This article examines the use of critical incident stress management techniques in the treatment of addictive diseases. Furthermore, it: defines what critical incidents are; provides examples and symptoms of critical incidents stress in the treatment of substance abuse; explains the role of grief and loss in the intervention process; enumerates the seven phases of a critical incident stress debriefing; and specifies four goals of critical incident intervention in the treatment of addictive clients.

Mary, a 25 year-old female client, is being treated for drug addiction in your inpatient substance abuse program. Following detox and 14 days in the program, her HIV test results come back positive. Mary may not be aware, but she is experiencing a critical incident that could sabotage her recovery. This is just one of several critical incidents in the course of treatment clients may face. Can Mary effectively focus on her Alcoholics Anonymous (AA) steps and treatment goals without first addressing her emotional response to her positive HIV test results? What stress symptoms can be anticipated? Could the use of critical incident intervention techniques minimize the chances of relapse and keep Mary on track in her recovery?

What is a critical incident?
A critical incident is an event that is outside the client’s normal experience, and has the potential to create significant distress that can overwhelm a client’s defense mechanisms. The critical event often produces acute reactions or critical incident stress for the exposed client. The client’s response to the crises event often: (1) disrupts the client’s psychological balance; (2) overwhelms the client’s coping abilities; (3) creates distress, impairment, and dysfunction; and (4) significantly increases the likelihood of relapse (Everly, 1999).

Critical incident stress reaction should be viewed as a natural and normal human response to a traumatic event. This response is generally acute (short in duration) and non-pathological (Lewis, 1992). However, if the client’s symptoms do not subside within two to three months following the critical event, a serious pathology may develop, post-traumatic stress disorder (PTSD).

PTSD is a significant pathology in which the client “stays stuck” in a traumatic event. The client is unable to move past the event or successfully cope with everyday life situations, and as a result, suffers a number of emotional problems and symptoms including intrusion, avoidance, and arousal (Williams and Poijula, 2002). The symptoms and diagnostic requirements associated with PTSD are enumerated in the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, (American Psychiatric Association, 1994).

PTSD or critical incident stress
Critical stress and PTSD seem to be describing a similar phenomenon. However, critical incident stress is a normal emotional response to an abnormal event, whereas PTSD should be viewed as a major pathology as described in the DSM-IV. PTSD diagnosis should be assigned only to clients whose symptoms persist over a number of months, or if the onset of severe symptoms occur at least six months after the time of the critical event. For clients suspected of experiencing PTSD, a more in-depth clinical assessment and psychiatric consultation are strongly suggested. Remember, the goal of critical incident stress intervention is to minimize the client’s chances of developing chronic PTSD.

There are several critical incidents that can occur during the treatment process with substance abuse clients, including:
• Client tests positive for HIV
• Treatment elopement of fellow clients
• Relapse of fellow clients
• Death of fellow clients
• Client recalls suppressed childhood trauma (i.e. sexual abuse)
• Client receives divorce papers
• Client receives notification of loss of custody of children
• Client facing legal consequences
• Client loss of job
• Counselor relapse

This, of course, is not an exhaustive list. Any one of these critical incidents can and often produces a strong response or reaction, that can overwhelm the recovering addict’s already weak psychological defense mechanisms. The reaction can take the form of numerous critical incident related symptoms. These stress response symptoms may be physical, cognitive, psychological, and/or behavioral in nature (Everly and Mitchell, 2002).

Critical incident related symptoms may include physical symptoms, such as: sleep disruption; headaches; nausea; fatigue; weakness; chest pain; elevated BP; shock symptoms; visual difficulties; and loss or increase of appetite. Critical incident stress also can result in psychological and/or emotional symptoms, such as tension, anger, feelings of helplessness, fear, sadness, irritability, guilt, grief, panic, denial, anxiety, agitation, irritability, and depression.

Cognitive symptoms arising from a critical incident may include: difficulty concentrating; memory problems; confusion; uncertainty; hyper-vigilance; intrusive images; poor problem solving; and memory disorientation to time, place, or person. Critical incident may also result in behavioral symptoms, including: psychological withdrawal from treatment process; self medication through alcohol or drug use; leaving treatment against medical advice; discontinuing attendance at AA meetings; violence toward other clients and other antisocial acts; and multiple relapses.

Counselors should keep in mind that these stress symptoms are normal and are directly related to the critical incident. Furthermore, the counselor should not interpret the client’s critical incident stress symptoms as a simple manifestation of the client’s addiction or presume the presence of some other co-occurring pathology.

The roles of grief and loss
Grief and loss are major elements in addictive diseases. Addiction, in many ways, is a disease of loss — loss of control of drinking or drug use; loss of family; loss of job; loss of friends; loss of money; and loss of health. Recovery, too, requires a major loss — the loss of the client’s primary psychological defense mechanism; drinking and using drugs.

To effectively intervene in a critical incident, the counselor needs to be aware that usually some form of loss is being felt by the client, and that the client is experiencing one of the stages of the grief process. Many of the critical incidents mentioned above (as well as others) involve some form of loss.

Dr. Elizabeth Kubler-Ross (1969) and many others (Kelly, 1997) in the field of death and dying have suggested there are a number of stages of grief that a person must move through to fully recover from his/her loss. Kubler-Ross suggests the following five stages:
1. Denial — This is an initial reflexive reaction that protects the client from being overwhelmed with emotional pain. This stage is some times referred to as shock. Clients in denial, upon being told that they have a positive test for HIV, will often respond by requesting a second test be done.
2. Anger — As the client realizes that he/she does not have control over the process, and realizes there has been a disruption in their lives, he/she will feel intense fear and anger. This anger may manifest itself in antisocial behavior or a return to drug use.
3. Bargaining — The client realizes that something serious is happening and will often attempt to control “it” by making deals. An example of bargaining is when a client is told the HIV positive test results are true, and they bargain to stop drinking or go to AA meetings, if God will allow them to live.
4. Sadness — The client experiences a sense or feeling of despair and desperation and may lose a sense of hope for the future. If the critical incident is profound, the client may experience clinical depression and/or relapse.
5. Acceptance — This stage is characterized by the client “letting go” and accepting on an emotional level, that his/her life will not be the same. With HIV clients, they will understand and accept that their lives may be shortened. For some, this is a time when they experience a sense of peace and inner strength to move forward with their lives.

The grief process is non-linear. The client often will vacillate between stages over time. A key clinical objective for the counselor is to assist the client through the grief stages and insure the client does not get “stuck” in one or more of these stages.

Phases of critical incident intervention
Everly and Mitchell (2002) have suggested the intervention (debriefing) session include seven basic phases. These are:
1. Introduction: Counselor and clients define expectations, set limits, and address confidentiality.
2. Fact phase: Client(s) describes the critical event from his/her perspective. “Tell us what happened.”
3. Thought phase: Client(s) describes what his/her thinking or thoughts were. “When you had a chance to think about the incident, what were your first thoughts?”
4. Reaction phase: Client(s) describes his/her response to the even “What was the worst part of this event for you?”
5. Symptom phase: Client(s) describes what changes (physical, emotional, mental, or behavioral) he/she has experienced since the critical event. “What has life been like since the event?”
6. Teaching phase: After the client(s) have expressed his/herself in the previous debriefing phases, the counselor teaches the basic concepts of critical incident stress management, grief and loss, relapses prevention in recovery. The teaching phase is also incorporated into many of the other intervention phases.
7. Re-Entry phase: This is the closure phase characterized by emphasizing normalization, answering questions, “reframing”, and summarizing the session to achieve a sense of closure.

Often, focusing on “lessons learned” and positive aspects of the event can be therapeutic during this closure phase.

Goals of intervention sessions
Critical Incident Stress Debriefing (CISD) refers to structured crisis intervention techniques used by counselors to address client needs concerning a critical incident. This debriefing may be done in either an individual or group therapy setting. There are four major goals in critical incident debriefings or interventions, including: stabilization of client; symptoms reduction; normalization of feelings; and facilitation of client movement through the emotional stages of the grief process. As with other treatment goals, moving through all the grief stages may not be feasible during a brief inpatient stay. Therefore, critical incident grief issues should be incorporated in both the client’s primary treatment plan and long term continuing care plan.

Conclusion
To effectively use critical incident stress management techniques in the treatment of addictive diseases, counselors should: identify critical incident stress of clients during the treatment process; conduct intervention counseling/debriefing with the client to address the stress response and; incorporate critical incident intervention goals in both the client’s master treatment plan and continuing care plan.

Critical incident stress management techniques are valuable intervention tools in the treatment of addiction. With prompt intervention, the chances of relapse or PTSD are minimized and, thus, the likelihood of recovery from addiction is greatly enhanced.

For additional web based resources concerning Critical Incident Stress Management (CISM) or the Grief Process refer to the following:
CISM:
http://www.jayleeinc.com/More%20Resources.
htm
http://www.icisf.org/
http://www.foh.dhhs.gov/Public/CISM/CISMInfo.
asp
http://www.ncptsd.org/facts/disasters/fs_faq_
disaster.html
http://www.vaonline.org/cism.html

Grief Process:
https://www.americanhospice.org/griefzone/
general.htm
http://www.billwilsoncenter.org/thecentre/pro_
comm.html
http://www.thesupportnetwork.com/CASP/kelly.
htm
http://www.nmha.org/reassurance/coping.cfm

Jay Lee, PhD, is the President of B.Y. Lee & Associates, Inc., a health and human services management consulting firm located in Lake Worth, Florida. Dr. Lee may be contacted at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it or www.jayleeinc.com.

David McVinney, MPS, CAP, LMHC, is the Executive Director of The Palm Beach Institute, a substance abuse treatment program in West Palm Beach, Florida; and the current President of Florida NAADAC. Mr. McVinney may be contacted at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association.
Everly, G. S. (1999). A Primer on Critical Incident Stress Management: What’s Really in a Name? Journal of Emergency Mental Health, 2, 76-78.
Everly, G. S., Mitchell, J. T. (2002). Critical Incident Stress Management: Advanced Group Critical Intervention Workbook. Ellicott City, MA. International Critical Incident Stress Foundation, Inc.
Dyregrov, A. (1997). The Process in critical incident stress debriefing. Journal of Traumatic Stress, 10, 589-605.
Kubler-Ross, E. (1969). On Death and Dying. New York, N.Y. Touchtone/Simon & Schuster.
Kelly, J. (1997). The Grief Process: a Cognitive Equilibrium Model in Adapting to Loss. Paper: 8th annual Conference of Canadian Assoc. of Suicide Prevention (CASP). Oct. 29, 1997, Thunder Bay, Ontario.
Lewis, G. W. (1992). The Management of Critical Incident Stress and Trauma in the Workplace: a professional manual. Framingham, MA: Compass.
Williams, M. B., Poijula, S. (2002). The PTSD Workbook. Oakland, CA. New Harbinger Publications, Inc.

This article is published in Counselor,The Magazine for Addiction Professionals, December 2005, v.6, n.6, pp.34-37.

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