Foreword

by John Durkin

It is an honor to be invited to write the foreword to a publication that addresses the two stress-interventions that have enhanced my personal and professional life immeasurably. Critical Incident Stress Management (CISM) and Traumatic Incident Reduction (TIR) have each led me to expect, rather than hope for, success in preventing and overcoming the debilitating psychological aftermath of traumatic experience. Each stands on its own as a practical and effective alternative to the isolation, avoidance and rumination of being left alone or being pushed to admit our reactions to a mental-health professional who may judge, label and medicate us.

This publication offers an extensive theoretical account of TIR, with consideration of why (or not) certain therapeutic approaches may be successful, courtesy of Dr. Moore's chapter. Nancy Day takes her experience of TIR into the world of crisis-response and identifies areas where those committed to crisis-intervention can benefit. Jill Boyd, a nurse who has been trained in both CISM and TIR, provides her unique view of how facilitation skills from TIR can improve CISM delivery. Karen Trotter shows how flexibly and confidently crisis-intervention can be applied in an extended and effective fashion through the Green Cross Projects, using examples from major disasters. These contributions explain how the approaches of CISM and TIR can complement and enhance each other.

Critical Incident Stress Management is a comprehensive system of crisis-intervention that employs peersupport for dealing with the aftermath of incidents that can have an overwhelming impact on those exposed to them. A short period of specialized training enables those with an interest in maintaining the mental-health of their colleagues to confront and address the emotional expression of their distress at the appropriate time. It is structured, phased and organized to facilitate recovery whenever an emotionally disturbing incident disrupts the ability to function. If you have not yet had formal reading or training on CISM, I would suggest starting with Appendix B, which reviews some fundamental aspects and definitions you'll need to successfully navigate this book. Similarly, if this is your first exposure to TIR you may want to start with Appendix A.

Traumatic Incident Reduction enables its practitioners, after a short period of specialized training, to resolve a range of distressing and disabling psychological symptoms. Following the Rules of Facilitation (see Appendix C) through an established protocol of repeated direction and enquiry, a rapid conclusion to even chronic symptoms can occur, often in a single session.

My discovery of CISM and TIR was the result of a search for practical and effective ways to deal with distress that came out of my own experience as a firefighter in England and as someone who was not helped by the clinical advice and treatment offered in the 1990s. I was retired from the fire service in England with Post-traumatic Stress Disorder (PTSD). I had been injured in a fall that saw me away from work for six months, during which time I became increasingly anxious about returning. Now, as a psychologist, I think I can see what would have helped me and why. I now train firefighters and paramedics in the crisis-intervention tactics of CISM and offer TIR training to the same people. Both groups of emergency workers are frequently and repeatedly exposed to incidents and scenes that can lead to PTSD and which puts them at high-risk for other trauma-related problems. I believe that CISM will soon be shown to be preventative for such problems and TIR reparative. While the academic and clinical communities argue about "effective treatments" and "evidence-based practice", I have witnessed nothing more impressive than watching anxious and fearful individuals piece together a new understanding of their experience to emerge, sometimes dramatically, with a renewed energy for their work and their loved ones. It seems to require no more than the safe-space that CISM and TIR can generate, motivation to stick at the task to completion and the discipline to follow the protocols.

The current advice of the National Health Service in the UK for people exposed to traumatic incidents is to allow a four-week "watchful-waiting" period, and to refer those showing symptoms of PTSD for cognitive-behavioral therapy (CBT), Eye-movement Desensitization and Reprocessing (EMDR) or drug therapies. The reliance on "experts" to deal with the effects of post-traumatic stress makes me uncomfortable. Reflecting on my own reluctance to approach or engage with a mental-health professional, I recall my belief that only a firefighter would understand what I was saying. Anyone who did not do the same job as me was unlikely to be able to acknowledge realistically what it could feel like. Additionally the outsider, no matter how expert they were in their field, was not an expert in mine. I even feared they might not believe me, or get upset or hurt by my vivid descriptions or judge me on dubious actions carried out when I felt I had no other choice. They might criticize, patronize or sympathize like non-fire service friends who wanted to know "what it was like" to attend certain incidents. Ironically, when I did seek professional help, I protected the therapist by pulling back from telling the whole story, only to realize that I was keeping them safe at the time I needed them to keep me safe.

If the most likely source of support in emergency work is a colleague, perhaps it is because they operate in the same space, share a culture and a language that is exclusive to the profession and tailored to the team; often they are referred to as "family". Not all families are healthy, but where justice, affection and equitable rules exist, there seems a good chance of a positive environment in which to operate. In a job (or a family) where safety is not assured, it takes the accumulated wisdom of history, insight and experience to survive and to function in a positive fashion. It is the wisdom, insight and experience of high-risk occupations that has informed CISM.

Critical Incident Stress Debriefing (CISD) was the forerunner to CISM and was first described by Jeff Mitchell in 1983. It was a formal procedure for emergency workers to meet under the guidance of a mental-health professional and a team of trained peers following a "critical-incident". Such an incident was one that might overwhelm an individual's normal coping ability such as the death of children, a colleague's suicide or a protracted, failed rescue. The emergence of additional interventions to add to the original CISD procedure (to become CISM) demanded a more flexible approach from its practitioners as crisis-intervention moved out of the meeting room to virtually anywhere a crisis-reaction might occur. Emotional reactions are not events that can be synchronized or predicted. Emergency responders sometimes recall significant parts of a critical-incident long after it has ended. Some will have aspects "stick" from the moment they are witnessed or felt and remain indefinitely in the form of unwelcome thoughts, images or sensations. An intervention should be available whenever an individual reacts and CISM is designed to do just that.

The limitations of the crisis-intervention tactics of CISM are acknowledged by being described as "emotional first-aid". The implications of the "first-aid" description are that crisis-intervention is likely to be brief, intended to prevent worsening and to promote recovery. Where significant improvement does not occur, referral to a higher level of care is demanded. With little more than a few days of training, it is assumed that crisis-intervention skills would not match those of mental-health professionals with years of academic education and clinical experience behind them. One crucial advantage of "peer-support" over referral to a mental-health professional, however, is access. Peers are not only familiar, they are available and likely to be familiar with the situations that have triggered difficult and painful reactions. Firefighters usually find something in the tragic that is positive, amusing or even hilarious and rarely, in my experience, do they ever seem worse for talking about it.

In her book Trauma & Recovery, Judith Herman identified three conditions that had to be satisfied before any progress toward resolution could be expected. She reported that safety was crucial, insisting that no recovery was likely without it. Remembrance and mourning could follow and then reconnection with people and what went before. This was the concluding stage and the best evidence of recovery. I have often compared that sequence to what I witnessed in colleagues in the midst of their crisis-reactions when no-one was available to provide the safety and therefore the opportunity to express what was remembered, what was lost and what it all meant. People in crisis are in fight/flight mode and cannot relax. They are therefore unlikely to find the time and space to piece together their experience, often fragmented, and arrive at an understanding of what actually happened and their part in it. No recall means no explanation and no explanation suggests that the job, the people or the world is not as predictable as previously assumed. When we sense a threat but cannot predict it, we seem to leave the radar on indefinitely. In CISM, a trained colleague is someone who is familiar with the landscape and can assist in realistically assessing the threat. Where this process is successful,...