Module: Dealing with Stress and Trauma
By Lisa Schirch and Dave Dyck; Eastern Mennonite University, Conflict Transformation Program, 1200 Park Rd., Harrisonburg, VA 22802; 540/432-4497; fax: 540/432-4449; e-mail: schirchl@emu.edu and dyckd@aslan.emu.edu

Goal
To describe the process and skills needed to address stress and trauma experienced by NGO workers after a critical incident.

Objectives
•	To describe the expected effects of stress and trauma on an individual
•	To detail the processes used in a “Critical Incident Stress Debriefing”
•	To provide a guide for those who need to conduct Critical Incident Stress Debriefings

Key Learning Points
•	Stress is a normal reaction to an abnormal situation
•	Addressing the stress and trauma of NGO workers in insecure environments needs to be integrated into NGO security procedures.
•	Active listening is important in debriefing individuals and groups who experienced stress and/or trauma.
•	Even those individuals not directly involved in the security incident may need to undergo some form of debriefing process to help them deal with the event.  This includes family members and other NGO colleagues.

Definitions:

Cognitive:  Understanding or reasoning

De-escalation:  To lesson the intensity of a situation

It is not unusual for individuals who have been exposed to an intense situation to experience many of the symptoms associated with trauma and victimization.  The physical and emotional aftermath of an incident in which one felt one’s life being threatened can be very intense.  What are the feelings people go through after such a shock?  What dimensions of our sense of self are violated?  What do people need from those around them when they have been traumatized?  More specifically, what kinds of approaches and skills are vital for NGO personnel to know when dealing with these types of situations?

This section of the module addresses the steps necessary to work effectively with the stress and trauma of others before also exploring what these processes imply with respect to self-management.  As the process is described, links are also made with the specific corresponding interpersonal skills required to carry out this process effectively.  The most important set of overall interpersonal skills in debriefing others after a traumatic incident are those associated with active listening.  Therefore, the most important self-management skills following a incident in which you have been traumatized include the ability to find a good listener and the ability and willingness to tell your story (self-disclosure).  (For more on listening skills, see the module on defusing anger and hostility.)

Some Definitions:

Stress results in physical, emotional, cognitive and/or behavioral change.  The change may be beneficial or harmful. 

Stress reaction can be:
•	immediate
•	delayed
•	cumulative

Emotional trauma is a shock to one’s self or spirit that overwhelms the coping mechanisms of an individual or group that often results in stress.

Level of stress is affected by:

		Intensity of Event		Individual Profile
     duration of incident		coping skills
     perception of danger		social characteristics
level of exposure		previous experience

Critical Incident Stress Management (CISM) is a comprehensive, organized approach for the reduction and control of the harmful aspects of stress resulting from exposure to a traumatic event.  It includes, but is not limited to the following:
•	Pre-incident traumatic stress education
•	Counseling and support services
•	Crisis interventions,  (de-escalations ) 
•	Debriefings (extensive interpersonal skills required)
•	Follow-up services
•	Research and development

CISM operates on the assumption that individualized stress is the normal reaction of a normal person to an abnormal situation.
Debriefing is a group process (30-45 min.) provided immediately after a traumatic event once the individuals involved are disengaged from the on-scene operations.

Goals and Process of Debriefing After a Traumatic Event:
The goals of the debriefing are to:
•	mitigate the impact of the event
•	accelerate the recovery process
•	assess the need for debriefing or other support
•	reduce cognitive, emotional, and physiological symptoms 
The process of the debriefing aims to:
•	establish non-threatening social environment
•	allow rapid ventilation of stressful experience
•	equalize access to facts and information
•	restore cognitive processing of event
•	provide information for stress survival
•	affirm value of individuals
•	establish linkages for additional support
•	develop expectancies for the future

The debriefing components are as follows:
	1. Introduction
•	introduce facilitator (hosting - creating an emotionally safe atmosphere)
•	state purpose (disclosure skills)
•	invite voluntary participation 
•	establish ground rules (not necessarily therapy, not investigation)
•	assure confidentiality (no notes, recordings, etc.)
•	describe process
•	offer additional support
	2. Exploration
•	ask individuals to describe what just occurred (open-ended questioning)
•	allow only minimal clarification questions (silence, paraphrasing)		
•	review experiences and reactions (summarizing skills)
•	assess need for more help
•	reassure as necessary
	3. Information
•	accept/summarize their exploration (validate and summarizing skills)
•	normalize experiences and reactions (extend empathy and support; speak from    personal experience if possible)
•	teach multiple stress survival skills (elicit experiences from individuals)
•	advise on diet & nutrition, alcohol/caffeine avoidance 
•	pay attention to proper rest & relationships (speak from experience)
•	recommend recreation & exercise (speak from experience)
	4. Aftermath
•	make personal contact with each participant (open-ended consultations)
•	assure one-on-one follow-up
•	make determination to proceed with debriefing

The Goals and Process of Critical Incident Stress Debriefing:
The debriefing process may provide sufficient support to groups or individuals, however it may happen that the debriefing will reveal the need for further support.  Indicators that additional support may be necessary include:
•	intense emotions, unusual behavior
•	unfinished business
•	a sense (sometimes subtle) of incompleteness
•	excessive silence

Critical Incident Stress Debriefing (CISD) is a guided group discussion (2-3 hrs.) of a traumatic event occurring 48-72 hrs. after the event that aims to:
•	prevent stress dysfunction
•	screen and prioritize individual needs
•	identify areas for follow-up support and referrals

The CISD process is delineated into seven distinct steps.  It is important to follow all the steps in order to realize optimal effectiveness.  The CISD moves the participants from the cognitive level (less threatening to express) through the emotional level (essential to explore and address) and back to the cognitive level (where the participants find comfort).

COGNITIVE

		1. Introduction					7. Re-entry
		2. Fact						6. Teaching
		3. Thought Reaction				5. Reframing
4. Emotional Reaction

EMOTIONAL

The seven stages of the CISD process are as follows:

Stage 1	Introduction	Introduce intervention team members, explain process, set expectations, establish confidentiality (active listening throughout process)	
Stage 2	Fact	Have each participant describe the nature of their participation, from a cognitive perspective.  “What did you see/hear/do?”
(open-ended, fact focused questions)	
Stage 3	Thought Reaction	Solicit cognitive responses to: “What were you thinking as this was happening?  What aspect held the most negative impact for you?”, transition from cognitive to emotional processing.
(open-ended, cognitive focused questions)	
Stage 4	Emotional Reaction	Solicit emotional reactions to or consequences of cognitive responses given in Stage 3.  “How has this experience affected you?”
(open-ended, emotional focused questions)	
Stage 5	Reframing	Transition from emotional domain back to cognitive.  “What lessons could be learned from this experience?” or “What is something positive that you will take away from this experience?”  Be gentle here - Do not insist that people identify positive learning if they are not ready.
(open-ended, reframing questions)	
Stage 6	Teaching	Educate participants to normal reactions (not necessarily shared by everyone) and teach basic stress management, if applicable.
(disclosure, speaking skills)	
Stage 7	Re-entry	Summarize experience with emphasis on positive learning aspects.	

Before debriefing it is important for the intervention team to: 
	•	Review case documents, incident reports, press clippings, etc. 
      •	Circulate among the group in order to establish informal contacts, study relationships and individual behavior, and gather additional background information.
•	Hold strategy meeting to agree on focus, roles and responsibilities, and critical communication and support skills.

After debriefing it is important for the intervention team to:
•	Make one-on-one contact with all participants, inviting those deemed needful of further individual support to attend follow-up session.
	•	Conduct post-debriefing review with team :
		- “how did we do?”
		- “what did we learn?”
		- coordinate any follow-up
		- check-in with each team member, “are you okay?”
•	If necessary, write post-action report keeping it general, ensuring confidentiality, 	and focusing on lessons learned

Attending to Yourself - Ensuring Your Own Debriefing:
The steps involved in facilitating a defusing process for others are the same steps you need to ensure you take for yourself after you have experienced a traumatizing incident.  If it is not readily provided for you by others (as it should be), you will need to seek it out for yourself.  Ideally, persons who can listen actively to you about your experience in a nonjudgmental, open way will be available.  It is usually critical to share openly about your thoughts and feelings during the incident as well as the ongoing impact of the incident on you.  It is also important to raise whatever questions the incident has left you grappling with (For example: “Why me?  Was I especially targeted?  Is there something I should have done differently?  What will happen to the aggressors?  Will they strike again?”  These are normal, typical questions).  

It is also helpful to talk to people who can actually relate to your experience and normalize the different emotions you are going through.  Strong reactions, such as nightmares and the fear of going to work and carrying on, are not uncommon.  It is also critical that you be willing to ask for additional help or support in the form of counseling if you want or need it.  Do not be shy or embarrassed about caring for yourself.  It is not unusual to require additional support after being victimized in a security incident.  In addition, be willing to insist that you are given time to rest and to process what has happened to you.  Finally, if no one is available to help you adequately reflect upon your experience, it is often helpful to work through the above CISD process through writing.