The scene through the windscreen of my car was a monochrome apocalypse; charred black Eucalypts in every direction and white ash covering the ground. Taking a deep breath, I braced myself and stepped out of the car. The overwhelming smell of burnt Eucalyptus hit me first, and then, the squawks of Emergency workers’ walkie-talkies. As I made my way towards the centre of activity, I came across small clusters of people; their faces tired, hollow, and expressionless. This was Kinglake on the 9th of February, 2009 – 48 hours after Black Saturday Bushfires.
I had joined the many other volunteers to provide Critical Incident Stress Debriefing (CISD). Our task; “to support victims and emergency workers in processing the events and to facilitate their return to normal functioning”. However, this event seemed beyond our capacity – both in its magnitude and severity. Immediately, I felt the familiar physiological responses; elevated heart rate, respiration, adrenaline, and cortisol levels. In the days that followed, I experienced the full gamut of emotions; confusion, sadness, shock, and helplessness; to name but a few. Nevertheless, as time went on we did see small signs that gave us hope – a nod of understanding from a group member, or an occasional sigh of relief. After each session, the participants often said they felt better and thanked us for our support.
While those days at Kinglake were extraordinary, we Critical Incident Stress Debriefers regularly enter into the aftermath of traumatic events. Our goal is to help victims make sense of the events, understand their reactions to it, and thus minimise the risk of unresolved issues leading to further trauma.
What is a ‘critical incident’ anyway?
For most of us, we accept that a degree of discomfort, struggle, and suffering is inevitable in life. So, how do we delineate between the general stressors of life and that of a ‘critical incident’? In truth, the definition of a critical incident is intentionally broad. In simple terms, a critical incident is an event which overwhelms your ability to cope. As examples, here are some of the other events that I have used CISD in response to:
- Workplace fatalities
- Attempted suicides
- Occupational violence
- Removal of children in dangerous circumstances from their parents by Protective Services
- …and one riot in Juvenile Justice Centre
As you can see, what constitutes a ‘critical incident’ differs greatly. However, what all these examples share is the fact that these are sudden, shocking, and outside of what you would consider ‘ordinary’. That, in a nutshell, is a critical incident.
What do ‘critical incidents’ have to do with trauma?
Before we can answer this question, we need to differentiate between the technical definition of psychological trauma and its lay usage. While we might refer to organising our taxes, or having dinner with the in-laws, as traumatic experiences, it’s unlikely we are being technically accurate; simply being uncomfortable or moderately stressed does not suffice. There are multiple definitions of what constitutes psychological trauma, but the following is one of the most commonly cited:
Psychological trauma is the unique individual experience of an event or enduring conditions, in which:
- The individual’s ability to integrate his/her emotional experience is overwhelmed, or
- The individual experiences (subjectively) a threat to life, bodily integrity, or sanity. (Pearlman & Saakvitne, 1995, p. 60)
The key word to focus on in that definition is ‘integrate’. Essentially, trauma occurs when something so unexpected and shocking occurs that our brain cannot reconcile what we have experienced with our concept of reality. By this definition, it’s analogous to a physical wound that is too deep and wide to naturally heal. This is why the abrupt and confronting nature of critical incidents can induce trauma in people. CISD is comparable to psychological first-aid; a battlefield suture that stabilises the wounded by providing victims with the opportunity to better make sense of the event and its effects.
Many are surprised to discover that CISD is not a form of psychotherapy. Rather, it is a focused and structured discussion designed specifically to lead a small group of participants through a series of stages whereby they share their experiences of the incident and their reactions to it. In doing so, participants typically gain an appreciation of how the versions of events change from person to person, and consequently, how each reacted. Additionally, it’s important to point out that CISD is used for the secondary victims – typically the witnesses – not the primary victims. Another common misconception is that the process must begin immediately after the event. This is ill-advised as victims are often in shock and exhausted. Ideally, the session should be conducted only once victims are sufficiently psychologically ready, typically 24-72 hours after the event. Lastly, the group should be homogenous, which is to say, have a shared background; e.g. from the same workplace, or performing the same function as in police officers or firefighters. All of these guidelines aim to nurture a sense of stability and shared experience, which in turn leads to improved communication and mutual understanding.
Once the group is formed, a minimum of 2 specially trained facilitators ( a mental health professional and support staff) lead the group through the process which usually takes 1 – 3 hours. In each phase, the facilitator goes around the circle inviting each participant to contribute.
The seven stages of CISD are as follows.
- Phase 1 – Introduction: Guidelines are explained, participants are given an idea of what to expect, including encouragement to contribute to the discussion.
- Phase 2 – Facts: Participants offer brief overviews of what they observed.
- Phase 3 – Thoughts: Participants are asked about the initial or most prevalent thoughts that they had.
- Phase 4 – Reactions: Participants share what emotions emerged. Commonly they are; anger, frustration, sadness, loss, confusion. Additionally, participants are invited to share what is the worst thing about the event for them personally.
- Phase 5 – Symptoms: Participants are asked to share how the impact of the event has manifested itself personally; cognitively, physically, emotionally, or behaviourally.
- Phase 6 – Teaching: The lead facilitator explains and normalises the symptoms mentioned in the previous stage as well as the typical reactions as well as methods to manage the associated stress.
- Phase 7 – Re-entry: Participants are invited to ask questions or add any final comments after which the facilitators summarise what has been discussed, and further guidance (both written and verbal) is offered.
- Follow-up: It is beneficial to then spend time having some light refreshments. The purpose of this is to provide a pleasant, informal activity whereby the group experience further normalcy. This also provides the participants one-on-one time with the facilitators.
As you can see, by leading participants from the objective external realities, towards subjective internal phenomena, each phase paves the way for the next, allowing each person to reflect and offload a little of their burden. The power of CISD is in its simplicity, and logically, it is, therefore, unreasonable to suggest that it is a remedy for all eventualities that traumatic events bring about. Indeed, it should be only one part of a complete Critical Incident Stress Management program comprising of education and additional professional support for victims as well as their families.
Ultimately, the aim of CISD is simply this; to help the victims normalise their reactions to the incident and accelerate their adjustment to the new reality. In doing so, it is intended that they will return to being a healthy and cohesive group. It has been my experience that, when followed correctly, the CISD process achieves this aim. Unfortunately, however, a pattern of misuse and misunderstanding both by practitioners and researchers has led to instances of sub-optimal outcomes for many, and in some cases, potential harm to participants. The subsequent controversy regarding CISD and its efficacy is a topic I will explore in my next post.
Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the Therapist. New York: NY. W. W. Norton & Company.