Refugees and Internally Displaced Persons:
Challenges Confronting the International Community
Ellen Frey-Wouters, PhD, LLB
Contributing editor, International Organizations
The need for protection and assistance of more than 40 million of the world's refugees and internally displaced persons -- the victims of armed conflicts -- constitutes a major challenge to the international community. In many situations, these needs have not been met effectively, and serious gaps in provisions have been evident. Most disturbing from the point of view of ISTSS is that the international community often ignores that the psycho-social harm inflicted on traumatized persons can be as damaging as physical pain and insults, and must receive equal attention.
U.N. Secretary-General Kofi Annan noted in June 1998:
"In the past year, there has been more evidence of ... disturbing trends. ... There has been further erosion in the respect for humanitarian principles, both in terms of denial of access to people in need and through deliberate violence against civilians and aid workers. ... Increasingly, such attacks have become the objective of armed conflict, rather than an unfortunate byproduct. Warring parties seek to terrorize populations into leaving specific areas. Hatred and suspicion between members of different ethnic or religious groups are incited by ... faction leaders." (Document A/53/139-E/1998/67,p.3)
Strengthening Coordination of U.N. Emergency Humanitarian Assistance
During the ECOSOC Substantive Session in July 1998, the first humanitarian segment was held to identify challenges facing the international community in the field of emergency humanitarian assistance. This segment was part of the implementation of the U.N. program of reform endorsed by the General Assembly. Reflecting these changes, the Department of Humanitarian Affairs became the Office for the Coordination of Humanitarian Affairs, with a focus on three core functions: policy development and coordination, coordination of humanitarian emergency responses, and advocacy of humanitarian issues.
In January 1998, Sergio Vieira de Mello of Brazil was appointed to head the new office, as undersecretary-general. ISTSS would like to express its full support to the creation of OCHA and the nomination of de Mello. For the society, this has proven to be a fortunate choice. His previous experience in humanitarian and peacekeeping operations, as well as his many field visits, make him fully aware of the traumatic impact of armed conflict on refugees and internally displaced persons.
On July 15, during the ECOSOC Humanitarian Segment, de Mello stated: "Since my appointment ... I have visited four of the regions in which humanitarian programs are facing the most severe challenges. In Afghanistan, we are confronted by a country brought to its knees by a conflict, which has now lasted over 20 years. Inhumane policies of discrimination against women in large parts of the country pose particular difficulties for humanitarian agencies. In Sierra Leone, I saw with my own eyes the victims of unspeakable atrocities committed by supporters of the former junta. ... In Angola, I saw how new waves of displacement are resulting from a contested peace process and how new land mines have been planted in several areas."
As a result of the special segment, the way the U.N. system can move forward has become clearer. Complex emergencies require an integrated response by a widerange of national and international governmental and nongovernmental actors. The role of OCHA is to facilitate the development of a concerted response in which each actor is able to fulfill its mandate within a jointly agreed framework. Progress has been made in defining ways of doing this in different sets of circumstances, recognizing that each situation is sui generis and requires its own model.
New forms for joint programming and partnerships among OCHA, the High Commissioners for Refugees and Human Rights, UNICEF, UNDP, U.N. Peace-keeping Operations, the World Food Program, and a widerange of committed and skilled NGOs are being developed. The status of ISTSS at -- and within involvement with -- all relevant aspects of the work of the United Nations has become more important than ever.
ISTSS Participation in ECOSOC Deliberations
As an ISTSS representative, I presented two written and oral statements during the ECOSOC session. On July 14, in a special workshop on refugees and internally displaced persons chaired by Undersecretary-
General de Mello, I pointed out that millions of refugees and internally displaced persons run a risk of depression, anxiety disorders, PTSD, and other forms of mental distress caused by traumatic experiences including the violent death or torturing of a parent, husband, or close relative; family separation and displacement from home and community; participation in or witnessing of atrocities; exposure to combat; and other life threatening situations. They are often the victims of abuse and are arrested and held in detention camps. Scholarly literature, especially a range of studies presented in the Journal for Traumatic Stress Studies, indicates that without a support system, refugees and internally displaced persons are vulnerable to various stress reactions. The nature of the reaction depends on the type of trauma, the number of traumatic stressors, the frequency and length of exposure and the person's individual characteristics. Response to trauma can be immediate or delayed for weeks, months, or years.
Strategies for coping with and reacting to stress and trauma differ markedly between cultures, communities, and individuals. An understanding of cultural differences and local traditions for dealing with stress must be the starting point of any intervention effort, and community participation must be ensured.
In the speech, I indicated that ISTSS members would be interested in participating in the identification of appropriate psychotherapeutic methods. ISTSS is aware that while many forms of external interventions can promote psycho-social recovery, psychotherapeutic approaches based on western models may not be feasible in all contexts.
On July 28, in regard to social and human rights questions, I made four specific recommendations covering better training of U.N. and NGO personnel, with specific emphasis on:
- Expertise in trauma treatment;
- Improved cooperation, especially in the field between relevant governmental and NGO agencies;
- Strengthening of emergency preparedness and monitoring and evaluation efforts; and
- Greater attention to the provision of services for traumatized U.N. and NGO help givers.
I observed that ISTSS encourages contracts between NGOs, including ISTSS, and U.N. agencies. Existing contractual arrangements such as the UNICEF/University of London program in Mostar and Zenica, the UCLA and UNICEF project in Bosnia, and others were used as examples.
ISTSS Status and Involvement at the United Nations
Except for two additional speakers, no other representatives during a four-week conference addressed the traumatic stress dimensions of armed conflict and other man-made and natural disasters. The ISTSS must remember that some influential members of the U.N.'s international community argue that few people are traumatized in war and natural disasters, and the concept of PTSD is a Euro-American concept that has little, if any, place in international thinking.
Yet, one may conclude that the current climate at the United Nations is ready for the wide involvement of members of ISTSS in U.N. activities on all levels. The ISTSS is not alone in its dedication to the discovery of knowledge and advancement of policy and service initiatives that seek to reduce traumatic stressors and their immediate and long-term consequences. By invitation of the U.N. Division for Social Policy and Development and OCHA, I am developing several ISTSS/U.N. joint activities along with ISTSS members Matthew Friedman and Terence Keane.
Finally, ISTSS must pay tribute to the courage and dedication of U.N. and NGO aid workers throughout the world who face daily the traumatic realities of refugees and internally displaced persons.
In response to one child refugee's fate, James Kunder, a special advisor to UNICEF, stated: "Esmeralda does not know the word for artillery, but she remembers clearly the night her hamlet exploded. In drawings, she pictures the ground littered with pieces of bodies. She remembers running through dense forest for days, where it was always cold and wet, and where horrible insects crawled at night. Her younger brother, she recalls, coughed constantly until he died. Now she lives in a place called a 'camp.' The adults who guide her through her eight years cry a lot now, and strange men come in the evening to issue orders."
In January 1997, I visited a refugee camp for Rwandan children in Goma. I came away numb with disbelief that human beings could suffer so much mental and physical pain. We, the members of ISTSS, serve as witnesses and must do everything possible to ease the trauma of refugees and internally displaced persons. We must commit ourselves to soften their miseries.
Editor Says Goodbye, Passes Newsletter Reins
Arthur S. Blank Jr., MD
It has been an honor to serve as editor of Traumatic StressPoints for the past four years. I am now moving on, and Elana Newman begins as editor.
Traumatic StressPoints continues to grow and develop as a central member benefit and has won an award for its improvements in the association management field. The society has implemented a number of contributing editors for special areas, improved the format, encouraged the publication of views on critical and controversial issues, and enhanced overall society and traumatic stress news coverage. Plans for Web site editions in languages other than English are in the works to encourage the society's international scope.
Angelo Artemakis has also moved on from the Sherwood Group Inc. and Felicia Strong is the new managing editor at headquarters.
My best wishes to the leaders and members of ISTSS.
Annual Conference Signals Changes
Sandra Bloom, MD
The ISTSS 14th Annual Conference in Washington, D.C. is almost upon us, and that signals the end of my presidency. A year turns out to be a short time, in the grand scheme of things, but it has been a pleasure to be a part of what ISTSS has accomplished. Congratulations to the Millennial President, John Fairbank and newly elected board members Rachel Yehuda, Susan Solomon, Bonnie Green, Roger Pitman, and Daniel Kaloupek.
The ISTSS pamphlet Childhood Trauma Remembered is being disseminated around the country and internationally, and the society can be proud of this terrific accomplishment. A press conference about the pamphlet should be held before year-end. The managed-care survey results are being tabulated as of this writing, and a report should be ready by the annual conference, Nov. 19-23.
The society is pursuing a plan, approved by the board and spearheaded by David Mackey and Ray Scurfield, to increase membership diversity. With the guidance of Bessel van der Kolk, the society also is developing a strategy to pursue a public policy initiative. A mammoth effort is under way, thanks to Edna Foa to have a draft of the Practice Guidelines for PTSD ready to present to the board at the annual meeting.
One of my saddest tasks is to say goodbye to Art Blank as the editor of Traumatic Stresspoints. Art has been a positive and stabilizing force in the society, at the board meetings, and as Stresspoints editor for many years. He has served as an important voice of institutional memory and will be sorely missed. The society wishes him well in his new and exciting endeavors. Art has chaperoned the new Editor, Elana Newman, through the initiatory process of putting out the fall issue. Welcome to Elana and thanks for pitching in, yet again.
As the annual meeting titled "Ending Cycles of Violence: Integrating Research, Practice and Social Policy" draws closer, I want to share a few thoughts about the meeting and the process involved in formulating the program. This year there were more than 450 submissions for 160 time slots. Not only has the quantity of submissions increased, but the quality was unusually good. This made the decision-making tasks almost impossible. ISTSS is extremely diverse -- multidisciplinary, multinational, and multispecialized, representing every known survivor group -- and every effort was made to address this diversity, while including as many submissions as possible. The society realizes how vital acceptance becomes when trying to obtain funding to attend the conference so the selection committee tried to accommodate as many members as possible. At the same time, if the society is to grow, it is important that new people are encouraged to join and cross-fertilize. The committee sought to address that need as well. The result is that, as in previous years, the schedule is packed. Many contributors will be disappointed that they did not receive the amount of time requested or had good proposals turned down. The committee had to make difficult decisions so that the conference could have something for everyone, and I think we have accomplished that goal.
I mention all of this to suggest that soon, we must consider how best to meet the needs of this expanding society. Should the conference be longer? Is there some other way to address quantity without sacrificing quality? These questions must be taken up by the board, but I hope members will share their opinions on the evaluation forms as well.
I am excited about the conference, but like everyone else, I am going to wish I could split myself in two (or maybe five). There will be a variety of tracks that attendees will be able to follow throughout the conference if they choose -- Liz Kuh's and my way of trying to impose a little more structure on this mammoth affair.
The posters will be on view throughout the conference, and a session will be scheduled for the presenters to be with their posters all at once. The specialty training course schedule is exciting, and I urge attendees to choose one. We have tried to make the theme sessions have a coherent thread, have named them, assigned them to a track, and appointed chairs for each one. Make a point to come to the banquet this year -- I arranged for a friend of mine, a West End performer, Simon Green, to do a piece of his cabaret show.
I hope to see you in Washington, D.C., and as I move aside and welcome our new and first truly international President, Sandy McFarlane, I hope that ISTSS will continue to pursue excellent research, dedicated practice, and a commitment to positive social change.
Promoting Membership Diversity in ISTSS:
Recent Initiatives for Growth and Development
David Mackey, MSW, and
Raymond Scurfield, DSW
The ISTSS recently took a significant step in its organizational growth and development by launching a plan to increase diversity within the society's membership and among participants at annual meetings. This article describes initial efforts regarding this endeavor and solicits active input from anyone who would like to contribute ideas and creative energies.
In 1994, Arthur Blank, then vice president of ISTSS, spearheaded discussions that spawned ideas for strengthening the organization's appeal to a diverse range of new and potential members. In recent years, there has been a positive increase in international membership. However, there has been minimal membership representation and relatively little involvement in annual meetings from African Americans, Hispanics/Latinos, Asian American/Pacific Islanders, and Native Americans. Professional and peer counselors who work with physically disabled, homeless, alternative lifestyle, and sexual orientation populations also are underrepresented. Consequently, we have proposed initiatives to increase diversity.
In response, ISTSS President Sandra Bloom and the board of directors have invited us to coordinate the development of a committee to implement a plan for achieving this
goal and allocated organizational resources to support the committee's efforts. The initial action plan -- an interorganizational outreach campaign aimed at the vigorous recruitment and retention of new members -- targets relevant segments of established, broad-based professional groups such as the American Psychological Association's Office of Ethnic Minority Affairs, the National Association of Social Workers' Committee on Minority Affairs, and the Council of Social Work Education's Commission on Gay Men and Lesbian Women. Additionally, the committee will seek to offer financial incentives for students throughout the various social-service disciplines to become active members. Outreach to other organizations, such as self-help groups, is also of interest.
The committee also welcomes suggestions about individual and organizational contacts who could help increase the participation and diversity of attendees and agency representatives at annual meetings, especially by those who are from the region in which the meetings occur. Ultimately, the committee's aim is to encourage the ongoing, active involvement in ISTSS of diverse groups and viewpoints among workshop presenters, symposia discussants, and committee participation and leadership.
If you have questions about these efforts or would like to become involved in committee activities, contact David Mackey, clinical coordinator, U. S. Department of Veterans Affairs Vet Center, 4801 Swift Road, Suite A, Sarasota, FL 34231; phone, 941/927-8285; e-mail, Songal@AOL
.com; or Raymond Scurfield, assistant professor, School of Social Work, University of Southern Mississippi; phone, 228/867-8797; e-mail, Raymond.Scurfield@USM.edu.
Origins and Development of the ISTSS -- Part II
Sandra L. Bloom, MD
This is the second in a series of articles that look at the origins and development of the ISTSS. It includes edited excerpts from Our Hearts and Our Hopes Are Turned to Peace: Origins of the ISTSS, to be published by Plenum in the new volume,International Handbook of Human Response to Trauma, edited by Sandy McFarlane, Arieh Shalev, and Rachel Yehuda.
In the late 1960s, Sarah Haley worked as a social worker at the Boston Veterans Administration Hospital. At the VA hospital, young men returning from the Vietnam War presented severe psychiatric symptoms. These men were routinely diagnosed as character disordered or paranoid schizophrenics, but Haley did not entirely concur. Unlike most of her colleagues at the time, Haley recognized that many of her patients who had seen combat in Vietnam were being misdiagnosed because mental health professionals had failed to recognize the symptoms related to war. But she knew them.
Haley had grown up with a father who was a World War II veteran, a special agent for the OSS, and an alcoholic. She had heard stories of trauma and wartime atrocities from the time she was a little girl and had personally experienced the long-term impact of war on her father's behavior and his treatment of her.
When she met a Vietnam veteran who claimed to have been involved in the massacre of a village called My Lai, she did not conclude that he was delusional -- she believed him. It was through Haley that Robert Lifton met and interviewed that soldier (Scott, 1993).
Lifton, an ardent anti-war activist, had served in Korea as a military psychiatrist; by the time he met the soldier from My Lai, he had already studied and written about the survivors of Hiroshima (Lifton, 1967). Lifton and Haley met through mutual contacts at the New York and Boston chapters of the activist veterans' group, Vietnam Veterans Against the War. In January 1970, Lifton testified to a Senate subcommittee about the brutalization of soldiers in Vietnam, a brutalization that he believed made massacres like My Lai inevitable (Lifton, 1973). In April 1970, the United States invaded Cambodia, and students across the country rose up in protest.
Within days, the Ohio National Guard had fired into a crowd at Kent State, killing four students and wounding nine others -- an act that provoked an outpouring of rage and despair throughout the country. The nation was divided, campuses were in upheaval, authority was being challenged everywhere, and, yet the war continued. Many returning veterans suffered the brunt of this enormous social conflict. On one hand, some anti-war activists and pacifists labeled the veterans baby killers. On the other hand, the military establishment refused to see the damage that had been done -- and continued to be done -- to those men.
John Kerry (now Senator John Kerry) was a founder of the VVAW and holder of three Purple Hearts, a Bronze Star Medal, and a Silver Star Medal for his service in the war. He reported that a Minnesota American Legion post excluded Vietnam veterans because they lost the war (Shatan, 1987).
The military even victimized some veterans as they left the war by giving bad discharge numbers. According to a discreet coding system, numbers were entered on discharge papers that identified veterans who had been considered troublemakers while in the service; the codes were distributed to employers and personnel officers. In the media, especially television, the stigmatization was furthered by the portrayal of Vietnam veterans as dangerous and psychotic freaks, murderers, and rapists (Leventman, 1978).
In response to this discrimination, the veterans and their supporters organized a counterVA composed of therapeutic communes, storefront clinics, veteran centers, and bars. The counterVA organized social and political protests and conducted street theater with mock pacification operations in New Jersey. In December 1970, another veterans' group, the Citizens' Commission for Inquiry into U.S. War Crimes in Vietnam, held the first war crime hearings in Washington, D.C., at the Dupont Circle Hotel. Shatan and Lifton testified at the hearings as did congressmen Conyers and Dellums, who made sure that a report was entered in the Congressional Quarterly in 1971 (Shatan, 1998).
In January 1971, the VVAW organized war crime hearings in Detroit called the Winter Soldier Investigation. Robert Lifton, along with 115 veterans, presented testimony about atrocities committed during the Vietnam War. In most of the major activist actions that the veterans took, mental health professionals went too, moving beyond therapy and detachment to advocacy.
As Shatan noted years later, "We went, with the veterans, wherever we could be heard: to conventions, war crimes hearings, churches, Congress, the media, and abroad. We, too, suffered insomnia and had combat nightmares." (Shatan, 1987).
In 1970, the National Council of Churches established an office under the Rev. Richard Kilmer, an ordained Presbyterian minister, to help those hurt by the Vietnam War. At first, the NCC focused efforts on draft resisters and anti-war protesters. However, in 1973, at the urging of Shatan and Lifton, the NCC began laying plans for the First National Conference on the Emotional Needs of Vietnam-Era Veterans. The Missouri Synod of the Lutheran Church put up $80,000 for expenses and agreed to host the meeting at its seminary in St. Louis -- appropriately situated in the middle of the country.
According to Shatan, about 130 people attended the conference, which was arguably the first multidisciplinary gathering to focus on what became known as posttraumatic stress. The group was composed of "60 veterans, 30 shrinks, 30 chaplains, and 10 central office people [VA] who came on at the last minute." (Scott, 1993).
At the conference, Lifton and Shatan spent time with reporters talking about the problems of Vietnam veterans. The conference lasted three days, April 2628, 1973, and out of the conference the National Vietnam Veterans Resource Project was created with a governing council of 16 people co-directed by Chaim Shatan and veteran activist Jack Smith, with representatives from all three groups -- veterans, chaplains and mental health professionals.
The project was to have several functions: to search and gather data about the effects of combat stress, and help coordinate a self-help movement of veterans groups (Shatan, 1987; 1997a).
Leventman, S. (1978). Epilogue: Social and historical perspectives on the Vietnam veteran. C. R. Figley (Ed.), Stress disorders among Vietnam veterans: Theory, research and treatment, Brunner/Mazel pp. 291-295.
Lifton, R. J. (1967). Death in life: Survivors of Hiroshima. New York: Basic Books.
Lifton, R. J. (1973). Home from the war. New York: Basic Books
Scott, W. (1993). The politic of readjustment: Vietnam veterans since the war. Hawthorne, NY: Aldine de Gruyter.
Shatan, C. (1987). Johnny, we hardly know you: The grief of soldiers and the Vietnam veterans' self-help movement.Presented at the Third Annual Meeting of the Society for Traumatic Stress Studies, Baltimore, MD., October 23.
Shatan, C. (1997a). Personal interview with the author, October 28.
Shatan, C. (1998). Personal interview with the author, February 24.
ISTSS Forms Criminal Justice Special Interest Group
Members interested in adult and juvenile criminal justice including law-enforcement approaches, therapeutic techniques, and new programs for treatment and prevention of crimes are invited to participate in a special interest group during the 14th annual conference, Nov. 19-23 in Washington, D.C.
The Criminal Justice Special Interest Group will give members an opportunity to meet each other, and share ideas and concerns. The group will also provide a format from which to present findings. Look in the annual conference program for the time and location of the meeting.
Critical Incident Stress Management:
A New Era in Crisis Intervention
Jeffrey T. Mitchell, Ph.D., University of Maryland; and
George S. Everly Jr., Ph.D., Johns Hopkins University
Note: This is an invited response to the article "First Report of Psychological Debriefing Abandoned The End of an Era?" (StressPoints, Summer 1998) Readers are encouraged to submit views on critical and controversial topics to increase dialogue regarding traumatic stress issues.
Recent announcements about the end of the debriefing era, as the famous American writer Mark Twain once said of premature announcements about his death, are greatly exaggerated. To suggest that debriefings be abandoned when there is considerable evidence that these crisis intervention techniques are quite effective when properly applied, seems at least hasty, if not irresponsible. We suggest instead a careful look at the opposite side of the argument and a more concerted effort to determine what about debriefings is helpful to those who participate in them.
To understand debriefings, one must first place them within appropriate conceptual and historical frameworks. A debriefing is merely one group intervention technique within the whole field of crisis intervention. Conceptually, crisis intervention is emergency psychological care. Indeed, it is often thought of as emotional first aid (Neil, Oney, DiFonso, Tacker, and Reichart, 1974).
Historically, though most trauma specialists today point to Eric Lindemann and Gerald Caplan as the developers of modern crisis intervention theory and practice (Parad, 1966; Neil, Oney, DiFonso, Thacker, and Reichart, 1974; Caplan, 1964; Slaikeu, 1984), one of the earliest systematic inquires into disaster psychology was the work of Edward Stierlin (1909), who investigated the psychological aftermath of a major European mining disaster in 1906. Later, from the work of T.W. Salmon (1919) in World War I, and Kardiner and Spiegel (1947) in World War II, the three principles of crisis intervention -- immediacy, proximity, and expectancy -- were formulated. The primary goals of crisis intervention are to stabilize the current situation, assist people in mobilizing their resources, and restore people to an adaptive level of independent functioning that approximates the precrisis level of adaptation.
A new era in crisis intervention began in the mid-1970s with the development of the field of Critical Incident Stress Management, which, in contrast to the formative years of crisis intervention, represents a more comprehensive, systematic and multicomponent approach to managing stress, particularly traumatic stress. CISM represents advances beyond previous crisis-intervention applications in that it covers the complete crisis continuum from precrisis through follow-up services. There are seven primary components of an integrated and comprehensive CISM system. They are:
- Precrisis education and preparedness training;
- One-on-one psychological support sessions;
- Disaster demobilizations and predeployment briefing sessions for large groups;
- Small group brief defusings immediately after the traumatic event (20-40 minutes in length);
- Significant other support programs and organizational support programs (education and crisis intervention);
- Critical Incident Stress Debriefings, which are structured into one- to three-hour, seven-phase group discussions of a highly stressful event; and
- Follow-up and referral mechanisms for further assessment and therapy.
A few clarifying words about the group crisis intervention technique, CISD, are appropriate here because much confusion about the process exists. CISDs are a group discussion of a traumatic event experienced by the group. They are crisis intervention techniques, not psychotherapy or a substitute for psychotherapy. They are only used for the most severe events that affect a group.
CISDs are used to equalize the information about a traumatic event among the group members and instruct the participants about practical steps that can assist in recovery from the traumatic experience. One of the most important functions served by the group CISD process is a screening function. It facilitates identification of group members who may need additional intervention or psychotherapy. CISM services, including the specific group process CISD, have been detailed in numerous publications (Mitchell, 1983; Mitchell, 1988a,b; Mitchell and Bray, 1990; Mitchell and Everly, 1993; Mitchell and Everly, 1996; Everly and Mitchell, 1997).
As indicated above, CISM has components used before, during, and after traumatic events. The CISM field also has components for use with individuals, groups, and organizations or environments that surround
people. The CISD is simply one type of group intervention. It was not designed to be a stand alone or one-off procedure. Using CISD outside
of the context of a comprehensive, systematic and multicomponent approach to traumatic stress management is not recommended.
Though it is not recommended that the group CISD be used outside the CISM context, some have successfully done so. For example, Jenkins (1996) performed a controlled longitudinal study of the effectiveness of the CISD variation of debriefing after a mass shooting in Texas. Recovery from the trauma appeared most strongly associated with participation in the CISD process. CISD was useful in reducing symptoms of acute depression and anxiety for those who participated in the CISD compared with those who did not. Similarly, Wee (1995) found the CISD intervention led to more rapid reductions in symptoms of posttraumatic stress among emergency response personnel after the Los Angeles civil disturbance compared with those who did not participate in the debriefings.
Not all studies support the debriefing process. Often cited studies by Kenardy et al. (1996), McFarlane (1988), Bisson et al. (1997), Gerson, Carlier and Vrijlandt (1997), and Hobbs et al. (1996) have found no support for the effectiveness of the debriefing intervention.
Unlike specific CISD studies, nonspecific "debriefing" studies fail to operationally define what the independent variable (debriefing intervention) actually consisted of. This is especially obvious in the Kenardy et al. (1996) investigation. The authors themselves comment about the ambiguity surrounding the debriefing process. As Mullen (1989) points out, ambiguous independent variables yield ambiguous outcome. Further adding to the confusion, Bisson et al. (1997) and Hobbs (1996) apparently failed to use the debriefing process in the group format as originally intended.
Therefore, in an attempt to assess the overall affect of group debriefings, Everly, Boyle, and Lating (1998) submitted 10 controlled-group (n=698) debriefing investigations to meta analysis. The meta-analysis yielded a mean Cohen's D of .54 indicative of a moderate positive effect size.
In an additional study, Everly and Boyle (1997), in an effort to assess the effectiveness of the CISD debriefing model, subjected five investigations (Bohl, 1995; Chemtob, et al., 1997; Jenkins, 1996; Nurmi, 1997; and Wee, 1995) to meta-analysis. All five investigations used Mitchell's specific group CISD model. In an aggregated sample size of 337, the resultant mean Cohen's D was .86, indicative of a large positive effect attributable to the CISD intervention. The probability that such a finding might be derived by chance alone approaches zero.
Whenever some studies demonstrate negative outcomes and others demonstrate positive outcomes, one should consider several important issues. Are the researchers following the same debriefing procedures? Are the debriefings the same? Are the debriefings provided in a timely fashion? Have the service providers been adequately trained, and have they developed the skills necessary to conduct the interventions? Are the group members experiencing the same level of trauma? Are researchers measuring the same things? Are the outcome expectations on the part of the researchers, such as the complete elimination of stress symptoms after debriefing, realistic? Unfortunately, in the debriefing studies to date, the answer is frequently no.
Dyregrov (1997) masterfully points out the difficulties of providing debriefing services. There are numerous factors that must be carefully and skillfully integrated to ensure the success of complex-group debriefing interventions. The most important of the many factors involved in a debriefing session are the training and skill of the provider. Poorly trained helpers who have a paucity of group intervention skills are not likely to be helpful to a group in crisis. A lack of skill on the part of the provider will, of course, be reflected in the results of certain debriefing studies. Among other related factors that Dyregrov addresses are group history, group cohesiveness, intensity of the traumatic experience, internal group leadership, communication skills, timing of intervention, the environment in which the group debriefing is held and readiness of the group members to accept help. Studies that do not take these factors into consideration are likely to render ambiguous results.
Just as it is not an acceptable standard of care to use the group CISD procedure without the benefit of a full CISM program, it is also inappropriate to investigate the CISD as a stand-alone process or a psychotherapy. For the reasons described above, CISD is not a stand-alone process nor is it a therapy or a substitute for psychotherapy. It is aimed at mitigation of acute traumatic reactions and prevention of traumatic stress problems, not at curing posttraumatic stress disorder or other post-trauma reactions. It is our firm belief that the evaluation of single-intervention strategies for stress management, such as evaluations of CISD alone, are misguided. Evaluations of multicomponent interventions are far more likely to contribute substantially to the knowledge and appropriate applications of services in the CISM field.
It is notable that when multicomponent traumatic stress management programs (CISM) that include CISDs as one of many interventions are evaluated, there are consistently positive results. Chemtob (Chemtob et al., 1997) used CISD and combined it with traumatic stress education. Subjects were divided into two groups in a time-lagged design so that the pretreatment assessment of the second group was concurrent with the posttreatment of the first group. The IES scores (Horowitz et al., 1979) for both groups were significantly reduced when compared with pretreatment levels.
Leeman-Conley (1990) used a multiple intervention strategy that incorporated debriefings after robberies in a large banking system in Australia. The program included precrisis training, individual crisis interventions, group training for managers, group debriefing procedures and referrals for professional counseling when necessary. The CISM model appeared to reduce sick leave by 60% and workers compensation claims by 68%.
In what is by far the most rigorously controlled investigations into multicomponent intervention, Flannery and his coworkers (Flannery, 1998; Flannery & Penk, 1996; Flannery et al., 1991), evaluated the affect of CISM services including group debriefings, individual support, family counseling, and professional referral on staff personnel in psychiatric hospitals. There was less turnover of staff, use of sick time, workers compensation claims, and medical and legal expenses once the program was put in place.
Finally, from a cost effectiveness perspective, Western Management Consultants (1996) evaluated a comprehensive CISM program of pre-incident training, individual counseling, and Mitchell model CISDs for nurses in Canada. There were 236 nurses responding to the study of interventions after crises. Results indicated that there was reduced staff turnover and use of days absent from work. The cost savings attributed to CISM services were determined to be $7.09 for every dollar spent to establish the program.
What we have learned so far about debriefings is that when they are applied inappropriately as stand-alone substitutes for psychotherapy or when they are studied in research projects replete with methodological flaws they render mixed or negative results. When debriefings are clearly defined and applied properly in the context of a broader, comprehensive, systematic, and multicomponent program, they produce consistently positive results.
There are many other studies that should be considered before anyone suggests that the debriefing era has come to an end. Two recent literature reviews by Mitchell and Everly, (in press) and Everly, Flannery and Mitchell (in press) conduct narrative reviews of the CISM field and address the confusion that has been generated by unclear definitions of debriefing, violations of standard procedures, and methodologically flawed studies. We encourage continued use and review of CISM services, including debriefings. We encourage, however, a movement away from single intervention strategies (debriefings alone) back to the original design of multicomponent CISM services. Such a movement will ensure a more appropriate use and evaluation of multicomponent intervention strategies (CISM). We need to ask not whether one single intervention works, but rather what about that intervention and its combination with other services enhances or limits positive outcomes.
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Dyregrov, A. (1997). The process of psychological debriefing. Journal of Traumatic Stress, 10, 589604.
Everly, G. S. & Boyle, S. (1997). Critical Incident Stress Debriefing (CISD): A meta analysis. Paper presented at the Fourth World Congress on Stress, Trauma, and Coping in the Emergency Services Professions, Baltimore, MD.
Everly, G. S., Boyle, S., & Lating, J. (1998, May 1014). Psychological debriefing: A Meta Analysis. Paper presented at First Nations' Emergency Services Society Critical Incident Stress Conference, Vancouver, BC, Canada.
Everly, G. S. and Mitchell, J. T. (1997). Critical Incident Stress Management (CISM): A New Era and Standard of Care in Crisis Intervention. Ellicott City, MD: Chevron Publishing.
Everly, G. S., Flannery, R., & Mitchell, J. T. (in press). CISM: A review of the literature. Aggression and Violent Behavior: A review Journal.
Flannery, R. B. (1998). Assaulted Staff Action Program. Ellicott City: Chevron Publishing.
Flannery, R. B., & Penk, W. E. (1996). Program evaluation of an intervention approach for staff assaulted by patients: Preliminary inquiry. Journal of Traumatic Stress, 9, 317324.
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Hobbs, M., Mayou, R., Harrison, B, & Worlock, P. (1996). Randomized controlled trial of psychological debriefing for victims of road traffic accidents. British Medical Journal, 313, 14381439.
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Mitchell, J. T. & Everly, G. S. (1993). Critical Incident Stress Debriefing (CISD): An operations manual for the prevention of traumatic stress among emergency services and disaster workers. Ellicott City, MD: Chevron Publishing.
Mitchell , J. T. & Everly, G. S. (1996). Critical Incident Stress Debriefing(CISD); an operations manual for the prevention of traumatic stress among emergency services and disaster workers. Second edition, revised. Ellicott City, MD: Chevron Publishing.
Mitchell, J. T. & Everly, G. S. (in press). Critical Incident Stress Management: Evolution , effects and outcomes. In B. Raphael & J. Wilson (Eds.), Psychological Debriefing.
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Nurmi, L. (1997, April). Experienced stress and the value of CISD among Finnish emergency personnel in the Estonia ferry disaster. Paper presented to the fourth World Congress on Stress, Trauma, and Coping in the Emergency Services Professions. Baltimore, MD.
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Research Methods Interest Group Sponsors
Specialty Training Course
Danial King, PhD, and Lynda King, PhD
Research Methods Interest Group Co-chairs
A half-day specialty training course titled "Introduction to Outcomes Research: Quality of Life and Health Economics Evaluations," sponsored by the ISTSS Research Methods Interest Group, will be offered at the annual meeting in Washington, D.C., Nov. 19-23. The course evolved from suggestions made by interest group members at the 1997 annual meeting in Montreal.
Presenters will be Dennis Revicki, vice president, Center for Health Outcomes Research, and Anne Elixhauser, senior research scientist, both from MEDTAP International in Bethesda, Md. Revicki has more than 17 years of experience in designing and conducting studies involving health-related quality of life assessment, economic evaluation, health services research, medical technology assessment, psychometrics, and primary care. Elixhauser is an expert in health-services research and cost-effectiveness analysis. Her research experience spans an array of topics including economic analyses of preventive interventions; differences in use of health care resources by gender, race, and ethnicity; and measurement of comorbidities using administrative data. Both presenters are well published and well recognized in the field of health outcomes research.
The course will be presented at an introductory level and is intended for researchers and practitioners interested in this important contemporary research area. The course will provide an introduction to health-related quality of life assessment and cost-effectiveness methods. Examples will be used to illustrate key methodological concepts and issues, and emphasis will be placed on prospective designs. Registration information will be included with annual meeting announcements.
The Research Methods Interest Group seeks to foster communications among investigators and practitioners and provide educational opportunities on state-of-the-art methodological approaches for trauma research. The group will
convene at the annual meeting. All interested individuals are invited to attend. Committee co-chairs are Daniel King, PhD, and Lynda King, PhD, National Center for PTSD, Boston Department of Veterans Affairs Medical Center; e-mail: firstname.lastname@example.org or lking @world.std.com.
APA Helps Start Science Initiative
The American Psychological Association along with other public health, scientific, and advocacy groups, are rallying to get the years 20002010 designated as "The Decade of Behavior." If instituted, the designation would help the behavioral sciences in several ways.
The goals of the initiative are:
- Institute an education program to change the public image of the behavioral and social sciences;
- Increase research funding;
- Design training strategy for future behavioral and social scientists; and
- Support use of research findings to solve world problems.
For more information, contact Diane Maranto at email@example.com.