CRITICAL INCIDENT STRESS MANAGEMENT CISM

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CRITICAL INCIDENT STRESS MANAGEMENT (CISM)

• Brian A. ChopkoThe University of Akron

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Psychological Debriefing

• CISM
• CISD

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The following definitions are provided by
Mitchell and Everly

• (2003)

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CRISISa response to an event wherein

• an individuals psychological homeostasis is
  disrupted
• ones usual coping mechanisms have failed
• there is evidence of distress and significant
  functional impairment

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CRITICAL INCIDENT

• the event which has the potential to engender a
  crisis response often confused with the crisis
  response itself.

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CRISIS INTERVENTION

• as physical first-aid is to surgery, crisis
  intervention is to psychotherapy

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CRITICAL INCIDENT STRESS MANAGEMENT (CISM)

• a comprehensive, integrated multi-component
  crisis intervention system

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Functional Goals of CISM

• Symptom stabilization
• - prevent the symptoms of distress / impairment
  from worsening.
• Symptom reduction
• Re-establish functional capacity
• Seek further assessment and
• / or a higher level of care

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CISM

• spans the entire temporal spectrum of a crisis
• consists of a set of core interventions

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CISM includes the following ten points

• Pre-crisis planning/education
• Individual crisis intervention (one-on-one)
• Small group crisis intervention- Defusing
• Small group crisis intervention- Critical
  Incident Stress Debriefing (CISD)
• Large group crisis intervention- Demobilizations
  (for public safety, rescue, disaster personnel)

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CISM includes the following ten points

• Large group crisis intervention- Crisis
• Management Briefing (CMB) for civilian
  populations, schools, businesses, communities,
  etc.
• 7. Organizational consultation
• 8. Family crisis intervention
• 9. Pastoral crisis intervention
• 10. Mechanisms for follow-up and referral

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Types of Psychological Debriefings

• CISD
• The Raphael Model
• Process Debriefing
• ASAP (Assaulted Staff Action Program)
• NOVA

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CISM Critics

• Lits Gray, 2002
• Gist, 2002

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Lits Gray, 2002

• Most people exposed to trauma
• adapt well on their own
• Victims should be assisted in the least intrusive
  manner
• Recovery will occur naturally
• Formal preventative interventions should only be
  provided to those individuals who show elevated
• risk for chronic PTSD

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The following should be assessed to make
decisions about resource allocation

• Prior Trauma
• Social Support
• Hyperarousal
• Post-traumatic resources

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Criticizing CISM

• Suggests
• no formal interventions should be considered
• Reports
• no study included to support claims of the CISD
  approach is not sufficiently internally valid
• several RCTs found no evidence to support the
  use of single session to individual trauma
  survivors

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Criticizing CISM contd

• States
• carefully designed RCTs debriefings adhering
  rigorously to the boundary conditions of CISD
  need to be conducted
• it is premature to conclude that psychological
  debriefings worsen adaptations to trauma (based
  on flawed studies using MVAs and burn victims)

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CISM is criticized because

• it does not take into account research on risk
  for PTSD
• it has no formal screening or assessment to
  identify those who could benefit from intervention

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CISM Critics

• Gist, 2002

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The Cochrane Reviews (2001)

• There is no current evidence that psychological
  debriefing is a useful treatment for the
  prevention of PTSD after traumatic incidents.
  Compulsory debriefing of victims of trauma should
  
• cease.

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The Health Services of New South Wales in
Australia

• In preparation for the 2000 Olympic Games in
  Sydney concluded that most investigations have
  found that debriefing at best has no effect and
  some have found psychological debriefing may
  actually interfere with recovery.

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The British National Health Service

• lists debriefing as contra-indicated for
  victims of trauma based on studies reported in
  the scientific literature.

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Other critics of CISM

• The International Society for Traumatic Stress
  Studies (ISTSS 1998)
• U.S. Department of Defense and the National
  Institute of Mental Health (2001)
• NATO-Russia Advanced Workshop on Social and
  Psychological Consequences of Chemical,
  Biological, and Radiological Terrorism (2002)

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Conclusions of Critics

• Cognitive distancing may represent a far more
  functional approach
• Studies repeatedly found no evidence of
  preventive impact compared to nonintervention
  controls

• The following CISM strategies may overload coping
  systems
• emphasis in debriefing on immediacy (24 to 72
  hours)
• heavy emphasis on reconstruction of the traumatic
  episode
• articulation of the most distressing emotional
  episode

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Middle Ground Thinking

• Van Emmerik Arnol (2002)
• Morrison (2000)

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Van Emmerik Arnold(2002)

• Meta-analysis was based on small numbers of
  studies
• Despite empirical research showing no efficacy in
  single session CISD
• this is not the only reason debriefings are
  offered

• Conducted meta-analysis on single session
  debriefings (various types)
• Found CISD was no more effective than non-CISD
  interventions

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Other aims include

• reduction of immediate distress and
  identification and referral for further treatment
  for those at risk of developing more severe
  symptoms
• Perceived helpfulness by participants might be
  sufficient reason to continue to offer
  debriefings.

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Middle ground thinking

• Premature to conclude that psychological
  debriefings worsen adaptations to trauma
• Debriefing seen as a tool to
• validate feelings
• confront inappropriate responsibility/guilt
• normalize stress reactions
• integrate the traumatic event

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ARGUMENTS SUPPORTING CISM

• Mitchell Everly (2003)
• Everly, Flannery Eyler (2000)
• Mental Health and Mass Violence (2002)
• Robinson (2000)

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Mitchell Everly(2003)

• CISD
• designed to be only one component of
  comprehensive multi-component crisis intervention
  program (CISM).
• never designed to used as a one shot or stand
  alone intervention outside of the CISM system.
• can mitigate the symptoms of psychological
  distress even when
• used outside of context

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Mitchell Everly(2003)

• The practical utility of some of the reviews and
  the validity of their conclusions have been
  compromised
• Only studies purporting to specifically assess
  the CISD model were analyzed

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Everly, Flannery Eyler(2000)

• Conducted a meta-analysis to assess the overall
  magnitude and effectiveness of CISM
• A large effect size was revealed attesting to the
  power of CISM to mitigate symptoms of
  psychological distress

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RobinsonMethodological Weakness of Studies
(2000)

• No pre-trauma baseline data
• No description of the debriefing interventions
  used
• Unrealistic expectations of
• debriefings

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Robinson

• CISM commonly studied in large-scale emergencies
• CISM more commonly used in day-to-day incidents
  with high impact

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Robinson

• CISM is designed for secondary victims
• ie emergency service personnel
• Primary victims show different kind of trauma

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Support Summary

• Research showing no or possible harmful effect is
  methodologically flawed
• Critics of CISM say debriefings should be
  abandoned until clear evidence of effectiveness
  is available
• Controlled and randomized studies
• with clearly defined variables are
• needed

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Support SummaryMorris (2002)

• Future research should examine
• Appropriate populations
• Personal qualities and skill
• Application of techniques
• Where most effective

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