Critical Event Stress Management

Abstract

Stress has considerable potential to affect individuals. Humans mostly reflect their own stress on their work, family, environment and personal lives. Stress is a kind of risk source since it creates differentiated reactions to stimuli, and stress has considerable potential to affect our motivation level, as motivation is of critical importance to individual performance. Individual performance creates organizational performance, therefore stress must be managed by managers to sustain business. We present a considerable topic in this part as Critical Event Stress Management . As members of the aviation industry, we are also risk managers since even small mistakes may create disasters and our error free behavior according to established procedures may save many lives.

Stress is a state of psychological and physiological imbalance resulting from the disparity between situational demand and the individual’s ability and motivation to meet those needs.

—Dr. Hans Selye.

4.1 Stress

In article by (Revathi et al. 2014).

Revathi et al. (2014) Stress is defined as “a state of psychological and physiological imbalance resulting from the disparity between situational demand and the individual’s ability and motivation to meet those needs.”

Stress can be positive or negative:

• 1. Stress is good when the situation offers an opportunity to a person to gain something. It acts as a motivator for peak performance.

• 2. Stress is negative when a person faces social, physical, organizational, and emotional problems.

Factors that are responsible for causing stress are called stressors (Akrani, 2011).

4.1.1 Sources of Stress

According to Klinic Community Health Centre (2010), there are some sources of stress. The first one is the environment: the environment can bombard you with intense and competing demands to adjust. Examples of environmental stressors include weather, noise, crowding, pollution, traffic, unsafe and substandard housing and crime.

Social Stressors : we can experience multiple stressors arising from the demands of the different social roles we occupy, such as parent, spouse, caregiver, and employee. Some examples are deadlines, financial problems, job interviews, presentations, disagreements, demands for your time and attention, loss of a loved one, divorce, and co-parenting.

Physiological Stressors : Situations and circumstances affecting our body can be experienced as physiological stressors. Examples are aging, illness, giving birth, accidents, and lack of exercise.

Thoughts : Your brain interprets and perceives situations as stressful, difficult, painful, or pleasant. Some situations in life are stress provoking, but it is our thoughts that determine whether they are a problem for us.

4.1.2 Stress Management

It is inevitable that every manager or executive who works in a business face a stress factor. All of these stress factors cannot be defined negatively because it is also true that stress can impact motivation. However, wrongly directed stress can be costly for both the individual and the organization. Methods to eliminate the impacts on individuals have been examined with two groups––individual and organizational.

Managers should make some changes within their business to eliminate stress symptoms. A stress prevention program can be implemented according to an organization’s structure. The programs can be defined based on three goals (Kırel, 2013b, s. 130)

• 1. Diagnosing and defining the stress symptoms

• 2. Identifying their impacts in individuals

• 3. To support employees to deal with stress negative impacts.

It is really hard to implement methods for dealing with stress in a rapidly moving business environment.

4.1.3 Critical Event Stress Management

4.1.3.1 Critical Event

A critical incident is any situation that causes an individual to experience unusually strong reactions to stress that the individual perceives as disturbing or disabling (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

A critical incident is the stimulus or stressor event that can cause an emergency situation to develop during a daily routine and has the potential to produce a crisis (Beaton, 2003).

Critical incidents are emotionally powerful events that overwhelm an individual’s or a crew’s ability to function normally. They can create the starting point for a crisis reaction. Critical incidents are perceived to be overwhelming, threatening, frightening, disgusting, dangerous, or grotesque circumstances (Mitchell, 2006).

Powerful traumatic events trigger the crisis response. These events are usually outside of the usual range of normal human experiences on the job or in one’s personal life. Examples are line of duty deaths or serious injury to operations personnel. Child deaths, multiple casualty events, and severe threats to emergency personnel are also classified as “critical incidents” (ibid, s. 2).

Any type of situation faced by employees has the potential to cause unusually strong emotions and/or reactions which may interfere with employees’ ability to function effectively either at the said time, or later. This incident may be the foundation for critical stress if it is not resolved effectively and quickly (USACE, 2007, s. 44).

4.1.3.2 Critical Incident Stress

Every day, we exercise in handling our daily stress; we deal with its symptoms. The symptoms of CIS are often similar, but their impact is heavier. A person’s balance can break after a critical incident, and the stress symptoms deal with the person instead of the person dealing with the symptoms. Elements that trigger this disequilibrium differ for each person, for each situation and at each moment. CIS reactions can last for days, weeks, or even months. This has nothing to do with personal weakness; it can happen to anyone at any time (EUROCONTROLs. 11).

Historically, CIS was called traumatic stress, combat fatigue, and rapid-onset burnout.

Abnormal events cause a series of reactions. These reactions may be unpleasant, but they are normal human reactions. Every person will—after a critical incident—experience recurrent and intrusive recollections of the event, including images, thoughts, or perceptions. Critical Incident Stress reactions (CIS reactions ) influence, for a short or a longer period of time, the functioning of a person, and can happen to anyone at any time. Critical Incident Stress is something that the person feels; the fact that the most reactions are hardly visible for others makes coping with CIS reactions extra difficult (EUROCONTROLs. 11).

Critical Incident Stress is the psychological consequence of a critical incident that is perceived by the emergency responder to be outside the normal range of their daily experience. It can have a profound impact on the cognitive, emotional, and behavioral realms of an emergency responder, potentially resulting in long-term distress. Critical Incident Stress is a subspecialty of psych traumatology (Beaton, 2003, s. 8).

A state of cognitive, physical, emotional, and behavioral arousal accompanies a crisis. The elevated state of arousal is caused by a critical incident. If not managed and resolved appropriately, either by oneself or with assistance, it may lead to several psychological disorders including Acute Stress Disorder, Posttraumatic Stress Disorder, Panic Attacks, Depression, Abuse of Alcohol and Other Drugs, etc. (ibid).

Every shocking event causes feelings of intense fear and helplessness or horror; the event causes a “psychological wound”, a “trauma”. Many people switch to “automatic pilot” during an incident. Their reactions are remarkably appropriate and important and necessary decisions are taken; procedures are followed to the letter, etc. (EUROCONTROL).

Emotions come afterwards and can be recognized by symptoms of:

• Intrusion (like nightmares, acting, or feeling as if the event were recurring, flashbacks),

• Avoidance (like avoidance of conditions related to the event, inability to recall important aspects of the event, loss of interest),

• Hyper arousal (like difficulty in concentrating, difficulty in falling or staying asleep, irritability) (EUROCONTROL).

These emotions come with questions about the event and the individual’s role in it. “What happened?”, “Why did it happen?”, “Why did I do this…?”, “Why did I decide that…?”, “How will I react next time?” Each person involved will find his or her own answers to these questions. The questions help the recovery of the internal control systems in a human being (EUROCONTROLs. 11). Approximately 86% of persons experiencing CIS will experience some cognitive, physical, or emotional reaction within 24 h after the incident (EUROCONTROLs. 15).

4.1.3.3 CIS Reactions

The course of CIS reactions can be divided into three phases:

• (a) Acute stress reactions

  • During the incident and up to 24 h after the incident

  • Massive stress reactions/stress symptoms

  • Individual coping strategies should become effective

• (b) Acute stress disorder

  • Between 24 h and four weeks after the incident

  • Massive stress reactions or stress symptoms continue to exist or reoccur on a regular basis with constant intensity

  • Individual coping strategies remain ineffective

• (c) Chronic stress disorder

  • More than four weeks after the incident

  • Massive stress reactions or symptoms continue to exist (frequently or sporadically) with constant intensity

  • Individual coping strategies remain ineffective

  • Delayed onset of stress reactions is possible (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008, s. 18)

4.1.3.4 The Symptoms of CIS Reactions

CIS reactions can be thought of falling into four broader groups, each containing several “symptoms” that belong to that group. It is important to understand that all of them are normal human reactions to an abnormal event.

Reactions on the different levels are for example:

Cognitive:

• General confusion

• Difficulty in decision-making

• Difficulty in identifying people known to the individual

• Disorientation in terms of time and place

• Change in readiness to react to situations

• Changed perception of surroundings

• Distrust

• Nightmares

• Deterioration in ability to concentrate and being alert

• Memory lapses, blanks.

Emotional:

• Fear and insecurity

• Feelings of guilt

• Feeling of being overwhelmed/helpless

• Anxiety

• Irritability/aggression

• Fits of anger

• Increased excitability

• Panic attacks

• Over exaggerated expressions of grief

• Suppression of feelings/elusive behavior

• Lack of emotion or outbreaks of emotions

• Depression.

Physical:

• Sudden dizziness/feeling of faintness

• Dizziness/Numbness

• Sleeping disorder

• Faster pulse or higher blood pressure

• Breathing difficulties

• Dimness of vision

• Chills and fever

• Teeth grinding

• Increased fluid intake

• Drowsiness

• Nausea and vomiting

• Muscle twitching/nervous twitching/paralysis

• Headaches and chest pains

• Shock

Behavioral:

• Change in appetite

• Speech changes

• Changes in social behavior

• Isolation

• Over sensibility

• Hurry, restlessness

• Uncontrollable movements (for example ticks)

• Increased substance use

• Anger expression

• Increased excitability

• Panic attacks

• Over exaggerated expressions of grief

• Suppression of feelings/elusive behavior

• Lack of emotion or outbreaks of emotions

• Retreat, immobility, hyper mobility

CIS can occur with different combinations, over a longer period of time, in turn or delayed. In order to assess the individual and work-related impacts of CIS, it is important to consider that physical reactions are more easily detectable than cognitive reactions. On the one hand, this can lead to the more medical treatment of bodily symptoms, ignoring that they are CI-related and getting in the way of psychological coping. On the other hand, losses in cognitive capacity—in our metaphor a poor state of charge—are usually first recognized when needed the next time. CIS can impair these vital abilities—in the worst case, first noticed when cognitive capacity is next needed. Therefore, CISM interventions are also preventive in the sense that the reflection of the CI and CIS may help the affected person to detect latent cognitive impairments (Leonhardt & Vogt, 2006).

4.1.3.4.1 Individual Effects

These effects are emotionally demanding and unusual events require the sudden expenditure of energy, intensive thought and action, and exclusive concentration on the issues at hand. These are the normal processes by which experiences are integrated into the broader context of work and life. The experiences tend to become isolated, and normal cognitive and emotional mechanisms of integration become ineffective. When this occurs, a wide spectrum of stress effects may take place. Debriefing interventions assist individuals to break down the psychological isolation of the experience through communication in a safe group context. They also inform individuals about stress, its effects, and how to manage themselves in the current context (DHS, 1997).

4.1.3.4.2 Group Effects

Even if they only directly involve individuals, critical incidents place stress on the whole work group involved. Effective communication tends to be reduced, and emotional tension and uncertainty are increased. These changes render the group less able to solve otherwise normal problems. If this situation persists for any length of time, the group may then develop maladaptive attempts to manage the tensions, members misperceive or misinterpret the actions of others, and the group engages in inappropriate activity. Debriefing assists the group to gain an accurate, common understanding of the incident, identify problems and needs, and provides a foundation to plan suitable follow-up actions. It also promotes effective communication and the management of emotions (DHS, 1997).

4.2 Critical Incident Stress Management

4.2.1 Development of CISM

Disasters and occurrences which cause devastating damage always result in intensive media coverage and extended public interest. The Sioux City DC 10 crash, the high-speed train accident in Eschede, Germany, the avalanche incident in Galthür, Austria, the Concorde aircraft crash in Paris, the midair collision over the Lake of Constance, Germany, and above all, the recent terrorist attacks in the United States and Madrid, are examples of incidents that are etched firmly in the psyche of many individuals. Of course, for those directly involved in such incidents and in the subsequent aftermath, the effects are generally much more devastating and can be debilitating for some. Increasingly, there has been a focus on the effects of such incidents on the support services that assist following an incident, and in discussing the consequences of such involvement on the personal emotions of members of these individuals and the teams to which they belong. This led to the conclusion that it was necessary to implement a special approach to assist the members of these groups. One of the approaches is called “Critical Incident Stress Management (CISM)” (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008, s. 15).

4.2.1.1 What Is the Critical Incident Stress Management?

CISM is an integrated method which consists of several steps and helps those affected to cope with their Critical Incident Stress (CIS) reactions thanks to direct and immediate intervention. In this way, it may be possible to decrease the probability of consequential disorders. CISM is a comprehensive, systematic, and multi-component approach to the management of CIS (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008, s. 19).

Critical Incident Stress Management (CISM) is a package of numerous crisis intervention techniques that are blended and interrelated. CISM is a comprehensive, integrated, systematic, and multi-component crisis intervention program. There are features of a CISM program that are in place before a crisis strikes. Pre-crisis education, policy development, training, and planning are among many things that can be done to prepare to manage a crisis experience (ibid).

CISM is a comprehensive, systematic, and integrated multi-tactic crisis intervention approach to manage critical incident stress after traumatic events. It is a coordinated program of tactics that are linked and blended together to alleviate the reactions to traumatic experiences (ibid).

CISM methods are secondary preventive measures which consist of discussions about the incidents in the form of structured individual and group discussions and help the persons affected regain their ability to apply coping strategies. Most of the time, these discussions are performed by colleagues who have qualified in CISM programs (the so-called CISM peer diffusers or CISM peers) or by Mental Health Professionals (MHPs) who are qualified CISM experts. None of the CISM techniques can, or should be, regarded as psychotherapeutic measures (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

The general framework for CISM involves personal support. This includes informal social relations, management structures, staff supervision arrangements, administrative support, and the provision of specialized help. The process of coming to terms with a serious incident must be integrated into this framework. This is a two-way process. The debriefing and other interventions are initiated by the management system, and can be considered as a specialized part of the general staff support process, rather than a self-contained intervention (DHS, 1997, s. 11).

There is also a collection of crisis intervention tools that may be applied during a critical incident. Assessment, strategic planning, large group interventions, individual crisis intervention, and advice to management are typical during an event (ibid, s. 18).

4.2.1.2 The Phases of Critical Incident Stress Management Programs

The management of critical incident stress starts before the incident and is ideally an integrated part of the Human Resources policy of the organization. CISM consists of three phases: information, training, and post incident support (Fig. 4.1).

Fig. 4.1

Three phases of CISM. (EUROCONTROL)

Informing all employees and managers, and training the managers and peers are the basic elements of a comprehensive Critical Incident Stress Management Program. Information must be provided about the program, its objectives and type of effects, organizational rules, and procedures. Moreover, management and peers have to be informed about critical incidents and Critical Incident Stress Reactions, how they can be identified and assessed (Leonhardt, 2006).

4.2.1.3 Information Phase

The first phase is the awareness or information phase. This first step provides information about the phenomenon, describes potential reactions to critical incidents, and explains the different CISM support mechanisms. The information stresses the importance of proactively preparing and coping with unusual critical incidents (EUROCONTROL).

The earlier CIS is recognized and dealt with, the better individuals feel. It is very important that CISM services are advertised and that information about the nature of critical incident stress and its consequences is widely provided throughout the organization.

The promotion of CISM to the management and professional organizations is the first task to be accomplished because essential issues like confidentiality, institutional, organizational, and legal issues need to be clarified before the implementation of any CISM program. A top-down approach, beginning with higher management and working down the organization is advisable (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

In accordance with the stated policy, the CISM information phase can be carried out by means of the following:

• 1. Articles in newsletters, guild, or union magazines, ATC journals.

• 2. A personal letter, sent to home addresses so that the individual’s family becomes aware of CIS and their helping role in it. A checklist might help in the definition of their helping role.

• 3. Sessions or information days with a psychologist, with independent presentations of what is done in other domains. The idea is to create a forum where not only information is transmitted, but also where discussions can take place using current experience with CIS in ATS.

• 4. CISM glossary, including details of contact persons available in the operational environment. Such a brochure provides information on CIS, company policy, and a description of the CISM services implemented in the organization. The brochure also lists the names of people to contact both within and outside the organization (EUROCONTROL).

The information for the operational management and investigators has the general aim to impart fundamental understanding of CISM and the awareness about the impact of a critical incident or the investigation after the critical incident on an affected colleague (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

4.2.1.4 Training Programs in CISM

Training programs provide more detailed information about critical incident stress and the management of it. Moreover, volunteers are trained on how to support their colleagues immediately after a critical incident. Thus, part of the CISM program deals with the establishment of training courses (EUROCONTROLs. 17).

The training comprises the instruction of peers and is based on three interacting courses:

• Individual Crisis Intervention and Peer support

• Group Crisis Intervention

• Advanced Group Crisis Intervention (Leonhardt, 2006, s. 55).

The information phase provides a basic overview of what CISM is about; yet, awareness of CIS is only the first step. A natural and efficient way to continue the education on CISM is to introduce it into the current training programs. Training should thus address all levels in the organization (EUROCONTROLs. 27).

As mentioned before, CISM training should be integrated in traditional training curricula, as human factors and stress management in particular should be. In such a course, an instructor or a CISM expert teaches individuals how to recognize psychosomatic reactions, using realistic case studies or films (EUROCONTROLs. 27).

4.2.1.5 Support Phase in CISM

The third phase is carried out through a set of services assisting the person(s) involved in a critical incident. This form of support, offered after a critical event, can take different forms; for example, as an informal chat during the breaks or a more formal meeting, individually or in a group (EUROCONTROLs. 17).

4.2.2 CISM Working Principle

Immediate action-oriented intervention encourages a victim of incident stress to do something, to try to understand what is going on, instead of staying in a state of passiveness, shock, and confusion (EUROCONTROLs. 7).

Group support and peer support help to normalize the experience, reduce the sense of isolation, and allow the exploration of sensitive issues, which generates feelings of hope. Verbalization helps to ventilate and reconstruct the event, gives support in organizing thoughts and feelings, enhances reframing and encourages new perspectives. Help in structuring emotions and facts results in rational thoughts. CISM is an integrated program, and teaches people how to deal with the situation both before and after the critical incident through education and follow-up (EUROCONTROLs. 7–8).

4.2.2.1 Legal Component

The legal component is the third important issue in Critical Incident Stress Management . Remember: CISM deals with the human reaction to the critical event and is dealt with in complete confidence. Incident/Accident Investigation deals with the facts of a critical event. CISM and Incident/Accident Investigation should therefore be completely separate. The people dealing with CISM should not be the same people who deal with the investigation. No connection, managerial, organizational, or inter-personal, should exist. It is advisable to check national legislation on confidentiality (EUROCONTROL).

4.2.2.2 The Spider Model

The four components of Critical Incident Stress Management lead to the following representation (Fig. 4.2).

Fig. 4.2

The spider model in CISM (EUROCONTROL)

The management of critical incident stress is the structured assistance for a normal reaction to an abnormal event. Trained colleagues and/or mental health professionals help through education, information, and interviewing techniques, supported by a clear company policy and procedures. CISM needs to be strictly separated from Incident and Accident Investigation (EUROCONTROL).

4.3 The Role of CISM for Crisis Response

4.3.1 Crisis

Crisis is a heightened state of emotional vulnerability that produces an acute need to regain a sense of psychic control and mind–body equilibrium; that is, to reduce the profound tension and return the person to some pre-crisis level of adaptation. The event will overwhelm an individual’s usual coping mechanisms and produce evidence of functional impairment (Beaton, 2003).

An Crisis is an acute emotional reaction to a powerful stimulus or demand––a state of emotional turmoil. The three characteristics of a crisis are: The usual balance between thinking and emotions is disturbed; the usual coping mechanisms fail; there is evidence of impairment in the individual or group involved in the crisis (ibid, s. 1).

4.3.1.1 Crisis Response

Crisis response is the temporary, but active and supportive entry into the life of individuals or groups during a period of extreme distress.

Crisis intervention is acute psychological first aid that reduces anxiety resulting from the crisis event. There are four standard principles for crisis intervention: immediacy, proximity, expectancy, and brevity. The goals of crisis intervention are to mitigate the impact that the crisis has had on the individual, facilitate recovery, and identify those who may need additional service (Beaton, 2003, s. 8).

4.3.1.2 CISM of Crisis Response

As a solution to the risks facing first responders, CISM was designed to mitigate PTSD in first responders following a traumatic incident. It is a comprehensive, integrative, and multi-component crisis intervention system.

A crisis may include the following:

• Responding to or being a victim of a natural disaster

• Being a victim or witness of an attack involving deadly force

• Serious injury to yourself or another

• Gruesome injury or death of a child or elderly person

• Divorce, separation, or child custody dispute

• Lawsuits or internal investigations

• Financial difficulties (Chumley, 2012, s. 23).

CISM is considered comprehensive because it consists of multiple crisis intervention components, which functionally span the entire temporal spectrum of a crisis, and consists of interventions that may be applied to individuals, small functional groups, large groups, families, organizations, and even communities. These interventions range from the pre-crisis phase through the acute crisis phase, and into the post-crisis phase. Measures and Purposes of CISM.

Critical Incident Stress Management (CISM) is a multi-component program that works to decrease the effects of CIS early on, before reactions become rooted. CISM’s strength is attributable to its emergency service peer-driven process that is monitored by mental health professionals. The purposes in CISM are to restore the health and environment of the individuals, to decrease traumatic stress effects, and to speed recovery and productivity when they do occur (Pulley, 2000, s. 8).

4.3.2 Preventive Education and Training Methods

• Training courses for managers, members of staff, colleagues, and relatives of the above-mentioned professional groups or organizations

• Different modules, depending on the individual target groups

Pre-incident preparation and education means preparing for the CISM measures. If peers are dispatched to a crisis area, for example, it has proven helpful to mentally prepare the staff for this special situation. General information on stress and trauma are refreshed. Additionally, the peers are mentally and physically trained for the expected particularities of the situation. Moreover, acute as well as long-term coping strategies are introduced. The aim is to minimize the horror of the unexpected, to be prepared for possible mental and physical reactions and to keep one’s own resources available in the crisis (Leonhardt, 2006, s. 56).

This preparation involves a proactive educative program that addresses the setting of expectations for the high intensity stressors of emergency work. The setting of expectations serves as “psychological immunization”. In addition, pre-crisis preparation includes stress-coping skills and also discusses the direct correlation between stress, trauma, and safety (USACE, 2007, s. 22).

4.3.2.1 Individuals Crisis Response

Individual crisis response:

• Structured (individual) discussions with qualified CISM peers or mental health professionals onsite or immediately after the incident or mission

• Safer model as a one-to-one intervention method

Most of the crisis responses are done face to face and one on one. Individual crisis response is the main intervention method used by the CISM peers. It is applied directly after the incident and performed by a trained CISM peer. One method is called SAFER-R Model:

• Stabilize the situation and reduce stressors

• Acknowledge the crisis; ask about the facts and the individual stress reactions

• Facilitate, help to understand what the reactions are and normalize the reactions

• Encourage adaptive coping strategies and methods

• Recover the person to resume his/her normal functions or

• Refer to an internal or external mental health professionals if necessary (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008, s. 89).

4.3.2.2 Dealing with Crisis Incident

Structured discussions in groups performed by CISM peers or mental health professionals up to 24 h after the incident or mission.

4.3.2.3 Informing Crisis Incident Stress

Structured discussions in groups performed by mental health professionals and CISM peers between 72 h and four weeks after the incident/mission.

4.3.2.4 Demobilization

Quick informational and rest sessions are applied when a group of professionals have been released from service after a major incident. Among other purposes, it serves as a screening opportunity to assure that individuals who need assistance are identified after the traumatic event.

Demobilization is a measure for large groups at the end of an operation. The operation is over, the equipment has been laid down and the people have come together. At first, basic needs are cared for (food, drinks, warming up, and so on). Afterwards, the participants are informed about stress and stress management. If required, one-on-one interventions are initiated and phone numbers of the peers are distributed (Leonhardt, 2006, s. 57).

4.3.2.5 Crisis Management Briefing

The “crisis management briefing ” is a practical four-phase group crisis intervention. It is designed to be highly efficient in that it requires from 45 to 75 min to conduct and may be used with “large” groups consisting of 10–300 individuals. While designed to be used with primary victim civilian populations in the wake of terrorism, mass disasters, violence, and other large-scale crises, it may be applicable in other settings with other populations, as well (George & Everly, 2000, s. 54).

Briefings in large groups are performed immediately after the incident/mission; these briefings serve the purpose of providing information about CIS reactions and their consequences and about available support.

A crisis management briefing should be operated in cooperation with a representative of the organization or community and a CISM team member. The group should be homogenous and the time for discussion and questions should be restricted. Information on the incident and the status quo are provided, as well as information on stress, stress management, and the respective support. A list of the phone numbers of CISM team members is distributed. The crisis management briefing is to be repeated regularly for a fixed period of time, as by doing so, up-to-date information is ensured. Even no news is seen as important information to people in a crisis (Leonhardt, 2006, s. 57).

4.3.2.6 Relatives/Organizations Support

Relatives/Organizations support includes counseling and/or training for relatives and organizations of particularly affected professional groups, and after a critical incident has occurred.

In an acute crisis, community support might be the direct support with CISM measures. There are many examples where organizational/community support is needed: violence in schools, natural disasters, local incidents, or cases in which a community is particularly affected by the death of community members in an accident outside the community (Leonhardt, 2006, s. 61).

4.3.2.7 Follow-up

• Follow-up following CISM peer counseling is recommended. Typically, this may be one to one and for two to three sessions.

• If required, the persons affected may be referred to experts, doctors, or therapists for further measures (therapy) (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

During a CISM intervention, the need for further help may be identified. In this case, a referral to professional services is made. It is important that these services are known and referred to by the CISM facilitator. One aim of the peer training is to recognize the need for further assistance and initiate the standard procedure for a referral according to organizational practice (Leonhardt, 2006, s. 61).

A follow-up is a very important step, which is accomplished approximately 30 days with post-CISD and one-on-one interventions. If required, this facilitates access to the EAP for an employee who may still be experiencing distress or has not had a lessening of symptoms (USACE, 2007, s. 22–23).

4.3.2.8 Objectives of CISM Measures

Objectives to be achieved by applying CISM measure are to:

• reduce CIS reactions as quickly as possible,

• “normalize” the unusual experience and reaction,

• reactivate the cognitive functions and processes affected by the incident, and

• regain the ability to work as soon as possible.

It is claimed by advocates of CISM that, where CISM measures are implemented, it is easier for the persons affected to cope with the critical incident experience and quicker for them to reassume their tasks. In addition, it is possible to decrease the probability of consequential disorders and save the organization further costs (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008, s. 21).

4.4 CISM Techniques

CISM techniques are mainly developed by peers for peers. CISM techniques are not therapies but rather interviewing techniques. You don’t need a professional background in human sciences to apply CISM techniques, but you do need training and practical exercise (EUROCONTROLs. 20).

The techniques can be split into two complementary approaches. The first technique is one-on-one counseling. The helper—preferably a peer—talks with the victim and supports them in moderating the impact of the crisis. The second technique is the group session. This technique is preferably guided by a mental health professional. The various witnesses of the same critical incident gather and exchange their experiences. During this session, debriefing takes place with the help of a trained peer (EUROCONTROLs. 20).

4.4.1 Determining the Technique

The two techniques follow the same basic principle. The main difference is that the one on one technique offers the opportunity to design a tailored solution to the problem, while in the group technique the focus is put on normalizing the experience (EUROCONTROLs. 20).

Important factors in the choice of the techniques applied are:

• Cultural differences

• Available resources

• Time spent after the event

• Personality of the stressed individual(s).

4.4.1.1 One-on-One Intervention Technique

This technique intends to moderate the impact of critical incident stress and speed up the return to the pre-incident state (or even to a stronger and healthier state). Communication skills, more specifically active listening, but also knowledge of the CIS phenomenon are necessary in order to apply this CISM technique (EUROCONTROLs. 20–21).

When helping somebody in crisis after a critical incident, it is important to evaluate in which phase the person is in, in order to adapt the intervention and make it more efficient. High anxiety, remorse, denial, or grief are responses to the acute stress received, and the helper has to be prepared to cope with these during the interview/discussion (EUROCONTROLs. 21).

One-on-one interventions are voluntary and typically follow defusing or debriefings. One-on-one discussions are held entirely at the request of the employee. These are opportunities for individuals to raise issues not discussed within a group format. However, one-on-one interventions may be requested by an individual as a stand-alone intervention and not part of a previous defusing or debriefing (USACE, 2007, s. 21).

One-on-one counseling focuses on the individual rather than the group and may be accessed when an individual emergency responder perceives an incident to be critical. This is not psychotherapy; rather, it is the opportunity to discuss the incident with someone whom the effected responder trusts, whether it is a peer team member, a mental health professional or a chaplain (Beaton, 2003, s. 38).

It has been found effective in emergency services crises to start the discussion by asking questions requiring an answer at the cognitive level (the things we know), going then to the emotional level (the things we feel) and finishing back on the cognitive level. Consequently, a way of organizing a one on one discussion after a critical event is to (EUROCONTROLs. 21):

• 1. Start by introducing yourself and the role you will play; the confidentiality issue can be underlined at this stage.

• 2. Ask questions about the critical event—What happened?—Try to stay at the factual level until the operational details have all been gathered. When answering this question, the emotions felt during the event might come back again. Acknowledge them and steer the discussion toward a complete and as objective as possible description of what happened (EUROCONTROLs. 21).

• 3. Ask questions about the current emotional level––How are you doing?—Make the comparison with common critical incident stress symptoms, and explain that the reaction is normal. A normal reaction to an abnormal event.

• 4. Indicate coping strategies, suggest possible actions, ask an action plan to be established, and to meet again later to assess whether the plan works.

• 5. Close the discussion by reformulating what has been said––from the facts to the action plan passing via the stress reactions.

• 6. If needed give the name and phone number of a mental health professional.

4.4.1.2 Group Techniques

CISM group techniques address a group of people (more than three) having experienced the same critical incident: as one-on-one techniques, intend to moderate the impact of critical incident stress, and speed up the return to the pre-incident state (or even to a stronger and healthier state) (EUROCONTROLs. 21).

4.4.2 The Crisis Incident Stress Debriefing

CISD is a component of CISM and was developed to help law enforcement officers and emergency service workers understand that they are normal people experiencing normal reactions to abnormal events or situations. The concept behind CISD is to encourage free expression of thoughts, fears, and concerns in a supportive group environment after a major stressful incident. As short-term initial intervention, CISD often aids in preventing long-term effects caused by traumatic incidents (Chumley, 2012, s. 25).

The peers should have the same profession as the people affected in order to be able to assess the reactions and symptoms. In this way, the aspect of normalization as a central issue of crisis intervention, can be more authentically translated into action. Moreover, the group should be as homogeneous as possible and should have been equally exposed to the traumatic event (Leonhardt, 2006, s. 59).

The Critical Incident Stress Debriefing (CISD) is a specific, 7-step group crisis intervention tool designed to assist a homogeneous group of people after an exposure to the same significant traumatic event. It is not a stand-alone process and it should never be provided outside of an integrated package of interventions within the Critical Incident Stress Management (CISM) program. Under no circumstances should this group crisis intervention tool be considered psychotherapy or a substitute for psychotherapy (ibid, s. 4) (Fig. 4.3).

Fig. 4.3

7-Step technique (EUROCONTROL)

These steps consist of getting people to talk about:

• 1. Who they are (introduction phase)

• 2. What happened, what is the critical event (fact phase)

• 3. What they thought at the moment (thought phase)

• 4. What they felt, what was the worst thing (reaction phase)

• 5. Their symptoms of CIS (symptom phase)

• 6. Then show, by a mini-lecture, that their reactions are normal, that it was the situation that was abnormal (teaching phase)

• 7. And finally summarize and answer questions (reentry phase)

  (EUROCONTROLs. 22–23).

The first five phases of a debriefing include: the introduction phase in which the group sets its ground rules and expectations; the fact phase in which the facilitators listen to individuals provide factual accounts of what happened; the thought phase in which facilitators assist individuals in putting the thoughts they had during the event into words; the reaction phase in which facilitators assist individuals in expressing the emotions attached to their experience; and the symptom phase in which facilitators assist individuals in exploring the thoughts, feelings, and behavior they experienced. In the following phase, the education phase, the facilitators provide educational input on stress management. Finally, the facilitators lead the group through the reentry phase, wherein the facilitators summarize the intervention, provide options for ongoing treatment, and normalize the reactions that individuals might experience in their lives in the days and weeks ahead (Smith, 2013).

CISD is a structured process following 7 steps and guided by a CISM team—debriefer peers and/or a mental health professional. The debriefer peers tackle more operational issues and the mental health professional deals with emotion relief. The number of participants can be from 3 to a maximum of 20 persons. The room chosen is comfortable. A good arrangement is to seat people in a circle. The debriefing lasts up to three hours. No breaks are allowed and a doorkeeper (a CISM team member) could even be put in charge of preventing anybody from entering or leaving the room (EUROCONTROL).

The goals of debriefing are to:

• Reduce the stress reactions,

• Accelerate normal recovery processes,

• Identify people who need additional support,

• Bring people back to their normal functions (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

4.4.2.1 Defusing Crisis Incident Stress

Defusing is a shorter (20–60 min) and less formal process. A technique to encourage people to talk is not needed as the group is smaller, and the steps are followed in a somewhat less formal way (Fig. 4.4).

Fig. 4.4

Compared with defusing and debriefing (EUROCONTROL)

• 1. Introduction phase: The debriefer introduces him/herself, the “rules” of the game and asks each participant to introduce him/herself.

• 2. Exploration phase: This phase corresponds to the fact, thought, reaction, and symptoms phases of CISD, grouped and performed more flexibly (within 10–30 min).

• 3. Information phase: Corresponding to the teaching and reentry phases of CISD (not to be confused with our information phase of the CISM program).

The goals of the defusing are to:

• Reduce stress and tension,

• Accelerate a return to normal function,

• Identify individuals who may need further assistance, and

• Prepare the participants to accept further services if they are required

• (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

4.5 Crisis Response Team

The typical organized crisis intervention team has a mix of members from different parts of one organization or they have representatives from a variety of different organizations who work together. It is not uncommon to have police officers, fire fighters, paramedics, mental health professionals, chaplains, nurses, and other CISM-trained support personnel serving on the same team. On an aviation team there may be pilots, flight attendants, ground personnel, managers, flight safety personnel and mental health professionals. Air traffic control organizations generally have their own teams, but they are more than willing to combine their efforts with other teams if the circumstances warrant their involvement. When a critical incident of sufficient magnitude occurs, it is a common practice for many crisis response teams and organizations to unite into a task force to provide the best assortment of crisis intervention services (ibid, s. 19).

On most teams, which have combined many organizations into a unified system, when they receive a call for assistance, specific personnel are deployed from the team. For example, if law enforcement support services are required, only law enforcement personnel and specified mental health professionals are deployed to manage the situation. Likewise, in aviation , if a flight deck crew is dealing with a traumatic incident, only pilots and specified mental health professionals would be deployed from a CIRP team. Any combination of team members and tactics that appears to be helpful to support a distressed crew should be used (ibid).

These combinations are part of a strategic approach that matches resources to the needs of a group and to the individuals within that group. There is at least one major advantage in having all the personnel in a specific geographical area belong to the same team. In the event of a large-scale event, peers from different professional groups who belong to the same team can work together (ibid, s. 19).

4.6 Quality Management and Evaluation in Crisis Incident Stress Management Program

4.6.1 Quality Management

QM serves to: Increase the satisfaction of internal and external clients and continuously improve performance. Both targets require feedback loops into all stages of CISM implementation and operation. If, for example, the feedback of controllers (internal clients) is negative and manifests in high rejection rates of CISM offers, this can be due to poor quality of CISM introduction, inappropriate CISM peer selection and training, or missing management support after implementation. QM requires extensive data gathering and feedback. The checklists contain key questions on what to look for or provided in your quality system (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

4.6.2 Evaluation

This section provides general guidelines for the evaluation of Critical Incident Stress Management (CISM) Programs. Best practice evaluation requires on the one hand interdisciplinary, theory-led and methodologically sophisticated work and on the other hand a priori definitions of targets and evaluation aims. Although the targets can also be defined after implementation, an evaluation process starts ideally with the planning of an intervention, in this case CISM. Especially in this case, the handling of sensitive personal data is critical and is therefore addressed in:

• Evaluation as an interdisciplinary field

• Definition of targets

• Evaluation model, design, and procedure

• Evaluation tools and procedure

• Making use of feedback (ibid, Critical Incident Stress Management: User Implementation Guidelines, 2008).

4.7 CISM Effects to Safety Culture and Corporate Culture

CISM has affected the corporate culture in our company; there have been many positive effects with regard to communication and the understanding of reactions to critical incidents. Our staff has realized that the statistics serve the program and are not used against individual staff members. If the management of a company understands the importance of the program at a very early stage and supports its implementation, the staff will respond positively and see that they will benefit from it. Staff members feel that it is in place to directly support them (Riedle, 2006, s. 8–9).

CISM also affects our safety culture. This affects our safety culture in different ways: Mistakes are dealt with more openly, which leads to a lessons learnt effect. The know-how that is gained during and after incidents is applied within the company. This process directly contributes to a safety culture, it helps a person to learn from mistakes and avoid making the same ones again. It also affects other groups within the organization, such as the safety boards and incident investigators (Riedle, 2006, s. 8–9).

Managers in operations are an essential part of the CISM program. Staff and management have been shown that learning from mistakes is taken seriously, that dealing with incidents increases safety and that we do not aim at blaming or punishing individual employees. CISM has helped companies achieving all this and make it part of their corporate culture (Riedle, 2006, s. 8–9).

4.8 Crisis Incident and Crisis Incident Stress in Aviation

The aviation industry’s focus on safety leads to careful scrutiny of its personnel. Pilots and air traffic controllers must be medically screened on a routine basis to be in compliance with Federal Aviation Regulations. Conditions that would restrict their performance include many of those listed as symptom complexes for acute stress reactions, PTSD, or the variety of other psychological or medical complications that may arise. Self-evaluation of the impact of stress on an individual’s ability to function in demanding environments is difficult. Pilots and air traffic controllers may also face the dilemma of reporting psychological symptoms because revealing a mental health condition could later compromise their medical certification, and therefore their livelihood. In a safety culture where individuals are carefully monitored to minimize risks of performance problems, it may be difficult to identify impaired individuals in a proactive way (Kenville, ve diğerleri, 2009).

Aviation employees experience the many critical incidents that virtually every adult experiences in the course of their life and work. There are, however, critical incidents that are specific to the aviation industry. These critical incidents challenge, and frequently overwhelm, the coping abilities of individual employees or entire aircraft crews (ibid).

Whether they are the powerful general events that impact most people or the aviation specific situations listed in the previous section, critical incidents are the beginning point of the critical incident stress reaction. As noted earlier, critical incidents cause an acute state of emotional turmoil called a crisis. Critical Incident Stress is the cognitive, physical, emotional, spiritual state of arousal that accompanies the crisis response. When thinking, feelings, bodily functions, and belief schemes become aroused by exposure to a critical incident, behavior changes. For example, if a person becomes frightened, he or she may run away or hide. Running and hiding are behaviors that occur as a result of the crisis reaction (ibid).

The aviation industry has unique aspects as well. While the nature of CISM services is to address these types of issues, individuals are expected to face events that are associated with physical trauma. While Posttraumatic Stress Disorder (PTSD) is a well-known diagnosis, training and experience will offer some familiarity (not immunity) with these types of reactions. The aviation industry, outside the fire/rescue and security forces, may have personnel who may have not dealt with the stress of a disaster at any level in the course of their careers. This is not to say they are incapable of managing the incident, but as a group, they may have individual training or recovery needs that differ as a result of their work experience. These include the relative infrequency of aviation disasters compared to fire/rescue/police operations; the potential for a large-scale event; the potential of responsibility or blame for the accident on those who are now asked to be involved in the disaster support process; the large number of people (passengers, family members, rescuers, press, investigators, etc.) needing support services; and the intense press presence (Kenville, ve diğerleri, 2009, s. 7).

Factors that predict resilience have been identified. These factors may be considered for selection in high performance teams (e.g., military or exploration teams), but may not be seen as a viable screening tool for hiring in the aviation industry (Kenville, ve diğerleri, 2009 s. 7–8).

4.9 Crisis Incident Stress Management Strategic Programs for Aviation

Strategy is the art and science of maneuvering one’s resources into the most advantageous position in order to improve the chances of a successful outcome. It implies that the right people provide the right services to the appropriate targeted populations in the best possible time frame and under the most advantageous circumstances. An appropriate strategy is one reason why the Critical Incident Response Program (CIRP) or Critical Incident Stress Management (CISM) programs have been so well received by the aviation industry. They contain all of the elements of a sensible strategic approach to crisis intervention services. Here are the key elements of a sensible strategic psychological first aid program for aviation (Leonhardt, 2006, s. 34):

Assessment skills. The CIRP or CISM team should be able to assess both the severity of the incident and the level of distress in the personnel who were involved in or who witnessed the traumatic event.

Strategic planning skills. The CIRP team members should be able to develop a comprehensive, integrated, systematic and multi-component (CISM) approach to assisting traumatized individuals or groups within aviation .

Multi-tactic approach. No one crisis intervention service will be suitable to all people at all times and under all circumstances. A multi-component approach is the only realistic and sensible approach that is likely to be effective in crisis intervention within the aviation industry (see the sections on Critical Incident Stress Management earlier in this chapter).

Follow-up services. Once a series of crisis intervention services have been provided, it is essential that CIRP or CISM team members reconnect with individuals or group members to assure that they are in fact recovering from the traumatic experience. Telephone calls, visits to the work site ,or to a person’s home are crucial follow-up crisis intervention techniques in the field of emotional or psychological first aid.

Linkages to professional care. The vast majority of people in the aviation industry do not need professional psychological care. It would be irresponsible, however, not to have in place links and referral mechanisms to professionals for the few who would benefit from these services. In addition, CIRP or CISM team members need professional oversight and guidance to assure that their psychological first aid services are the very best available.