ISTSS News

Anna Avery and Roderick Orner, Clinical psychologists

Note: There will be an invited response to this article by Jeffery Mithchell, PhD, in the fall issue of Traumatic StressPoints.

The Lincolnshire Joint Emergency Services Initiative for Staff at Risk Following Critical Incidents was established in 1989 with participation from local fire and rescue, police, ambulance, and health and social services. To complement the priority given to critical incident stress education and training, a group of staff from emergency services were trained in the technique of critical incident stress debriefing as advocated by
Jeffrey Mitchell, president of the International Critical Incident Stress Foundation. The iniative assumed that by intervening at an early stage after a critical incident and convening psychological debriefing meetings for emergency responders, it should be possible to prevent the development of longer term psychological problems.

Research carried out during the mid- and late-1990s casts some doubt on the capacity of the critical incident stress-management service to deliver the anticipated outcomes. As reported in a recent issue of the ESTSS newsletter, a working group was established in Lincolnshire to review published outcome evidence and consider implications for future delivery of staff-support services.

The working group sought to define an evidence-based position with respect to the hotly argued and passionate controversies that characterize the ongoing debate about the status of psychological debriefing. This is not an easy task considering published reports draw data from a broad range of critical incidents of varying degrees of severity using subject populations rarely, if ever, chosen at random or using matched-group methodologies. Timing of interventions, training of debriefers, and differences in populations studied make comparisons across studies fraught with uncertainties.

Briefly summarized, the evidence position holds that though psychological debriefing has strong supporters, is widely used, and generally rated as a helpful procedure, no consistent evidence of its effectiveness as a preventive intervention in terms of post-traumatic morbidity exists. Reviews by Bisson and Deahl (1994) and Raphael, Meldrum, and McFarlane (1995) concluded that factors other than the presence or absence of psychological debriefing in the recovery environment determine outcomes for individuals exposed to traumatic stressors.

On this basis, the working group concluded that though the published evidence is inconclusive, it is extremely imprudent to continue to make claims for psychological debriefing not supported by evidence. Furthermore, the implications of the emergent uncertainties called for a review of critical incident staff-support protocols so that these could reflect the need to appraise unfolding situations with a view to offering flexible options for post-incident response rather than rely on a single prescriptive intervention protocol.

Singled out for particular consideration by the working group were those studies reporting attendance at debriefing meetings to be associated with higher risk of developing adverse psychological reactions and functional impairments than documented for those not debriefed (Bisson, Jenkins, Alexander, and Bannister, 1997; Gersons and Carlier, and Vrijlandt, 1997). One likely implication of these studies suggests that in future personal litigation cases involving emergency services, legal argument will be informed by expert witnesses advocating the existence of circumstances when psychological debriefing is contradicted. At such times, an employer's responsibility under duty-to-care regulations is to ensure psychological debriefing is not sanctioned.

On the basis of evidence gathered from an audit of local debriefing meeting between 1991 and 1995, the working group reached a consensus that only major disasters and life-threatening situations could likely evoke psychological reactions of such intensity and severity as to warrant mobilization of critical incident staff-support services for all responder staff. A more typical scenario shows that critical events carry particular risks for certain individuals but by no means everyone.

The paramount challenge for providers of staff-support services is therefore to identify those most at risk and target help to them. In so doing, the explicit assumption should be that responder staff do have coping strategies and personal strengths that improve prognosis compared to other victim groups subjected to similar stressors. The rationale for the new staff-support response protocol is no longer drawn from crisis intervention theory but, whenever possible, relies on published evidence about risk factors, risk assessment, and a salutogenic perspective on human response to trauma.

In practical terms, the implication for current staff-support services is that help is initially provided for managers and supervisors of responder staff. This ensures that the impact of events is systematically assessed, information in booklet form is disseminated to staff and their families, advise is offered as to who may be most at risk of developing longer term psychological reactions, and a range of staff-support services are considered for their appropriateness at various stages post incident. Incident review and follow-up meetings (IReF-meetings) can be convened but only after it has been established that this is what the responders want and deemed appropriate given prevailing circumstances. At each stage of support provision, the line manager or supervisor and members of a dedicated support team must agree on a action plan which crucially incorporates arrangements for review and closure.

So, a review that started with a recognition that the Lincolnshire Joint Emergency Services Initiative would be well advised to review its debriefing protocol, has culminated in a broad service review of all aspects of staff-support provision. After consulting nationally and internationally on a new response protocol, a decision was formally taken in October 1997 to discontinue use of the critical incident stress debriefing protocol.

The working group takes the view that future critical incident staff-
support services should be flexibly provided, undergo constant review in light of published evidence, and the manner of delivery a compromise between ideals of methodological rigor and that which is acceptable to service users. For instance, some emergency services view the use of formal questionnaires and rating scales with extreme suspicion. In view of what is now understood about traumatic stress reactions and their course over time, no justification exists for claiming they are consistently prevented by one-off early interventions. This means the rationale for critical incident stress-management services has to be restated, and within the Lincolnshire Joint Emergency Services Initiative therapeutic fervor has been tempered so that the aim we aspire to achieve is to effect an improvement in the quality of the recovery environment. While extremely general in formulation, this aim can be operationalized for research purposes by referring to the now considerable evidence about what constitutes quality in the recovery environment (e.g. extent of hyperarousal, group cohesion, and social support).

Current service arrangements lack the conviction-led certainty that inspired original schemes to provide staff-support services, but evidence-led practice confers on the Lincolnshire Joint Emergency Services Initiative a freedom of practice it did not enjoy while confined by the evangelical orthodoxy sometimes manifest in psychotraumatology.

The Initiative received notification of a three-year grant awarded to evaluate the new service protocol.

References

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

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

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.

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