Professional Documents
Culture Documents
A Field Study of Critical Ncident Stress Debriefing Vs Critical Incident Stress Management
A Field Study of Critical Ncident Stress Debriefing Vs Critical Incident Stress Management
A Field Study of Critical Ncident Stress Debriefing Vs Critical Incident Stress Management
DAVID RICHARDS
Abstract
This prospective field trial compared two post-trauma support systems following armed robberies
Critical Incident Stress Debriefing (CISD) as a stand alone group intervention and integrated Critical
Incident Stress Management (CISM) delivered to two groups of raided employees. Morbidity was
measured using two measures of post-traumatic stress and a general health measure. Morbidity in both
groups was equivalent at day 3 and one month post-raid. The CISM group had significantly less post-
trauma morbidity at follow-up (312 months post raid) compared to CISD alone supplying evidence
for the superior efficacy of postdisaster interventions when these are delivered in an integrated CISM
format. Calls to cease debriefing are premature and integrated CISM systems should now be the
subject of randomised controlled studies.
ISSN 0963-8237print/ISSN 1360-0567online/2001/030351-12 Shadowfax Publishing and Taylor & Francis Ltd
DOI: 10.1080/09638230020023868
352 David Richards
and 6.7% met current PTSD criteria, giving a traumatic experiences in a group setting. It
total population PTSD prevalence of 12.3% attempts to accelerate recovery before harm-
lifetime and 4.6% current. European studies ful stress reactions have a chance to damage
of crime victims on this scale are absent but the performance, careers, health and families
smaller scale studies tend to concur with of victims (Busutill & Busutill, 1997). It is
those from the US. For example, Fisher & recommended that CISD be incorporated into
Jacoby (1992) found that 23% of bus crews an integrated system of pre-incident training,
subject to violent assault developed PTSD initial post-incident defusing, group debrief-
compared to no cases in a control group of ing and further counselling, referred to by
non-assaulted crews. Brewin et al. (1998) Mitchell & Everley (1997) as Critical Inci-
found that 20% of crime victims met criteria dent Stress Management (CISM).
for PTSD 6 months after their trauma. Unfortunately, the evidence base is gener-
The last 15 years have seen significant ally characterised by a lack of robust control-
advances in the development of treatments led evidence for the efficacy of early inter-
for PTSD. Major controlled studies have ventions in traumatic stress CISD or CISM.
demonstrated the efficacy of a range of treat- The efficacy of CISD in particular is a matter
ments, particularly those based on cognitive of debate. Recently, several randomised con-
behavioural approaches (Foa et al., 1991; trolled trials have demonstrated that, when
Keane et al., 1989; Marks et al., 1998). The CISD was carried out with individual trauma
main techniques studied have been (a) pro- victims rather than in groups it produced
longed exposure, where the patients re-expe- either no improvement compared to controls
rience their traumatic memories until habitu- (Brewin et al., 1998; Hobbs & Adshead,
ation and emotional processing are complete; 1996) or, had the potential to cause signifi-
(b) stress inoculation training, where patients cant harm to those debriefed (Bisson et al.,
are instructed in symptom management tech- 1997). These studies have led to claims that
niques; and (c) cognitive restructuring, where CISD is an ineffective crisis intervention
patients are helped to consider alternative technique which should be discontinue d
interpretations of the incident itself, the world (Avery & Orner, 1998; Wessley et al., 1998).
and their own self image. Mitchell and others (Mitchell & Everley,
Early intervention or crisis intervention 1997) have criticised these studies on the
services (Raphael, 1986) have been devel- grounds that they sacrifice internal validity
oped with the explicit aim of reducing the for experimental control, participants are self-
initial psychological impact of trauma and to selected, CISD timing is outside that recom-
prevent the development of long-term mor- mended and debriefers appear inadequately
bidity. A common organisational response to trained.
traumatic stress has been the development of However, there are also methodologica l
Critical Incident Stress services including, as objections to those studies which purport to
a major component, Critical Incident Stress show CISD delivered in a CISM framework
Debriefing (CISD) based on Mitchells work in a positive light (e.g. Bohl, 1991; Chemtob
(Mitchell, 1983) with emergency service per- et al., 1997; Robinson & Mitchell, 1993)
sonnel. CISD is defined as a meeting of those including participant self-selection, variable
involved in a traumatic event which aims to intervention timings and a lack of control
diminish the impact of the event by promot- comparison groups. Essentially, the debate
ing support and encouraging processing of hinges on the degree to which trade-offs
Field trial of CISM v. CISD 353
acted robberies together with instruction they were in no need of further assistance. In
on procedural and anxiety management the CISM condition, pre-raid training was
coping strategies. Each employee was timetabled as part of the overall training
given an individual workbook, which con- structures used to deliver other training such
tained information and exercises on cop- as financial product training. No employees
ing with robberies. The training took raided in the CISM condition had previously
place in four monthly parts with home- refused to take part in the training.
work exercises between each training ses-
sion. Measures
(b) CISD was identical to that delivered in the All raided employees completed standard
CISD alone group. health questionnaires at day 3 post-raid, im-
(c) Each raided employee received an indi- mediately before the start of the CISD. Ques-
vidual counselling session, lasting between tionnaires were also collected 1 month after
0.5 and 1 hours, 1 month after the robbery. the raid and at 3, 6 and 12 months post raid.
In this session the same debriefer assessed The Impact of Events Scale
the employees recovery and identified The impact of events scale IES (Horowitz
any ongoing difficulties. Individually tai- et al., 1979) is a 15-item scale measuring both
lored advice and guidance was given, intrusive and avoidant symptoms of post-
structured around a cognitive-behavioural / traumatic stress. Respondents were asked to
problem focused model of intervention . rate on a 0, 1, 3, 5 scale how often 15 state-
For example, employees with sleep diffi- ments such as I had waves of strong feeling
culties were advised on sleep hygiene; about it or I tried not to talk about it were
those experiencing nightmares instructed true for them. Scores above 26 are regarded
on nightmare relief; avoidant employees as indicating significant clinical psychopa-
given advice on prolonged exposure. thology (Corneil et al., 1994).
Note: All interventions were delivered as The Post-traumatic Stress Scale
part of the companys standard support pro- The post-traumatic stress scale PSS (Foa
cedure. The company had a history of pro- et al., 1993) is based on the DSM (III) R
viding employee care and counselling after diagnostic criteria for PTSD (APA, 1987). It
raids. As raids increased in frequency, em- asks respondents to score on a 0, 1, 2, 3 scale
ployees expected to be given support and how troubled they are by symptoms such as
almost no one refused to take part in either distressing dreams or avoiding activities
CISD or CISM. Employees worked in close and situations which remind you of the event.
knit teams where supporting ones colleagues The General Health Questionnaire - 28
was seen as a key element of the occupational (GHQ-28)
culture which typified the day to day working The GHQ-28 (Goldberg & Hillier, 1979) is
environment. While refusal to participate a 28 item measure of psychological distur-
was always an option, only five people de- bance consisting of four, seven-item sections
clined to take part in CISD and two people in which relate to psychosomatic symptoms,
the initial CISD element of CISM. Of the 299 anxiety symptoms, social functioning and
people in the CISM condition offered indi- depression. Scoring is 0, 0, 1, 1 for each item.
vidual counselling one month after the raid, A score of four or above is regarded as
50 declined stating that they did not feel they indicating a significant level of psychiatric
needed to be seen by the debriefer again as caseness
Field trial of CISM v. CISD 355
Table 1: Outcome measures post raid for both intervention groups at day 3, 1 month and follow-
up, total sample and sample of respondents who returned data at all three time points.
Initial symptom severity was high with x time F=0.06, ns. On two out of the three
mean scores on both the IES and GHQ above outcome measures, therefore, the main ef-
the cut off points, which would indicate clini- fects of time and group x time demonstrate
cal concern. However, by 1 month post-raid, the superior outcomes for employees receiv-
symptoms had reduced considerably and re- ing CISM over CISD alone when initial symp-
mained low in both intervention groups at tom severity is controlled for. Furthermore,
follow up. At day three and 1 month, scores independent sample t-tests at each time point
in the CISD alone group were marginally reveal that the mean differences between the
lower than the CISM group. However, at groups were only significant at follow up
follow up the CISM group scored lower on all (IES: t=3.43 p<0.01; PSS: t=2.55, p<0.05,
measures. GHQ: t=0.49, ns) and in favour of the CISM
In the sample of employees for whom data group. This was true only for specific post-
is available at all three time points (n=217), trauma symptoms. GHQ scores were not
scores for 1 month and follow up measures significantly different between groups at any
were entered into repeat measures analyses time.
of covariance ( ANCOVA) with day three scores
entered as covariates to control for initial Clinical cases
post-robbery symptom severity, yielding the The mean symptom scores for the sample
following results. IES: group F=0.76, ns; as a whole (reported above) are well below
time F=22.43, p<0.001; group x time F=10.76, those considered clinically significant. How-
p<0.01. PSS: group F=1.68, ns; time F=20.57, ever, a proportion of employees continued to
p<0.001; group x time F=5.14, p<0.05. GHQ: experience raised levels of symptoms above
group F=0.57, ns; time F=3.89, p<0.05; group a clinical threshold. Figure 1 illustrates the
80
67.2
64.5
60
CISD alone
Percentage cases
CISM
40
20 15.7
12.3 11.3
5.3
0
Day 3 1 month Follow up
Table 2: Comparison of initial symptom scores at day 3 for employees returning subsequent
questionnaires compared to those that failed to return questionnaires at 1 month and
follow-up
PSS 1 month CISD 111 13.83 (8.67) 113 13.90 (10.41) 0.06 0.95
Measures CISM 247 15.53 (10.50) 52 14.64 (11.73) 0.55 0.58
Follow-up CISD 101 15.14 (9.44) 123 12.82 (9.58) 1.81 0.07
Measures CISM 152 15.45 (10.68) 147 15.31 (10.77) 0.11 0.91
GHQ 1 month CISD 111 7.50 (6.32) 114 7.18 (6.76) 0.37 0.71
Measures CISM 247 7.96 (6.48) 52 7.75 (7.07) 0.21 0.84
Follow-up CISD 101 8.25 (6.48) 124 6.59 (6.50) 1.91 0.06
measures CISM 152 7.65 (6.46) 147 8.21 (6.70) 0.74 0.46
ration of the initial CISD alone procedure Brewin et al. (1998) also suggested that inter-
into an integrated CISM system of pre-raid ventions of 48 hours in length might be
training and a short, focused mental health delivered to the 20% of trauma victims who
advice session one month after a raid to are in danger of developing chronic PTSD.
robbery victims produced significantly im- The results from the current study indicate
proved recovery rates in terms of mean symp- that in the context of an integrated CISM
tomatology. There was also a trend to signifi- system, significant improvement may be
cance for clinical caseness. Employees in the gained with even smaller investments of thera-
CISM group were less traumatised at later pist time and that these can indeed be achieved
follow-up and the proportion of clinically by intervening 1 month after a trauma.
significant cases was less than half the number
in the CISD alone group. Limitations
The timing of the extra individual session The results of this study are limited by its
in CISM deserves comment. A number of non-randomised field trial methodology. A
studies have suggested that at 1-month post more robust trial would have involved ran-
trauma it is possible to identify victims who dom allocation to the two groups with a no
will go on to develop chronic disorders and intervention control. This trade-off between
therefore, it is at this time that one should experimental rigour and pragmatic investi-
offer effective interventions. Rothbaum et gation is familiar to those working in post-
al. (1992) found that 1 month after a rape event situations where the nature of the serv-
trauma it was possible to distinguish between ice delivery contract and employees expec-
women who would recover and those who tations for post-incident care render no-treat-
were likely to develop chronic PTSD, a feat ment controls unethical and impractical
impossible closer to the time of the trauma. (Chemtob et al., 1997). Indeed, given that the
Field trial of CISM v. CISD 359
number of other people, supporting each other tarily entering into potentially traumatic situ-
and often socialising together. Social sup- ations. Thirdly, while both Bisson et al.
port has been identified as a major protective (1997) and Brewin et al. (1998) argue against
factor post-trauma, enhancing the opportuni- the provision of immediate services for all
ties for recovery (Joseph et al., 1992, 1997). victims suggesting instead a symptom moni-
Experiencing and recovering from traumatic toring system to pick up cases at one month
incidents together with ones colleagues in a post-trauma such a strategy is unlikely to
pre-existing supportive environment may lead engage victims in therapy unless initial con-
to better outcomes. tact has been made with victims earlier.
It is certainly possible, however, that the Evidence for the last point is unexpectedly
design of CISD as implemented in this study provided in Brewin et al.s own study (Brewin
1.52 hours long, in groups and as such et al., 1998), where less than 10% of those
much closer to the model proposed by Mitchell crime victims initially approached came for-
(1983) may have had more of a therapeutic ward into the study, despite being offered an
effect than the short, individually focused intervention not normally available to the
intervention procedures used in the published general public. Given the choice, the trauma-
negative effect randomised controlled stud- tised do not readily volunteer for assistance.
ies (Bisson et al., 1997; Brewin et al., 1998; CISD might work best as part of the inte-
Hobbs & Adshead, 1996). Certainly, the grated CISM approach proposed by Mitchell
level of clinically significant cases in this (Mitchell, 1983, Mitchell & Everley, 1997)
study even at 1-month post-trauma was by allowing the therapist or counsellor to
considerably lower than that found in similar build a rapport and establish competence.
victim populations in the UK. When coupled with the positive experience
reported by the majority of those debriefed,
Is CISD an appropriate early interven- CISD (and/or the SIT pre-trauma training)
tion? may lead to enhanced compliance with sub-
Whereas many studies have concentrated sequent interventions at one month post-
on long-term psychiatric morbidity, research- trauma or later. Indeed, in this study, even
ers, policy makers and service managers when CISD alone was offered as a standard
should remember that the potential beneficial intervention, the response rate to postal moni-
effects of CISD can also be measured in toring questionnaires (51% of those origi-
many other outcome domains. First, CISD is nally debriefed) was five times that of Brewin
a highly valued people management tool in et al. (1998). The effect of CISM was to
organisations, which suffer repeatedly from increase this engagement rate to 83% when
traumatic incidents. Studies have shown that employees were offered a visit from the
it is appreciated by both the traumatised and debriefer one month post raid.
their managers (e.g. Flannery et al., 1991;
Shapiro & Kunkler, 1990; Turner et al., 1993). Conclusion
Secondly, doing nothing in response to a
traumatic event is not an option for managers Despite its necessary methodological com-
where expectations of appropriate post- promises, this study has shown that embed-
trauma care are part of the implicit bargain ding CISD within an integrated CISM sys-
between employers and employees which tem can significantly reduce the levels of
facilitates employees repeatedly and volun- long-term morbidity in crime victims com-
Field trial of CISM v. CISD 361
pared to both a stand alone CISD intervention Busuttil, W. & Busuttil, A. (1997). Debriefing and
and morbidity levels reported elsewhere. The crisis intervention. In D. Black, M. Newman, J.
Harris-Hendricks. & G. Mezey (Eds.), Psychologi-
debate on the effectiveness of CISD itself is cal Trauma: A Developmental Approach, pp. 238
unresolved but it would be unwise to heed the 249. London: Gaskill.
calls to cease CISD on the basis of studies, Chemtob, C.M., Tomas, S., Law, W. & Cremniter, D.
which apply CISD alone in an inappropriate, (1997). Postdisaster psychological intervention: A
field study of the impact of debriefing on psycho-
individualised manner. Even if CISD alone
logical distress. American Journal of Psychiatry,
is clinically ineffective, it may serve to in- 154, 415 417.
crease the acceptability of and compliance Corneil, W., Beaton, R. & Solomon, R. (1994). In
with subsequent interventions. This study, Shapiro F. (Ed.), Eye Movement Desensitization
therefore, provides important evidence, which and Reprocessing: Level 1 Basic Workshop Manual,
p.39. Pacific Grove, EMDR Institute.
should be used in the development of CISM Curran, P.S., Bell, P., Murray, A., Loughrey, G., Roddy,
systems. Rather than the watered down, R. & Rocke, L.G. (1990). Psychological conse-
internally invalid procedures currently being quences of the Enniskillen bombing. British Jour-
cited as evidence against debriefing, CISM nal of Psychiatry, 156, 479 482.
Davidson, J.R.T., Hughes, D., Blazer, D.G. & George,
must now be studied in empirically rigorous
L.K. (1991). Post-traumatic stress disorder in the
randomised controlled trials. Such studies community: An epidemiological study. Psycho-
are sorely needed before policy makers should logical Medicine,21, 713 721.
heed the premature cries to cease debriefing. Fisher, N. & Jacoby, R. (1992). Psychiatric morbidity
in bus crews following violent assault: a follow-up
study. Psychological Medicine, 22, 685 693.
References Flannery, R.B., Fulton, P., Tausch, J. & DeLoffi, A.
(1991). A program to help staff cope with psycho-
American Psychiatric Association (1987). Diagnostic logical sequelae of assaults by patients. Hospital
and Statistical Manual of Mental Disorders (3rd Community Psychiatry, 42, 935 938.
edn. revised) (DSM-IIIR). Washington, DC: Foa, E.B., Riggs, D.S., Dancu, C.V. & Rothbaum, B.O.
American Psychiatric Association. (1993). Reliability and validity of a brief instru-
Avery, A. & Orner, A.A. (1998). First report of psycho- ment for assessing post-traumatic stress disorder.
logical debriefing abandoned the end of an era? Journal of Traumatic Stress, 6, 459 473.
Traumatic Stress Points, 12, 34. Foa, E.B., Rothbaum, B.O., Riggs, D.S. & Murdock,
Bisson, J.I., Jenkins, P.L., Alexander, J. & Bannister, T.B. (1991). Treatment of post-traumatic stress
C. (1997). Randomised controlled trial of psycho- disorder in rape victims: A comparison between
logical debriefing for victims of acute burn trauma. cognitive and behavioural procedures and counsel-
British Journal of Psychiatry, 171, 7881. ling. Journal of Consulting and Clinical Psychol-
Blanchard, E.B., Hickling, E.J., Mitnick, N., Taylor, ogy, 59, 715 723.
A.E., Loos, W.R. & Buckley, T.C. (1995). The Goldberg, D.P & Hillier, V.F. (1979). A scaled version
impact of severity of physical injury and perception of the General Health Questionnaire. Psychologi-
of life threat in the development of post-traumatic cal Medicine, 9, 139 145
stress disorder in motor vehicle accident victims. Green, B.L., Lindy, J.D., Grace, M.C., Glesser, G.C.,
Behaviour Research and Therapy, 33, 529 534. Leonard, A.C., Koro,l M. & Winget, C. (1990).
Bohl, N. (1991). The effectiveness of brief psychologi- Buffalo Creek survivors in the second decade:
cal interventions in police officers after critical Stability of stress symptoms. American Journal of
incidents. In J. Reese, J., Horn & C. Dunning Orthopsychiatry, 60, 4354.
(Eds.), Critical Incidents in Policing. Revised. Helzer, J.E., Robbins, L.N. & McEvoy, L. (1987). Post-
Washington DC: US Government Printing Office. traumatic stress disorder in the general population.
Brewin, C.R., Andrews, B. & Rose, S. (1998). A Findings from the epidemiological catchment area
preventative programme for victims of violent survey. New England Journal of Medicine, 317,
crime: A Study Funded by the NHSE Research and 1630 1634.
Development Programme. Final Report. London: Hobbs, M. & Adshead, G. (1996). Preventative psy-
Royal Holloway College University of London. chological intervention for road crash survivors. In
362 David Richards
M. Mitchell (Ed.), The Aftermath of Road Acci- OBrian, L.S. & Hughes, S.J. (1991). Symptoms of
dents: Psychological, Social and Legal Perspec- post-traumatic stress disorder in Falklands Veter-
tives, pp. 159 171. London: Routledge. ans five years after the conflict. British Journal of
Horowitz, M., Wilner, N. & Alvarez, W. (1979). Im- Psychiatry, 159, 135 141.
pact of event scale: A measure of subjective stress. Raphael, B. (1986). When Disaster Strikes. London:
Psychosomatic Medicine, 41, 209 218. Hutchinson.
Joseph, S., Williams, R. & Yule, W. (1992). Crisis Resnick, H.S., Kilpatrick, D.G., Dansky, B.S., Saunders,
support, attributional style, coping style and post- B.E. & Best, C.L. (1993). Prevalence of civilian
traumatic symptoms. Personality and Individual trauma and post-traumatic stress disorder in a rep-
Differences, 13, 1249 1251. resentative national sample of women. Journal of
Joseph, S., Yule, W. & Williams, R. (1997). Under- Consulting and Clinical Psychology, 61, 984 991.
standing Post-Traumatic Stress: A Psychosocial Richards, D.A., Lovell, K. & Marks, I.M. (1994). Post-
Perspective on PTSD and Treatment. Chichester: traumatic stress disorder: evaluation of a behav-
Wiley. ioural treatment programme. Journal of Traumatic
Keane, T.M., Fairbank, J.A., Caddell, J.M. & Stress, 7, 669 680.
Zimmering, R.T. (1989). Implosive (flooding) Richards, D.A. & Rose, J.S. (1991). Exposure therapy
therapy reduces symptoms of PTSD in Vietnam for post-traumatic stress disorder: 4 case studies.
combat veterans. Behaviour Therapy, 20, 149 British Journal of Psychiatry, 158, 836 840.
153. Robinson, R.C. & Mitchell, J.T. (1993). Evaluations of
Kulka, R., Schlenger, W., Fairbank, J., Hough, R., psychological debriefings. Journal of Traumatic
Jordan, B. & Marmar, C. (1990). Trauma and the Stress, 6, 367 382.
Vietnam War Generation. New York: Brunner Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T.
Mazel. & Walsh, W. (1992). A prospective examination of
Madakasira, S. & OBrien, K.F. (1987). Acute post- post-traumatic stress disorder in rape victims. Jour-
traumatic stress disorder in victims of a natural nal of Traumatic Stress, 5, 455 475.
disaster. Journal of Nervous and Mental Disease, Shapiro, D. & Kunkler, J. (1990). Summary of a Report
175, 286 296. on Psychological Support for Hospital Staff initi-
Marks, I., Lovell, K., Noshirvani, H., Livanou, M. & ated by Clinical Psychologists in the Aftermath of
Thrasher, S. (1998). Treatment of post-traumatic the Hillsborough Disaster. Sheffield: Sheffield
stress disorder by exposure and/or cognitive re- Health Authority Mental Health Services Unit.
structuring. Archives of General Psychiatry, 55, Turner, S.W., Thompson, J. & Rosser, R.M. (1993).
317 325. The Kings Cross fire: early psychological reac-
Mitchell, J.T. (1983). When disaster strikes. The criti- tions and implications for organising a Phase Two
cal incident stress debriefing process. Journal of response. In J.P. Wilson & B. Raphael (Ed.), Inter-
Emergency Medical Services, 8, 3639. national Handbook of Traumatic Stress Syndromes.
Mitchell, J.T. & Everly, G.S. (1997). Scientific evi- New York: Plenum Press.
dence for CISM. Journal of Emergency Medical Wessley, S., Rose, S. & Bisson, J. (1998). A systematic
Services, 22, 8793 review of brief psychological interventions (de-
Norris, F.H. (1992). Epidemiology of trauma: fre- briefing) for the treatment of immediate trauma
quency and impact of different potentially trau- related symptoms and the prevention of post trau-
matic events on different demographic groups. matic stress disorder (Cochrane Review). In The
Journal of Consulting and Clinical Psychology, Cochrane Library, Issue 3. Oxford: Update Soft-
60, 409 418. ware.