while the first tasks in disaster management are to secure the scene , to triage , and to evacuate victims to definitive care , the disaster plan fails if it stops at the hospital door .
it has been recognized that both disaster victims and workers are at risk for acute and chronic post - traumatic stress disorder ( ptsd ) .
all this has led to attempts to intervene early so as to prevent , or at least minimize , psychological morbidity following traumatic events .
the underlying premise for early intervention is to limit the establishment of maladap - tive and disruptive cognitive or behavioral patterns .
mitchell described , in 1983 , a brief , structured , interventional technique to be used immediately or shortly after a traumatizing event , and coined the term ' critical incident stress debriefing ' ( cisd ) .
a critical incident is one that leads to an unusually powerful stress reaction that overwhelms the person 's ability to adjust emotionally . in 1989 , dyregrov modified and expanded the technique and called it ' psychological debriefing ' .
this was designed to take place within a group setting 4872 hours after a traumatizing event in an attempt to assist participants in cognitively and emotionally processing their experiences .
cisd is now part of a comprehensive spectrum of techniques called critical incident stress management ( cism ) , and may be supplemented by earlier interventions , such as demobilization or defusing , or one - on - one encounters .
cisd is neither psychotherapy nor counseling , but is instead designed to promote emotional health through verbal expression , cathartic ventilation , normalization of reactions , health education , and preparation for possible future reactions .
the debriefing technique consists of reviewing the traumatic experience , encouraging emotional expression and promoting cognitive processing .
all this is carried out in group sessions , facilitated by a mental health professional and a peer of the group but one that was not involved in the event .
the group setting is preferred as a forum for communication as it helps to re - establish order and a sense of safety .
participants are invited to recount their experiences chronologically and to describe the most terrifying aspects .
the facilitators acknowledge the intensity of the experience , but also emphasize the universality of their reactions .
they also describe reactions that the group should expect and teach coping strategies , including the importance of resuming normal activities and the value of continued dialog with friends and family .
reserved for dramatic events , cisd does not focus on work - related complaints because these are the province of an employee assistance plan .
it is part of the systematic approach to cism that includes pre - incident stress education programs , on - scene support , peer support programs , follow up services , and referral procedures .
there is no doubt that working in the emergency services exposes workers to numerous stressors .
critical incidents include deaths in the line of duty , coworkers committing suicide , significant events involving children , incidents involving relatives or knowing the victims , excessive media interest , and disaster or mass casualty events .
one of the most difficult aspects of the emergency services , including disaster work , is the exposure to sudden , violent death , including that of children , and the exposure to dead bodies and body parts .
the risk to personal safety , especially in an age of biohazards , adds to the stressors of service delivery .
these stressors are often cited as reasons for increased rates of divorce , substance abuse , and loss of personnel through attrition .
common signs and symptoms of excessive stress include cognitive , emotional , behavioral and physical aspects , and these are described in table 1 .
common signs and symptoms of excessive stress the notion of ' victim ' , however , is not generally applied to rescue , medical , or support staff associated with disaster medicine .
nevertheless , several studies suggest that personnel involved in disaster medicine , especially those involved with the recovery and identification of human remains , are at particular risk for the development of ptsd .
for instance , a survey of 459 australian firefighters identified that 32% self - reported psychological disturbances 4 months after they combated a disastrous bush conflagration .
after 29 months , 18% reported that recurring imagery continued to interfere with their lives . in a different study ,
nearly one - half of 285 emergency workers surveyed 1 year after two major bus crashes reported stress - related symptoms , and 13% felt they would probably never recover .
a study of 116 us soldiers handling remains from operation desert storm , employing the impact of event scale , identified a significant association of intrusive and avoidance behavior 35 months after their return home that was directly related to the number of bodies handled in a ' dose response ' fashion .
intrusive and avoidance symptoms of ptsd were also present , at a high clinical threshold , among 16% of 54 navy personnel involved in mortuary duties following the 1989 turret explosion on the uss iowa .
during the past two decades , cisd has been successfully used with emergency workers and prehospital providers such as the emergency medical service ( ems ) , police and fire - rescue , as well as with soldiers , prisoners of war , hostages , and disaster workers .
police officers and firefighters receiving as little as a 1.5-hour debriefing within 24 hours of an incident exhibited statistically significant less depression , anger , and stress - related symptoms at 3 months than did nondebriefed subjects .
ems personnel receiving cisd after the 1992 los angeles riots also exhibited significantly less stress than non - debriefed ems staff .
a decrease in impact of event scale scores among rescue workers in hawaii after hurricane iniki in 1992 included both clinical and administrative workers .
eighty - eight percent of 219 emergency department nurses felt that the cisd process was helpful to them after a tragedy .
anxiety scores from 35 british police officers 3 months and 3 years after retrieval and identification of remains from the 1988 piper alpha oil rig disaster were significantly lower in the intervention group compared with controls .
these individuals received cism in the form of pre - event orientation , nightly debriefings , and the pairing of experienced with inexperienced personnel . because they had taken part in an occupational survey prior to the disaster , it was possible to determine that anxiety levels returned to near baseline in the treatment group .
for instance , debriefings may have been performed improperly , they may have been unstructured or delayed , or the outcome measures used were unclear .
outcomes other than ptsd may be important to investigate . using the cage measure of problem drinking , 25% of 106 british servicemen returning from bosnia had scores consistent with alcohol misuse .
at 12 months after a single cisd debriefing , the intervention group had a 6.3% rate of alcohol misuse versus 30.4% for those randomized to the nondebriefing arm .
a 1999 meta - analysis of five studies of the ' mitchell model ' of cisd , incorporating 341 adult subjects , demonstrated a large effect size supporting the power of cisd to mitigate the symptoms of psychological distress .
an infrastructure for cisd should be incorporated into hospital and regional disaster plans , including provisions for volunteer and inhospital workers .
the call volume to new jersey 911 dispatchers increased 66% during 08:00 to 14:00 on the day of the world trade center attack .
unlike the usual , short duration calls reporting an accident , these calls were often from individuals inside the world trade center itself . often long , final conversations from anguished trapped victims asking what to do , these were calls for which the dispatchers were not trained . some of the dispatchers have not yet returned to work 1 month later ( new jersey ems council , personal communication , 2001 ) .
not only are positive effects more probable , but also the chance of inadvertent harm is reduced after cisd .
mistakes in providing cisd as part of a disaster response include failure to have an adequate number of trained mental health professionals , misunderstanding the cism process , not having a cisd team strategy , attempting to turn cisd into psychotherapy , and breaking confidentiality . a peer is always required for emergency services , hospital - based personnel , military , and disaster worker debriefings . finally , it is important to recognize the risks associated with cisd .
adequate ' down time ' between debriefings , and defusings or debriefings for team members , will avoid stress reactions among the helpers of the helpers .
jh is section chief for trauma and surgical critical care at robert wood johnson medical school .
he serves as chairman of the new jersey chapter of the american college of surgeons committee on trauma .
he was actively involved in the 1980 miami ( florida ) riots and numerous hurricanes .
he is founder and medical director for cism team orion , which was activated in support of the wtc recovery .
she is co - director of cism team orion and was active as a group facilitator for police , ems , and national guardsmen after the wtc attack , and as an advisor to the state cism network .
cisd = critical incident stress debriefing ; cism = critical incident stress management ; ems = emergency medical service ; ptsd = post - traumatic stress disorder .
this article , and the series it is part of , is dedicated to the first responders  fire , police and medical personnel  who attended the world trade center disaster of 11 september 2001 .
they did not hesitate to place themselves in harm 's way to rescue the innocent , and without their efforts many more would have perished .
 healthcare and prehospital workers involved in disaster response are susceptible to a variety of stress - related psychological and physical sequelae . 
 critical incident stress management , of which critical incident stress debriefing is a component , can mitigate the response to these stressors . 
 critical incident stress debriefing is a peer - driven , therapist - guided , structured , group intervention designed to accelerate the recovery of personnel . 
 the attack on the world trade center , and the impact it may have on rescue , prehospital , and healthcare workers , should urge us to incorporate critical incident stress management into disaster management plans . 
Introduction
What are critical incident stress debriefing and critical incident stress management?
Do we need CISM?
But does CISM work?
CISM as part of a disaster plan
Competing interests
Abbreviations
Acknowledgement