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 Ineffective Ineffective No evidence that it works No evidence that it works Does nothing at all Does nothing at all Prevents healing Prevents healing

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

The Unexamined Life Is Not Worth Living Socrates

The Studies Harris - firefighters Harris - firefighters Mcnab – air ambulance Mcnab – air ambulance Deahl – body recovery soldiers Deahl – body recovery soldiers Bisson – burn victims Bisson – burn victims Hobbs – mvc victims Hobbs – mvc victims Rose – victims of violent crime Rose – victims of violent crime Carlier – police officers Carlier – police officers Amir – terrorist attack on Israeli women Amir – terrorist attack on Israeli women Hytten - firefighters Hytten - firefighters Litz – lit. review 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” 852 met selection criteria for the study. 852 met selection criteria for the study. Of these, 264 had attended CISD sessions following the Mitchell model. Of these, 264 had attended CISD sessions following the Mitchell model. 396 non-debriefed firefighters were randomly selected by computer as the comparison group 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.” 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.” “No relationship was found between debriefing and PTSD.”

Harris - The Rest of the Story The findings emphasize the need for further research on CISD, stress exposure, and dispositional variables in firefighters. 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. 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. Firefighters with more general and pervasive mental health difficulties may seek, and fact benefit from, CISD.

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. 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. 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 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 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 Our results are recommended to provide caution for future research and policy decisions regarding CISD. 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. 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 incidentStudy was done 6 months after the critical incident CISD participants has less negative affect at 6 monthsCISD participants has less negative affect at 6 months CISD participants had more positive beliefs and positive affect at 6 monthsCISD participants had more positive beliefs and positive affect at 6 months

They Call It “Quality Science” Title: Critical incident stress intervention after loss of an air ambulance: two-year follow-up. Title: Critical incident stress intervention after loss of an air ambulance: two-year follow-up. Type: Non-randomized controlled trial Type: Non-randomized controlled trial Journal: Prehospital Disaster Medicine1999;14(1):8-12 Journal: Prehospital Disaster Medicine1999;14(1):8-12 Authors: Macnab, Russel, Lowe, Gagnon Authors: Macnab, Russel, Lowe, Gagnon

They Call It “Quality Science” Air ambulance accident in British Columbia killed 5. Air ambulance accident in British Columbia killed 5. Directly involved paramedics, physicians, and nurses received CISM. (defusing, debriefing, follow-up). Directly involved paramedics, physicians, and nurses received CISM. (defusing, debriefing, follow-up). CISD provided by CISM -trained chaplain assisted by BCAS CISM team. CISD provided by CISM -trained chaplain assisted by BCAS CISM team. Control group derived from non-involved peers. Control group derived from non-involved peers.

They Call It “Quality Science” Standard psychological measures used. Standard psychological measures used. Debriefed group had more stress symptoms at 1 week. Debriefed group had more stress symptoms at 1 week. CISD did not appear to reduce the severity of stress symptoms. 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. People with pre-existing stress management routines appeared to have less symptoms at 6 months.

Mcnab – The Rest of the Story Air ambulance fails to arrive to evacuate a patient in early morning hours Air ambulance fails to arrive to evacuate a patient in early morning hours Unknown if it crashed Unknown if it crashed Information sharing session initiated at hospital by cism team Information sharing session initiated at hospital by cism team Defusing 1400 hours 1730 hours Defusing 1400 hours 1730 hours

Mcnab - The Rest of the Story Next day – spousal debriefing session Next day – spousal debriefing session 2 days later another CISD for all at hosp. who wanted it 2 days later another CISD for all at hosp. who wanted it Fate of crew still unknown Fate of crew still unknown 5 days after the event the wreckage was found and only 2 bodies recovered 5 days after the event the wreckage was found and only 2 bodies recovered

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. 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 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. 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” Title: Psychological sequelae following the Gulf War: Factors associated with subsequent morbidity and the effectiveness of PD. Title: Psychological sequelae following the Gulf War: Factors associated with subsequent morbidity and the effectiveness of PD. Type: Non-randomized CT Type: Non-randomized CT Journal: Brit J Psych, 165 (1994) Journal: Brit J Psych, 165 (1994) Authors: Deahl et al Authors: Deahl et al

They Call It “Quality Science” Evaluated 62 soldiers in the British Army AWGS. Evaluated 62 soldiers in the British Army AWGS. 69% received PD. 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.” 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 Less alcohol use in debriefed group Less alcohol use in debriefed group Not a RCT 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 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 Single session debriefing

Deahl - The Rest of the Story Debriefing not rigorously standardized in content or timing 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 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 Despite our findings we remain committed to the principle of debriefing

They Call It “Quality Science” Title: Randomised controlled trial of psychological debriefing for victims of acute burn trauma. Title: Randomised controlled trial of psychological debriefing for victims of acute burn trauma. Type:RCT Type:RCT Journal: Brit J Psych, 171 (1997) Journal: Brit J Psych, 171 (1997) Authors:Bisson, Jenkins, Alexander, Bannister Authors:Bisson, Jenkins, Alexander, Bannister

They Call It “Quality Science” 132 adult burn victims entered into study 132 adult burn victims entered into study Randomly assigned to a group that received PD or a control group that did not. 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. 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 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.” “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” “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 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.” “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 Debriefed group scored higher on whether other people were involved in the accident Debriefed group scored higher on whether other people were involved in the accident Debriefed group had more serious injuries Debriefed group had more serious injuries Debriefed group also had higher initial scores on psychopathology Debriefed group also had higher initial scores on psychopathology Shorter period of time between the burn trauma and debriefing session Shorter period of time between the burn trauma and debriefing session

Bisson - The Rest of the Story Debriefed group had more financial difficulties Debriefed group had more financial difficulties Some sessions were as short as 40 minutes Some sessions were as short as 40 minutes Bisson describes debriefing as “intense imaginal exposure to a traumatic incident” Bisson describes debriefing as “intense imaginal exposure to a traumatic incident”

They Call It “Quality Science” Title: A randomised controlled trial of PD for victims of road traffic accidents. Title: A randomised controlled trial of PD for victims of road traffic accidents. Type: RCT Type: RCT Journal: Brit Med J ; 313 (1996) Journal: Brit Med J ; 313 (1996) Authors: Hobbs, Mayou, Harrison, Worlock Authors: Hobbs, Mayou, Harrison, Worlock

They Call It “Quality Science” 106 victims of MVCs were randomly assigned to a PD group or a control group. 106 victims of MVCs were randomly assigned to a PD group or a control group. PD was completed within hours. (in most cases) PD was completed within 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.” 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” Proponents of CISM often discount this study because the debriefed group was more severely injured. 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. But the authors report PTSD was no different between the groups. CISD is supposed to mitigate PTSD symptoms, not physical injuries. CISD is supposed to mitigate PTSD symptoms, not physical injuries.

Hobbs - The Rest of the Story Debriefed group had worse injuries Debriefed group had worse injuries 1 hr debriefing 1 hr debriefing Debriefed group had longer hospital stay Debriefed group had longer hospital stay Individual intervention Individual intervention The training and experience of his debriefers is unknown The training and experience of his debriefers is unknown

They Call It “Quality Science” Title: A randomised controlled trial of individual debriefing for victims of violent crime. Title: A randomised controlled trial of individual debriefing for victims of violent crime. Type:RCT Type:RCT Journal: Psych Med; 29 (1999) Journal: Psych Med; 29 (1999) Authors:Rose, Brewin, Andrews, Kirk Authors:Rose, Brewin, Andrews, Kirk

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: 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, 1. Assessment only, 2. Education, 2. Education, 3. Education & PD (based loosely on Mitchell’s model). 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.” 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 Loosely based on Mitchell’s Model 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 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 Debriefings lasted 1 hour

Rose – The Rest of the Story It is important to clarify that our study does not speak to the efficacy of group debriefing. 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. 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 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” Title: The influence of occupational debriefing on post-traumatic stress symptomatology in traumatized police officers. Title: The influence of occupational debriefing on post-traumatic stress symptomatology in traumatized police officers. Type: Non-randomized CT Type: Non-randomized CT Journal: Br J Med Psych; 73 (2000) Journal: Br J Med Psych; 73 (2000) Authors: Carlier, Voerman, Gersons Authors: Carlier, Voerman, Gersons

They Call It “Quality Science” A sample of 243 traumatized police officers were divided into three groups: A sample of 243 traumatized police officers were divided into three groups: 1. Debriefed officers (86), 1. Debriefed officers (86), 2. Non-debriefed-internal (82) 2. Non-debriefed-internal (82) 3. Non-debriefed-external (75) 3. Non-debriefed-external (75) Three group successive debriefing sessions (24 hours, 1 month, and 3 months post-trauma). Three group successive debriefing sessions (24 hours, 1 month, and 3 months post-trauma). Debriefings followed Mitchell’s (1983) model. Debriefings followed Mitchell’s (1983) model.

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.” 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.” “High levels of satisfaction with debriefing were not reflected in positive outcomes.”

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

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 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 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” Title: Debriefing with brief group psychotherapy in a homogenous group of non-injured victims of a terrorist attack: a prospective study. 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 Type: Prospective non-controlled Journal: Acta Psych Scand; 98 (1998) Journal: Acta Psych Scand; 98 (1998) Authors: Amir, Weil, Kaplan, Tocker, Witztum Authors: Amir, Weil, Kaplan, Tocker, Witztum

They Call It “Quality Science” 15 non-injured women exposed to a terrorist bombing in Israel while on a day care bus trip. 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. 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.” 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 It is possible that debriefings and early interventions focus on irrelevant issues. It is possible that debriefings and early interventions focus on irrelevant issues. The IES showed a significant decrease in intensity. 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. 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” Title: Fire fighter: A study of stress and coping Title: Fire fighter: A study of stress and coping Type: Non-randomized, controlled Type: Non-randomized, controlled Journal: Acta Psych Scand; 355 (1989) Journal: Acta Psych Scand; 355 (1989) Authors: Hytten & Hassle Authors: Hytten & Hassle

They Call It “Quality Science” 58 non-professional firefighters participated in a major 12-story hotel fire where 14 guests lost their lives. 58 non-professional firefighters participated in a major 12-story hotel fire where 14 guests lost their lives. 39 men participated in PD 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.” 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 Of the 39 who participated – 2/3 claimed the effort had been professionally useful and felt their self confidence had increased 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 Also mentioned as positive aspects of the debriefing experience was Enhanced group cohesion

Hytten - The Rest of the Story More knowledge about people’s responses More knowledge about people’s responses And a different priority of values And a different priority of values Never defines debriefing 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.” “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” Title: Early interventions for trauma: Current status and future directions Title: Early interventions for trauma: Current status and future directions Type: Collective Review Type: Collective Review Journal: Clin Pscyh Sci Prac; 9(2002) Journal: Clin Pscyh Sci Prac; 9(2002) Authors: Litz, Gray, Bryant, Adler Authors: Litz, Gray, Bryant, Adler

They Call It “Quality Science” Collective review of all current literature pertaining to PD/CISD/CISM. 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.” 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 It appears that there is sufficient empirical evidence to recommend that PD not be provided to individuals immediately after trauma. 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 …. In our opinion, one session, one-on-one meetings between trauma survivors and professionals are appropriate if they ….

Litz – The Rest of the Story A. assess the need for sustained treatment A. assess the need for sustained treatment B. provide psychological first aid B. provide psychological first aid C. provide education about trauma and treatment resources C. provide education about trauma and treatment resources

Litz – The Rest of the Story 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. 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 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. 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.