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Critical Incident Stress Debriefing: How It Works & What to Expect

Originally designed for responders to traumatic events, critical incident stress debriefing (CISD) is a structured, brief intervention provided in a small group setting immediately following a crisis. It’s designed to help people process the event to minimize symptoms of traumatic stress, depression, and anxiety. Critical incident debriefing consists of seven stages, and altogether, it lasts approximately three hours or less.


What Is Critical Incident Stress Debriefing?


Critical incident stress debriefing is a highly specific, structured crisis intervention to reduce traumatic stress, increase coping, and facilitate group solidarity among people who have experienced the same trauma together.1 It was developed in 1974 by Dr. Jeffrey Mitchell, a former firefighter and paramedic, as one component of a broader critical incident stress management (CISM) program.


The intervention, which involves emotional processing and psychoeducation, is intended for police officers, firefighters, emergency medical professionals, disaster workers, and people in similar occupations who respond to often gruesome or catastrophic emergencies.2 It’s used to help them manage an intense stress reaction and return to their typical level of functioning when their usual coping mechanisms have been overwhelmed.1,2


Trained teams of two to four mental health professionals or experts in disaster response and peer support personnel (responders who have experienced traumatic events in the past) offer critical incident debriefing interventions.1,3 Typically, the workplace hires the team, and the intervention is offered free of charge to personnel who have just faced the critical incident. CISD is delivered in a group setting with a maximum of 25 people per group.4


Specific requirements for this structured program are:1,4

  • The group must be homogenous (all members are of the same occupation and participated together in the critical incident)

  • Members had approximately the same amount of exposure to the traumatic event

  • No one is currently involved in the response efforts

  • Participants must be psychologically ready rather than extremely fatigued or distraught.

  • The standardized procedure and all seven steps must be followed completely and properly

  • The intervention is not stand-alone but instead is one component of a crisis response management program that involves other interventions and services

This debriefing intervention progresses through seven stages during one single session that lasts approximately one to three hours. For maximum effectiveness, CISD is done within the first 24-72 hours after the rescuers have completed their response work for the critical incident.1,5

What Is a Critical Incident?

“Critical incident” is another term for a traumatic event.1 It includes any occurrence faced by public safety responders, emergency workers, and related personnel that causes distress and disruption to typical psychological or physiological functioning.5 Critical incidents often involve death or extreme threats to safety, life, and well-being.

Examples of critical incidents include:

  • Catastrophic fires

  • Mass shootings

  • Workplace violence

  • Serious accidents

  • Natural disasters (storms, wildfires, earthquakes, etc.)

  • Industrial disasters

Short- and long-term side effects of a critical incident may include:5

  • Numbness or shock

  • Life-disrupting emotions and other psychological reactions (anger, denial, grief, confusion, terror, survivor guilt, blame, difficulty concentrating, flashbacks, etc.)

  • Acute stress disorder or post-traumatic stress disorder (PTSD)

  • Difficulty eating and/or sleeping

  • Missed work

  • Substance use problems

  • Relationship difficulties

  • Depression

  • Anxiety

CISD seeks to lessen the impact of a traumatic event, aid in recovery and resiliency, enhance understanding of how a critical incident naturally impacts people, build coping skills, and identify people who may benefit from additional help like individual mental health therapy.1,3,4


7 Stages of Critical Incident Debriefing

The seven stages of CISD are purposefully designed to help people retell the event, share reactions and symptoms, and learn factual information in order to promote recovery and overall mental health.1,2 This program is intended to reduce symptoms and the risk of developing mental health disorders like acute stress disorder, post-traumatic stress disorder, substance use disorders, depression, and anxiety.


Step 1: Assess the Critical Incident

The initial stage of CISD primarily involves the team leaders. The people conducting the program carefully consider the specific situation and the people involved in order to tailor each step precisely to the needs of the group. When the participants join, team members introduce themselves, explain the process, and set guidelines.


Step 2: Identify Safety & Security Issues

In this stage, participants are encouraged, but never forced, to open up and provide a brief, factual account of the event from their own point of view. This is a safe discussion that does not dive into details or emotions. The purpose of step two is to help people feel safe, reduce anxiety, provide a sense of personal control, and encourage discussion.


Step 3: Allow Venting of Thoughts, Feelings, & Emotions

This stage begins by talking about what people think about the critical incident. A typical question is, “What was your first thought or your most prominent thought once you realized you were thinking?”1 This is done as a group go-around, with each person getting the chance to share. The discussion transitions from thoughts to feelings and emotions. It’s important that venting and validation occur so people can share their emotions in a safe, supportive environment.


Step 4: Share Emotional Reactions

This phase is the heart of CISD and focuses on the event’s impact on the participants.

Participants can answer questions such as:1,4

  • “What was the worst thing about this event for you personally?”

  • “If you could erase one part of the situation, what would you erase?”

  • “What aspects of the situation cause you the most pain?”

Through discussion, participants not only process the event but begin to prepare and plan for the immediate and long-term future. While it is highly focused on reactions and impact, the sharing is less structured than in the other stages. Each participant is allowed the chance to participate and share concerns. The discussion continues until all emotions or other issues have been addressed. This stage helps reduce chronic crisis reactions and returns a sense of control to the participants.


Step 5: Review Symptoms & the Incident’s Impact

During this segment, participants explore and express their symptoms and the effect the incident is having on them. Leaders might ask, “How has this tragic experience shown up in your life?” or “What cognitive, physical, emotional, or behavioral symptoms have you been dealing with since this event?”1 This stage helps spot potential problems with coping and identify people who may need additional support.


Step 6: Teach & Bring Closure to the Incident

This educational phase helps participants understand their symptoms and effects. It helps them know that their reactions are a normal response to traumatic events. Leaders provide stress management tools and other information tailored to the exact incident and specific group involved. This phase helps people center themselves and feel more grounded and stable.


Step 7: Assist In Re-Entering the Workplace/Community

As the session draws to a close, leaders review and summarize what has been discussed and learned. Sometimes, handouts are provided that offer information, resources, and action steps. Participants have the opportunity to ask questions and make any final statements. The purpose is to help participants move forward into their deeper healing and recovery process.

Rather than abruptly dismissing the participants at the end of step seven, team leaders offer refreshments to anchor the group and allow them to connect with each other and transition gradually out of the intervention. Leaders talk with each individual participant as the first part of follow-up services available after the CISD session.


Is Critical Incident Stress Debriefing Effective?

CISD was developed using established crisis intervention and group theories; however, research into its effectiveness has yielded mixed results.1,2,6

Here are several studies that indicate that CISD is effective:

  • In a 1991 study, within 24 hours of a critical incident, 40 police officers received CISD while 31 did not. Those officers who experienced CISD reported fewer symptoms of depression, stress, and anger during a follow-up conducted three months after the intervention.1

  • In a 1995 study of emergency medical responders, 36 were offered CISD within 24 hours after a mass shooting resulting in numerous deaths and critical injuries. Those that received the intervention were given repeated follow-up assessments and about half reported fewer symptoms of traumatic stress, anxiety, and depression.7

  • Two groups of counselors responding to hurricane victims were compared in a 1997 study. One group received CISD while the other did not. The CISD group reported less distress than the group who did not participate in the intervention.8

Other studies have found evidence against the use of CISD:

  • A random controlled trial conducted in 1997 involved 103 people hospitalized for severe burns. Of these burn victims, 57 received CISD while 46 did not. When researchers followed up three months later, there was no difference between the groups, and when they followed up again after 13 months, the CISD group experienced much higher rates of PTSD, anxiety, and depression.9

  • FEMA conducted a 3-year study, reported in 2002, to determine the effectiveness of CISD for firefighters. Across the study, 264 people completed a CISD intervention and 396 did not. Researchers analyzed mental health issues such as depression, anxiety, PTSD, and coping skills and found no evidence to support the effectiveness of CISD on mental health of firefighters experiencing traumatic events.10

  • The American Red Cross conducted a study review to determine whether CISD should be recommended for responders after a traumatic event. Reviewers initially examined studies conducted between 1966 and 2010 and then re-examined them later, this time emphasizing studies conducted in 2006 and beyond and analyzing them for evidence in favor of and against CISD. They discovered no significant evidence that CISD is effective in reducing the risk of PTSD and found that CISD can cause harm by increasing symptoms in people who didn’t previously experience them and worsening symptoms in those who were vulnerable. Thus, the Red Cross concluded that CISD should not be used for responders after a traumatic event.6

Risks of Critical Incident Stress Debriefing

Critics of critical incident debriefing argue that it could increase PTSD symptoms due to the intense recall and personal descriptions expressed so soon after the event.2,4,6 There is also some concern that without proper screening prior to delivery, it may be given to people who either aren’t distressed about the incident or are too distressed for a group intervention involving shared thoughts and feelings, thus causing or worsening symptoms.3

Additionally, one risk is that some people may think that CISD is enough and fail to reach out for further help.3 If it is offered in isolation rather than as part of a larger CISM effort, people aren’t likely to receive ongoing support and active interventions to further reduce negative mental health symptoms.3


Criticisms of Critical Incident Stress Debriefing

The take-away from conflicting studies, risks, and criticisms is that critical incident debriefing can indeed be effective in specific situations. It should not be provided as a stand-alone intervention but instead must be part of a greater CISM program; further, leaders providing the intervention must be properly trained and adhere to accepted standards rather than modifying the stages.1

Prominent critiques include:2,4

  • Most research studies (both those in support of CISD and against it) have been flawed and are thus unreliable

  • Because of the nature of CISD, random controlled trials—the gold standard in research studies—are very difficult to conduct at all, let alone properly

  • Participants often report that CISD is helpful, but this doesn’t equate to actual clinical improvement

  • Group members aren’t screened for readiness, and their prior state of mental health isn’t considered, potentially putting them at risk for new or worsening symptoms

Despite the fact that CISD has been adapted and used with other groups and even individual victims of trauma, it is not intended to be used for these purposes.1,2 It appears that, when used expressly as it was intended, CISD can potentially help emergency responders cope with the traumatic stress of critical incidents.


What to Expect During CISD Sessions

Critical incident stress debriefing is designed to allow people to talk about the traumatic event and how it is affecting them. It relies heavily on participants sharing their descriptions, thoughts, and feelings. It is a safe, non-threatening environment, and while everyone is gently encouraged to participate actively, no one is ever forced to do so.1 Everything discussed during the session is considered confidential.


This intervention is relatively quick, lasting approximately one to three hours depending on the size of the group and intensity of the critical incident.1,4 While CISD is often conducted as a single session, sometimes groups may meet a few times over the span of several days.4


How One-on-One Therapy May Still Be Helpful


Critical incident stress debriefing is not designed to replace individual therapy with a mental health professional.3 In fact, one purpose of CISD is to identify people who may benefit from one-on-one therapy, and leaders often provide referrals to professional care.1 If the impact of the traumatic event is severe, people may need professional care on an ongoing basis.5

Signs that individual work with a therapist may be helpful are:4

  • Continuing sleep difficulties

  • Intense and/or chronic anxiety

  • The presence of depression symptoms

  • New or intensified substance use

  • Prolonged fear

  • A sense of having no control over one or more aspects of life

  • Simultaneous life stressors in addition to the effects of trauma

  • Previously existing mental health challenges

  • Lack of social support

Final Thoughts on Critical Incident Stress Debriefing

When delivered as intended (to homogenous groups of responders by trained leaders), CISD can be an effective component of dealing with traumatic stress. Critical incidents are difficult to deal with and disrupt life in numerous ways. With help and support, including that offered by CISD as well as individual therapy, it’s possible to move forward, experience mental health and well-being, and function the way you’d like to.


Additional Resources

Online Therapist Directory: Sort therapists by specialty, cost, availability and more. Watch intro videos and see articles written by the therapists you’re considering working with. When you’ve found a good match, book an online therapy appointment with them directly.

 

This article was re-posted with permission from Choosing Therapy and the author.


Choosing Therapy

Choosing Therapy is on a mission to make mental health care more accessible, approachable and inclusive. They make it easy to connect with a qualified, experienced therapist.

Choosing Therapy has a nationwide network of licensed therapists who offer video-based therapy for individuals, couples, and families. Choosing Therapy’s therapists are available when you are: mornings, afternoons, evenings, and weekends. Video-based therapy means there’s no commuting, no waiting rooms, and you’re no longer limited to just the professionals in your town.

You can schedule a free, confidential phone call with one of Choosing Therapy’s Navigators to get personalized therapist recommendations, or connect with a therapist on your own by using the Choosing Therapy Directory. Either way, your first therapy session can take place in as little as 12 hours.


Tanya Peterson

Tanya Peterson is a National Certified Counselor (NCC), author of multiple books and regular contributing writer for Choosing Therapy, a premier mental health resource site, national therapist directory and online therapy platform. Tanya's current areas of expertise focus on mindfulness, stress, positive psychology, and acceptance & commitment therapy. Tanya currently helps teens and adults of all ages transcend challenges and create a quality life through speaking and writing articles and books on mental health. Tanya Peterson has a background in teaching and school counseling, and has written extensively on parenting and kids' mental health. She has also written four non-fiction books that focus on helping people deal with anxiety through mindfulness, and has a mental health course for kids aged 8-12 with an online education company.

Tanya Peterson is a Diplomate of the American Institute of Stress (DAIS) and a mindfulness expert.


SOURCES
  1. Mitchell, J.T. (n.d.). Critical incident stress debriefing (CISD). Trauma. Retrieved from http://www.info-trauma.org/flash/media-f/mitchellCriticalIncidentStressDebriefing.pdf

  2. Barboza, K. (2005). Critical incident stress debriefing (CISD): Efficacy in question. The New School Psychology Bulletin, 3(2): 49-70. Retrieved from https://ovc.ojp.gov/sites/g/files/xyckuh226/files/media/document/ci_lr_cisd_efficacy_in_question-508.pdf

  3. International Critical Incident Stress Foundation. A Primer on Critical Incident Stress Management (CISM). Retrieved from https://icisf.org/a-primer-on-critical-incident-stress-management-cism/

  4. Regehr, C. (2001, September). Crisis debriefing groups for emergency responders: Reviewing the evidence. Brief Treatment and Crisis Intervention, 1(2): 87-100. Retrieved from https://www.researchgate.net/publication/247903560_Crisis_Debriefing_Groups_for_Emergency_Responders_Reviewing_the_Evidence

  5. Mitchell, J. T. (September/October, 1986). Critical incident stress management. Response, 24-25.

  6. American Red Cross. (n.d.). ACFASP scientific review: Critical incident stress debriefing (CISD). Retrieved from https://www.redcross.org/content/dam/redcross/Health-Safety-Services/scientific-advisory-council/Scientific%20Advisory%20Council%20SCIENTIFIC%20REVIEW%20-%20Critical%20Incident%20Stress%20Debriefing.pdf

  7. Jenkins, S.R. (1998, August). Emergency medical workers’ mass shooting incident stress and psychological recovery. International Journal of Mass Emergencies and Disasters, 16(2): 181-197. Retrieved from http://www.ijmed.org/articles/182/download/

  8. Chemtob, C.M., Tomas, S., Law, W., & Cremniter, D. (1997, March). Postdisaster psychosocial intervention: A field study of the impact of debriefing on psychological distress. American Journal of Psychiatry, 154(3): 415-417. Retrieved from https://pubmed.ncbi.nlm.nih.gov/9054792/

  9. Bisson, J.I., Jenkins, P.L., Alexander, J., & Bannister, C. (1997). Randomised controlled trial of psychological debriefing for victims of acute burn trauma. British Journal of Psychiatry, 171(1): 78-81. Retrieved from https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abs/randomised-controlled-trial-of-psychological-debriefing-for-victims-of-acute-burn-trauma/88DF4DEC1FE89C6B6F817EAF82C7CF32

  10. Harris, M.B., Baloğlu, M., & Stacks, J. R. (2002) Mental health of trauma-exposed firefighters and critical incident stress debriefing. Journal of Loss and Trauma, 7(3): 223-238. Retrieved from https://psycnet.apa.org/record/2002-13847-003


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