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'A support structure for those experiencing
Critical Incidents'
By
Richard Cross
The
views expressed in this article are not that of
any organisation, first published in The Prison
Service Journal, November 1998 No 120 p46 –49,
and reproduced with kind permission of the
author…
In light of recent research and legislation this
paper proposes a structure to provide support
for individuals experiencing a traumatic event
(Critical Incident Stress Management).
It evaluates the nature of Post Traumatic Stress
Disorder (PTSD) and how it manifests itself in
the individual. Before going onto look at a
CISM structure for ensuring prompt and adequate
support for those involved. It is based on
recent research into this area and takes into
account the subjective view of the author who
has not only suffered
 from Post Traumatic Stress
(PTS) but also who delivers debriefing for those
who have experienced critical incidents. It is
also written primarily suggesting a structure
for organisations and was written from the
perspective of an employee within the Prison
Service.
Definition of PTSD & symptoms:
One legacy of the Vietnam War was the
recognition that many of the troops were
suffering psychological distress. This led to
the diagnosis of a syndrome of human reactions
to traumatic stress which was termed PTSD. This
though was only officially recognised in 1980
with its inclusion in the Diagnostic &
Statistical Manual of Mental Disorders
(DSM-111).
“The development of certain characteristic
symptoms following a psychologically distressing
event which is outside the range of normal
experience” (DSM-111, 1980)
If you take the job of a Prison Officer;
recently officers who had been taken hostage by
rioting prisoners were found to of developed
psychological disorder without the occurrence of
personal injury. (Cooke, 1992)
This emphasises an important element (criteria
1); individuals need not be injured or for
 that
matter be directly involved in the event to be
affected by the disorder. Even the witnessing of
an event that involves death, injury, or a
threat to the physical safety of another person
may create the correct environment for the
disorder (Brooks & McKinlay, 1992)..
A clear
example of this is that of Prison staff having
to deal with a suicide. For this reason clients who have been involved
in a traumatic incident need to be assessed by
using a set of criteria that denotes PTSD:
-
The client must have witnessed or
experienced a serious threat to their life
or physical well being.
-
This must be re-experienced in some way.
-
The client must persistently avoid stimuli
associated with the trauma or experience a
numbing of general responsiveness.
-
The client must experience persistent
symptoms of increased arousal.
-
The symptoms must have lasted at least a
month.
Diagnostic system as referred by DSM-111.
(Alternative system may be employed namely the
ICD10 diagnostic system).
The re-experiencing of the trauma (criterion 2)
can occur by numerous means; intrusive thoughts,
recurrent dreams, nightmares, flashbacks or
reliving the experience. These may be triggered
by the exposure to ideas, cues, or stimuli
associated with the event. This may mean for the
Prison officer who has dealt with a suicide
having flash backs. When near the cell or doing
checks of those on observation, or when
receiving external stimuli in the form of
sounds, smells, or images linking him to the
time, place and thus the event.
This can mean those who are suffering from such
stress may attempt to avoid the stimuli
associated with the stressor (criterion 3); and
might appear emotionally numb as to avoid
having to deal with the emotions arising from
the event. Many deserters who were shot as
cowards during the second world war are now
believed to have been suffering from PTSD.
This leads onto the symptoms of heightened
arousal (criterion 4) which interferes with the
normal functioning of the individual. These may
include insomnia, difficulties in concentrating,
being on ‘edge’, erratic emotional responses and
heightened sensitivity to external stimuli. An
example of this is when I was involved in the
‘Gulf War’. During a traumatic period I had made
a stimulus - response association to a siren
which sounded during a period of difficulty.
However no matter how hard I tried after this
time, every time the siren sounded or a similar
sound even after I left the area. I would react
with a startled automatic response which was
accompanied by thoughts of the previous event.
The final criterion relates to the fact that
there may be a delay following the trauma before
the onset of symptoms must last for 1 month
following the first four weeks of the event.
However for a more detailed diagnosis the
following applies:
-
last less than 1 month & occur within first
four weeks: ‘Acute Stress Disorder’
-
Less than 3 months: ‘Acute PTSD’
-
3 months + : ‘ Chronic PTSD’
-
Symptoms after 6 months : Delayed Onset PTSD
e.g. 90% of rape victims will suffer from acute
PTSD and about half of these will go on to
develop Chronic PTSD (Scott, 1995)
As we can see then PTSD is a response to a
reappraisal of the trauma in which it is decided
it is safer to assume that ‘Danger’ is
everywhere. This means a continual physiological
arousal which as we have seen is accompanied by
irritability, sleeplessness, impaired
concentration.
The dimensions of this disorder are emotional
(depression), behavioural (avoidance), cognitive
(reliving event) and motivational (maintain
safety) dimensions. It is subsequently on these
fronts in which the Stress Management and
counselling can focus on helping the client see
the event and enable it to be placed within the
wider context of life.
A structure for dealing with the aftermath
of a Traumatic event
1.Stress Management Training:
The ability to be able to relax is essential not
only for those involved in a traumatic event but
for everyone. The problem is that many people in
today’s society have lost the ability to relax
after times of stress or crisis. This means that
it is essential for all occupational management
structures to ensure that this basic knowledge
is available to be imparted to staff. This means
that individuals within an organisation will not
only be better equipped to deal with daily
stress, but also have the relaxation skills at
their disposal to deal with the stress reaction
(PTS) following crisis.
Stress management and education is the initial
step prepare the individual for the effects of
the trauma through knowledge, preparation and
training. If people already know the signs and
the effects of a stressful event; then the
conscious realisation, that the stress reaction
following an traumatic event is entirely natural
and normal. Means the individual can more easily
accept the internalised feelings and thus deal
with them. It also means that the individual
will be able to employ stress relieving
techniques after the event in attempt to regain
equilibrium. Meichenbaum (1977, 1986) advocates
such ‘stress inoculation’ based on the belief
that individuals can affect their ability to
deal with stress by modifying their beliefs and
self statements about their performance in
stressful events.
The aim of this approach is to provide
individuals with the opportunity to develop
their skills to help them monitor feelings and
behaviour in each of the four areas. As we can
see if they can respond to a stressful incident
by activating appropriate coping resources
(relaxation techniques; deep breathing, Physical
& mental, muscular, negative thinking etc.).
They will then be able to deal with the given
situation more effectively. This means the
individual’s are able to reduce the overall
stress response; meaning an increase in
well-being, functioning, productivity and
enjoyment within there employment.
2. Defusing (Day of event)Following a
traumatic incident there should be an
opportunity for all those involved to get
together. This procedure with offer an
opportunity to offer support, caring and to
informally talk through what has happened.
(Parkinson, 1993). Even in this unstructured
setting it provides the environment that is
conducive to show that they are not alone and
enable the natural supporting mechanisms of
groups who have undergone an traumatic event.
This will stop the feeling of many that they are
‘alone’ immediately preceding the event and also
give a chance for support for those who are
distressed immediately after the event. This may
elevate the feeling of anxiety which I felt
following times of crisis; sometimes even just
being with those who had experienced the same
incident was a comfort for me as ‘they had been
there’ and this avoids individuals leaving the
scene who haven’t had the opportunity to
receive some form of support if they wish it.
3. Critical Incident debriefing (After 48
hrs)This should take place after about 48hrs
(not before 24hrs). It is a meeting for all
those involved in the event and provides them
with an opportunity to review any thoughts,
feelings, impressions or emotions arising from
or after the event.(Dyregrov,1989) This
procedure helps to resolve psychological
distress associated with the incident and helps
to relieve stress. There are also several
secondary goals:
·
education about stress and
subsequent reactions.
·
emotional ventilation by sharing
experiences in a controlled environment.
·
Emphasising that the stress
response is controllable and recovery is likely.
·
Allowing support to build within
the group to dispel the feeling of uniqueness.
·
enable the realisation that
reactions to such events are ‘normal’.
·
Prevention of the onset of PTSD
·
Provide a contact point for
support and also referral as required.
I however believe the main success of the
debriefing process is that it enable all those
involved in the incident to get together in a
safe environment and share if they want to any
feelings and emotions arising from the event.
It also provides the opportunity for;
normalising these feelings which avoids the
sense of ‘ I am going mad’ and the imparting of
knowledge to those who may be unable to deal
with the strength of the trauma at that time and
thus be able to access support in the future.
These are then the beneficial aims to date
namely helping to normalise, inform, and support
all those involved.
This process within an organisation structure
shall provide many benefits. It should help to
reduce the incidence of sickness and absenteeism
following the incident. A reduction in personal,
marital, relationship and work problems should
ensue for those involved. Anxieties will be
reduced concerning thoughts about coping, asking
for help and general anxiety about the ‘future’.
There may be more than one session, but this is
up to the group to decide after the initial
debrief (empowerment). Up to this stage the
process has been aimed at counteracting the PTS
reaction; and counteract the possible onset of
PTSD.
3. Support for those after the first month:
As was outlined in the definition of PTSD, if
individuals have not experienced a diminishing
of the symptoms of PTS or have experienced an
increase after the first month following the
event. The individual will have to be assessed
as to the possibility of suffering from PTSD.
This may be done by a structured interview or by
using questionnaires such as the Impact of
Events Scale (Horowitz et al ., 1979).
These questionnaires attempt to gauge the
emotional state of the client and can be used as
an effect measure to the progress of the client.
From this point interventions can take place to
enable the client to reappraise the event.
Conclusion:
By having help and support available to
individuals through Stress Management training
and Critical Incident Debriefing; those
experiencing abnormal traumatic events and acute
stress, can be helped to deal with the
subsequent stress reactions more successfully.
This structure cannot be seen as an optional
extra for organisations, particularly in light
of the employers liability to maintain a ‘Duty
of Care’ (HSWA & MHSW). Furthermore failure to
provide adequate support might mean people
suffer unnecessary for a long period of time;
and this can mean an increased amount of
absenteeism or sickness (Cooper et al., 1996).
In conclusion, below are outlined
recommendations to aid the implementation of an
appropriate structure to deal with PTSD and
chronic Stress:
Legitimise stress so individuals feel
comfortable coming forward. Improving the
culture and increasing the awareness shall help
this factor. Post traumatic stress reactions are
completely normal following a abnormal event and
this can be imparted to people through
therapeutic information (Dyregrov, 1989).
By creating a support mechanism this provides
‘critical help’ in coping to those
involved in the incident. (Wilson, 1980)
Having a stress management policy in place to
guide all those within the organisation (MHSW).
Imparting the necessary skills to individuals so
the can adopt more appropriate coping strategies
to deal with stress through stress management
training. (Meichebaumn, 1977)
Have the additional support network in place to
help those who need additional support and who
may be suffering from PTSD.(HSWA)
It has been shown such actions can mean valuable
benefits for all those concerned; individuals,
families, groups and the organisation as a
whole. This structure will not only deal with
the effects of critical incidents; but also
greatly improve quality of life by alleviating
the harmful effects of stress in the work force.
Which can only be to the benefit of all
concerned.
“..debriefings in addition to other measures can
accelerate normal recovery and prevent
post traumatic stress disorder.” (Dyregrov,
1989)
First published Nov 1998, Prison Service
journal No 120 p 46-49
References:
Cooke DJ (1992) The psychological impact of
Prison riots on Prison Staff in Scotland (HMSO)
Cooper, Liukkonen, Cartwright (1996) Stress &
Prevention in the work place. The European
Commision. HMSO
Dyregrov, A (1989) Caring for helpers in
disaster situations: psychological Debriefing.
In Disaster management 2.
Horowitz MJ (1979) Impact of event scale
‘Psychomatic Medicine’, 41: 209-218.
Meichenbaum D (1977) Cognitive Behavioural
Modification; An Integrative approach
Meichenbaum D (1986) Cognitive Behavioural
Modification: helping people change: a text book
of methods(pp 346-380)
Parkinson F (1993) Post Traumatic Stress:
Insight Books
Scott, Stradling, Dryden (1995) Cognitive
Behavioural Counselling.
Wilson JP (1980) Towards
Understanding PTSD amoung Vietnam Vertans
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