Critical Incident Stress Debriefing CISD

There is an almost intuitive understanding amongst people that telling or talking about what happened in a traumatic event has healing power and qualities. This may very well be part of our natural response systems to traumatic stress that allow for the majority of us to never develop PTSD. The formal process of being allowed to do this, to be able to review what happened and attempt to make sense of an event or events, has come to be known as psychological debriefing. Raphael and Wilson (2000) state that debriefing is an attempt to facilitate this type of review.

Psychological debriefing as a formal mental health practice began as an intervention targeting emergency workers and military personnel. The impact on emergency personnel of working with trauma survivors and amidst the aftermath of a trauma, such as a natural disaster, fire, or airline crash, became a focus for the agencies these workers worked for and mental health professionals alike.

There are numerous forms of psychological debriefing, some with a focus on psychoeducation and others focused on catharsis. The most well-developed, researched, and widely used form of psychological debriefing was developed by Mitchell and Everly (2000) and is called critical incident stress debriefing (CISD). According to Litz and Gray (2004), CISD is so popular that the American Red Cross mandates its use when services are offered on the ground. Critical incident stress debriefing is considered only one component, however, of a larger systematic prevention program for emergency workers and personnel called critical incident stress management (CISM). Critical incident stress management includes CISD but also involves the prebriefing or psychological preparation before entering dangerous work, consultation, and longer-term facilitation of treatment and crisis management. Mitchell and Everly (2000) identify three main categories of CISM: (1) interventions for the individual (e.g., stress management education, on-scene support, and referrals for psychotherapy), (2) interventions for groups (e.g., preincident education and follow-up meetings), and (3) interventions for the environment (e.g., support for families, community outreach, and community education).

Mitchell's model of CISD has been adapted to specific groups and altered by many different practitioners, but at the core, each of these share the same common goals. Bisson et al. (2000a, b) and Mitchell and Everly (2000) identify the following goals and components of CISD:

Reduce initial distress.

Prevent the development of later psychological sequelae (e.g., PTSD).

Promote emotional processing through ventilation and normalization of reactions.

Prepare for future experiences.

Identify individuals who may need further treatment.

Avoid psychiatric labeling and emphasis on normalization.

Educate individuals about stress reactions and ways of coping adaptively with them.

Provide information and opportunities for further treatment.

Mitchell outlines CISD as consisting of a seven-phase model. It is usually offered to individuals and groups within 24 to 72 hours of a traumatic event (Mitchell & Everly, 2000). As was mentioned earlier, many adaptations have been made of the original Mitchell model. The following description of the seven-phase-model is based on an adaptation by Dyregrov (1989), as discussed in Bisson et al. (2000a, b).

1. Introduction. The purpose of the meeting is made explicit, it is to review and discuss the participants' reactions and come up with ways to adaptively cope with these. The debriefer establishes him- or herself as competent, and three rules are stated: (1) There is no obligation to talk about anything other than why they are there and what their role was in the event, (2) confidentiality is emphasized, and (3) the focus is on the impact and reactions to the event.

2. Expectations and facts. The details of the event are discussed without focusing on thoughts, feelings, or impressions. Participants are asked to discuss their expectations at this point.

3. Thought and impressions. Thoughts and impressions are then elicited with targeted questions with the goals of constructing a picture of the event, placing reactions into perspective or context, and facilitating the integration process. Focusing on the five senses is encouraged.

4. Emotional reactions. There is an attempt by the debriefer to facilitate the catharsis and emotional release process by asking questions about fear, helplessness, frustration, anger, or depression. Emotions felt since the event are also discussed.

5. Normalization. The survivor's reactions are normalized by the debriefer by stating that these are understandable, common, and normal reactions. The debriefer also educates about potential future symptoms and experiences, such as avoidance reactions, detachment, anhedonia, irritability, nightmares, or hypervigilance.

6. Future planning and coping. Methods and techniques for managing symptoms and difficulties are discussed with an emphasis on talking to supportive others and loved ones.

7. Disengagement. Suggestions are made if further help is needed, and participants are advised to consider getting more help if their symptoms persist for 4 to 6 weeks, if they increase, if there is disruption in family and occupational functioning, or if others comment on marked personality changes.

Although the steps outlined in the preceding appear to be straightforward and perhaps rather simple, CISD is a technical intervention, and it is recommended that those who wish to provide it be specifically trained and even certified in CISD provision. Also, as is the case with psychological first aid, ultimately, CISD and other forms of psychological debriefing have not been found to prevent PTSD in well-designed empirical studies. However, it is still considered a very beneficial program in helping reduce overall levels of distress and in education, screening, and support (Bisson et al., 2000a, b).

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