What Can We Learn From The Criticism of CISM

1. What Can We Learn From The Criticism of CISM Vaughn Donaldson, Dist. Chief Midland Fire Dept. Midland, TX

2. The Rest Of The Story By Vaughn Donaldson, Dist. Chief Midland Fire Dept. Midland, TX

3. The Bad Stuff • Ineffective • No evidence that it works • Does nothing at all • Prevents healing

4. Really Bad Stuff • Makes people worse • Causes PTSD • Not only does it not work….it hurts

5. The Unexamined Life Is Not Worth Living Socrates

6. The Studies • 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

7. 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

8. They Call It “Quality Science” • 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.”

9. Harris - The Rest of the Story • 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.

10. Harris – The Rest of the Story • 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.

11. Harris – The Rest of the Story • 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

12. Harris - The Rest of the Story • 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.

13. 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

14. They Call It “Quality Science” • 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

15. They Call It “Quality Science” • 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.

16. They Call It “Quality Science” • 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.

17. Mcnab – The Rest of the Story • 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

18. Mcnab - The Rest of the Story • 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

19. Mcnab - The Rest of the Story • 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.

20. Mcnab - The Rest of the Story • 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.

21. They Call It “Quality Science” • 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

22. They Call It “Quality Science” • 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.”

23. Deahl - The Rest of the Story • 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

24. Deahl - The Rest of the Story • 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

25. They Call It “Quality Science” • 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

26. They Call It “Quality Science” • 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.”

27. They Call It “Quality Science” • “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.”

28. Bisson - The Rest of the Story • 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

29. Bisson - The Rest of the Story • 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”

30. They Call It “Quality Science” • 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

31. They Call It “Quality Science” • 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) • 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.”

32. They Call It “Quality Science” • 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.

33. Hobbs - The Rest of the Story • 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

34. They Call It “Quality Science” • 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

35. They Call It “Quality Science” • 2,161 victims of violent crime were contacted, 243 replied, 157 selected for study and randomly assigned to one of three groups: • 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.”

36. Rose – The Rest of the Story • 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

37. Rose – The Rest of the Story • 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

38. They Call It “Quality Science” • 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

39. They Call It “Quality Science” • A sample of 243 traumatized police officers were divided into three groups: • 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.

40. They Call It “Quality Science” • 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.”

41. Carlier – The Rest of the Story • Debriefing adapted for use with individual trauma victims • First debriefing lasted avg. 41.4 minutes • Second lasted 17.4 • Third lasted 15.9 minutes

42. Carlier - The Rest of the Story • 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

43. They Call It “Quality Science” • 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

44. They Call It “Quality Science” • 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.”

45. Amir – The Rest of the Story • 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.

46. They Call It “Quality Science” • Title: Fire fighter: A study of stress and coping • Type: Non-randomized, controlled • Journal: Acta Psych Scand; 355 (1989) • Authors: Hytten & Hassle

47. They Call It “Quality Science” • 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.”

48. Hytten - The Rest of the Story • 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

49. Hytten - The Rest of the Story • 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.”

50. They Call It “Quality Science” • 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