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  1. 1. CRITICAL INCIDENT STRESS MANAGEMENT (CISM) Brian A. Chopko The University of Akron
  2. 2. Psychological Debriefing <ul><li>CISM </li></ul><ul><li>CISD </li></ul>
  3. 3. The following definitions are provided by (2003) Mitchell and Everly
  4. 4. CRISIS a response to an event wherein: <ul><li>an individual’s psychological homeostasis is disrupted </li></ul><ul><li>one’s usual coping mechanisms have failed </li></ul><ul><li>there is evidence of distress and significant functional impairment </li></ul>
  5. 5. CRITICAL INCIDENT <ul><li>… the event which has the potential to engender a crisis response; often confused with the crisis response itself. </li></ul>
  6. 6. CRISIS INTERVENTION <ul><li>… as physical first-aid is to surgery, crisis intervention is to psychotherapy </li></ul>
  7. 7. CRITICAL INCIDENT STRESS MANAGEMENT (CISM) <ul><li>… a comprehensive, integrated multi-component crisis intervention system </li></ul>
  8. 8. Functional Goals of CISM <ul><li>Symptom stabilization </li></ul><ul><ul><ul><li>- prevent the symptoms of distress / impairment from worsening. </li></ul></ul></ul><ul><li>Symptom reduction </li></ul><ul><li>Re-establish functional capacity </li></ul><ul><li>Seek further assessment and </li></ul><ul><li>/ or a higher level of care </li></ul>
  9. 9. CISM <ul><li>spans the entire temporal spectrum of a crisis </li></ul><ul><li>consists of a set of core interventions </li></ul>
  10. 10. CISM includes the following ten points: <ul><li>Pre-crisis planning/education </li></ul><ul><li>Individual crisis intervention (one-on-one) </li></ul><ul><li>Small group crisis intervention- Defusing </li></ul><ul><li>Small group crisis intervention- Critical Incident Stress Debriefing (CISD) </li></ul><ul><li>Large group crisis intervention- Demobilizations (for public safety, rescue, disaster personnel) </li></ul>
  11. 11. <ul><li>Large group crisis intervention- Crisis </li></ul><ul><li>Management Briefing (CMB) for civilian populations, schools, businesses, communities, etc. </li></ul><ul><li>7. Organizational consultation </li></ul><ul><li>8. Family crisis intervention </li></ul><ul><li>9. Pastoral crisis intervention </li></ul><ul><li>10. Mechanisms for follow-up and referral </li></ul>CISM includes the following ten points:
  12. 12. Types of Psychological Debriefings <ul><li>CISD </li></ul><ul><li>The Raphael Model </li></ul><ul><li>Process Debriefing </li></ul><ul><li>ASAP (Assaulted Staff Action Program) </li></ul><ul><li>NOVA </li></ul>
  13. 13. CISM Critics Lits & Gray, 2002 Gist, 2002
  14. 14. Lits & Gray, 2002 <ul><li>Most people exposed to trauma </li></ul><ul><li>adapt well on their own </li></ul><ul><li>Victims should be assisted in the least intrusive manner </li></ul><ul><li>Recovery will occur “naturally” </li></ul><ul><li>Formal preventative interventions should only be provided to those individuals who show elevated </li></ul><ul><li>risk for chronic PTSD </li></ul>
  15. 15. The following should be assessed to make decisions about resource allocation: <ul><li>Prior Trauma </li></ul><ul><li>Social Support </li></ul><ul><li>Hyperarousal </li></ul><ul><li>Post-traumatic resources </li></ul>
  16. 16. Criticizing CISM <ul><li>Suggests: </li></ul><ul><ul><li>no formal interventions should be considered </li></ul></ul><ul><li>Reports: </li></ul><ul><ul><li>no study included to support claims of the CISD approach is not sufficiently internally valid </li></ul></ul><ul><ul><li>several RCT’s found no evidence to support the use of single session to individual trauma survivors </li></ul></ul>
  17. 17. Criticizing CISM – cont’d <ul><li>States: </li></ul><ul><ul><li>carefully designed RCT’s debriefings adhering rigorously to the boundary conditions of CISD need to be conducted </li></ul></ul><ul><ul><li>it is premature to conclude that psychological debriefings worsen adaptations to trauma (based on flawed studies using MVAs’ and burn victims) </li></ul></ul>
  18. 18. CISM is criticized because <ul><li>it does not take into account research on risk for PTSD </li></ul><ul><li>it has no formal screening or assessment to identify those who could benefit from intervention </li></ul>
  19. 19. CISM Critics Gist, 2002
  20. 20. The Cochrane Reviews (2001): <ul><li>“ 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 </li></ul><ul><li>cease.” </li></ul>
  21. 21. The Health Services of New South Wales in Australia <ul><li>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.” </li></ul>
  22. 22. The British National Health Service <ul><li>lists debriefing as “contra-indicated” for victims of trauma based on studies reported in the scientific literature. </li></ul>
  23. 23. Other critics of CISM <ul><li>The International Society for Traumatic Stress Studies (ISTSS: 1998) </li></ul><ul><li>U.S. Department of Defense and the National Institute of Mental Health (2001) </li></ul><ul><li>NATO-Russia Advanced Workshop on Social and Psychological Consequences of Chemical, Biological, and Radiological Terrorism (2002) </li></ul>
  24. 24. Conclusions of Critics <ul><li>The following CISM strategies may overload coping systems: </li></ul><ul><ul><li>emphasis in debriefing on immediacy (24 to 72 hours) </li></ul></ul><ul><ul><li>heavy emphasis on reconstruction of the traumatic episode </li></ul></ul><ul><ul><li>articulation of the most distressing emotional episode </li></ul></ul><ul><li>Cognitive distancing may represent a far more functional approach </li></ul><ul><li>Studies repeatedly found no evidence of preventive impact compared to nonintervention controls </li></ul>
  25. 25. Middle Ground Thinking: Van Emmerik & Arnol (2002) Morrison (2000)
  26. 26. Van Emmerik & Arnold: (2002) <ul><li>Conducted meta-analysis on single session debriefings (various types) </li></ul><ul><li>Found CISD was no more effective than non-CISD interventions </li></ul><ul><li>Meta-analysis was based on small numbers of studies </li></ul><ul><li>Despite empirical research showing no efficacy in single session CISD </li></ul><ul><ul><li>this is not the only reason debriefings are offered </li></ul></ul>
  27. 27. Other aims include: <ul><li>reduction of immediate distress and identification and referral for further treatment for those at risk of developing more severe symptoms </li></ul><ul><li>Perceived helpfulness by participants might be sufficient reason to continue to offer debriefings. </li></ul>
  28. 28. Middle ground thinking <ul><li>Premature to conclude that psychological debriefings worsen adaptations to trauma </li></ul><ul><li>Debriefing seen as a tool to: </li></ul><ul><ul><li>validate feelings </li></ul></ul><ul><ul><li>confront inappropriate responsibility/guilt </li></ul></ul><ul><ul><li>normalize stress reactions </li></ul></ul><ul><ul><li>integrate the traumatic event </li></ul></ul>
  29. 29. ARGUMENTS SUPPORTING CISM Mitchell & Everly (2003) Everly, Flannery & Eyler (2000) Mental Health and Mass Violence (2002) Robinson (2000)
  30. 30. Mitchell & Everly (2003) <ul><li>CISD: </li></ul><ul><ul><li>designed to be only one component of comprehensive multi-component crisis intervention program (CISM). </li></ul></ul><ul><ul><li>never designed to used as a “one shot” or “stand alone” intervention outside of the CISM system. </li></ul></ul><ul><ul><li>can mitigate the symptoms of psychological distress even when </li></ul></ul><ul><ul><li>used outside of context </li></ul></ul>
  31. 31. Mitchell & Everly (2003) <ul><li>The practical utility of some of the reviews and the validity of their conclusions have been compromised </li></ul><ul><li>Only studies purporting to specifically assess the CISD model were analyzed </li></ul>
  32. 32. Everly, Flannery & Eyler (2000) <ul><li>Conducted a meta-analysis to assess the overall magnitude and effectiveness of CISM </li></ul><ul><li>A large effect size was revealed attesting to the power of CISM to mitigate symptoms of psychological distress </li></ul>
  33. 33. Robinson: Methodological Weakness of Studies (2000) <ul><li>No pre-trauma baseline data </li></ul><ul><li>No description of the debriefing interventions used </li></ul><ul><li>Unrealistic expectations of </li></ul><ul><li>debriefings </li></ul>
  34. 34. Robinson: <ul><li>CISM commonly studied in large-scale emergencies </li></ul><ul><li>CISM more commonly used in day-to-day incidents with high impact </li></ul>
  35. 35. Robinson: <ul><li>CISM is designed for secondary victims </li></ul><ul><ul><li>ie: emergency service personnel </li></ul></ul><ul><li>Primary victims show different kind of trauma </li></ul>
  36. 36. Support Summary <ul><li>Research showing no or possible harmful effect is methodologically flawed </li></ul><ul><li>Critics of CISM say debriefings should be abandoned until clear evidence of effectiveness is available </li></ul><ul><li>Controlled and randomized studies </li></ul><ul><li>with clearly defined variables are </li></ul><ul><li>needed </li></ul>
  37. 37. Support Summary Morris (2002) <ul><li>Future research should examine: </li></ul><ul><ul><li>Appropriate populations </li></ul></ul><ul><ul><li>Personal qualities and skill </li></ul></ul><ul><ul><li>Application of techniques </li></ul></ul><ul><ul><li>Where most effective </li></ul></ul>
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