Critical Incident Stress Management: A New Era in Crisis Intervention

Jeffrey T. Mitchell, PhD

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.

References

Bisson, J. and Deahl, M. (1994). Psychological debriefing and prevention of post-traumatic stress--More research is needed. British Journal of Psychiatry, 165, 717­720.

Bisson, J., Jenkins, P., Alexander, J., & Bannister, C. (1997). Randomized controlled trial of psychological debriefing for victims of acute burn trauma. British Journal of Psychiatry, 171, 78­81.

Bohl, N. (1995). The effectiveness of brief psychological interventions in police officers after critical incidents. In J. Reese, J. Horn, & C. Dunning (Eds.), Critical Incidents in Policing. Revised (pp. 31­38). Washington, DC: Department of Justice.

Caplan, G. (1964). Principles of
Preventive Psychiatry. New York: Basic books.

Chemtob, C., Tomas, S., Law, W., & Cremniter, D. (1997). Postdisaster psychosocial intervention: A field study of debriefing on psychological distress. American Journal of Psychiatry, 154, 415­417.

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.

Flannery, R. B., Fulton, P., Tausch, J., & Deloffi, A. (1991). A program to help staff cope with the psychological sequelae of assaults by patients. Hospital and Community Psychiatry, 42, 935­938.

Gerson, B. P. R., Carlier, I .V. E., & Vrijlandt, I. (1997). Some urgent questions regarding the practice of debriefing on the basis of research findings in Amsterdam. Paper presented at the Fifth European Conference, Maastricht, The Netherlands.

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.

Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of event scale: A measure of subjective distress. Psychosomatic Medicine, 41, 208­218.

Kardiner, A. & Spiegel, H. (1947). War, stress and neurotic illness. New York: Hoeber.

Kenardy, J. A., Webster, R., Lewin, T., Carr, V., Hazzell, P., & Cater, G. (1996). Stress debriefing and patterns of recovery following a natural disaster. Journal of Traumatic Stress, 9, 37­49.

Jenkins, S. R. (1996). Social support and debriefing efficacy among medical workers after a mass shooting incident. Journal of Social Behavior and Personality, 11, 477­492.

Leeman-Conley, M. (1990). After a violent robbery... Criminology Australia, April / May, 4­6.

Mc Farlane, A. C. (1988). The longitudinal course of posttraumatic morbidity. Journal of Nervous and Mental Disease, 176, 30­39.

Mitchell, J. T. (1983). When disaster strikes...The critical incident stress debriefing process. Journal of Emergency Medical Services, 8 (1), 36­39.

Mitchell, J. T. (1988a). The history, status and future of critical incident stress debriefings. Journal of Emergency Medical Services, 13 (11), 49­52.

Mitchell, J. T. (1988b). Development and functions of a critical incident stress debriefing team. Journal of Emergency Medical Services, 13 (12), 43­46.

Mitchell, J. T. & Bray, G. P. (1990). Emergency Services Stress: Guidelines for preserving the health and careers of emergency services personnel. Englewood Cliffs, NJ: Prentice Hall, Brady Publications.

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.

Mullen, B. (1989). Advanced BASIC meta-analysis. Hillsdale, NJ: Erlbaum.

Neil , T., Oney, J., DiFonso, L., Thacker, B., & Reichart, W. (!974). Emotional first aid. Louisville: Kemper-Behavioral Science Associates.

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.

Parad, H. (1966). The use of time limited crisis intervention in community mental health programming. Social Service Review, 40, 275­282.

Raphael, B., Meldrum, L., & McFarlane, A. (1995). Does debriefing after psychological trauma work? British Medical Journal, 310, 1479­1480.

Salmon, T. W. (1919). War neuroses and their lesson. New York Medical Journal, 109, 993­994.

Slaikeu, K. A. (1984). Crisis intervention: A handbook for practice and research. Boston, MA: Allyn and Baco.

Stierlin, E. (1909). Psycho-neuropathology as a result of a mining disaster, March 10, 1906. Zurich: University of Zurich.

Wee, D. (1995, April). Stress responses of emergency medical services personnel following the Los Angeles civil disturbance. Paper presented to the 3rd World Congress on Stress, Trauma and Coping in the Emergency Services Professions, Baltimore, MD.

Western Management Consultants (1996). The Medical Services Branch CISM evaluation report. Edmonton: Alberta, Canada: Western Management Consultants.