversity. Common emotional reactions include anger, anxiety, irritability, guilt, remorse, fear, and depression.
Cognitive Domain
Some of these stress chemicals, like cortisol, interact with the brain in a way that shuts off or slows down higher cognitive functioning, a process thought to have been functional when running from a predator in the stone age, but has the side effect of making regular thinking much harder. Common stress reactions include inability to concentrate, problem solve, calculate, or remember. Other reactions include ambivalence, confusion, acute sensory distortions, rumination, and an inability to comprehend the consequences of our actions.
Behavioral Domain
Once this disruption in thinking and feelings occurs, we start to see noticeable changes in one’s regular activities. If one is unable to comprehend the consequences of their actions it is understandable that they may be more likely to take more risks than usual, do things others might find unreasonable or unnecessary, act out of character and exhibit a drastic decline in performance. Common behavioral stress reactions include impulsiveness, risk-taking, change in eating behaviors, changes in sleep, changes in alcohol or drug consumption, withdrawal, hyper startle and relationship discord.
Spiritual Domain
In turn, stress can change the way we perceive ourselves and our world views. Common spiritual reactions include a decrease in self-efficacy, self-worth, self-esteem, loss of meaning or purpose, increased existential angst, apathy, conflict of faith, withdrawal from faith-based community or regular faith-based practices, and anger toward god, a creator or the world.
A traumatic event is when the critical incident is particularly grotesque, horrific, or life-threatening. The specific type of stress response that gets activated by the nervous system is called a threat response which prepares the organism for anticipated bodily harm constricting the blood vessels to prevent excessive bleeding and increasing the body’s inflammatory response to promote healing. This response is functional in the short term if in present danger of acquiring bodily harm, however, in modern civilized societies most people are not facing present or imminent danger but how we perceive the stressors and threats in our social and physical environments can turn on the same threat response having very negative consequential effects on our health and well-being. It is important to note here that the threat response can also be activated by exposures to critical incidents as well as life events as some people develop a preferential default to this type of response when experiencing any kind of adversity, however, a traumatic event is more likely to consistently elicit a threat response more frequently with greater severity regardless of who you are. Reactions to traumatic events are identical to critical incident stress and manifest in the same 5 domains of common reactions, however, are called Post-Traumatic Stress.
Post-Traumatic Stress (PTS) are natural and normal responses to a very abnormal experience, the traumatic event. When there is a disruption to the natural recovery process where these symptoms of PTS linger beyond 30 days post-incident, and along with DSM-V diagnostic criteria, that is when we see PTS turn into a PTSI (Post-Traumatic Stress Injury) such as Depression, Anxiety, Substance Abuse Disorder or PTSD (Post-Traumatic Stress Disorder). PTSIs require a referral to a culturally competent third-party registered mental health professional who is trained in the assessment and delivery of trauma related evidence-based mental health treatments.
Dr. Anne Balboni, ICIRA Clinical Director, USA Operations, reminds us CISM services are not therapy. If a Lifeguard Peer Support Volunteer (LPSV) notices pervasive distress or other concerning symptoms, they will work to transfer the impacted Lifeguard or Aquatics Manager to an ICISF Certified Peer Para-Counselor or Mental Health Professional. Likewise, if a Lifeguard/ Aquatics Manager undergoing CISM services notices thoughts of self-harm, feelings of hurting someone else, or other concerning symptoms, they are strongly encouraged to seek more advanced mental health care, up to and including going to the nearest Emergency Room or calling their local emergency service number.
CISM Overview
The What
Peer Support provides a safety net, using all six core components of the ICISF model of CISM Peer Support.
Effective CISM systems require:
- Delivery of resiliency training to proactively boost psychological immunity.
- Ongoing assessment, surveillance, and psychological triage.
- Ongoing strategic planning.
- Proficiency using various interventions (individual, informational groups and interactive groups)
Peers support a person in crisis as they search for their inner-coping strategies through simple tasks, quick contacts, innovative techniques, practical suggestions, and comfortable environments. Peers provide proximal peer-to-peer interactions, the immediacy of access to support, and the expectancy of reasonable positive outcomes (Everly & Mitchell, 2016)
CISM Overview
The How
Critical Incident Stress Management Peer Support is Comprehensive in that it covers the entire scope of a critical incident from pre-incident education, during time of impact, to post incident intervention and education, to the recovery/referral process. CISM is Integrated in that all of these interventions are integrated within one another and are not meant to be used as stand-alone techniques since they all build on one another. CISM is Systematic in that the interventions are phase-sensitive and work with the timing of the incident and the effects of the exposure.
CISM is a Multi-Component (Components 1-6) approach in that it involves surveillance and assessment techniques to inform the peer team what interventions may be useful for the peer group. There are interventions that can reach individuals that are affected, other interventions can reach larger mixed groups, and other interventions that can reach smaller groups.
1
Step 1
We start with building resistance through pre-incident education where we teach our Lifeguards & Aquatic Management Teams how to recognize the signs and symptoms of distress and dysfunction in themselves and each other. Giving factual information about stress management and how to access external resources and services that are available to them through their place of employment and communities.
2
Step 2
The first thing we do when our Lifeguards, Aquatic Management Teams and Alllied Aquatic Professionals do when they have been exposed to a critical incident is use our surveillance skills to assess for the impact the critical incident has on those involved. We are looking for signs and symptoms of distress and dysfunction and any change in the group’s cohesion, performance, or communication.
3
Step 3
Once we have made a full assessment we are now able to formulate a strategic plan using the 5 Ts: Theme, Target, Type, Timing, and Team. This will answer the what, where, why, when, and how of crisis intervention tactics.
4
Step 4
The majority of interventions we use in Peer Support are Individual interventions such as the SAFER-R. We start with individual interventions so that we can immediately provide support to those showing signs of need and help us gain a better assessment of the level of impact the event has had on those involved. This will give us information that will help us determine the appropriate next steps, maybe an informational group intervention, such as a Crisis Management Briefing, is required to fill in the gaps of factual information about the incident, how to recognize the signs and symptoms of stress, and stress management. This is meant to control the spread of rumours and mitigate stress reactions. Afterwards we would continue with more individual interventions and assess for the need of an interactive group intervention such as a defusing or CISD that is meant to mitigate stress reactions and restore the group back to their cohesive functioning.
5
Step 5
Finally, we would follow up with those we provided interventions and assess for whether or not they have recovered adaptive functioning or require a referral to formal mental health or other external support services appropriate for their needs.
CISM Strategy
Critical Incident Stress Management Information: Overall Strategy
Critical Incident Stress Management (CISM), is a term that refers to a comprehensive, integrated, strategic planning system complete with a multitude of crisis intervention tactics. Due to the wide variety of crisis intervention skills and the continuum of support practice available, it limits the possibility of first responders being missed or “falling through the cracks”. An effective CISM response system can provide immediate crisis intervention to individuals, as well as interventions in small groups for those directly affected, or large group interventions for those indirectly affected.
Effective CISM programs require proficiency in assessment, observation and triaging; skills in individual, informational group interventions and small interactive group interventions; as well as the ability to plan the strategic aspects of the response and the flexibility to adapt when a new situation arises.
The safety net provided through this program can increase resistance to the psychological after effects of traumatic experiences as well as equip aquatic first responders with skills that support resiliency and reinforce the capacity to return to adaptive function. Education is an important aspect of CISM programs and is incorporated into our outreach programs for Lifeguards as well as their loved ones.
A peer support program utilizing the ICISF model has been shown to be the most effective and most frequently utilized model with first responders and other high-risk job environments in the United States, Canada and in many countries across the world. When needed, they can be an effective conduit to ongoing support services and referrals for continued care. We strive to develop relationships with other agencies and organizations who are part of the overall support network for those in crisis.
Tactical Deployment
Critical Incident Stress Management Information: Tactical Deployment
CISM Peer Support is Comprehensive in that it covers the entire scope of a critical incident and disaster mental health from pre-incident education, during time of impact, to post incident intervention and education, to the recovery/referral process. CISM is Integrated in that all of these interventions are integrated within one another and are not meant to be used as stand-alone techniques since they all build on one another. CISM is Systematic in that the interventions are phase-sensitive and work with the timing of the incident and the effects of the exposure.
CISM is a Multi-Component (Components 1-6) approach in that it involves surveillance and assessment techniques to inform the peer team what interventions may be useful for the peer group. There are interventions that can reach individuals that are affected, other interventions can reach larger mixed groups, and other interventions that can reach smaller groups.
- We start with building resistance through pre-incident education where we teach our colleagues how to recognize the signs and symptoms of distress and dysfunction in themselves and each other. Giving factual information about stress management and how to access external resources and services that are available to them through their place of employment and communities.
- The first thing we do when our colleagues have been exposed to a critical incident is use our surveillance skills to assess for the impact the critical incident has on those involved. We are looking for signs and symptoms of distress and dysfunction and any change in the group’s cohesion, performance, or communication.
- Once we have made a full assessment we are now able to formulate a strategic plan using the 5 Ts: Theme, Target, Type, Timing, and Team. This will answer the what, where, why, when, and how of crisis intervention tactics.
- The majority of interventions we use in Peer Support are Individual interventions such as the SAFER-R. We start with individual interventions so that we can immediately provide support to those showing signs of need and help us gain a better assessment of the level of impact the event has had on those involved. This will give us information that will help us determine the appropriate next steps, maybe an informational group intervention, such as a Crisis Management Briefing, is required to fill in the gaps of factual information about the incident, how to recognize the signs and symptoms of stress, and stress management. This is meant to control the spread of rumours and mitigate stress reactions. Afterwards we would continue with more individual interventions and assess for the need of an interactive group intervention such as a defusing or CISD that is meant to mitigate stress reactions and restore the group back to their cohesive functioning.
- Finally, we would follow up with those we provided interventions and assess for whether or not they have recovered adaptive functioning or require a referral to formal mental health or other external support services appropriate for their needs.
Note: CISM services are not therapy. If a Lifeguard Peer Support Volunteer notices pervasive distress or other concerning symptoms, they will work to transfer the impacted Lifeguard to more advanced care. Likewise, if a Lifeguard undergoing CISM services notices thoughts of self-harm, feelings of hurting someone else, or other concerning symptoms, they are strongly encouraged to seek more advanced mental health care, up to and including going to the nearest Emergency Room or calling their local emergency service number.
