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DEEP BLUE


December 28, 2012
By Dorothy Cotton

1579 words – MR

HEAD: There’s no evidence CISD works

Research. Continuous learning. Change. You gotta hate all that stuff. Here we were puttering along nicely, doing all kinds of stuff that we thought was JUST FINE, THANK YOU VERY MUCH… and then suddenly, it turns out the facts don’t support what we’re doing and we have to start all over again. Phooey.

While there are any number of things we do that would probably fit the above bill, the one I am currently in a snit about is the practice of Critical Incident Stress Debriefing (CISD). I’ll bet your police service has a CISD or CISM (M for Management) team and whenever some horribly dreadful thing happens, you are all asked to disappear into a secret room to follow a strict procedure of telling what happened, where you were, how it unfolded, how you felt – stuff like that. The theory was that this would decrease the likelihood of people getting PTSD. Sounds like a good plan to me.

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Alas, as it turns out, it doesn’t work. Like I said… phooey.

The observation that exposure to significant trauma and experiences outside the normal realm of human routine may cause psychological disturbance is not new. References in this area date back to the mid-1800s. Terms such as battle fatigue, shell shock and battle neurosis date from the early 20th century and were used to describe soldiers who displayed significant psychological disturbance following exposure to war.

The concept of severe psychological effects from psychological trauma became widely developed during the 1970s and 1980s. In part, this resulted from the presence of post-traumatic stress disorder (PTSD) in Vietnam war veterans. At the same time, the general notion began to be applied to people experiencing other kinds of traumas, including natural disasters, rape and sexual assault and exposure to other horrible things – and to people who respond to such disasters.

The vast literature on PTSD reflects a general belief that it can result from prolonged exposure to highly stressful events and situations (such as battle and witnessing pervasive atrocities), specific individual instances of serious psychological magnitude (such as sexual or physical assault) and witnessing or responding to serious single traumatic events (such as the Oklahoma City bombing or Hurricane Katrina). Using the “what’s-good-for-the-goose-must-be-good-for-the-gander” approach, interventions for people involved in critical incidents were expanded and widely adopted among first responders.

The term “critical incident” is most commonly associated with the work of Jeffrey Mitchell and we often talk about the “Mitchell Model” when we discuss CISM. Most first responder-type organizations have adopted it and its use is pervasive. This would be a good thing if it really achieved its purpose. However, the research about its effectiveness is “problematic.” (This is a polite word we use in evaluating research when we really mean “it stinks.”)

This field of study does not easily lend itself to rigorous data collection in that the events themselves are unpredictable and the assignment of affected individuals to ‘no treatment’ control groups can be viewed as unethical. Needless to say you also cannot assign people ahead of time so you know who will have a critical incident and who will not. (“Hey Ted – we want to see if you will fall apart when you see body parts strewn on the road so for now, you will be assigned to all the really gory stuff. OK?”).

Most early studies of the Mitchell Model were conducted by the same individuals who developed the techniques. This is generally not considered good form in the research world. There is that whole “bias” thing to be considered. Not surprisingly, they provide some evidence for the effectiveness of critical incident stress programs. A review by of 20 papers that evaluated specific CISM programs indicated that generally, findings were positive and supportive of the model.

However, as time has gone on, other reviews completed by independent researchers describe much more equivocal findings. Many found no evidence debriefings reduced general psychological morbidity, depression or anxiety or that there was either no or a slightly negative effect on the presence of PTSD symptoms after debriefing. Other studies found the techniques had no clear positive or negative effects compared to other interventions, although participants did seem to evaluate them positively, or that it wasn’t possible to draw firm conclusions about the benefit or harm of CISM .

Some have expressed concerns parts of the process may actually be harmful to psychologically vulnerable individuals, amounting to re-victimization. There is also concern that those with the highest symptom levels, who on the surface appear to most need debriefing services, may also be the most likely to suffer paradoxical reactions (that means they get worse rather than better). The process also does not seem to be effective in identifying people who might be at greatest risk for developing PTSD – which presumably was the original intent.

Finally, in situations where people may be later required to testify about the events surrounding a critical event, the retelling and comparing of notes in a debriefing can cause significant difficulties. Participants can be influenced, both consciously and unconsciously, to alter their stories.

In some ways, these results are not terribly surprising. It is not like a critical incident in and of itself is the major cause of PTSD. I’d have to write a 10 page article to explain all the causes and influences – even if we really knew – but let us just say we know that the vast majority of people exposed to critical incidents do NOT go on to develop PTSD so obviously there is a little more to it than just a single icky incident – or even a long series of semi-icky incidents.

Currently the jury appears still out on the subject of the efficacy of standardized critical incident stress interventions. On the one hand, there does not appear to be compelling evidence of their benefit; on the other hand, there is also an absence of compelling evidence that they are unilaterally harmful. As noted, one of the driving forces behind providing critical incident services is that it provides visible evidence that the employer is actively invested in the welfare of employees. It seems clear debriefed parties seem to appreciate the gesture. Client satisfaction is typically high.

It is also generally agreed that most organizations are sincere in their desire to assist employees and clients exposed to critical incidents. However, the evidence that individuals who experience the most psychological stress, and therefore may be the most vulnerable, are least likely to benefit from these procedures and may actually suffer some harm because of them is sobering.

In view of these concerns, a number of national and international organizations – including the Canadian Psychological Association, National Institute of Mental Health (NIMH, 2002), Department of Health Clinical Practice Guidelines (UK Department of Health, 2001) and the World Health Organization (WHO, 2004) – have issued statements advising against the use of single-session psychological debriefings.

Err… so now what? Do you just ignore critical incidents? Pat people on the head and say “there there there?”

Well, there are a bunch of options – too many to describe here – but my favourite make sense and reflects the things we DO know about PTSD.

The (http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh13.pdf) is a comprehensive, 192 page report. It was “developed in accord with National Health and Medical Research Council guideline development requirements, by a working party comprising key trauma experts from throughout Australia and around the world. Of particular interest is the section on early interventions (pp. 103ff), which includes the following recommendations (p. XIX):

<5.1 For adults exposed to trauma, structured psychological interventions such as psychological debriefing should not be offered on a routine basis.

5.2 For adults exposed to trauma, clinicians should implement psychological first aid in which survivors of potentially traumatic events are supported, immediate needs met and monitored over time. Psychological first aid includes provision of information, comfort, emotional and instrumental support to those seeking help. Psychological first aid should be provided in a stepwise fashion tailored to the person’s needs.

5.3 Adults exposed to trauma who wish to discuss the experience and demonstrate a capacity to tolerate associated distress, should be supported in doing so. In doing this, the practitioner should keep in mind the potential adverse effects of excessive ventilation in those who are very distressed.

5.4 For adults who develop an extreme level of distress or are at risk of harm to self or others, immediate psychiatric intervention should be provided.>

Psychological First Aid (referred to as Mental Health First Aid (MHFA) in Canada) is currently offered around the country under the auspices of the Mental health Commission of Canada and is already used by some police services (http://www.mentalhealthcommission.ca/English/Pages/MentalHealthFirstAid.aspx).

In the context of the Australian Guidelines, MHFA is seen as one of the first steps in identifying and supporting people who may be experiencing psychological distress following a traumatic or critical incident.

Essentially, the Australian Guidelines suggest that, rather than utilizing a shotgun/one-size-fits-all CISM model, an employer should develop a means for identifying and monitoring those few individuals who are at significant risk. Of course this would mean an employer would need to have a comprehensive workplace mental health system in place.

Gee, it seems to me that by the time this article runs, the new national standards from CSA for Psychological Safety in the Workplace will have been released. Might be worth a look (http://www.csa.ca).