What Can we Learn From The Criticism of CISM

Report
What Can We Learn From The
Criticism of CISM
Vaughn Donaldson, Dist. Chief
Midland Fire Dept.
Midland, TX
The Rest Of The Story
By
Vaughn Donaldson, Dist. Chief
Midland Fire Dept.
Midland, TX
The Bad Stuff
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Ineffective
No evidence that it works
Does nothing at all
Prevents healing
Really Bad Stuff
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Makes people worse
Causes PTSD
Not only does it not work….it hurts
The Unexamined Life Is Not
Worth Living
Socrates
The Studies
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Harris - firefighters
Mcnab – air ambulance
Deahl – body recovery soldiers
Bisson – burn victims
Hobbs – mvc victims
Rose – victims of violent crime
Carlier – police officers
Amir – terrorist attack on Israeli women
Hytten - firefighters
Litz – lit. review
They Call It “Quality Science”
Title: Mental health of trauma exposed
firefighters and critical incident stress
debriefing
Type: Survey
Journal: Journal of Loss and Trauma 2002,
223 – 238
Authors: Harris, Baloglu, and Stacks
They Call It “Quality Science”
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852 met selection criteria for the study.
Of these, 264 had attended CISD sessions
following the Mitchell model.
396 non-debriefed firefighters were randomly
selected by computer as the comparison group
Conclusion: “Within this model, we find no
evidence of a significant direct contribution of
debriefing to coping skills or traumatic stress
reactions.”
“No relationship was found between debriefing
and PTSD.”
Harris - The Rest of the Story
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The findings emphasize the need for further
research on CISD, stress exposure, and
dispositional variables in firefighters.
The nature and quality of debriefings attended
by the firefighters in FEMA Region VI were no
doubt diverse.
Firefighters with more general and pervasive
mental health difficulties may seek, and fact
benefit from, CISD.
Harris – The Rest of the Story
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On the other hand seeking treatment for
personal mental health issues in the context of
one’s coworkers and workplace may not be in
the best interests of those so affected.
Pre-employment mental health screening and
appropriate selection criteria…..could be argued
to represent a bona fide occupational
requirement.
Harris – The Rest of the Story
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Ethical issues of dual roles, confidentiality,
provision of unnecessary services,
competence and beneficiance to those
affected require serious consideration in
policymaking regarding the provision of
mental health services on a mandatory
basis
Harris - The Rest of the Story
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Our results are recommended to provide
caution for future research and policy
decisions regarding CISD.
Clinical wisdom might suggest that there
is inherent value in the provision of
support and psychosocial instruction
during the post-exposure period, and
empirical evidence from this study does
not contradict that notion.
Harris – The Rest of the Story
• Study was done 6 months after the critical
incident
• CISD participants has less negative affect
at 6 months
• CISD participants had more positive
beliefs and positive affect at 6 months
They Call It “Quality Science”
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Title: Critical incident stress intervention
after loss of an air ambulance: two-year
follow-up.
Type: Non-randomized controlled trial
Journal: Prehospital Disaster
Medicine1999;14(1):8-12
Authors: Macnab, Russel, Lowe, Gagnon
They Call It “Quality Science”
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Air ambulance accident in British Columbia
killed 5.
Directly involved paramedics, physicians,
and nurses received CISM. (defusing,
debriefing, follow-up).
CISD provided by CISM -trained chaplain
assisted by BCAS CISM team.
Control group derived from non-involved
peers.
They Call It “Quality Science”
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Standard psychological measures used.
Debriefed group had more stress
symptoms at 1 week.
CISD did not appear to reduce the severity
of stress symptoms.
People with pre-existing stress
management routines appeared to have
less symptoms at 6 months.
Mcnab – The Rest of the Story
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Air ambulance fails to arrive to evacuate a
patient in early morning hours
Unknown if it crashed
Information sharing session initiated at
hospital by cism team
Defusing done @ 1400 hours and @ 1730
hours
Mcnab - The Rest of the Story
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Next day – spousal debriefing session
2 days later another CISD for all at hosp.
who wanted it
Fate of crew still unknown
5 days after the event the wreckage was
found and only 2 bodies recovered
Mcnab - The Rest of the Story
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The hospital stress management team,
particularly those unfamiliar with the
working environment of the transport
team, were not seen to be as helpful or
comforting during CISD as did those from
the Ambulance Service.
Mcnab - The Rest of the Story
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Particularly resentment occurred when
team members felt there was impulsive
and unusual interest in their welfare, with
the assumption of inappropriate intimacy
and familiarity with the realities of their
work environment.
They Call It “Quality Science”
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Title: Psychological sequelae following the
Gulf War: Factors associated with
subsequent morbidity and the
effectiveness of PD.
Type: Non-randomized CT
Journal: Brit J Psych, 165 (1994)
Authors: Deahl et al
They Call It “Quality Science”
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Evaluated 62 soldiers in the British Army AWGS.
69% received PD.
Conclusion: “These findings show that a
psychological debriefing following a series of
traumatic events or experiences does not appear
to reduce subsequent psychiatric morbidity and
highlights the need for further research in
military and civilian settings.”
Deahl - The Rest of the Story
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Less alcohol use in debriefed group
Not a RCT
Low symptoms of distress in both groups
from the outset, but debriefed group
started out with much lower symptoms of
distress, although it didn’t get much lower
Single session debriefing
Deahl - The Rest of the Story
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Debriefing not rigorously standardized in
content or timing
Highlights the need for studies to
investigate the whether there is a role for
screening those recruited into “high-risk”
professions
Despite our findings we remain committed
to the principle of debriefing
They Call It “Quality Science”
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Title: Randomised controlled trial of
psychological debriefing for victims of
acute burn trauma.
Type:RCT
Journal: Brit J Psych, 171 (1997)
Authors:Bisson, Jenkins, Alexander,
Bannister
They Call It “Quality Science”
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132 adult burn victims entered into study
Randomly assigned to a group that received PD
or a control group that did not.
They were subsequently evaluated by an
assessor blind to PD status at 3 & 13 months.
Conclusion: 26% of the PD group had PTSD at
13 months compared to 9% of the control group
“This study seriously questions the wisdom of
advocating one-off interventions post-trauma
and should stimulate research into more
effective initiatives.”
They Call It “Quality Science”
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“The excess number in the PD group was due to
absence of block randomization and termination
of recruitment when preliminary analysis of the
data revealed possible adverse consequences for
the intervention group.”
“The PDs adhered to the structure first
described by Mitchell (1983) adapted for use
with either an individual or a couple. The
facilitator proceeded through a seven-phase
semi-structured approach.”
Bisson - The Rest of the Story
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Debriefed group scored higher on whether
other people were involved in the accident
Debriefed group had more serious injuries
Debriefed group also had higher initial
scores on psychopathology
Shorter period of time between the burn
trauma and debriefing session
Bisson - The Rest of the Story
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Debriefed group had more financial
difficulties
Some sessions were as short as 40
minutes
Bisson describes debriefing as “intense
imaginal exposure to a traumatic incident”
They Call It “Quality Science”
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Title: A randomised controlled trial of PD
for victims of road traffic accidents.
Type: RCT
Journal: Brit Med J ; 313 (1996)
Authors: Hobbs, Mayou, Harrison,
Worlock
They Call It “Quality Science”
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106 victims of MVCs were randomly assigned to
a PD group or a control group.
PD was completed within 24-48 hours. (in most
cases)
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Conclusions: “Psychiatric morbidity was
substantial 4 months after injury, with no
evidence that debriefing had helped—and,
indeed, indications that it might have been
disadvantageous.”
They Call It “Quality Science”
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Proponents of CISM often discount this
study because the debriefed group was
more severely injured.
But the authors report PTSD was no
different between the groups.
CISD is supposed to mitigate PTSD
symptoms, not physical injuries.
Hobbs - The Rest of the Story
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Debriefed group had worse injuries
1 hr debriefing
Debriefed group had longer hospital stay
Individual intervention
The training and experience of his
debriefers is unknown
They Call It “Quality Science”
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Title: A randomised controlled trial of
individual debriefing for victims of violent
crime.
Type:RCT
Journal: Psych Med; 29 (1999)
Authors:Rose, Brewin, Andrews, Kirk
They Call It “Quality Science”
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2,161 victims of violent crime were contacted, 243
replied, 157 selected for study and randomly assigned to
one of three groups:
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1. Assessment only,
2. Education,
3. Education & PD (based loosely on Mitchell’s model).
Conclusions: “No evidence was found to support the
efficacy of brief one-session interventions for preventing
post-traumatic symptoms in individual victims of violent
crime.”
Rose – The Rest of the Story
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Loosely based on Mitchell’s Model
Participants were prompted with specific
questions designed to elicit facts,
cognitions and were encouraged to
express negative emotions such as fear,
guilt or shame which in normal
circumstances might have remained
hidden
Debriefings lasted 1 hour
Rose – The Rest of the Story
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It is important to clarify that our study does
not speak to the efficacy of group debriefing.
The sample contained substantial subgroups
with high levels of previous psychopathology,
and of previous assaults in childhood.
It is possible that individual one-session
debriefings are insufficient to bring about
changes among those with previous psych or
trauma history
They Call It “Quality Science”
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Title: The influence of occupational
debriefing on post-traumatic stress
symptomatology in traumatized police
officers.
Type: Non-randomized CT
Journal: Br J Med Psych; 73 (2000)
Authors: Carlier, Voerman, Gersons
They Call It “Quality Science”
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A sample of 243 traumatized police
officers were divided into three groups:
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1. Debriefed officers (86),
2. Non-debriefed-internal (82)
3. Non-debriefed-external (75)
Three group successive debriefing
sessions (24 hours, 1 month, and 3
months post-trauma).
Debriefings followed Mitchell’s (1983)
model.
They Call It “Quality Science”
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Conclusions: “No differences in
psychological morbidity were found
between the groups at pre-test, 24 hours,
and 6 months post-trauma. One week
post-trauma, debriefed subjects exhibited
more post-traumatic stress disorder
symptomatology than non-debriefed
subjects.”
“High levels of satisfaction with debriefing
were not reflected in positive outcomes.”
Carlier – The Rest of the Story
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Debriefing adapted for use with individual
trauma victims
First debriefing lasted avg. 41.4 minutes
Second lasted 17.4
Third lasted 15.9 minutes
Carlier - The Rest of the Story
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Internal control group declined the offer
for debriefing because they did not
perceive the event as shocking or had no
time for a debriefing interview
As we focused on individual debriefing,
the results may not be directly comparable
with data on group or couple debriefing
They Call It “Quality Science”
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Title: Debriefing with brief group
psychotherapy in a homogenous group of
non-injured victims of a terrorist attack: a
prospective study.
Type: Prospective non-controlled
Journal: Acta Psych Scand; 98 (1998)
Authors: Amir, Weil, Kaplan, Tocker,
Witztum
They Call It “Quality Science”
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15 non-injured women exposed to a terrorist
bombing in Israel while on a day care bus trip.
All women participated in a group debriefing 2
days after the attack followed by 6 group
psychotherapy sessions.
Conclusion: “The results of the present study
show that the psychological intervention did not
bring substantial relief of the suffering of
terrorist attack victims in this study.”
Amir – The Rest of the Story
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It is possible that debriefings and early
interventions focus on irrelevant issues.
The IES showed a significant decrease in
intensity.
These women were day care workers in
an area an hour away from their home in
an area with much political unrest and
continuous terrorist attacks on civilians.
They Call It “Quality Science”
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Title: Fire fighter: A study of stress and
coping
Type: Non-randomized, controlled
Journal: Acta Psych Scand; 355 (1989)
Authors: Hytten & Hassle
They Call It “Quality Science”
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58 non-professional firefighters participated in a
major 12-story hotel fire where 14 guests lost
their lives.
39 men participated in PD
Conclusion: “Those who took part in formal
debriefing claimed that it had helped them.
Nevertheless, there was no significant difference
on the IES between those who received formal
debriefing versus those who only talked with their
colleagues in more informal settings.”
Hytten - The Rest of the Story
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Of the 39 who participated – 2/3 claimed
the effort had been professionally useful
and felt their self confidence had
increased
Also mentioned as positive aspects of the
debriefing experience was
Enhanced group cohesion
Hytten - The Rest of the Story
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More knowledge about people’s responses
And a different priority of values
Never defines debriefing
“We do not know enough about how
debriefing help is brought about, an how it
should be arranged to become most
effective.”
They Call It “Quality Science”
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Title: Early interventions for trauma:
Current status and future directions
Type: Collective Review
Journal: Clin Pscyh Sci Prac; 9(2002)
Authors: Litz, Gray, Bryant, Adler
They Call It “Quality Science”
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Collective review of all current literature
pertaining to PD/CISD/CISM.
Conclusions: “Based on available evidence,
we propose that psychological first aid is
an appropriate initial intervention, but it
does not serve a therapeutic or
preventative function.”
Litz – The Rest of the Story
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It appears that there is sufficient empirical
evidence to recommend that PD not be
provided to individuals immediately after
trauma.
In our opinion, one session, one-on-one
meetings between trauma survivors and
professionals are appropriate if they ….
Litz – The Rest of the Story
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A. assess the need for sustained treatment
B. provide psychological first aid
C. provide education about trauma and
treatment resources
Litz – The Rest of the Story
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Since PD is fully accepted as standard
practice for emergency personnel and
well-received by groups and organizations,
it is hard to find fault in it’s application in
disasters.
Litz – The Rest of the Story
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Formal debriefing may serve to maintain
morale and cohesion….feel validated,
empowered,…and that the group based
approach contributes to better functioning
in the work environment after a high
stress incident.
What Can We Learn From The
Criticism of CISM?
What Can We Learn?
Meet BASIC needs first and foremost
Follow accepted standards – don’t start
doing CISDs before you even know what
happened
Use EXTREME caution in mandating
attendance at interventions
Pre-incident education,
What Can We Learn?
Pre-employment screening needs to be
mandatory in high stress professions
CISM is not a one shot deal
Stop probing and trying to turn group
crisis intervention into group therapy!!!
Don’t use crisis intervention to treat
psychopathogy
What Can We Learn?
Match peers for the profession….duh!
We need unbiased research into CISM
What we’re doing is working………when
we follow the “Standard of Care”
Overwhelmingly, the recipients of our
services appreciate what we’re doing,
and find the process helps them recover
traumatic events.

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