Career Perspectives
Care After Chaos: Use of Critical Incident Stress Debriefing After Traumatic Workplace
Events
Susan Bendersky Sacks, MSN, RN, CS, Paul T. Clements, PhD, RN, CS, and
Theresa Fay-Hillier, MSN, RN, CS
The increase in workplace violence has heightened pub-
lic awareness of the unexpected and spawned a new
sense of insecurity about when and where the next trau-
matic event will occur. Workplace safety is driving orga-
nizations and communities to adopt drastic preventive
measures, early detection, and psychological post-
trauma interventions. Critical incident stress debriefing
(CISD) mitigates traumatic stress, accelerates the recov-
ery process, and potentially restores employees to nor-
malcy following the devastation caused by traumatic
event. CISD assists individuals, work groups, and orga-
nizations, enriches the community, and provides an al-
ternative career path for the advanced practice nurse
(APN).
Critical Incident Stress Management and the
Advanced Practice Nurse
With specialized training in critical incident stress
management (CISM), APNs can adapt their psychother-
apeutic skills for application to this nontraditional role
within the workplace setting. A career in CISM is a natu-
ral extension of advanced practice nursing. By virtue of
the nursing paradigm, APNs can skillfully assess and
treat responses to critical incidents and successfully re-
store individuals and group systems to equilibrium.
With CISM training and certification through the Inter-
national Critical Incident Stress Foundation (ICISF),
APNs can make outstanding contributions in the pre-
vention and mitigation of traumatic stress.
Qualifications
Eligibility as a CISM Crisis Response Provider begins
with masters preparation in a mental health field and a
minimum of 5 years experience in crisis intervention.
Given the nature of the role of the advanced practice
psychiatric nurse, these requirements typically are at-
tained without difficulty. Next, certification in Basic
Group CISM is required through the ICISF. Information
regarding course offerings, locations, and scheduling can
be accessed at www.icisf.org. Certification is awarded
Perspectives in Psychiatric Care Vol. 37, No. 4, October-December, 2001
after attending a 2-day course in Basic Group CISM.
Documentation is not required to apply, and there are no
written or oral examinations. On certification, a masters-
prepared nurse becomes qualified as a CISM-certified
Mental Health Professional/Crisis Response Provider.
No additional specialized training is required.
Referral Sources
Following certification, nurses must approach referral
sources for potential CISD activity. One way to obtain
these referrals is to contact behavioral managed care
providers from national listings. Another is to identify
local CISM teams and either network to gain potential
referral sources or join the existing team as a crisis re-
sponse provider.
Requests for CISM work may be sporadic, largely de-
pending on the geographic area served and the number
of insured lives covered by a given behavioral managed
care provider. The potential exists for part-time work
with compensation comparable to private practice rates.
Twenty-four-hour availability is mandatory for inde-
pendent crisis response providers. The acute and trau-
matic nature of events resulting in request for CISD in-
tervention means referrals usually are generated within
4 to 12 hours following a critical event. Flexibility is cru-
cial for each assignment, because work requests may ex-
tend several hours beyond the original agreement. This
typically is in response to an on-site identified need for
additional psychoeducation, consultation, referrals re-
lated to the traumatic event, and follow-up. Ultimately,
providers are under no obligation to accept CISM re-
quests and may decline a specific request for CISM
based on availability of the crisis response provider. This
flexibility of scheduling is often an alluring facet of this
genre of work, as it can be done in concert with other
employment obligations.
Professional Burnout
Depending on the number and nature of CISD refer-
rals that a Crisis Care Provider accepts, the potential for
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Career Perspectives
professional burnout is real, stemming from the scope
and severity of employee traumatization, unpredictable
schedules, and extensive hours. When traumatic events
occur, the crisis response provider may be pelted with a
wide variety of employee and management reactions
and emotions. Although the crisis response provider is
not directly affected by the traumatic event, there is
clearly the possibility for vicarious traumatization when
she or he is flooded with the sometimes horrific details
about an event and its aftermath. The intrapsychic pres-
sure that can be exerted by the climate of anxiety and
fear require that the crisis response provider be able to
assess, interpret, and integrate the large amounts of
highly charged incoming information without becoming
overwhelmed and reactive.
Burnout can be minimized by interspersing CISD
with noncrisis CISM work. Arguably the healthiest
lifestyle among crisis response providers may include
pre- and postincident education, outpatient private prac-
tice, and supervision from a CISM-certified crisis re-
sponse provider. Burnout prevention may be maximized
by working within a provider network that includes a
qualified CISM team. This can facilitate ease of access to
peer supervision and subsequent individual processing
and debriefing for the crisis response provider.
CISM Teams
Crisis response providers often join an established
CISM team as an alternative to independent practice.
Traditional CISM teams offer crisis intervention services
spanning the precrisis, acute crisis, and postcrisis phases.
Seven core services are offered: preincident preparation;
education, demobilization, and group informational
briefing; defusing; CISD; individual and family interven-
tion; follow-up; and referral services (Everly & Mitchell,
2000). CISM teams comprise professional support per-
sonnel including masters-prepared mental health pro-
fessionals and clergy. Peer support personnel (e.g.,
nurses, physicians, police officers, firefighters,
paramedics, disaster workers) may be involved as well
(Mitchell & Everly, 1998). There are more than 400 CISM
134
crisis response teams throughout the world (Mitchell &
Everly, 1997). These teams are affiliated with the Interna-
tional Critical Incident Stress Foundation, which can be
contacted through their Web site.
Critical Incident Stress Debriefing
Critical incident stress debriefing is a specific model of
psychological group debriefing developed by Dr. Jeffrey
T. Mitchell in the late 1970s. It is a standardized, seven-
stage crisis-intervention process that contains both psy-
chological and educational elements, and is based on cri-
sis-intervention theory and educational-intervention
theory (Mitchell & Everly, 1998). CISD is one formal in-
tervention within the broader category of (CISM), which
is a collection of comprehensive, multicomponent crisis-
response technologies. The objectives of CISD are to pre-
vent or reduce the intensity and chronicity of trauma-re-
lated symptoms, facilitate psychological closure, and
quickly restore groups of individuals to normalcy (Ca-
plan, 1964; Everly & Mitchell, 1999). Although CISD has
therapeutic qualities, it is neither psychotherapy nor in-
tended to replace psychotherapy.
CISD was created for high-risk occupational groups
such as emergency, rescue, and disaster teams. As erup-
tions of violence have been spreading throughout the
country, however, CISD is being offered to the general
population. CISD has been used successfully in schools,
hospitals, courtrooms, airports, banks, and other busi-
ness and industrial settings, providing benefits for the in-
dividual employee as well as the overall organization
(Mitchell & Everly, 1997). Precipitating incidents have in-
cluded violence, threats of violence, sudden death, occu-
pational accidents, and organizational downsizing.
Employee Reactions
COPE Consultants is an independent, nurse-directed
CISM team that provides crisis intervention services for
the northeastern private sector after traumatic workplace
events that include bank robberies, corporate downsizing,
and sudden employee death from illness or occupational
Perspectives in Psychiatric Care Vol. 37, No. 4, October-December, 2001
injury. The following is a compilation of typical em-
ployee reactions from our on-site CISD interventions.
Bank and pharmacy robberies. Employees relate a
harrowing brush with death experience with sudden
subsequent awareness of exposure, vulnerability, and
violation. Employees often fear repeat holdups from
the nonapprehended suspects. Most customers are
viewed with suspicion and as potential assailants; trepi-
dation often impedes a return to work. Employees
often are tormented by persistent and intrusive images
of the traumatic event, compounded by the realization
that someone could have been murdered during the
robbery.
Workplace violence: Murder, bomb threats, vandal-
ism, and suicide. Employees may return to work dazed,
shaken, and incensed. Hypervigilance and fear of copy-
cat attacks are common. Anger often is directed at col-
leagues and supervisors, with demands for immediate
remedies for potentially hazardous work conditions and
improvement on existing policies. Painful feelings of am-
bivalence often are experienced when the assailant and
victim were both well liked. Trauma responses may be
heightened when employees witness the event or after-
math (e.g., a dead body, blood, racial epithets or graffiti,
property damage) firsthand.
Employee death from illness. Disbelief and shock
tend to overwhelm employees even when the condition
of the deceased employee was known. Feelings of regret
surface from the sense of not having done enough, and
this often results in fervent offers to plan memorials.
Anxiety surrounds the personal invasion of the de-
ceased employees office and premature replacement of
his position. Employees assess and discuss the overall
response from management and interpret the perceived
level of empathy, extrapolating for themselves an indi-
cation of how their own death might be handled in the
future.
Corporate downsizing. Shock and demoralization
overwhelm employees following job terminations that
arise from budget constraints and organizational restruc-
turing. Employee reactions vary, depending greatly on
their own personal financial predicaments and how the
Perspectives in Psychiatric Care Vol. 37, No. 4, October-December, 2001
downsizing process has been facilitated. When the pro-
cess is handled mechanically, impersonally, or abruptly,
employees may voice feelings of betrayal, anger, confu-
sion, and panic. When only a small segment of the work
population is laid off, those employees often experience
feelings of inadequacy, being singled out, humiliated,
and isolated (Noer, 1997). This may be particularly true
when the employee is terminated not as a result of poor
performance but due to position elimination.
Summary
CISD is a specific model of group debriefing, which
can be used to accelerate recovery from traumatic work-
place events. The impact of critical incidents may be de-
bilitatingfrom recurrent intrusive images, persistent
fear, displaced anger, guilt, and isolation. CISD can ac-
complish psychological closure, prevention, and mitiga-
tion of traumatic stress, and promote return to normalcy,
benefiting the individual, organization, and the commu-
nity at large.
The field of critical incident stress management is
open to advanced practice nurses who seek to apply
their crisis-intervention expertise within a nontraditional
role and workplace setting. With specialized training, the
advanced practice nurse may pursue a career as a crisis-
response provider, working independently or with an
established CISM team. Practice requirements include
CISM certification, along with the acquisition of a refer-
ral source. The prevention and mitigation of traumatic
stress can yield a rewarding career in CISM.
Susan Bendersky Sacks, MSN, RN, CS
Psychotherapist in private practice
Lecturer, University of Pennsylvania
Paul T. Clements, PhD, RN, CS
Assistant Professor, College of Nursing
University of New Mexico
Theresa Fay-Hillier, MSN, RN, CS
Lecturer, University of Pennsylvania
Author contact: copeconsultants@hotmail.com, with a copy to
the Editor: mary77@concentric.net
135
Career Perspectives
References
Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic
Books.
Everly, G.S., Jr., & Mitchell, J.T. (1999). Critical incident stress manage -
ment-CISMA new era and standard of care in crisis intervention (2nd
ed.). Ellicott City, MD: Chevron Publishing.
Everly, G.S., Jr., & Mitchell, J.T. (2000). Critical incident stress manage -
ment: Advance group crisis interventions. A workbook. Ellicott City,
MD: International Critical Incident Stress Foundation.
Mitchell, J.T., & Everly, G.S., Jr. (1997). Critical incident stress debriefing
(CISD): An operations manual for the prevention of traumatic stress
among emergency services and disaster workers (2nd ed.). Ellicott City,
MD: Chevron Publishing.
Mitchell, J.T., & Everly, G.S., Jr. (1998). Critical incident stress manage -
ment: The basic course workbook (2nd ed.). Ellicott City, MD: Interna-
tional Critical Incident Stress Foundation.
Noer, D. (1997). Breaking free. A prescription for personal and organizational
change. San Francisco: Jossey-Bass.
Whitehorn, D., & Nowlan, M. (1997). Towards an aggression-free
health care environment. Canadian Nurse, 93, 2426.
Search terms: Crisis intervention, critical incidents, work -
place violence
Working With Adult Homicide Survivors, Part II
(continued from page 124)
Redmond, L.M. (1989). Surviving: When someone you love was murdered.
Clearwater, FL: Psychological Consultation and Educational Ser-
vices, Inc.
Shalev, A.Y. (2000). Measuring outcome in posttraumatic stress disor-
der. Journal of Clinical Psychiatry, 61(Suppl. 5), 3339.
Shalev, A.Y., Foa, E.B., Kessler, R.C., McFarlane, A.C., Lecrubier, Y.,
Ballenger, J.C., & Davidson, J.R.T. (2000). Discussion: Measuring
outcomes in posttraumatic stress disorder. Journal of Clinical Psychia -
try, 61(Suppl. 5), 4042.
Spungen, D. (1998). Homicide: The hidden victims. Thousand Oaks, CA: Sage.
Tedeschi, R.G., & Calhoun, R.G. (1995). Trauma and transformation:
Growing in the aftermath of suffering. Thousand Oaks, CA: Sage.
Tedeschi, R.G., & Calhoun, R.G. (1996). The posttraumatic growth in-
ventory: Measuring the positive legacy of trauma. Journal of Trau -
matic Stress, 9, 455471.
van der Kolk, B.A. (1987). The role of the group in the origin and reso-
lution of the trauma response. In B.A. van der Kolk (Ed.), Psycholog -
ical trauma (pp. 153171). Washington, DC: American Psychiatric
Press.
van der Kolk, B.A. (1997). The psychobiology of posttraumatic stress
disorder. Journal of Clinical Psychiatry, 58(Suppl. 9), 1624.
136
Survivors of Infamy
The events of September 11, 2001, will live long in the
psyche of those closest to the victims, the rest of the
American people, and many of our friends and support-
ers throughout the world. Mass murder has its own dy-
namics and reactions, which must be addressed in caring
for both survivors and the community at large.
Never have so many people been present to such
events, either as eye witnesses or via real-time media
coverage and frequent replays. The horror of watching
the second plane hit the World Trade Center or of people
falling or jumping to their death engendered feelings of
shock and disbeliefthat what we were watching was
really a new sequel to Die Hard.
The reactions of survivors of those killed will be the same
as for survivors of any murder victim. People described feel-
ings of disbelief and shock, fear and anxiety, anger or rage,
uneasiness, difficulty sleeping and eating, and poor concen-
tration. The shattering of their assumptions brought loss of a
sense of control and fears about present and future safety
fears that are realistic and geared toward survival. Many
people have experienced additional losseshomes, busi-
nesses, jobs, medical insurance. That the deaths were sud-
den, deliberate, unanticipated, and extremely violent may
put large numbers of people at risk for post-traumatic stress
disorder as well as complicated mourning.
We as caregivers must be prepared to help care for the
psychological casualties resulting from these acts of terror-
ism. It is our responsibility to know what our boundaries
are in caring for others, to seek peer support/counseling
to deal with primary and vicarious traumatization, and to
care for each other. We are in a key position to assist those
who have experienced trauma and losses; we must be-
come knowledgeable regarding the synergy between loss
and trauma and the impact on individuals and the com-
munity. Knowledge in CISM will enable us to collaborate
with local and national disaster response agencies.
These evil and criminal acts have left many seriously
traumatized and bereaved people in their wake. As care-
givers, we are called to respond in the aftermath and
must be prepared to use every psychological weapon
available to us to help clients cope with what has already
occurred and to face what may lie ahead.
M. Regina Asaro
Perspectives in Psychiatric Care Vol. 37, No. 4, October-December, 2001