Forensic psychology: Part 5: Chapter 16: Supporting staff

by Lois Roisine Ph.D., C.Psych.^{Footnote 1}

• To provide guidelines for managers regarding the types of critical incidents that require intervention.
• To identify the types of intervention services that can be provided.
• To offer guidelines for clinical practice.
• To identify professional needs.

Penal institutions represent an occupational context where exposure to trauma related events is not unusual (Rosine, 1992a). Personnel working within such settings often become desensitized to the traumatic aspects of the environment and tend to see the environment as "normal." This belief is further supported by a correctional sub-culture image of ((machismo" where personnel attempt to present themselves as being unaffected by unpleasant or frightening events (Rosine, 1992b). Unfortunately, in spite of these beliefs, job related traumatic events have the potential to overwhelm the normal coping skills of employees, leading to the development of critical incident stress reactions (Mitchell (Sz. Resnik, 1981) and in some cases post-traumatic stress disorder (PTSD)^{Footnote 2} (Corneil, 1993; Rosine, 1992b).

A critical incident refers to a traumatic environmental event that threatens the safety and security of an individual. Exposure to occupation-related traumatic events are common within the Correctional Service of Canada (CSC).^{Footnote 3} It is recognized that while exposure to trauma is a routine part of employment in a correctional setting, critical incidents constitute a class of events that fall outside the range of most human experience.

The literature on employee stress has recently begun to identify the occurrence of symptoms of PTSD in number of occupational groups who, by the nature of their work, are being exposed to traumatic events. These groups include police (Loo, 1986; Martin, McKean & Veltkamp, 1986), fire fighters (Corned, 1993; Durham, McCammon & Allison, 1985), medical personnel, disaster workers (Raphael, 1984), correctional officers ^{Footnote 4} (Rosine, 1992b), rape crisis workers and other clinicians (McCann & Pearlman, 1990; Talbot, 1990). Traumatization can occur through direct exposure to trauma, or indirectly ^{Footnote 5} through exposure to the aftermath of the traumatic event and its victims (McCann & Pearlman, 1990).

The human and economic costs associated with traumatic stress are significant. These include increased absenteeism from work, resignation from work, increased use of medical services, health deterioration, marriage breakdown, and suicide (Davidson, 1979; Mitchell, 1984, 1987; Mitchell & Bray, 1990; Veronen & Kilpatrick, 1980). The clinical literature examining traumatic stress has emphasized prevention through education and through immediate intervention after an incident (Mitchell & Bray, 1990; Spitzer & Burke, 1993; Van den Bergh, 1992; Walker, 1990). ^{Footnote 6}

It is not possible to predict all the events that will cause critical incident stress reactions. However, the following types of incidents have been found to have a high probability of affecting the staff involved (Hazzan, 1993; Mitchell & Bray, 1990; Rosine, 1992b):

• line of duty death or serious injury of a colleague;
• suicide or attempted suicide by an inmate or colleague;
• excessively violent incidents (e.g., assaults, murders, rapes, incidents involving a great deal of blood);
• serious injury or death of an inmate; mass casualty events;
• events with unusually or disturbing sights, sounds, smells (e.g., riots, burning flesh, body parts);
• threats to staff or staff's family safety; working in potentially dangerous situations (e.g., riot);
• excessive or unusual media interest or coverage;
• situations where everything goes wrong and there is a negative outcome;
• events that "shouldn't have happened" — that goes against the staff member's world view (e.g., the hostage taking and rape of an nurse when she is helping an offender); and
• any other event that evokes unusually strong emotional reactions in those involved in the event.

When events such as those described above occur, consultation with a psychologist knowledgeable in the area of critical incident stress is recommended. The psychologist can then determine the most appropriate type of intervention for the particular incident that occurred.

Conceptual models of traumatic stress and its development have significantly influenced the nature of traumatic stress research (Wolfe & Keane, 1990). Exposure to traumatic stress was originally conceptualized as activating a pre-existing psychiatric problem (Andreasen, 1985). Following this, traumatic stress was seen as the adverse effects of exposure to traumatic stimuli on any person — even well-adjusted individuals (Wolfe & Keane, 1990). Both of these models assume a stimulus-response paradigm, where the individual is essentially a passive reactor to external forces (Cornell, 1990). More recent research has shown that other factors are influential in the development of traumatic stress reactions. These factors include dispositional and demographic variables, behaviourial and cognitive slcills, and environmental variables (Corneil, 1993; Green, Wilson & Lindy, 1985; Keane, Wolfe & Taylor, 1987; Reich, 1990; Rosine, 1992b; Vitaliano, Maiuro, Bolton (St Armsden, 1987).

Vitaliano et al. (1987) argue that dynamic models of traumatic stress are necessary to understand personenvironment interactions. In the general stress literature, Lazarus and his associates have argued cogently for a process-oriented approach to the study of stress (Folkman, Lazarus, Dunkel-Schetter, Delongis & Gruen, 1986). In this model, stress is conceptualized as a relationship between the person and the environment that is reciprocal, bi-directional and dynamic (Follcman, Lazarus, Gruen (Sz.. DeLongis, 1986). A stress response is assumed to occur when the person assesses the situation "as taxing or exceeding his or her resources and as endangering well-being" (Folkman, Lazarus, Gruen & DeLongis, 1986, p. 572). The stressful person-environment relationship and subsequent outcomes are mediated by cognitive appraisal and coping. Appraisal is seen as a two-part process with primary appraisal occurring when the person evaluates the type and degree of threat, and the degree of potential h.arm or benefit to personal well-being. Secondary appraisal occurs when the individual determines a response choice to prevent or minimize harm or to maximize benefit. Some form of cognitive and/or behaviourial coping is then implemented to bring about change in internal states and/or the external environment.

In the area of traumatic stress, three hypothesis have been proposed regarding the way in which traumatic events and the survivor's personality and personal resources can interact. The first hypothesis is that the traumatic experience and personality are completely independent of one another. This is unlikely given current understanding of the nature of stress and its interaction with appraisal variables and coping styles (Folkman & Lazarus, 1988). The second h.ypothesis postulates an inverse relationship. This assumes personality factors are important when exposed to low intensity events, but become increasingly less important as the intensity and seriousness of the stimulus increases. This premise is supported to some extent by the early combat literature where exposure to combat was significantly related to subsequent development of PTSD (Foy, Sipprelle, Rueger (St. Carroll, 1984). The final hypothesis is that the relationship is curvilinear — where situations of "very low stress and those of extreme and extended stress diminish the role of personality on psychological effects" (Hartsough, 1988, p. 150). In other words, in critical incidents with very little threat value, few psychological effects are evoked, whereas in incidents of extreme and ongoing stress, a relatively uniform stress response is elicited across individuals. Support for the final theory is developing in the more recent combat literature (Solomon, Mikulincer & Hobfoll, 1986; Solomon, Mikulincer & Hobfoll, 1987). Hartsough (1988) postulates that in incidents of moderate stress, or events of severe stress but of short duration, there is an interaction between personality differences and the stressor. In situations of extreme stress, however, the effect of individual differences disappears and a relatively homogeneous stress response occurs.

There are major difficulties in attempting to study the impact of exposure to traumatic events. It is impossible to predetermine when disaster, war, riots, murder or most other traumatic events are going to occur (Green, Grace & Gleser, 1985). Generally, the appropriate data cannot be collected prior to the event (the exception being in those cases were the data were collected for other purposes). This necessitates the use of retrospective studies (Solomon & Flum, 1988) which make causal inference difficult.

In one of the few prospective studies ^{Footnote 7} of trauma, Card (1987) found that more than ten years after completion of their military service, men exposed to Vietnam combat reported significantly more problems related to nightmares, loss of control over behaviour, emotional numbing, withdrawal from the external environment, hyper-alertness, anxiety and depression than did their peers. Further, the greater the individual's exposure to combat and injury, the greater the number of PTSD-related problems he experienced at the time of the post-war, follow-up study.

Many existing studies have been limited to anecdotal accounts and clinical reports of single events (Wilkinson, 1983,) or descriptions of the sequela of traumatic exposure (Loo, 1986; Martin, McKean & Veltkamp, 1986; R.M. Solomon, 1988). Much of the research has restricted study to exposed populations and not an examination of the total at-risk population (Cornea, 1993).

Two recent studies on critical incident stress have attempted to address some of these problems (Corneil, 1993; Rosine, 1992b). A substantially large portion of subjects in each of these samples experienced levels of psychological distress sufficient to warrant intervention. Further, approximately 17% of the subjects in both studies met diagnostic criteria for PTSD yet they continued to function on the job despite such distress.

Finally, many of the psychometric measures used in existing research have been limited in the reporting of reliability and validity data (Corneil, 1993). Further, the lack of use of standardized measures have prevented comparisons being made across either populations or types of traumatic events.

The study of traumatic stress in the workplace is a relatively new area of research. In the 1970s, a growing body of knowledge was being accumulated on the effects of occupational stress on the employee. Workers were identified as suffering from a number of physiological and emotional difficulties related to stress (Cheek (St. Miller, 1983; Maddi, Bartone Puccetti, 1987). As the 1980s approached, clinicians began to recognize that public safety personnel were presenting symptoms of PTSD. It soon became clear that, as a function of their job responsibilities, emergency and public safety personnel are exposed to a number of extremely unusual and traumatic events. This chronic, or in some cases acute exposure to critical incidents was identified as contributing, if not causing, a number of physical, behaviourial, emotional and cognitive difficulties ^{Footnote 8} in front-line personnel.

Recently, PTSD has become recognized as a legitimate work related claim by the Worker's Compensation Board. Compensation is possible when psychological injury is caused by physical trauma, but it is still extremely difficult to obtain when the causal factor is deemed to be psychological (Cornea, 1990).

For clinical purposes, critical incident stress can be considered as falling along a continuum of stress severity, with PTSD at the extreme pole, and critical incident stress approaching the PTSD end of the continuum (Rosine, 1992a). The main symptoms of PTSD include: hyper-vigilance, nightmares, intrusive memories of the traumatic event, intense psychological distress when exposed to stimuli associated with the original trauma, and an exaggerated startle response. The differences between critical incident stress and PTSD lie in the number of symptoms experienced and the duration of these symptoms.

Clinically, when an individual is exposed to a job-related traumatic event that overwhelms his or her personal resources, a number of stress reactions occur. The stress response can occur immediately at the scene, within 24 hours or be delayed - occurring weeks or even months after the incident. Symptomatology may be cognitive (e.g., flashbacks), behavioural (e.g., angry outbursts), physical (e.g., chest pains), and/or emotional (e.g., panic reactions). Whatever the reactions, a feeling of vulnerability and loss of control may be experienced.

Herman (1992) and Janoff-Bulman (1992) suggest that a person's fundamental assumptions about the world being a safe and predictable place are jeopardized during and after traumatic exposures. Similarly, belief in self and one's ability to maintain control in the face of trauma are brought into question. If one's behaviour or self is evaluated as having fallen short of internally imposed expectations or perceived external expectations (e.g., those of peers, supervisors, or managers), then positive perceptions of one's self and one's ability are compromised. It is this sense of loss of control and vulnerability that are vital in the postvention and recovery process following exposure to critical incidents. When stress reactions are identified as normal and attributed to the critical incident, then personnel need not attribute their own emotional, cognitive, physical or behavioural responses to some character defect or deficit. A frequent comment made by personnel experiencing stress reactions after incidents is: "I thought I was losing my mind!" If attribution for stress reaction symptomatology can be made to an external environmental event (e.g., the traumatic incident) rather than a character weakness (e.g., going mad) then recovery should be easier. The clinical implications of this attributional phenomena are important in both prevention and intervention. In terms of prevention, it highlights the need for education (before an incident occurs) to teach personnel that reactions to critical incidents are normal and expected. From a post-incident perspective, it points to the need for rapid intervention to prevent the development of negative and self-blaming attributions that have the potential to increase post-incident symptomatology and increase the risk of PTSD formation.

Critical incident stress reactions are the unpleasant thoughts, feelings and emotions experienced both during and after a critical incident. Reactions vary greatly among people (Corneil, 1993; Mitchell, 1982; Mitchell & Bray, 1990; Rosine, 1992a). Not all people experience the same reaction, at the same intensity, nor for the same length of time. As mentioned above, critical incident stress can be thought of as falling along the stress continuum with PTSD at the extreme pole. As critical incident stress approaches the PTSD end of the continuum, the frequency, intensity, variety and/or duration of symptoms increases.

Critical incident stress reactions can be physical, cognitive, emotional or behavioural in nature, and can occur at the time of the incident or later. Stress reactions can be short lived, or can extend days, weeks or months beyond the event, and can range from mild to severe.

Most individuals exposed to a critical incident will experience some stress reactions, but these are usually temporary and subside in a few days or weeks. ^{Footnote 9} Personnel experiencing reactions that persist beyond a month, interfere with the individual's personal or work life, or cause the person concern, should be seen by a mental health professional.

The following are some of the stress symptoms that may occur at the scene:

• Physical: muscle tremors; cardiac arrythmias;• nausea; chest pains;* headaches; excessively elevated blood pressure;* profuse sweating; excessive vomiting;' signs of severe shock;• muffled hearing; dizziness;' poor coordination; difficulty breathing;• and rapid heart rate.
• Cognitive: poor concentration; mental confusion;* tunnel vision; disoriented to person, time, space; difficulty focusing; difficulty making decisions; short-term memory problems; flashbacks to prior incidents; and difficulty communicating with others.
• Emotional: frustration; panic reactions;* selfdoubt; phobic reactions; irritability; loss of control;* fear; inappropriate emotions;* anxiety; anger; and emotional numbness.
• Behavioural: extreme hyperactivity; and excessively angry outbursts.
• * = These symptoms require immediate attention and in the case of the physical symptoms, indicate the possible need for a medical evaluation.

Delayed critical incident stress reactions can occur hours, weeks, or years later. Because critical incident stress is part of the stress continuum, the provision of an exhaustive list of all stress reactions would be an ordeal to read. Instead, a list of the more common post-incident difficulties ^{Footnote 10} experienced by correctional personnel are provided. However, when assessing an individual, be aware that he or she may also be experiencing some of the more general symptoms of stress:

• Physical: difficulty falling asleep and staying asleep; waking too early; diarrhea; fatigue; dry mouth; loss of libido; loss of appetite; gastro intestinal difficulties; muscle tension and soreness; and headaches.
• Cognitive: flashbacks, intrusive images, nightmares; distractibility; decreased attention span; difficulty concentrating; feelings of vulnerability; fear of recrimination at coroner's inquest, trial, etc.; and "If only I had done ...."
• Behavioural: distancing from family, friends and/or peers; increased alcohol, caffeine and nicotine consumption; depression; preoccupation with the incident; family conflict; peer conflict; jumpiness; and increased risk taking behaviours.
• Emotional: anger; resentment towards peers and supervisors; intolerance towards family, friends and/or peers; feeling of vulnerability; loss of emotional control; fear and anxiety; and severe/inappropriate guilt reactions.

Critical incident stress reactions are not signs of instability or psychiatric impairment, but rather the reactions of normal people to abnormal events. Unfortunately, in correctional settings, some staff and managers wrongly believe that the more traumatic incidents an individual is exposed to, the more hardened and less affected they are by the events.

This belief can lead to several negative outcomes:

1) lack of support or even ridicule of others who experience stress reactions; and 2) failure to seek early intervention, thereby increasing the probability of the development of more serious problems. In reality, exposure to occupational trauma in corrections is the converse of the above belief — increased exposure to trauma leads to increased post incident symptoms and greater likelihood of current clinical difficulties (Rosine, 1992b). In other words, the more critical incidents a person is exposed to, the more likely they are to have difficulties, both at the time of the incident and currently. ^{Footnote 11}

There are a number of person variables that are thought to influence the degree to which exposure to traumatic stimuli impact on an individual. These include:

• the degree of threat perceived by the individual;
• similarity between this event and a previous critical event(s);
• the level of life stress the person is experiencing at the time of the event (e.g., a recent death or serious illness of a loved one, recent divorce, financial difficulties, health problems, work related problems, etc.,);
• several critical incidents occurring within a relatively short time frame;
• the reaction to the event by significant others;
• nature and/or strength of the relationship between individual and the victim;
• the use of denial as a coping strategy;
• having a support network that understands critical incident stress;
• the ability of the individual to identify and talk about feelings and the experience; and
• prior traumatization either in childhood or adulthood.

The effect of some of these variables (such as the use of denial and repetitive exposure to traumatic events) has been demonstrated empirically (Rosine, 1992b).

A number of models for managing traumatic stress have been developed. The federal government has provided inter-department training in the Mitchell model (Rosine, 1992a) and it is being widely used by a number of departments (Health and Welfare, Transport Canada, RCMP, DND, Public Works Canada, etc.). CSC is currently developing a training package ^{Footnote 12} and an implementation model to help standardize critical incident stress management practices across the regions.

The critical incident stress management (CISM) process was specifically developed for occupational groups exposed to traumatic events. However, it can be used for other groups such as victims of disasters and offenders. The goal of CISM is to reduce critical incident stress reactions and prevent the development of PTSD. CISM is a multi-pronged approach that involves pre-incident education as well as on-scene and post-incident interventions.

Workshops and educational seminars that teach staff about the effects of critical incident stress and methods of reducing stress are the first step in the protection of personnel. Individuals who understand critical incident stress and who are practising effective stress management techniques are less likely to be seriously impacted by a critical incident. If they are impacted, they are more likely to seek out and accept assistance. ^{Footnote 13} This type of training appears to provide a stress inoculation effect (Meichenbaum, 1985).

The following services can be provided on-scene:

• human resource management consultation to the crisis manager; and
• direct service to staff.

Hazzan (1993) suggests that mass casualty or prolonged major incidents are situations where psychological services can be beneficial. Given the varied nature of psychological training, psychologists ^{Footnote 14} can provide a variety of services to the organization during an incident. It will be important for both the psychologist and the crisis manager to be clear on what is expected of the individual psychologist. For example, it would be impossible for the same psychologist to provide direct service to the staff and consultation to the hostage negotiation team. Such a situation could place conflicting demands on the psychologist and lead to ethical dilemmas and/or violations. To address this situation, there may be a need for several psychologists. This will necessitate co-ordination of activities among the psychologists.

In prolonged incidents, one of the most important roles of psychology is to ensure that staff are provided with basic services. These include, but are not restricted to:

• bathroom facilities;
• running water for washing;
• healthy food ^{Footnote 15} and beverages; ^{Footnote 16}
• shelter from the weather, if necessary;
• warm, dry clothing; ^{Footnote 17}
• if possible, a telephone so staff can communicate with their loved ones;
• rest area for staff ^{Footnote 18} (Hazzan, 1993); and
• protection from the media. ^{Footnote 19}

The nature of correctional work often dictates police involvement following an incident. This frequently means that staff must remain on the scene hours after the event has ended, while the police conduct their investigation. The provision of the on-site services described above is extremely important under such circumstances. Waiting causes additional stress. Officers are often "high" on adrenaline and there is little or no opportunity for them to expend this energy. People will become irritable and anxious.

It is important to inform them of this potential and normalize their reactions. Additionally, individuals will need to be monitored while they wait so that those having difficulties can be identified and offered support. Recommendations can be made to the crisis manager and/or the police regarding who should be interviewed first. This will allow those experiencing the most difficulty, ^{Footnote 20} or having special needs, to leave quickly. ^{Footnote 21} Psychological support on the scene is first-aid in nature. It focuses on providing an opportunity for personnel to express their feelings and reactions, to have their experiences validated, and to be reassured that their reactions are normal and expected. It is a time to ask what help is needed ^{Footnote 22} and to provide assistance if possible.

This is not the time to provide counselling or therapy for other problems. The intervention technique is psychoeducational and designed to facilitate staff functioning.

Personnel experiencing critical incident stress are tired, emotionally exposed, their personal resources spent and psychological defenses down. They are vulnerable to revealing information about their personal lives that they might not do under normal conditions. To focus on issues beyond the present critical incident would be inappropriate and of questionable ethics.

In terms of post-incident intervention, the type of assistance provided will be determined by the nature of the event, the impact on staff, and the stage of the event. Post-incident CISM services are provided at the lowest level of intensity necessary.

This is important, as overuse of the higher levels of intervention can lead to reduction in effectiveness (Mitchell & Bray, 1990) and/or a rejection of the entire process. ^{Footnote 23}

The decision regarding the type of intervention needed is a clinical decision made at the time of the incident, and is based on the psychologist's assessment of the particular situation.

The following provide examples of the types of intervention and their respective level of intrusiveness:

• least intrusive — psychological demobilization, "check-in" contact or phone call;
• moderate — defusing; and
• highest — debriefing.

The demobilization, used mainly for prolonged or large scale events, occurs immediately following the incident, before staff go home.

The demobilization is used to: recognize the efforts of staff; identify the more commonly reported stress reactions; normalize stress reactions; ^{Footnote 24} provide information on the stress management techniques to be used over the next few days; inform staff about any follow-up services; ^{Footnote 25} and provide staff with an opportunity to speak with psychological support personnel if they wish.

All on-site staff, including senior personnel ^{Footnote 26} should be encouraged to attend. The demobilization is a brief 15- to 20-minute session.

However, keep in mind that following an incident, personnel are often tired, hungry and their emotions are numb. Many of them have been operating on ''automatic pilot" and it is unlikely they will remember what has been said.

The provision of a handout ^{Footnote 27} with information about common stress reactions, basic stress management techniques and contact phone numbers will be an important reference later, when they begin to have a reaction. ^{Footnote 28}

The check-in is a brief and discreet contact at the work site or via phone (Rosine, 1992a). This procedure may be used as the only intervention or as a follow up to any of the more formal interventions.

It is used as a sole contact when stress reactions are mild. The check-in should occur as quickly as possible ^{Footnote 29} following the incident, and provide standard information to normalize reactions, inform about stress and its management, and provide contact name(s) and number(s) should additional assistance be needed.

The defusing can be done on an individual or group basis, and is used when personnel are experiencing moderate stress reactions or when it is unclear if a debriefing is necessary. The defusing should occur as close in time as possible within the 24 hours following the incident or, in some cases, the same day as the incident. ^{Footnote 30}The time lag is to allow physically and emotional drained responders an opportunity to eat, rest and replenish their personal resources. The underlying assumption is that rapid intervention lessens the impact of the event on the individual.

Defusings last from 45 minutes to an hour and should be conducted in a quiet place, free of interruptions. Personnel must be relieved of their duties for the duration of the session. A defusing is not an operational critique nor an organization bashing session. It is a psychological process designed to provide the opportunity for emotional venting.

The format of the defusing involves setting the parameters of the session, facilitating ventilation, validating reactions and feelings, normalizing the experience, providing information on common stress reactions and basic management techniques, and providing contacts for follow-up support if needed. Again, it is useful to provide a summary handout ^{Footnote 31} of the information provided.

The critical incident stress debriefing (CISD) is used for incidents that have the potential to cause severe stress reactions. The debriefing is a structured psychoeducational process, conducted in a group format and designed to mitigate stress reactions. It is not used to debrief operational issues or to evaluate the organization.

The types of situations that are likely to warrant a psychological debriefing include:

• a number of staff ^{Footnote 32}are reporting severe stress reactions;
• personnel are demonstrating significant behavioral change and diminished coping;
• significant stress reactions are continuing after a group defusing;
• distress symptoms continue beyond three weeks;
• personnel had a strong relationship with a victim; ^{Footnote 33}
• the hostage taking of a staff member;
• the potential of having to shoot an offender; ^{Footnote 34}
• serious injury to a staff member or a line-of duty death; ^{Footnote 35} and
• observing a serious event but being unable to respond quickly because of physical barriers and/or security procedures.

Debriefings are best held within 24 to 48 hours of the incident. However, there is a decreasing window of opportunity that closes by six or eight weeks post-incident. The longer the delay post- incident, the greater the likelihood of the development of post-event symptoms and difficulties.

The debriefing lasts from two to four hours, depending on the group size. The maximum optimum group size for debriefings with correctional personnel should be about 25 participants. Personnel must be freed up from all responsibilities during the debriefing. Where possible, the debriefing should be held off site in a quiet, comfortable setting.

Only those individuals involved in the incident are debriefed and professional staff involved in the incident do not conduct the debriefings but are part of those requiring a debriefing. ^{Footnote 36} Groups sharing a common experience, regardless of rank or function, are debriefed together.

The focus of the debriefing is the current critical incident. It is not appropriate to allow the focus to shift to historical events. Should personnel need to deal with a prior event, another time and format should be identified to address the issue. Allowing the focus to move from the current incident can create serious problems and/or diminish the effectiveness of the debriefing process. ^{Footnote 37}

Debriefings are conducted by a four-member team ^{Footnote 38}consisting of one or two mental health professionals and two or three trained peers. ^{Footnote 39} All debriefings are led by a team leader who is a CISD trained mental health professional.

The debriefing process has seven stages:

1. Introduction: During the introductory phase, the rules of the CISD process are clarified, group members are encouraged to participate, participant confidentiality is emphasized, and limits of confidentiality ^{Footnote 40} are defined. Participants are cautioned to speak only of their own experiences.
2. Fact phase: Group members are asked to identify themselves and to share information about what they saw, heard, and did during the incident.
3. Thought phase: Participants identify their cognitive reactions to the most stressful aspects of the incident.
4. Reaction phase: During this stage, members describe their emotional reactions at the time of the event and express their current feelings.
5. Symptom phase: Participants are asked about any physical or psychological symptoms they experienced — both at the time of the incident and subsequently.
6. Teaching phase: During this phase, the group leader teaches about the stress response syndrome, its symptoms, and specific coping and prevention strategies. The goal is to normalize the feelings and experiences related to the critical incident.
7. Re-entry phase: The re-entry stage allows participants a final opportunity to deal with any unanswered questions. Members are asked to reaffirm their commitment to confidentiality. Information on how to contact follow-up resources is provided and a summary handout can be given.

For detailed descriptions of the debriefing process see Mitchell and Bray (1990), and Hazzan (1993).

Following the debriefing session, it is important for team members to be available to participants who may have been reluctant to ask questions in the large group but want to do so individually. Provision of appropriate refreshments ^{Footnote 41} after the debriefing is one method of providing an informal setting for this type of contact with the team.

Following the completion of the CISD intervention, the CISD team will need an opportunity to debrief itself. The team debriefing should occur immediately following the CISD in a quiet setting where they will not be interrupted.

The CISD process is an effective strategy where intervenors often see immediate change in the participants. This is extremely gratifying for the intervenors. The CISM process is also very intense and emotionally demanding, requiring that the intervenor be extremely focused and "up." It is important for team members to have the opportunity to discuss what happened, how they are feeling about the intervention, and any concerns they may have. This will allow them to "come down," to ventilate their feelings, and to check one another to ensure that no team member has been vicariously victimized. Peers may require reassurance regarding their performance, particularly if they are new members.

The team debriefing is an informal session that involves only the CISD team members and generally takes 30 to 45 minutes. When the team has "debriefed" and "come down," members may feel physically and/or emotionally drained. For situations where team members must drive a long distance to return home, this emotional and physical tiredness will be an important consideration when planning the timing of the return trip.

In some situations, the CISD team may be vicariously affected by the experience of the personnel they were debriefing. The type of incident or the reactions of the participants may serve to overwhelm that resources of the team members. In such cases, it will be necessary to have another mental health team member from the larger CISM team ^{Footnote 42} intervene with the smaller CISD team. Intervention with the CISD team members will use the same CISM techniques discussed above.

There are a number of circumstance where both short- and long-term follow-up services are needed after a critical incident. These follow-up services will vary depending on the needs of the personnel.

Follow-up is necessary on the anniversary dates of a critical incident (e.g., 1 month, 1 year) or when other stimuli occur that have the potential to trigger the critical incident stress response (e.g., a family death or another critical incident within a short time).

Following a critical incident intervention, there may be individuals who require additional individual psychological support, either on a crisis or long-term basis. This will require referral to community services. ^{Footnote 43} It is important that the psychologist identify appropriate community services. This is difficult as there is often a limited number of professionals who have an understanding of critical incident stress and its treatment. The following are suggested as guidelines for selecting community resources professionals:

• the clinician needs to have training in the treatment of critical incident stress and PTSD;
• the clinician should understand that individuals experiencing critical incident stress are demonstrating normal reactions to abnormal events ;
• medication is a short term measure (e.g., two weeks) to be used only when symptoms are severe enough to interfere with psychological treatments (Everly, 1989); and
• the clinician should understand that feelings of vulnerability and loss of control are features of traumatic stress, and the goal is to help the individual regain control as quickly as possible.

Personnel should be encouraged to return to work as soon as they are able. Long- term sick leave immediately following an incident does not appear to be in the individual's best interest. This does not mean that special leave should not be granted, but rather that it be done on the basis of assessed need and be an intrinsic part of an overall prevention or treatment strategy. ^{Footnote 44} The at-risk person should provide input into the process, allowing the person as much decision making as possible.

As a cautionary note, current clinical wisdom suggests that when dealing with critical incident stress in public safety personnel, the outcome may not be "for better or for neutral." It appears that when personnel exposed to critical incidents are treated as "victims" rather than "normal" individuals having normal reactions to abnormal events, they may assume a victim role which will seriously delay or impede recovery.

Appearances at inquests or court proceedings are highly stressful events and the mere thought of having to appear at one can cause significant distress. These proceedings also have the potential to trigger the critical incident stress reactions that occurred at the time of the event.

An important function of the psychologist prior to any court related proceedings is to ensure that the impact of bureaucratic stressors are reduced. It will be necessary to identify these stressors for management so that the appropriate procedures can be put into place. Once the list of witnesses has been established, the following efforts will significantly lessen witness stress:

1. Ensure that dear directions are given to staff regarding where and when they are to appear (include a map).
2. For local witnesses, ensure that parking is available. For out-of-town witnesses, ensure that travel and hotel arrangements are looked after.
3. Locate accommodation near the court setting or ensure that transportation is available.
4. When a single parent has to appear at an out-of-town venue, ensure that their child care needs are not a problem. This is particularly important as court proceedings can extend much beyond expected time frames. A witness may have to wait several days beyond the scheduled appearance - an extremely stressful experience for a parent who is worried about child care resources. Out-of-town situations may also create a financial burden for a single parent.
5. Ensure that witnesses are informed that CSC will provide appropriate leave for them to attend the proceedings and costs associated with court or inquest related appearances are covered by the organization.
6. In high profile or sensitive cases, meet with the case-appointed CSC lawyer and coordinate orientation and/or educational session. ^{Footnote 45} several weeks prior to the actual trial or inquest.
7. During an inquest or trial, look after mid-day meal arrangements.
8. Ensure that all witnesses know that support is available before, during, and after the proceedings.

As with on-scene incident support, psychological support at the inquest or trial is first-aid in nature. The goal is to be available to witnesses, to coach them prior to their taking the stand,. ^{Footnote 46} and to reassure them. After they have given testimony, they will need to ventilate their feelings, be reassured regarding their performance, and be told that their reactions are normal and expected. This is also the time to ask what people need and to provide the assistance if possible. Be prepared to deal with some individuals who have been highly medicated by their physician and who may be coping very poorly. One of your most important functions on-scene is to protect staff from the media.

As quickly as possible following the inquest or court proceedings, assess how staff are functioning. For personnel experiencing difficulty, intervene at the least intrusive level. The formal debriefing process is not usually appropriate post trial/inquest. However, in high-profile cases or situations where there has been a good deal of negative media coverage, a group defusing would be an appropriate intervention.

As mentioned elsewhere in this paper, CISM teams consist of mental health professionals and peer support personnel. Peers play an important role in the delivery of CISM services and the mental health professionals will need to be able to rely on their judgment and skills. Similarly, peers look to the mental health professionals for leadership and direction. They depend on mental health professionals to identify their training needs, monitor their skills levels, and provide support and feedback on their development.

Not all persons are suited to do CISM work. Members need to be team players and need to be able to work within an established framework. They need to have good communication and problem-solving skills, be empathetic and concerned about others, and need to have worked through any trauma in their background. Most importantly, both the peers and the mental health professionals must be trusted by the personnel to whom they are to provide service.

CISM training. ^{Footnote 47} requires the involvement of both mental health professionals and peers to facilitate the development of the team. Training needs to be an ongoing process that maintains member skills and commitment. ^{Footnote 48} Participants need to be prepared to give of their own time, to respond on short notice to critical incidents, and to be available to others at inopportune times.

Provision of CISM services requires specialized training in the area of general stress and its management, traumatic stress and PTSD, disaster psychology and group dynamics (Mitchell & Bray, 1990). Mental health professionals should have formal training involving workshops and seminars provided by recognized specialists in the area of critical incident stress management, or have supervised "hands on" field training. Inappropriate interventions or lack of intervention can turn otherwise psychologically healthy individuals into psychologically impaired individuals.

The following sources are recommended to further augment your skills in working with correctional personnel:

• Hazzan, B. (1993). Critical Incident Stress in the Correctional Service. Unpublished monograph.
• Mitchell, J.T. & Resnik. (1981). Emergency Response to Crisis. London: Prentice-Hall.
• Mitchell, J.T. & G. Bray. (1990). Emergency Services Stress. Englewood Cliffs, N.J.: Prentice-Hall.
• Mitchell, J.T. (ST.. G.S. Everly. (1994). Human Elements Training For Emergency Services, Public Safety and Disaster Personnel: An Instructional Guide to Teaching Debriefing, Crisis Intervention and Stress Management Programs. Ellicott City, M.D.: Chevron.

Chapter 16 Appendix

Andreasen, N.C. (1985). "Posttraumatic stress disorder," in H.H. Kaplan & B.J. Sadock (Eds.), Comprehensive Textbook of Psychiatry IV: Volume 1. Baltimore: Williams & Wilkins.

Brodsky, C.M. (1982). "Work stress in correctional institutions," Journal of Prison and Jail Health, 2, 74-102.

Card, J.J. (1987). "Epidemiology of PTSD in a national cohort of vietnam veterans," Journal of Clinical Psychology, 43(1), 6-17.

Cheek, F.E. (1983). "Correctional officer stress," Corrections Today, 45, 14-18.

Cheek, F.E. (1984). Stress Management for Correctional Officers and Their Families. Maryland: American Correctional Association.

Cheek, F.E. & M.D.S. Miller. (1983). "The experience of stress for correctional officers: A double-bind theory of correctional stress," Journal of Criminal Justice, 11, 105-120

Corneil, W. (1990). Traumatic Stress as an Occupational Risk for Firefighters. Unpublished manuscript, Division of Behavioral Science, School of Public Health and Hygiene, Johns Hopkins University, Baltimore.

Comeil, D.W. (1993). Prevalence of Post Traumatic Stress Disorders in a Metropolitan Fire Department. Unpublished Doctoral Dissertation, The Johns Hopkins University, Baltimore, Maryland.

Cullen, ET., Link, B.G., Wolfe, N.T. & J. Frank. (1985). "The social dimensions of correctional officer stress," Justice Quarterly, 2(4), 505- 533.

Davidson, A.D. (1979). "Air disaster: Coping with stress," Police Stress, 2, 20-22.

Durham, T.W., McCammon, S.L. & E.J. Allison. (1985). "The psychological impact of disaster on rescue personnel," Annals of Emergency Medicine, 14(7), 664-668.

Everly, G.S. (1989). A Clinical Guide to the Treatment of the Human Stress Response. New York: Plenum Press.

Everly, G.S. (1991). Latest advances in treating FTSD: A neurocognitive therapy, advanced training in critical incident stress and post-trauma syndromes, Workshop, Sarnia, Ontario.

Folkman, S. & R.S. Lazarus. (1988). "Coping as a mediator of emotion," Journal of Personality and Social Psychology, 54(3), 466-475.

Folkman, S., Lazarus, RS., Dunkel-Schetter, C., DeLongis, A. 1SL R.J. Gruen. (1986). "Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes," Journal of Personality and Social Psychology, 50(5), 992-1003

Folkman, S., Lazarus, R.S., Gruen, R.J. & A. DeLongis. (1986). "Appraisal, coping, health status, and psychological symptoms," Journal of Personality and Social Psychology, 50(3), 571-579.

Foy, D.W., Sipprelle, R.C., Rueger, D.B. & E.M. Carroll. (1984). "Etiology of posttraumatic stress disorder in Vietnam veterans: Analysis of premilitary, military, and combat exposure influences," Journal of Consulting and Clinical Psychology, 52(1), 79-87.

Green, B.L., Grace, M.C. & G.C. Gleser. (1985). "Identifying survivors at risk: Long-term impairment following the Beverly Hills Supper Club fire," Journal of Consulting and Clinical Psychology, 53, 672-678.

Green, B.L., Wilson, J.P. & J.D. Lindy. (1985). "Conceptualizing posttraumatic stress disorder: A psychosocial framework," in C.R. Figley (Ed.), Trauma and Its Wake (Vol.1): The Study and Treatment of Post-Traumatic Stress Disorder (pp. 53-72). New York: Brunner/Mazel.

Hartsough, D.M. (1988). "Traumatic stress as an area of research," Journal of Traumatic Stress, 1(2), 145-154.

Hazzan, B. (1993). Critical Incident Stress in the Correctional Service. Unpublished monograph.

Herman, J.L. (1992). Trauma and Recovery. New York: BasicBooks.

Hughes, G.V. (1990). Personal Disposition, Coping, and Adaptation in Correctional Workers. Unpublished Doctoral Dissertation, Queen's University, Kingston.

Janoff-Bulman, R. (1992). Shattered Assumptions. Toronto: The Free Press.

Keane, T.M., Wolfe, J. & K.L. Taylor. (1987). "Post-traumatic stress disorder: Evidence for diagnostic validity and methods of psychological assessment," Journal of Clinical Psychology, 43(1), 32-43.

Lasky, G.L., Gordon, B.C. & D.J. Srebalus. (1986). "Occupational stressors among federal correctional officers working in different security levels," Criminal Justice and Behavior, 13(3), 317-327.

Loo, R. (1986). "Post-shooting stress reactions among police officers," Journal of Human Stress, Spring, 27-31.

Maddi, S.R., Bartone, ET. & M.C. Puccetti. (1987). "Stressful events are indeed a factor in physical illness: Reply to Schroeder and Costa (1981 )," Journal of Personality and Social Psychology, 52(4), 833-843.

Martin, C.A., McKean, H.E. & L.J. Veltkamp. (1986). "Posttraumatic stress disorder in police and working with victims: A pilot study," Journal of Police Science and Administration, 14(2), 98-101.

McCann, I.L. & L.A. Pearlman. (1990). "Vicarious traumatization: A framework for understanding the psychological effects of worlcing with victims," Journal of Traumatic Stress, 3(1), 131-149.

Meichenbaum, D. (1985). Stress Inoculation Training. New York: Pergamon Press.

Mitchell, J.T. (1982). "Recovery from rescue," Response, Fall, 7-10.

Mitchell, J.T. (1984). "High tension: Keeping stress under control," Firehouse, September, 86-89.

Mitchell, J.T. (1985). "Healing the helper," in B. Green (Ed.), Role Stressors and Supports for Emergency Workers. Washington, DC: Center for Mental Health Studies of Emergencies, U.S. Department of Health and Human Services.

Mitchell, J.T. (1987). "By their own hand," Chief Fire Executive, January/February, 49-72.

Mitchell, J.T. & G. Bray. (1990). Emergency Services Stress. Englewood Cliffs, N.J.: Prentice-Hall.

Mitchell, J.T. & H.LP. Resnik. (1981). Emergency Response To Crisis. London: Prentice-Hall International.

Poole, E.D. & R.M. Regoli. (1980a). "Work relations and cynicism among prison guards," Criminology, 7, 303-314.

Poole, E.D. & R.M. Regoli. (1980b). "Role stress, custody orientation, and disciplinary actions: A study of prison guards," Criminology, 18(2), 215-226.

Spitzer, W.J. & L. Burke. (1993). "A critical incident stress debriefing program for hospital-based health care personnel," Health and Social Work, 18(2), 149-156.

Raphael, B. (1984). "Who helps the helper? The effects of disaster on the rescue worker," Omega, 14(1), 18-22.

Reich, J.H. (1990). "Personality disorders and post-traumatic stress disorder," in M.E. Wolf :Sx. A.D. Mosnaim (Eds.), Post-traumatic Stress Disorder: Etiology, Phenomenology, and Treatment (pp. 65-79). Washington, DC: Arnerican Psychiatric Press.

Rosine, L (1992a). "Exposure to critical incidents: What are the effects on Canadian correctional officers?," Forum on Correctional Research, 4(1), 31-36.

Rosine, L (1992b). The Impact on Correctional Officers of Exposure to Critical Incidents. Unpublished Doctoral Dissertation, Carleton University, Ottawa.

Ross, R.R. (1981). Prison Guard/Correctional Officer: The Use and Abuse of the Human Resources of Prisons. Toronto: Butterworths.

Solomon, R.M. (1988). "Post-shooting trauma," The Police Chief, October, 40-44.

Solomon, Z. & H. Flum. (1988). "Life events, combat stress reaction and post-traumatic stress disorder," Social Science Medicine, 26(3), 319-325.

Solomon, Z., Mikulincer, M. & S.E. Hobfoll. (1986). "Effects of social support and battle intensity on loneliness and breakdown during combat," Journal of Personality and Social Psychology, 51(6), 1269-1276.

Solomon, Z., Mikulincer, M. & S.E. Hobfoll. (1987). "Objective versus subjective measurement of stress and social support: Combatrelated reactions," Journal of Consulting and Clinical Psychology, 55(4), 577-583.

Sparr, LE (1990). "Legal aspects of post-traumatic stress disorder: Uses and abuses," in M.E. Wolf & A.D. Mosnaim (Eds.), Posttraumatic Stress Disorder: Etiology, Phenomenology, and Treatment (pp. 238-269). Washington: American Psychiatric Press.

Talbot, A. (1990). "The importance of parallel process in debriefing crisis counsellors," Journal of Traumatic Stress, 3(2), 265-278.

Van den Bergh, N. (1992). "Using critical incident stress debriefing to mediate organizational crisis, change and loss," Employee Assistance Quarterly, 8(2), 35-55.

Van Goethem, R. (1986). What About the Proxy Victims in a Disaster? The Psychological Implication for Incident, Organizational and Occupational Stress on Rescue Response Personnel. Disaster Social Services, Alberta Public Safety Services, DSS-20.

Veronen, U. & D.G. Kilpatrick. (1980). "Self-reported fears of rape victims," Behavior Modification, 4(3), 383-396.

Vitaliano, P.P., Maiuro, RD., Bolton, P.A. & G.C. Armsden. (1987). "A psychoepidemiologic approach to the study of disaster," Journal of Community Psychology, 15, 99-122.

Walker, G. (1990). "Crisis-care in critical incident debriefing," Death Studies, 14(2), 121-133.

Wilkinson, C.B. (1983). "Aftermath of a disaster: The collapse of the Hyatt Regency Hotel Skywall," American Journal of Psychiatry, 140, 1134-1139.

Wolf, J. & T.M. Keane. (1990). "Diagnostic validity of post-traumatic stress disorder," in M.E. Wolf (Si. A.D. Mosnaim (Eds.). Posttraumatic Stress Disorder: Etiology, Phenomenology, and Treatment (pp. 49-63). Washington, DC: American Psychiatric Press.