2. Louise Bailey BA (SocWork) MAASW February 2010
Trauma and Debriefing
Louise Bailey
BA (SocWork) MAASW
February 2010

3. Summary of Presentation
Brief overview - Historical perception of Trauma
Trauma Reaction and Post Traumatic Stress Disorder (PTSD)
Mitchell Model of Debriefing, Defusing and Demobilisation
Efficacy of debriefing – The Current Debate
Outcomes of Debate
Conclusions

4. Only bad things happen quickly
Gordon Livingstone

5. Overview History of trauma
1900 BC Egyptian physicians report of “hysterical reactions” (Kunyus papyrus - First medical textbook)
Up to ~18th Century reactions to stressful events attributed to:
God
Evil spirits
Devil

6. Overview Warfare Vietnam War 1970s to present
Early 20th Century - World War I & II
Various terms used - shell shock, battle fatigue, war neurosis, lack of moral fibre
Vietnam War
1970s to present

7. Trauma reactions & PTSD
official publication of human stress response, to extreme traumatisation as a distinct valid diagnostic category (DSM III)
Named - Post Traumatic Stress Disorder (PTSD)

8. Trauma
Results from a person experiencing, witnessing or confronting an event(s)
that involve actual or threatened death or serious injury, or threat to physical integrity of self or others
The response involves intense fear,
helplessness or horror (DSM IV)

9. Event is sent to active memory
Traumatic event
Event is sent to active memory
Active memory
If unable to integrate
trauma memories, PTSD develops
Responses are
re-experienced
Past memories information either filed or sent back to active memory
Avoidance strategies and development of secondary symptoms aim
to reduce distress, but maintain the PTSD symptoms causing conflict

10. Post Traumatic Stress Disorder (PTSD)
….. Is an extreme stress reaction where symptoms are prolonged and chronic
There is a development of characteristic symptoms following a psychologically distressing event that is outside human experience…
….. It is usually experienced with intense fear, terror and helplessness. (DSM IV)

11. Common Indicators of Post Traumatic Stress
PHYSICAL
Increased arousal, restlessness, fatigue, nightmares, hyper-vigilance
BEHAVOURAL
Avoidance of reminders of incident, inability to stop talking about it or detach from event
MENTAL
Flashbacks, cannot stop thinking about the event,

12. Common Indicators of Post Traumatic Stress
EMOTIONAL
Fear of it happening again, lack of feelings, guilt, numbness,
SOCIAL
Avoid people, places, feel threatened wanting contact and assurance, poor relationships with others
EXISTENTIAL
Loss of job and work satisfaction, purpose, motivation, career plan. Sense of self and values may change

13. Debriefing and Defusing Critical Incident Stress Debriefing(CISD)
‘Mitchell model’ developed in Influenced from the military, police, emergency services psychology (crisis intervention) and disasters.
(Robinson & Mitchell 1995)
Recommendations
That debriefing be used as part of other procedures and be incorporated into a total approach
People who run debriefings be properly trained
Debriefers follow the debriefing protocol

14. Defusing
The main purpose is so people can talk about what they are thinking
A time to give information and ensure they are cared for at the time and when they return home
It is short and deals with what happened and what was the worst part

15. Debriefings Seven Stages; Introduction What we see What we think
What we feel
How we have reacted physically and psychologically
Teaching and learning what to do with these reactions and the event
Re-entry and completion.

16. Current debate on debriefing
Following a disaster often deluge of “counsellors” will offer various forms of debriefing and counselling
We are all eager to help
Are we becoming “Trauma tourists”
Experts say, ‘surely the worker and victims deserve interventions that are legitimised by research’

17. Current debate on debriefing
CISD Mitchell approach
Model never meant to be a stand alone method
It is not a cure for PTSD
Needs to be part of a CISM Plan in any organisation or Disaster

18. Current debate on debriefing
Mitchell says, “Assessment teams are sent in to identify groups or individuals who need individual help...”
“...then timing and interventions are planned....”
“...resources and personal provided...”
“...demobilisation and information given”

19. Current debate on debriefing
One to one support given
Group defusing may be done
Debriefings sometimes occur
weeks or months after event
CISD is not a therapy: “what has happened is they have taken what is a group process model which is designed for support and changed it into a therapy” (Mitchell 2003)

20. Current debate on debriefing
CISD was used as “one size fits all” Mitchell argues that his work has been misunderstood, misinterpreted and taken out of context
Mitchell has written guidelines, 250 articles and 10 books on the subject matter.

22. Supporting debriefing
Rob Gordon (2003) says “debriefing is a great tool for helping people make sense of traumatic situations in the work-place. If they are debriefed you can help them recapture their own sense of competence
Dr Rob Gordon Clinical Psychologist , Victorian Department of Human Services and Consultant to the Redcross

23. Supporting debriefing (Rob Gordon)
We need to adjust the technique for
Type of culture
type of people involved
type of situations

24. Supporting debriefing (Rob Gordon)
Broad principle
Go through the facts
Clarify what happened
Take stock of their thoughts and what meaning it has
Then move on, the symptoms
Advice about taking care of themselves
“That is the core of CISD, and what I find very valuable”

25. Arguments against debriefing 1 (Gist 2003)
Gist says some people are more resilient in the face of crisis, people naturally will talk to people they know, not strangers
people already have loved ones friends spiritual beliefs
Dr Richard Gist, Associate Professor,
University of Missouri Kansas City

26. Arguments against debriefing 2 (Wessley 2003)
Wessely says that debriefing is actually impairing the normal ways we understand, process and deal with emotion and normal networks. It could be too early and often we do not want to talk about it. We need to chose the time and place.
Dr Colin Wessley, Professor of Psychology,
Kings College London

27. Arguments against debriefing 3 (Raphael 2003)
Is debriefing the professionalization of distress?
Are people psychologically able to process information when they are in a hyper-vigilance state?
Every persons’ trauma is unique
Professor Beverly Raphael
Director of Mental Health,
NSW Department of Health

28. Arguments against Debriefing 4 Raphael 2003 (cont)
Raphael was a supporter but it was the consistency of negative reports and research showing either no or a negative response to debriefing
“I would really like there to be something simple that made it better, this is not the answer, maybe there are bits of it that are.”
Professor Beverly Raphael Director of Mental Health, NSW Department of Health & Social Services

29. Arguments against debriefing Raphael 2003 (cont)
Beverly states it is important to do no harm
Not used in proposal for NSW Health
Outcome of Consensus Conference (USA)
58 experts from 6 countries found that one to one debriefings is not recommened

30. Outcomes of debate Australian defence Force no longer use debriefing
Use instead focussing on information
Screening referral and social support
No longer the emotional retelling of the trauma
NSW Police force no longer use the Mitchell debriefing Model

31. Outcomes of the Debate Red Cross use a 4 stage form of debriefing
Disclosure of events
Talking about feelings
Reactions
Coping Strategies

32. Demobilisation… Step 1 Gather the staff Step 2 Summarise the events
Step 3 Questions and issues are discussed
Step 4 Arrangement for the next period
Step 5 Stress information is supplied
Step 6 Immediate needs are considered
Step 7 Problem Solving

33. Conclusion 1
Important to asses what, when and the type of intervention that is needed
Trauma is unique so the timing for everyone is different, debriefing does not prevent PTSD
80% will not go on and develop PTSD
Debriefing needs to be part of an overall plan to address trauma in the workplace and the community CISM

34. Conclusion 2
More research and discussion is needed although it is a difficult area for research
Research to date has shown that
one to one debriefing does not have a positive response and is not recommended
Non-voluntary debriefing is not recommended

35. Conclusion 3
It is important to put together a variety of techniques that may include debriefing to deal with peoples reactions to trauma.
Focus on clear information and assessment
Mobilisation
Individual counselling/crisis counselling
Ongoing support systems