America under attack: the "10 commandments" of responding to mass terrorist attacks.

On September 11, 2001 terrorist attacks caused the catastrophic collapse of the twin towers of the World Trade Center in New York City. Approximately 40 minutes after the World Trade Center was attacked, a similar terrorist attack was perpetrated against the Pentagon in Washington, D.C. Although the resultant physical devastation was beyond anything this nation has ever experienced, the psychological devastation may not be known for months, or even years. This paper discusses, not only a structure for understanding the phases of terrorism, but offers 10 recommendations for responding to acts of terrorism.

Reflections on the reconstruction of a nation: rebuilding the national identity of Kuwait.

The 10th anniversary of the liberation of Kuwait offers a time for reflection upon the reconstruction of a nation, not just physical reconstruction, but psychological reconstruction, as well. This paper briefly describes the efforts of the Social Development Office, Amiri Diwan, as an essential element in the preservation and reconstruction of the national identity of Kuwait in the wake of the Iraqi invasion and occupation. SDO may serve as a useful model for other war-torn countries on how to rehabilitate a national identity in the wake of a national disaster.

Overcoming the effects of disasters: a rationale for the Kuwaiti CISM Program.

Data suggest that the people employed in the emergency response professions are under unusually high stress. This factor may adversely affect their social, psychological and emotional well-being. The Critical Incident Stress Management (CISM) program was devised by Drs. Jeffrey T. Mitchell and George Everly, Jr. in order to help emergency workers overcome the obstacles that hinder them from performing positively in their chosen fields. The objectives of this paper are twofold: 1) it will report on the results of a study on 108 Kuwaiti firefighters and the relationship between cognitive interpretations and the manifestation of symptoms of PTSD; and, 2) it will describe the development of a CISM program to assist in the recovery from the Iraqi invasion of Kuwait.

Thoughts on early intervention.

The concept of early psychological intervention in response to traumatic events has been a compelling notion since World War I. Recently, its wisdom applied to mass disasters such as September 11th, has been called into question. A review of relevant research reveals support for its continued utilization, but not without caution. Crisis intervention, in response to mass disasters, should consist of an integrated multi-component intervention system.

The debriefing "controversy" and crisis intervention: a review of lexical and substantive issues.

Despite a long and rich history as a specialty within applied mental health, crisis intervention has, within recent years, been the target of criticism. Singled out for specific criticism has been the intervention referred to as "debriefing." Some authors have not only challenged its effectiveness but have raised the specter that it may cause significant harm. While superficially such arguments appear to have merit, closer scrutiny reveals an antiquated interpretation of even the most fundamental of terms and concepts inextricably intertwined with research based upon applications contrary to the most recent principles, prescriptions, and protocols regarding clinical use. A review of research based upon more extant formulations reveals many crisis intervention practices, including the Critical Incident Stress Debriefing model of "debriefing" and the Critical Incident Stress Management (CISM) model of crisis intervention to be highly clinically effective, indeed. This paper will review the terms and concepts which serve as the foundation of the field of crisis intervention, while subsequently reviewing key research investigations addressing its efficacy. It may be that outcome research directed toward assessing the effectiveness of crisis intervention can prosper from following trails blazed by psychotherapy researchers. The parallels seem striking. It may be that outcome research in crisis intervention (and "debriefing") needs to now focus upon "who" does crisis intervention, to "whom," and in "what specific situations," so as to maximize outcome associated with this clinically effective tool [International Journal of Emergency Mental Health, 2000, 2(4), 211-225].

The role of pastoral crisis intervention in disasters, terrorism, violence, and other community crises.

The term "pastoral crisis intervention" has been defined by Everly (2000) as the functional integration of faith-based resources with traditional crisis intervention assessment and intervention technologies. Pastoral crisis intervention has been differentiated from ministry and the provision of chaplaincy services. This paper provides a public health model for integrating pastoral crisis intervention services within the larger domain of community disaster response, crisis intervention, and emergency mental health.

The assaulted staff action program (ASAP) and declines in assaults: a meta-analysis.

Crisis intervention procedures have been demonstrated to be of assistance in addressing the aftermath of psychological trauma. The Assaulted Staff Action Program (ASAP) is a Critical Incident Stress Management (CISM) approach that has been associated with providing needed support to employee victims of patient assaults and sharp reductions in the frequency of assaults in facilities where ASAP has been properly fielded. The purpose of this study was to conduct a meta-analysis of the effectiveness of ASAP in reducing frequency of assault. Results yielded a highly statistically significant Cohen's d of 3.1 and fail safe number of 202. The implications for risk management are discussed.

Five principles of crisis intervention: reducing the risk of premature crisis intervention.

Crisis intervention, as it has evolved over the last five decades, has clearly demonstrated its effectiveness as a tool to reduce human distress. Nevertheless, as with any effort to alter human behavior, there are risks associated with crisis intervention. One such risk is that of premature intervention. Premature intervention may not only waste valuable intervention resources, but may serve to interfere with the natural recovery mechanisms of some victims. By clearly defining the nature of the crisis phenomenon itself, premature intervention may be averted.

Crisis management briefings (CMB): large group crisis intervention in response to terrorism, disasters, and violence.

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.

Crisis intervention: a review.

Critical incidents are sudden, unexpected, often life-threatening time-limited events that may overwhelm an individual's capacity to respond adaptively. Frequently, extreme critical incident stressors may result in personal crises, traumatic stress, and even Posttraumatic Stress Disorder. This paper presents a concise, fully-referenced, state-of-the-art review of crisis intervention procedures within the context of Critical Incident Stress Management.

"Pastoral crisis intervention": toward a definition.

The pastoral community represents a large and often untapped resource in times of crisis. It possesses a unique aggregation of characteristics that makes it uniquely valuable amidst the turmoil of a psychological crisis. In critical incidents such as terrorism, mass disasters, violence, the loss of loved ones, and any events wherein human actions result in injury, destruction, and/or death, the pastoral community may possess especially powerful restorative attributes. Unfortunately, heretofore, there has existed no generally recognized and accepted manner in which the healing factors inherent in pastoral care have been functionally integrated with the well-formulated principles of crisis intervention. This paper represents an initial effort to elucidate how the principles of pastoral care may be functionally integrated with those of crisis intervention. The amalgam shall heretofore be referred to as "pastoral crisis intervention" and is defined herein.

Prevalence of posttraumatic stress disorder among Kuwaiti firefighters.

It has been proven time and again that emergency service personnel experience much more stress than non-emergency workers. This has been a negative factor which affects their social, psychological, and emotional life. The purpose of the present study is to add to the cross-cultural data relating to the prevalence of posttraumatic stress among emergency services personnel, specifically firefighters. A random sample of 108 Kuwaiti firefighters yielded a psychometric prevalence of PTSD of 18.5%. These findings are consistent with data from the United States and from Canada.

Emergency mental health: an overview.

As any field of endeavor evolves, as the field of emergency mental health is evolving, it becomes important to reflect upon historical milestones and define key terms. This paper is an effort to provide a brief overview of the field of emergency mental health and to take a glimpse at its future.

"Syntonic change": a mental health perspective on avoiding the crises associated with change within organizations.

Historically, change within organizations has led to increased stress within the workforce. Organizational change is usually met with resentment and resistance yielding a crisis which impinges upon not only organizational effectiveness, but mental health as well. Most change efforts result in failure yielding dramatic declines in productivity, as well as accelerated attrition within the human resource. This paper proposes a model of "syntonic change" as a means of meeting both the needs of the organization to remain dynamic and flexible, and the needs of the workforce for a sense of trust and safety.

Community crisis intervention: the Coldenham tragedy revisited.

Crisis intervention is commonly thought of as acute psychological first-aid applied within close temporal proximity to the precipitating event. This paper reports the positive effects of a comprehensive crisis intervention applied over three years after the precipitating event and on a "community-wide" basis.

Toward a model of psychological triage: who will most need assistance?

While well developed within physical medicine, the concept of triage within emergency mental health is ill-defined. The purpose of this paper is to offer one formulation and a rudimentary set of guidelines for the process of psychological triage for individuals in crisis. These recommendations are unique in that they reflect an integration of clinical empiricism and applied physiological concepts. It is hoped that such an initiative will assist in the most efficient and effective allocation of mental health resources in acute crises, traumas, disasters, and even combat-related situations.

Critical incident stress debriefing (CISD): a meta-analysis.

Psychological debriefings represent a genre of group crisis interventions. Critical Incident Stress Debriefing (CISD) represents the oldest standardized variation of this genre. Recent reviews have called into question the effectiveness of CISD. In this study 5 previously published investigations were meta-analyzed revealing a large effect size (Cohen's d = .86) supporting the notion that the CISD model of psychological debriefing is an effective crisis intervention.