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Crisis Management Briefings (CMB):

Large Group Crisis Intervention in Response to Terrorism, Disasters, and Violence
George S. Everly, Jr., Ph.D.
ABSTRACT: A single act of violence or terrorism can adversely affect thousands of people. Such acts will invariably engender a psychological morbidity that will far surpass any physical morbidity. Heretofore, efforts in primary and secondary prevention have focused largely upon the physical consequences of these incidents, rather than their psychological consequences. This paper describes a practical group psychological crisis intervention, the "crisis management briefing" (CMB), that may be used with large groups of individuals in the wake of terrorism, violence, disasters, and other crises. This intervention, which is one component of the Critical Incident Stress Management (CISM) crisis intervention system, is designed to mitigate the effects of these crises and requires anywhere from 45 to 75 minutes to implement. The CBM may be employed with groups ranging from 10 to 300 individuals at one time [International Journal of Emergency Mental Health, 2000, 2(1), 53-57]. Innovations.
There can be little doubt that disasters, violence, and acts of terrorism engender a large scale psychological morbidity. In fact, the explicit goal of any true act of terrorism is to create a condition of fear, uncertainty, demoralization, and helplessness, i.e., "terror." As Shreiber (1978) noted, the direct target or victims of the terrorist act are not the real targets, rather they are but the means to an end. In the cases of terrorism, mass disasters, and acts of violence, the "psychological casualties" will virtually always outnumber the "physical casualties." Any effective response to such crises simply must mandate psychological intervention, as well as physical crisis intervention. As an example, the Defense Against Weapons of Mass Destruction Act of 1996 (Senators Nunn, Lugar, & Domenici) mandates the enhancement of domestic preparedness and response capabilities in the wake of attacks against the United States using weapons of mass destruction (WMD). Although a small component, provisions are made for psychological crisis intervention with both emergency responders and primary civilian victim populations. This paper describes a group psychological crisis intervention designed to mitigate the levels of felt crisis and traumatic stress in the wake of terrorism, mass disasters, violence, and other "large scale" crises. The intervention is referred to as the "crisis management briefing" (CMB) and is designed to be used with "large groups" of primary civilian victims which may range in size from 10 to 300 individuals at one time. The intervention is designed to be highly efficient, taking between 45 and 75 minutes to implement. The CMB may be implemented in schools, corporations, and community settings. The CMB is but one component of the comprehensive Critical Incident Stress Management (CISM) crisis intervention system.
A REVIEW OF CRITICAL INCIDENT STRESS MANAGEMENT (CISM)
Crises and disasters seem almost epidemic. The threat ofmass terrorism has become an ever-increasing reality. Even the instant mass media coverage of these events may, for some, represent a source of vicarious traumatization. In consideration of these realities, the need for effective psychological crisis response capabilities becomes obvious. Crisis intervention programs are recommended and even mandated in a wide variety of community and occupational settings (Everly & Mitchell, 1999). Critical Incident Stress Management (CISM) represents a powerful, yet cost-effective approach to crisis response (Everly, Flannery, & Mitchell, 1999; Flannery, 1998; Everly & Mitchell, 1999; Everly & Boyle, 1999; Everly, Flannery, & Eyler, 2000).
What is CISM? CISM is a comprehensive, integrative, multicomponent crisis intervention system. CISM is considered comprehensive because it consists of multiple crisis intervention components which span both the temporal and functional spectra of a crisis. CISM interventions range from the pre-crisis phase, through the acute crisis phase, and into the post-crisis phase. CISM is also considered comprehensive in that it consists of interventions which may be applied to individuals, small functional groups, large groups, families, organizations, and even entire communities. The core components of CISM are defined below and are summarized in TABLE 1.
1. Pre-crisis preparation. This includes stress management education, stress resistance, and crisis mitigation training for both individuals and organizations.
2. Disaster, terrorist, or other large scale incident interventions, including but not limited to: a) demobilizations for emergency response personnel, b) crisis management briefings (CMB) for school, corporate, and general civilian populations, c) "town meetings," and d) incident command staff advisement.
3. Defusing. This is a 3-phase, structured small group discussion provided within hours of a crisis for purposes of assessment, triaging, and acute symptom mitigation.
4. Critical Incident Stress Debriefing (CISD) refers to the "ICISF model" (Mitchell & Everly, 1996) 7-phase, structured group discussion, usually provided 1 to 10 days post crisis (3 to 4 weeks post disaster), and designed to mitigate acute symptoms, assess the need for followup, and if possible provide a sense of post-crisis psychological closure.
5. One-on-one crisis intervention/counseling or psychological support throughout the full range of the crisis spectrum (Everly & Mitchell, 1999). 6. a) Family crisis intervention, as well as, b) organizational consultation.
7. Follow-up and referral mechanisms for assessment and treatment, if necessary.
The effectiveness of CISM programs has been validated through thoughtful qualitative analyses (Everly & Mitchell, 1999; Everly, Flannery, & Mitchell, 1999; Miller, 1999; Dyregrov, 1997; Mitchell & Everly, in press), as well as through controlled investigations, and even meta-analyses (Everly, Boyle, & Lating, 1999; Everly & Boyle, 1999; Everly & Piacentini, 1999; Flannery, Penk, & Corrigan, 1999; Everly, Flannery, & Eyler, 2000; Flannery, 1998). Although not all reviews support the effectiveness of psychological crisis intervention programs such as CISM (Rose & Bisson, 1998), close scrutiny of ineffective outcome reveals the lack of a standardized, multicomponent intervention program. The standardized and multicomponent nature of the CISM system serves to remedy this shortcoming.
CRISIS MANAGEMENT BRIEFINGS (CMB)
The "crisis management briefing" (CMB) is a practical fourphase group crisis intervention. It is designed to be highly efficient in that it requires from 45 to 75 minutes to conduct and may be used with "large" groups consisting of 10 to 300 individuals. While designed to be used with primary victim civilian populations in the wake of terrorism, mass disasters, violence, and other large-scale crises, it may have applicability in other settings with other populations, as well. As noted in TABLE 1, the CMB (component 2b on TABLE 1) is but one component within the comprehensive CISM system as described by Everly and Mitchell (1999; Mitchell & Everly, 1996). The CMB is designed to be used within a comprehensive CISM framework, and should not be used as a "stand-alone" intervention. It is anticipated that, depending upon the crisis event, there will be a need for CISD (component 4 on TABLE 1) and individual (1:1) crisis interventions (component 5) subsequent to the CMB. And, as always, arrangements should be made for follow-up assessment and referral for continued psychological care (component 7), if needed.
PHASE ONE: The first phase of the CMB consists of bringing together a group of individuals who have experienced a common crisis event. In response to a school crisis, for example, an assembly could be held in the auditorium.
Depending upon the number of students, one grade could be addressed at a time, or other divisions of the student body could be used. In response to a workplace crisis, a company meeting room could be used, or a room could be rented at a local hotel or commercial meeting facility. In response to mass disasters, large-scale violence, or terrorism, local school auditoriums could be used to address the civilian populations that would correspond to the respective school districts. Announcements to that effect could be made via radio, television, and internet sites. Obviously, the CMB would be repeated until all constituents have been addressed within the given circumscribed area/population. This act of assembly is the first step in reestablishing the sense of community that is so imperative to the recovery and rebuilding process (Ayalon, 1993).
PHASE TWO: Once the group has been assembled, the next intervention component is to have the most appropriate and credible sources/authorities explain the facts of the crisis event. In many instances, the choice of a respected and highly credible spokesperson assists in the development of the perceived credibility of the message and the belief that the actions and support will be effective. The ethos of the spokesperson contributes to the effectiveness of the message/information being disseminated. Objective and credible information should serve to: 1) control destructive rumors, 2) reduce anticipatory anxiety, and 3) return a sense of control to victims. Without breaching issues of confidentiality, the assembled group should receive factual information concerning that which is known and that which is not known regarding the crisis event.
PHASE THREE: The next step is to have credible healthcare professionals (if available) discuss the most common reactions (signs, symptoms, and psychological themes) that are relevant to the particular crisis event. For example, in the case of a suicide, the psychological theme of suicide should be addressed. In the case of terrorism, the dynamics of terrorism should be discussed. Common signs and symptoms of grief, anger, stress, survivor guilt, and even responsibility guilt among survivors, friends, and others should also be addressed.
PHASE FOUR: The final component of the CMB is to address personal coping and self-care strategies that may be of value in mitigating the distressing reactions to the crisis event. Simple and practical stress management strategies should be discussed. Community and organizational resources available to facilitate recovery should also be introduced. Questions should be actively entertained as appropriate.
Each group participant should leave the CMB with a reference sheet that briefly describes common signs and symptoms, common stress management techniques, and local professional resources (with contact names and telephone numbers) available to recovery.
Timing for the CMB is highly situation-specific and flexible. The CMB can be repeated as long as it proves to be useful.
Summary
This paper has introduced the "crisis management briefing" (CMB) as an efficient large group crisis intervention that may be used for primary civilian populations (and perhaps others) in the wake of terrorism, mass disasters, violence, and similar large-scale "community," school, organization, and community-wide crises. While the CMB, and similar interventions have been in use for years and have been anecdotally reported to be effective, the goal of this paper is to move toward a standardization of such procedures. With standardization comes reliability in application/ implementation. In the final analysis, meaningful outcome research and its replication is based upon the reliable implementation of tactical protocols. Clearly, the overall effectiveness of the CMB should be submitted to controlled outcome investigations. This is a needed direction for the future. The human resource is the most valuable resource any organization or community possesses. The CMB is designed to protect that resource.
References
Ayalon, O. (1993). Posttraumatic stress recovery of terrorist survivors. In J. Wilson & B. Raphael (Eds). International handbook of traumatic stress syndromes (pp. 855-866). NY: Plenum.
Dyregrov, A. (1997). The process of psychological debriefing. Journal of Traumatic Stress, 10, 589-604.
Everly, Jr., G.S., & Piacentini, A. (1999, March). Effects of CISD on stress and trauma symptoms: A metaanalysis. APA-NIOSH Work, Stress, and Health Œ99 Conference, Baltimore.
Everly, Jr., G.S., Boyle, S., & Lating, J. (1999). The effectiveness of psychological debriefings in vicarious trauma: A meta-analysis. Stress Medicine, 15, 229-233.
Everly, Jr., G.S., & Boyle, S. (1999). Critical Incident Stress Debriefing (CISD): A Meta-Analysis. International Journal of Emergency Mental Health, 1(3), 165-168.
Everly, Jr.,G.S., & Mitchell, J.T. (1999). Critical Incident Stress Management (CISM): A new era and standard of care in crisis intervention (2nd Ed.). Ellicott City, MD: Chevron.
Everly, Jr.,G.S., Flannery, Jr., R.B., & Eyler, V. (2000, April). Effectiveness of a crisis intervention: A meta-analysis. Invited paper presented to the Third International Conference on Psychological and Social Services in a Changing Society, Kuwait City, State of Kuwait.
Everly, Jr.,G.S., Flannery, Jr., R.B., & Mitchell, J.T. (1999). Critical Incident Stress Management (CISM): A review of literature. Aggression and Violent Behavior: A Review Journal, 5, 23-40.
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