Addressing CRITICAL STRESS
the National Center for Post-Traumatic Stress
Disorder, Department of Veterans
The significance of critical incident stress debriefing (CISD) to the fields of traumatic stress and emergency response is evident in its worldwide application (e.g., the International Foundation for CISD), its extended use to individuals other than emergency response personnel (1-6), and its recent incorporation into disaster counseling projects and the American Red Cross disaster mental health training program (7). Originally developed to mitigate stress responses among emergency first responders (8), the growing use of these protocols with victims of community-wide disasters deserves scrutiny. As respondents to disasters who have conducted more than seventy-five community debriefings for the Federal Emergency Management Agency (FEMA), for the Department of Veterans Affairs, for the American Red Cross, California Office of Emergency Services, and for disaster crisis counseling projects, we recognize that CISD procedures may help some disaster victims. We are concerned, however, that an unreasonable expectation of CISD usefulness may be developing among field practitioners. In this article, we propose that important differences exist between a "critical incident" and a community-wide disaster, and draw attention to clinical issues related to CISD and questions that await study.
CISD is a generic label applied to a variety of group process protocols used in a variety of settings, with a variety of groups, and is often carried out by practitioners trained briefly in CISD. Usually, CISD is a facilitator-led group process conducted soon after a traumatic event with individuals considered to be under stress from trauma exposure. When structured, the process usually (but not always) consists of seven steps: Introduction; Fact Phase; Thought Phase; Reaction Phase; Symptom Phase; Teaching Phase; and Re-entry Phase. During the group process, participants are encouraged to describe their experience of the incident and its aftermath, followed by a didactic presentation on common stress reactions and stress management. The rationale given for this process is that providing early intervention, involving opportunities for catharsis and to verbalize trauma, structure, group support, and peer support are therapeutic factors leading to recovery (9).
CISD is used increasingly with individuals and in settings outside the normal emergency response sites (such as emergency rooms, and police or rescue stations), and is now being used with victims and providers of all kinds (e.g., teachers, clergy, victims, etc.), and in a wide range of settings (such as schools, community disaster field offices, churches, etc.). However, it is likely that not all disasters should be approached in the same manner. There are important differences between a "critical incident" and a community-wide disaster. Unlike most critical incidents (such as shootings, on-the-job accidents, etc.), community-wide disasters involve the political, cultural, and economic past of an affected community. These historical factors converge with the disaster itself (the number of deaths, physical and systemic destruction, relief and recovery efforts, etc.) to shape the future of the community and the individuals who live there (for detailed discussion on how disasters affect communities, see 10-16). Another difference is that the complex aftermath of community-wide disasters is characterized by newly arising stressors. In addition to the stress of trauma exposure and the initial losses incurred (e.g., loss of loved ones, friends, and/or property), the stress response of a survivor may be influenced by resulting problems with unemployment, financial resources, substance abuse, marital and family discord, or mental health problems, as well as disaster-related organizational politics involving safety, rebuilding, and relocating.
The lifetime and current prevalence rates of PTSD (9%) and adult psychiatric disorder (48%) suggest that many disaster victims need to address traumatic reactivation or pre-existing mental disorders (17-18). For example, an earthquake victim who has successfully readjusted following an earlier sexual assault may begin to re-experience intrusive thoughts or nightmares about the assault. Though this victim/survivor may benefit from understanding how the effects of these two events may be related, CISD protocols are not designed to accommodate this relationship. The anticipated therapeutic benefit of "universalization," that is, learning that one's reactions are common to other debriefing participants, may not occur in the case of the unwitting grouping of victims who are in different stages of adaptation (19) or in cases of traumatic reactivation (for detailed discussion of the treatment of disaster victims experiencing traumatic reactivation, see 20). Moreover, the National Co-morbidity Survey (18) found that the majority of people in the United States with mental illness never receive treatment. As many as one in four disaster victims may have a history of untreated mental illness, thus further questioning the usefulness of focusing solely on the "critical incident." In sum, CISD may provide some immediate opportunities for victims to talk with one another, but is unlikely to provide effective treatment for complex, ongoing, or persistent problems that are the result of the disaster itself, pre-disaster vulnerabilities, or the variety of social conditions that surround it.
Short term group discussion is, however, an opportunity to educate. The intent of the teaching is to normalize reactions, facilitate coping, increase awareness of adaptive and maladaptive behaviors, "spot" and refer individuals who may benefit from specialized assistance, and provide information about related community resources. Typically, the conventional teaching phase of CISD addresses common stress reactions and stress management. We recommend expanding the range of educational topics to include the complex factors associated with stress reactions. An overview of recommended topics is presented in Table 1).
A. Defining traumatic stress
1. Quantitative and qualitative dimensions (DSM-III-R criterion A; DSM-IV issues; sensory exposure; phenomenology of loss --loved ones, property, perceived control, and meaning)
B. Common stress reactions
1. Emotional (shock, anger, disbelief, terror, guilt, grief, irritability, helplessness, anhedonia, regression to earlier developmental phase)
2. Cognitive (impaired concentration, confusion, distortion, self-blame, intrusive thoughts, decreased self-esteem/efficacy)
3. Biological (fatigue, insomnia, nightmares, hyperarousal, somatic complaints, startle response)
4. Psychosocial (alienation, social withdrawal, increased stress within relationships, substance abuse, vocational impairment)
C. Factors associated with adaptation to trauma
1. Degree of sensory exposure (severity, frequency, and duration)
2. Perceived and actual safety of family members/significant others
3. Characteristics of recovery environment (existence/access/utilization of social support)
4. Perceived level of preparedness
5. Pre-disaster level of psychosocial functioning (coping efforts)
6. Pre-disaster level of psychosocial stress (vulnerability/resilience)
7. Interrelationship among factors of personal history, developmental history, belief system, and current and past stress reactions including previous exposure to trauma (war, assault, accidents)
D. Self-care and stress management
1. Relationship between behavior and stress (exercise, eating habits, exercise, receiving and giving social support, relaxation techniques -- excessive and deficient behaviors)
2. Self-awareness of emotional experience and selected self-disclosure
3. Stress-related disorders (PTSD; disorders which may be exacerbated by stress)
4. Parenting guidelines (how to enhance children's coping)
5. Disaster preparedness
6. Characteristics of the disaster environment (phases of disaster)
7. When and where to seek professional help
Are debriefings effective with disaster victims? Case reports and anecdotal evidence of debriefing suggest that they may indeed lead to symptom mitigation (9); however, there has not been rigorous, controlled investigation to date. The lack of data on the effectiveness of CISD present significant intervention risks, particularly with unknown or unassessed victims/participants, as is often the case in the provision of disaster mental health services. Recent reviews (21, 22) of the empirical evidence for the efficacy of a range of PTSD treatments (i.e., pharmacotherapy, behavior therapy, cognitive therapy, psychodynamic and hypnotherapies) indicate that certain procedures may be well-suited to one individual but not another, and that certain treatments may be more suitable for certain symptoms. This may also be the case in interventions for non-pathological stress reactions. Salient clinical issues such as intervention timing, short and long-term effects, victim-intervention matching, individual vs. group treatment, contraindications, pre-morbidity, etc., need further study.
Clearly, disaster helpers cannot wait for definitive proof of the efficacy of their efforts. In general, programmatic and therapeutic interventions typically develop from anecdotal evidence and we acknowledge that the difficulties in studying disaster protocols are numerous (for detailed discussion of practical, conceptual, and methodological issues, see 23). While it is true that psychoeducational intervention may help some disaster victims, we caution against the unquestioned acceptance of CISD debriefing procedures as a sufficient intervention following community-wide disasters. We propose that debriefing be viewed within its function to address a limited aspect of victims' disaster experience, that it serve as a means to educate participants about other critical factors affecting stress response, and that it be a means to make referrals to other related resources. Lastly, we recommend that other education-oriented interventions (e.g., outreach presentations to organizations, institutions, self-help groups, and special populations, media programs, hot lines, etc.) and efforts to mobilize and strengthen social networks receive equal effort by disaster mental health practitioners.
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Bruce Hiley-Young is Disaster Outreach Coordinator, National Center for PTSD, Clinical Laboratory and Education Division. Bruce has worked as a debriefer for the Federal Emergency Management Agency (FEMA) and California Office of Emergency Services, disaster counseling projects, as a volunteer for the American Red Cross Disaster Mental Health Services. and as a disaster services grant reviewer for the National Institute of Mental Health (NIMH). Ellen Gerrity is Chief of Emergency Research (including war, disaster, and sexual assault research) in the Violence and Traumatic Stress Research Branch, at NIMH. Ellen is also an experienced mental health/disaster researcher, and has worked as a reviewer and consultant to the American Red Cross and the Center for Mental Health Services (CMHS)/FEMA emergency mental health services grant program.
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