Crisis Management International - When Doing the Right Thing Might Be Wrong

  When Doing the Right Thing Might Be Wrong
      Research questions the value of Critical Incident Stress Debriefings (CISD)
      By Tonya T. Slawinski. Ph.D., Director of Training & Development,
      & Bruce T. Blythe, CEO

It is natural to want to offer help to those who are danger or pain. This altruistic impulse has contributed to the widespread use of Critical Incident Stress Debriefings (CISD) as a means of alleviating emotional and psychological pain in the aftermath of a crisis. However, in recent years there has been a growing body of research that challenges the efficacy of debriefing as it is currently practiced. Understanding of what works in post-crisis intervention is evolving, and an alternative model to the CISD is emerging.

Overview

Individual and group debriefings seem effective. Individuals who have participated in debriefings report that they appreciated the process and the fact that their companies have provided this service. It is easy enough to see that when one has been affected by a frightening or tragic event, personal attention and emotional support would seem helpful.

In the aftermath of the September 11th attacks, for example, Crisis Management International surveyed those to whom we had provided debriefings and there was an overwhelming response from participants saying that they found process helpful. However, responses given immediately following a debriefing process may be shaded by affected people's eagerness to feel better, or even their desire to comply with expectations that they should feel better after attending a meeting clearly intended to help them. There is no doubt that human kindness in the immediate aftermath of a crisis is valued by the victims. But we must also consider what the research shows regarding the long-term outcomes of debriefing.

Additionally, there has been recognition that the emergence of distress, grief or other reactions to a critical incident are highly individualized, unpredictable and unlikely to conform to a time frame pre-determined by any "helping model." Some individuals report reactions in the immediate aftermath of a critical event, while others may report reactions that surface slowly in the ensuing weeks or months. We have also recognized that some individuals may report few if any reactions following a crisis, which emphasizes the uniqueness of the response. Since the reactions to a critical incident are so varied, why should the intervention and support we offer be so limited?

As practitioners, our first obligation is to do no harm. But practitioners embraced Critical Incident Stress Debriefing before there was a solid foundation of evidence-based research to support or reject its efficacy. Research on debriefing is only now in its infancy, but it is important to note the implication that there is evidence emerging of a negative impact on a subset of the population receiving debriefing.

To address the potential problems that the research has begun to highlight, Crisis Management International has developed a Resiliency Management Model designed. Starting from a strengths-based perspective, its intention is to enhance natural resilience. It is built off the CISD platform, but meant to minimize the distress that CISD can cause for some people. The Resiliency Management Model eliminates some components of traditional debriefings - the rehashing of graphic details, and pathologizing – and replaces them with approaches designed to encourage natural recovery mechanisms and relationships of support. In appearance, the new model is not unlike the traditional CISD group. However the evidence-based methods it employs provide practitioners with defensible, ethical and effective post-crisis intervention services.

Why a resiliency-based approach? The literature on resiliency "suggests that most, if not all, humans have a capacity for overcoming the harshest of experiences and most actually do. For intervention, we must replace the imagery of deficits and pathology with imagery of strengths and resilience." (Rapp, 1998, p. 17) The concept of resiliency is not new, but embedded in therapeutic paradigms of treatment with families, children and other vulnerable populations. The focus shifts from pathology to a competency-based, strengths-oriented program, the value of which is inarguable.

The Origins of Debriefing

CISD was originally developed by Jeffrey T. Mitchell, Ph.D., an associate professor in the Department of Emergency Health Services at the University of Maryland. At a time when the standardized practice of crisis response was in its infancy, CISD was a welcome tool. Mitchell himself now says in response to the controversy that has arisen over the practice, "CISD was never intended to be a 'stand alone' intervention, nor a substitute for psychotherapy." He prescribes it as one element of an "integrated, multi-component crisis intervention system." Unfortunately, however, most providers of early crisis intervention services do not adhere to his multi-component system.

One of the shortfalls of debriefing is the lack of standards for judging the competency of its practitioners, or how they employ the technique. The broad willingness to adopt the practice may have been a function of our culture's fondness for the quick fix, or just a consequence of that perfectly human desire to assist people in need. "Prior to the 1980's," notes Michael Culotti, a consultation specialist at National Employee Assistance Service, Inc., "in the aftermath of disasters, basically nothing was done from a mental health perspective, and people were left to themselves. Then because of what we were learning from the Vietnam vets [about Posttraumatic Stress Disorder], something had to be done. And debriefing was the first thing that was developed. It seemed to be effective. At least you were doing something." But now, he says, debriefing is many corporate managers' default response to any potentially upsetting event.

Doubts about Debriefing Cannot Be Ignored

Findings that bring into question the effectiveness and even the safety of debriefing include:

The Cochrane Review, a collaborative survey of research studies produced at Oxford University and supported by the UK government, general practitioners, psychiatrists, counselors and psychologists concluded, "There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease."
The British National Health Service now considers debriefing "contraindicated" for victims of trauma.
The Health Service of New South Wales, Australia, in preparing for the 2000 Olympic Games in Sydney, surveyed the literature and found "no evidence to support the notion that debriefing should be offered to everyone involved in a major traumatic event."
The US Department of Defense and the National Institute of Mental Health convened a scientific consensus conference following the events of September 11, 2001, at which all but one of 60 experts agreed on eliminating references to debriefing – other than non-psychological operational debriefing – from guidelines for responses to incidents of mass violence.
The American Red Cross and American Psychological Association, conducting a joint review of disaster response protocols, have stated in a draft conclusion that post-trauma debriefing "has not been shown to prevent later difficulties and may even cause problems to become entrenched or more severe over time." Many other reviewers, including those at the International Society for Traumatic Stress Studies, have reached similar conclusions.

Obviously, more research is called for. But given the disturbing trend of these recent conclusions, practitioners need to re-consider their use of the CISD techniques, as these interventions may, at best, be ineffective and could even result in negative outcomes.

A New Model for Supporting People after a Crisis

Post crisis psychological/emotional support should emanate from a strengths based perspective. Crisis counselors should focus on positive coping strategies, not painful rehashing; and support programs should include both initial assessment and ongoing follow-up. Here are some suggestions, which are incorporated into the model that Crisis Management International now prefers:

Post-incident meeting. Within 24 to 72 hours post-incident, invite your impacted employees to a meeting; we call these Service Offering Sessions. The purpose is primarily to offer and describe a range of resources and information among which individuals can choose, such as referral to an Employee Assistance Program, on-site group sessions, and details about available medical benefits. This informational meeting is a management meeting, but not a psychological debriefing.
Group sessions. For those who are interested, crisis professionals should be available to provide a Group Resiliency Briefing, in which practical methods for positive coping are detailed. In this model, people are encouraged to share their reactions without rehashing distressing facts about the incident. The "sharing experience" of CISD is retained, but without the graphic re-enactment. This still gives counselors an opportunity to identify individuals who may need additional, personalized support. The resiliency model encourages use of the social support systems people already possess, such as family members, friends, co-workers and religious institutions. Support is the foundation for resiliency. Group resiliency briefings replace traditional CISD groups.
Individual sessions. As part of the recovery process it will be important for some individuals to examine their experience more fully. Individual Resiliency Briefings are beneficial for those who may want extra support. Verbalizing their experience and emotional reactions in a one-to-one setting with a crisis counselor provides not only additional individual support, but also avoids unnecessarily exposing others to additional traumatic material that could increase their distress.
Follow up. Crisis professionals should intermittently follow-up on participants' progress through brief surveys or other appropriate method. CMI's policy is to follow up at a minimum after two weeks, six weeks and one year. This follow-up provides a chance to assess those who are not adequately recovering over time, and to offer them additional assistance or referrals.
Additional resources. We at CMI have developed a web site for employees of our client companies that details numerous resiliency techniques people can use to enhance their positive coping. Employees, their families and close supporters can draw upon the resources of the site 24-hours per day, and in complete privacy, in the months following an incident.

Conclusion

CISD was developed in response to a real need, but has remained unchanged and unchallenged since then; a norm was established. However, best practice requires that norms be evaluated, and re-affirmed, refined or replaced if no longer efficacious. Of course, when a norm is challenged, and change is indicated, it can be unsettling.

It is our belief that by challenging the norm, we have an opportunity to expand the understanding and knowledge of crisis intervention both among practitioners and within the community at large.

Tonya Teal Slawinski, Ph.D. is the Director of Training and Development at Crisis Management International. She has been an adjunct faculty member at the University of Pittsburgh since 1996 and actively involved in crisis response since 1990.

Bruce T. Blythe, CEO of Crisis Management International, and author of Blindsided: A Manager's Guide to Catastrophic Incidents in the Workplace, heads a worldwide network of crisis consultants. He has worked with hundreds of companies dealing with crisis preparedness, response and recovery, and business continuity. CMI's focus is to prepare companies for potential crises and then help shell-shocked executives pick up the pieces, in virtually every aspect of crisis management.

Reference:

Rapp, C.A. (1998). The Strengths Model: Case management with people suffering from severe and persistent mental illness. New York, NY: Oxford University Press.



		Blindsided is the authoritative guide to crisis management. This "how to" handbook gives essential advice that every manager needs to know when a crisis hits. Written by CMI Founder/CEO Bruce Blythe, it's a fascinating, easy-to-read guide that draws on Blythe's 20+ years of experience as a pioneer in crisis management.