Critical Incident Stress Debriefing 1
The Importance of Critical Incident Stress Debriefing for Police Officers involved in a Shooting Incident.
Approved by Dr. Cheryl Banachowski-Fuller, Ph.D. on 10-31-2016
Critical Incident Stress Debriefing 2
The Importance of Critical Incident Stress Debriefing for Police Officers involved in a Shooting
Incident.
A Seminar Paper
Presented to
The Graduate Faculty
University of Wisconsin-Platteville
In Partial Fulfillment
of the Requirement for the Degree
Masters of Science in Criminal Justice
Andrew D. Mammen
April 2017
Critical Incident Stress Debriefing 3
ACKNOWLDEGEMENTS
I would like to thank all of the close people in my life that encouraged me to continue with my education. I never would have made it this far if it wasn’t for the positive influences surrounding my educational pursuit.
Thank you to all the staff at University of Wisconsin - Platteville for being, and maintaining a supportive, fair, and encouraging learning environment. Dr. Cheryl Banachowski- Fuller, this is a special thank you for giving me the opportunity to complete this final requirement.
I would also like to thank my partner Joel for his support and sacrifice for enduring the tension of my educational pursuit, as somedays were more difficult than others. Joel, you kept me motivated to continue and complete my education.
Critical Incident Stress Debriefing 4
ABSTRACT
The Importance of Critical Incident Stress Debriefing for Police Officers involved in a Shooting
Incident.
Andrew D. Mammen
Under the supervision of Dr. Cheryl Banachowski-Fuller, Ph.D.
After the officer involved shooting incident has occurred, officers can experience immediate stress reactions such as nausea, faintness and sweating, or delayed reactions such as grief, flashbacks, nightmares, and sleep disturbances (Bohl 2013). Police officers and other first responders experience rates of post-traumatic stress disorder (PTSD) far in excess of the general population (Walker, McCune, Ferguson, Pyne, Rattray 2016). Due to the general nature of work,
“policing necessitates the exposure to violent, and horrible events that can lead to an increased risk of post-traumatic stress disorder” (Hartley, Sarkisian, Violanti, Andrew, Burchfiel 2013). A working Critical Incident Stress Debriefing (CISD) plan should be in place so that the officer can begin the debriefing process soon after the incident. CISD is important because it helps to identify the stressors the officer may experience from the shooting incident, and it may help prevent or minimize mental health issues of PTSD or depression (Sones, Thorp & Rasking
2011). It is important to have a structured CISD program to begin the debriefing process because research suggests that that the early implementation of a CISD program can help reduce the effects of PTSD, and allow for a minimal negative impact to the officer’s mental health
(Journal of Occupational Medicine & Toxicology 2009). For a CISD program to be effective, identifying the type of trauma the officer encountered (primary or secondary trauma) will dictate how CISD is applied (Conn and Butterfield 2013). Different approaches are available for CISD such as the approach-avoidance coping program, and critical incident stress management Critical Incident Stress Debriefing 5
(CISM). Studies have also shown that the “narratives provided by the officers appear to lend further credence to the positive influence of an approach-avoidance coping skills program on perceived stress” (Anshel & Brinthaupt 2014). However, there are impeding issues of implementation that are due to the police culture. Police officers may be reluctant to use CISD programs that are available because some officers fear that they may be labeled as “softies” or that participating in CISD may imply weakness from other officers (Miller 2000). Other unique factors noted is that the “police culture” of officers does dictate that they are tough, vigilant, self- reliant, and disciplined individuals who have a hard time seeking help (Brucia, Cordova, Ruzek
2016). The changing of the police culture would be beneficial so that it would remove those stereotypical barriers and allow the officer to seek psychological help. Indications are that some departments do not have a CISD program due to the police culture, shift work of officers, and the general lack of willingness of the officers to be involved, or to disclose information (Malcom
2005).
Critical Incident Stress Debriefing 6
Table of Contents
APPROVAL PAGE 1
TITLE PAGE 2
ACKNOWLEDGEMENTS 3
ABSTRACT 4
TABLE OF CONTENTS 6
CHAPTERS
I. INTRODUCTION 8
A. Research problem 11
II. Review of the Literature Related to the Research Problem 12
A. Increasing number of Police Involved Shooting Incidents 12
B. Critical Incident Stress Debriefing (CISD) Review 14
C. CISD and the relationship to causes of PTSD 16
D. Causes of PTSD 18
E. Combating PTSD 19
F. Levels of Identification to reduce PTSD 21
G. Need for Early CISD 22
H. Current problems with applying the concept of CISD to police 23
officers
I. Models of approach 25
J. Types of coping framework 28
III. Methodological Strategies 29
A. Immediate Single-Session Approach 29 Critical Incident Stress Debriefing 7
B. Brief Delay-Multiple Session Approach 30
C. Emotional Processing Theory 31
D. Over-Engagement 33
E. Under-Engagement 33
IV. ANALYSIS OF COMPARISON OF CISD PROGRAMS 35
A. 0p5: from the Grand Rapids Police Department and Kent County 35
Sheriff’s Office
B. CISD: from the Los Angeles County Fire Department 37
C. CISM/Peer Support: model from the Peoria Police Department, 38
Arizona
D. Post Trauma Staff Support Program: from the State of Texas 39
Department of Public Safety
E. Peer Stress Program: Multnomah County, Oregon Sheriff’s 41
Department
V. RECOMMENDATIONS FOR AN EFFECTIVE CISD PROGRAM FOR
POLICE OFFICERS FOLLOWING A SHOOTING INCIDENT. 43
A. Implement the CISD within 24-72 hours following the incident 43
B. Form small groups to begin the CISD process 45
C. Complete the phases of the CISD by well-trained team members 46
D. Follow up with the affected individuals 47
VI. CONCLUSION 47
VII. REFERENCES 49
Critical Incident Stress Debriefing 8
CHAPTER 1: INTRODUCTION
The Importance of Critical Incident Stress Debriefing for Police Officers involved in a
Shooting Incident is vital. Police officers deal with work related stress factors due to the trauma of a critical incident, such as an Officer Involved Shooting (OIS) incident. It is important that police officers involved in a shooting while on duty receive Critical Incident Stress Debriefing
(CISD) opportunities after the incident to relieve the stress or anxiety caused by that incident.
The reason for CISD is to minimize the effects that the stress of the critical incident has on the individual, and the earlier the implementation of CISD the sooner the healing process begins.
Following a critical event a person needs to experience closure, and seeking closure of these events is a normal process of the brain (Christensen, 2017). Debriefing after an incident takes the memories of the incident that are still active in the mind and then stores them into long term memory. A negative consequence of these memories caused by the critical event is that the person may feel like he or she has lost control. Issues such as Post Traumatic Stress Disorder
(PTSD) and depression can be a direct result of the stress from the incident. PTSD is a mental health condition that is triggered by a terrifying event followed by symptoms such as nightmares, anxiety, flashbacks or depression. The objective of a CISD plan is to decrease the symptoms of stress, prevent PTSD, regain self-control, and to inform the individual affected about stress and its reactions, and to obtain closure after an incident (Christensen, 2017).
Since the early 1980’s, researchers have been studying the effects of critical incidents and the role it plays on ones’ mental health following an incident, how to relieve the trauma caused by the incident, and whether CISD models are effective in helping the police officer or public safety official cope with the experienced trauma. The findings from these studies show that the early implementation of structured CISD program will effectively reduce the risk to an Critical Incident Stress Debriefing 9 individual potentially suffering from PTSD or depression (Sones, Thorp & Rasking 2011).
Research also shows that the early implementation of a CISD program increases the likelihood that an officer will suffer less from the trauma if there is an effective CISD program, and it may increase the likelihood that he or she will return to work sooner (Malcolm, Seaton, Perera,
Sheehan, & Van Hasselt 2005). Controlled studies have shown positive effectiveness with the use of CISD program to all emergency services personnel, not strictly to police officers (Tuckey
& Scott 1014).
The first topic that will be covered in this research paper is the need for early implementation of a CISD program. The early implementation of CISD is important to alleviate stress from the officers involved in the shooting. Research suggests that there is a lack of departments that have a structured CISD program available for officers after an OIS (Malcom
2005). Many departments also fail to recognize the importance of the program until after the incident has occurred. It is important to focus on the need for those programs and to identify stressors that may occur after the incident to prevent mental health issues such as PTSD or depression (Sones, Thorp & Rasking 2011). Also, a police department providing a structured
CISD program as soon as feasibly possible to an officer in need, can help relieve the stress that may cause PTSD (Sones, Thorp & Rasking 2011). Police officers deal with stressors after an on- duty shooting incident and that those stressors may have a negative impact on the officers’ mental health. Those stressors are especially noticeable soon after the officer was involved in the critical incident such as an OIS (Chopko 2010). Debriefing by use of CISD should be provided as soon as possible, and if possible, within 24 to 72 hours directly following the critical incident.
As the time increases between the initial incident and the onset of the CISD plan, the less effective the CISD will be for the person in need. The goal of early intervention is to reduce the Critical Incident Stress Debriefing 10 effects of this disorder, help the police officer maintain a healthy life, and maintain a healthy mental status following the incident (Journal of Occupational Medicine & Toxicology 2009).
As noted above, police officers and other first responders experience rates of PTSD higher than the general population. In fact, these specific individuals far exceed the general population (Walker, McCune, Ferguson, Pyne, Rattray 2016). Simply due to the general nature of police work, “policing necessitates the exposure to violent, and horrible events that can lead to an increased risk of post-traumatic stress disorder” (Hartley, Sarkisian, Violanti, Andrew,
Burchfiel, 2013, pg.241). A working CISD plan should be in place so that the officer can begin the debriefing process soon after the OIS incident. With police departments offering a CISD program that can be implemented early after an OIS or other critical incident it may change the officer’s ability to cope with the negative stress in a positive way and to deal with the perceived trauma (Plat, Westerveld, Hutter, Olff, Frings-Dresen & Sluiter 2013).
Secondly, this research paper will address how the strategies of approach are beneficial to the person exposed to the critical incident who may be suffering from its negative effects. The strategies that will be discussed are treatment options for those affected by PTSD following the
OIS or critical incident. In conjunction with the strategies, the third section of this paper will examine five example programs used by various public safety departments. Areas to be analyzed is the CISD structure and content of the listed programs, and its treatment effectiveness. Having a well-developed CISD plan that is implemented soon after an OIS or critical incident will reduce the probability of PTSD and depression for the officers involved (Malcolm, Seaton,
Perera, Sheehan, & Van Hasselt 2005). This research paper will also use facts available from other studies to prove that the early implementation of the CISD plans, such as the ones that will be discussed, can and will help maintain an officer’s mental health. Critical Incident Stress Debriefing 11
Finally, recommendations on how to initiate a CISD plan and how to treat persons with
PTSD will be given. Areas of focus will be the best practices for the time frame of initiation of a
CISD program, the importance of small group therapy, how and why it is important to use well trained individuals that are knowledgeable in CISD and PTSD, and the follow-up that is needed to ensure that the treatments is effective.
Research Problem
This research will present peer reviewed literature and studies that focus on the development of CISD programs to combat the issues of PTSD for police officers and public safety officials involved in a critical incident. The development of CISD has been noted differently by means of its effectiveness by mental health professionals since the 1980’s when
CISD really became a main priority for first responders. The studies of, and the implementation of CISD programs, paved the way to understanding the effects that critical incidents have on a person’s mental health. These studies also allowed for the understanding of how the brain processes a critical incident and why certain therapy treatments are necessary. A model to examine the best practice will be put together using the methodological studies of the Immediate
Single-Session approach theory, Brief Delay-Multiple Session approach theory, Emotional
Processing theory, Over-Engagement theory and the Under-Engagement theory.
The 0p5 program from the Grand Rapids Police Department and Kent County Sheriff
Office, the CISD from the Los Angeles Fire Department, CISM/Peer Support model from the
Peoria Police Department in Arizona, Post Trauma Staff Support Program from the State of
Texas Department of Public Safety, and the Peer Stress Program of the Multnomah County,
Oregon Sheriff’s Department will be compared and presented to understand the similarities and differences from each public safety agency, as a tool to combat and minimize PTSD and Critical Incident Stress Debriefing 12 depression. Finally, recommendations for an effective CISD model with early implementation will be suggested for public safety agencies to use. The idea is that the early implementation of a
CISD plan and Critical Incident Stress Management (CISM) will be effective in reducing PTSD and depression amongst police officers and first responders.
CHAPTER II. REVIEW OF THE LITERATURE TO THE RESEARCH PROBLEM
The development of a best practices model for PTSD for police officers and first responders requires an exploration of the historical perspective of the origins, and the development of the use of treatment for PTSD. This exploration entails the evolution of PTSD and the psychological effects. Understanding of how PTSD relates to police officers puts a context on how to develop a treatment option for those effected by the critical incident. This in- depth exploration points out the issues that critical incidents have on the first responder’s mental health. The suggested best practices model to improve mental health will be presented in a later section of this paper.
Increasing Number of Police Involved Shooting Incidents
Police shooting incidents have increased across the Unties States, and not just in one area in particular. One study that was conducted in Newark, NJ found that in shootings increased by half, indicating that gun violence in general is on the rise in New Jersey (King, 2015). In response to this increase, the State of New Jersey sent the state police into Newark to help decrease the gun violence. For a two and a half year period the state police assisted with the violence, effectively reducing the violent crime. By August of 2015, the number of incidents had increased again prompting the request of additional law enforcement help from the state police to help quell crime.
The increased violence from shootings had an effect on the area police officers, and Critical Incident Stress Debriefing 13 police officer involved shootings are increasing each year due to gun violence. The police officer fires his or her weapon in the performance of their duty, and in most cases, has to act in self-defense due to a perceived level of threat. Officers respond by shooing a suspect due to the severity of the threat that he or she perceives at the time of the threat occurrence, or when he or she perceives a viable threat to their personal safety. Nieuwenhuys, Cañal-Bruland, & Oudejans note, in general, that “When people are afraid of something, this is related to their perception of the environmental terms of anticipated events” (Nieuwenhuys, Cañal-Bruland, & Oudejans 2012, pg. 609). Studies have also shown that psychological and physiological influences contribute to the possibility of certain actions when confronted with the threat (Nieuwenhuys, Cañal-Bruland,
& Oudejans 2012).
Another threat perception detailed in the study, was when individuals hold a tool and perceive the distance from the target, the previewed distance decreases only when that individual intended to use the tool, and would be able reach the intended target possibly causing harm. The other example was the perception of height when standing on a high balcony, equating to the perceived feeling that the height was higher than it actually was when he or she was asked about falling (Nieuwenhuys, Cañal-Bruland, & Oudejans 2012).
This study was developed to determine how a threat to a police officer influenced his or her shooting behavior against a subject. Due to distance perception of a threat, it is reasonable to believe that the distance to the danger is a realistic influence of when an officer would shoot a person in self-defense. This is because when a person decreases the distance and the subject continues to approach, the danger level increases. This causes the officer to have an increase in his or her feeling of anxiety, and causes the officer to shoot sooner as the threat comes closer
(Nieuwenhuys, Cañal-Bruland, & Oudejans 2012). Critical Incident Stress Debriefing 14
Critical Incident Stress Debriefing (CISD) Review
There are several core components to CISD that need to be understood in order to implement any treatment options, and a person must understand what a critical incident is. A critical incident is defined as a “stressful incident that is so consuming it over-whelms existing coping skills” (Malcolm, Seaton, Perera, Sheehan, Van Hasselt 2005, pg. 262). There are a few variations on the definition of a critical incident, but they all seem to have the same commonality. The commonality is that a critical incident is one that upsets the mind and how perceives and how it processes a severe incident. The definition is further defined, “as an event that has the potential to interfere with a person’s normal management of everyday stress”
Malcolm, Seaton, Perera, Sheehan, Van Hasselt 2005, pg. 262). A critical incident event processes through a person’s mind differently than other less severe incidents that become normalized in the process.
It is also important to understand that there is a difference between a critical incident event and a crisis response. Malcom and his team of researchers have defined and separated the two terms. A critical incident is the actual event itself, that has inherent risk of dysfunction by the individual involved. While similar, a crisis response is the presentation by an individual who’s coping skills have been overwhelmed by the critical incident itself, and that the person is showing signs of emotional impairment from the incident (Malcolm, Seaton, Perera, Sheehan,
Van Hasselt 2005).
An acting CISD model is in effect for police officers in critical incidents. The article
ACFASP Review: Critical Incident Stress Debriefing (CISD) uses the CISD model also noted by
Malcom using the Mitchell Model. For police officers, the introductions stage consisted of a peer law enforcement officer, and a mental health professional. In the first phase, the Critical Incident Stress Debriefing 15 introduction phase, the process and rules of confidentiality are discussed. The second stage, the fact phase, the officers were asked what their specific role was in the critical incident. The third stage, the thought stage, officers were asked what their thoughts were following the incident.
The fourth stage, the reaction stage, it explored the reactions of the officer. The fifth stage, known as the symptom stage, the “signs and symptoms” of stress are acknowledged by the group. The group talks about the experienced stress, and then those stresses are able to be normalized. The sixth phase, the teaching phase, police officers are taught how to deal with the encountered stress. In the seventh and final phase, known as the reentry phase, this phase the officers are asked to discuss any other issues that may be related (Pia, Burkle, Stanley, &
Markenson 2011).
To further expand on CISD, Critical Incident Stress Management (CISM) was developed and designed to provide “pre-incident educational training to help normalize psychological reactions to traumatic events” (Pia, Burkle, Stanley, & Markenson 2011, pg. 3). Other elements of care provided are to offer acute care services to an individual, group, or an organization involved in a critical event. The CISM program would also send the incidents to treatment specialists to evaluate each case for future studies and developments.
The CISD evolved into CISM as a “stand-alone” method using eight key components to manage CISD. The eight key components are first, the pre-crisis preparation, second, demobilization, third, defusing, fourth, critical incident stress debriefing, fifth, individual crisis intervention, sixth, pastoral involvement, seventh, family or organizational crisis intervention or consultation, eighth, and final component of follow-up referral, and evaluation for possible psychological assessment and treatment following the treatment (Pia, Burkle, Stanley, &
Markenson 2011). CISD and CISM will be explained in more detail later in this seminar paper. Critical Incident Stress Debriefing 16
CISD and the Relationship to Causes of PTSD
Multiple studies have found that coping with secondary stresses of police work increases mental health issues. Reported areas of mental health are depression, PTSD, and anxiety (Conn
& Butterfield 2013). In a study conducted by Conn & Butterfield, it was found that police officers already suffer from a higher rate of these mental health issues, and that the rate of effect had doubled between 1993 and 2003. There was also a correlation found between mental health and how it negatively impacts an officers’ physical health. This, in turn, caused behavioral effects such as absenteeism, domestic violence incidents, substance abuse, and excessive force incidents (Conn & Butterfield 2013).
Conn and Butterfield had summarized police work operational stressors into two categories of primary and secondary traumas. The primary trauma is an event that involved a threat to the police officers’ life, specifically being noted as a main cause of an officer-involved shooting. Another primary event is the continual or repeated exposure of the suffering of others
(Conn & Butterfield 2013). Secondary Traumatic Stress (STS) is a psychological symptom that has effects similar to PTSD, but is caused by “exposure to persons suffering from the effects of trauma” (Conn & Butterfield 2013, pg.273). This type of stress focuses on the therapists or counselors instead of the public safety workers such as the police officers. However, studies have also shown that police officers do suffer from STS because of repeatedly responding to traumatic events, and may develop PTSD from this exposure (Conn & Butterfield 2013). Other indicators of STS or PTSD noted can be from general occupational stress such as shiftwork, management issues, or personnel issues.
The development of the Critical Incident Technique (CIT) followed five outlines by ascertaining the general aims of the activity being studied, making plans and setting Critical Incident Stress Debriefing 17 specifications, collecting data, analyzing the data, and interpreting the data (Conn & Butterfield
2013). The study referenced by Conn and Butterfield used police officers who use general coping strategies for STS. The second step included the use of a written questionnaire. The third step used in-person interviews to collect data, and the fourth step was analyzing the data.
The fifth step was conducting credibility checks and writing a final report. The CIT study found
14 different categories in which officers used to lower secondary stress. The first and most prevalent category was Self-Care. For self-care, purposeful activity such as exercise, prayer, sleep, and time-outs were reported as a distraction from the stress. Significantly, out of the study, only 4 participants of the 10 that were used for the study reported that the availability of mental health personnel assisted with stress relief (Conn & Butterfield 2013).
In response to treatment of PTSD, the “Window of Opportunity” or the “Golden Hours”, which is the first few hours following a critical incident, is the most important time frame to initiate a CISD plan. Initiating within this window could have dramatic effects that can
“dramatically alter the trajectory of PTSD” (Zohar, Sonnino, Cwikel-Hamzany, Balaban &
Cohen 2011, pg. 303). During that window of opportunity, it is important to start the debriefing process to allow the brain to process the incident as normal. PTSD is developed from the reoccurring memories that can expose themselves through flashbacks, and nightmares that are set off due to a triggering event. During the debriefing process, it is also important not to disrupt the spontaneous recovery of the mind and coping process. The spontaneous recovery is the process that most individuals recover from the critical event or from PTSD. As noted in the study, “the vast majority (80% to 90%) experience spontaneous recovery from these symptoms, and hence, one way to conceptualize PTSD is as a disorder” (Zohar, Sonnino, Cwikel-Hamzany, Balaban &
Cohen 2011, pg. 303). The reduction in memory of the event causes the individuals to recover Critical Incident Stress Debriefing 18 from those negative memories that are causing disturbances or symptoms of PTSD, and is noted as a normal cognitive mental process.
Causes of PTSD
As noted above, a critical incident is defined as “a stressful event that is so consuming it overwhelms existing coping skills” (Malcolm, Seaton, Perera, Sheehan, Van Hasselt 2005, pg.
262). To break down the definition into one that is more direct it could be defined as an event that may potentially interfere with the normal management of stress. The Mitchell Model, created by Jeffrey Mitchell, differentiates the differences between a critical event and a crisis response.
Malcom also clarifies the definition in that a critical incident is the event itself, which because it is critical, has the potential to engender dysfunction. A crisis response is defined as the
“actual presentation of an individual whose coping resources have been overwhelmed by the incident and there is evidence of impairment” (Malcolm, Seaton, Perera, Sheehan, Van Hasselt
2005, pg. 262). Incidents causing PTSD are severe incidents that affect the normal operation of the brain, and the normal ability to process events due to the severity of the incident shocking the mind and coping ability of the individual. Specific incidents such as defined below may foster effects of PTSD and is characterized as an “event that involves death, serious physical injury, or sexual violation (either actual or threatened), and that this exposure takes the form of a personal experience, first-hand witnessing of the event as it occurred to others, learning of the event as it occurred to a close friend or relative, or repeated exposure to the event as it occurred to others”
(Zohar, Sonnino, Cwikel-Hamzany, Balaban & Cohen 2011, pg. 301). Some other major contributors to PTSD are daily events, such as witnessed or some sort of experienced violence Critical Incident Stress Debriefing 19 that occurred, not just large events such as war or large scale terrorist attacks. Most PTSD is caused by daily activities that happen to a general person.
Combating PTSD
To combat the effects of PTSD, the specific identifiable event that caused the stress must be identified for a person to be treated. After identification, the event can “lend itself to the application of prevention strategies for at-risk individuals” (Sones, Thorp & Rasking 2011, pg.
79). Examples used by Sones, are the inoculation of combat personnel and emergency service personnel by exposing them to specific traumatic events prior to deployment for military persons, and allowing emergency services workers to witness critical events. It was also noted that the identification of a casual style event may make the prevention efforts of PTSD more effective.
Sones reviewed the identified risk factors that develop PTSD. It is suggested that trauma memories are verbally accessible memories (VAMs) and situationally accessible memories
(SAMs). VAMs contain the information about an event that has been fully processed by the conscience and are able to be verbally retrieved from the long-term memory of the affected individual. SAMs are the perceptual information of the event that include the information of the senses such as the sounds, smells, and sights. Also included are the emotions the person experienced and the physical body reactions. The memories are characterized as vague and are difficult to recall but are generally triggered by a reminder of the event. Because the memories have not been properly processed into the memory it may result in symptoms of PTSD that can be reoccurring (Sones, Thorp & Rasking 2011). Feelings such as fear, hopelessness, and horror have been identified as the reoccurring symptoms. Those reoccurring feels are the signs that should be identified and noted. Critical Incident Stress Debriefing 20
Psychological interventions for PTSD have been applied in an effort to prevent and reduce the psychological development symptoms. Psychological interventions have shown to be effective in reducing PTSD after it has been developed, however there are mixed results indicated for the intervention efforts noted and explained in the immediate single-session approach intervention and the brief delay, multiple session intervention (Sones, Thorp & Rasking
2011).
The intervention of medications has been tested to induce the memory loss of the event, and this intervention method has been studied for its effects. The use of benzodiazepine (BNZ) is used to calm the horror or the fear that is associated with the exposure to trauma (Zohar,
Sonnino, Cwikel-Hamzany, Balaban & Cohen 2011). Through the 1970’s, a common treatment practice for PTSD was using BNZ’s to help the individual go through, and re-experience the event. In a study conducted of 13 individuals it was found that using medications such as BNZ, which is a combination of clonazepam and alprazolam, was not a beneficial measure of treatment. A follow up conducted after the first month and after the sixth month found that nine of the 13 individuals used for the study developed PTSD as compared with 3 of the 13 with other controls (Zohar, Sonnino, Cwikel-Hamzany, Balaban & Cohen 2011). Also found was that administering medications, specifically alprazolam, within the first hour after the incident was
“associated with significantly more extreme behavioral response” in studied lab rat testing
(Zohar, Sonnino, Cwikel-Hamzany, Balaban & Cohen 2011, pg. 304). Some of the data collected from human pilot studies coupled with the animal study with lab rats, indicates that the early administration of BNZ could interfere with the spontaneous recovery that the brain is required to have to recover from the effects of PTSD (Zohar, Sonnino, Cwikel-Hamzany,
Balaban & Cohen 2011). Critical Incident Stress Debriefing 21
Levels of Identification to Reduce PTSD
Sones, Thorp, and Rasking have identified three levels of prevention for PTSD in order to reduce the risk of mental health disorders. Because PTSD is a direct result of an identifiable event, it makes it a candidate for prevention strategies for police officers and first responders because they are considered at-risk individuals. Sones, Thorp, and Rasking state in their article
Prevention of Post-Traumatic Stress Disorder, “personnel can be targeted before deployment, and attempts can be made to inoculate emergency personnel to potentially traumatic events they may witness or experience.” (Sones, Thorp & Rasking 2011, pg. 79). The three levels of prevention have been created and designed to prevent PTSD for those prior to experiencing the trauma.
The three levels of prevention to reduce the PTSD disorder are identified as Universal,
Selected, and Indicated. Universal, otherwise known as primary, are a set of preventions that are applied to the general population. The risk factors implied do not have to be specific to the individual. Sones, Thorp, and Rasking wrote “For PTSD, universal prevention efforts aim to reduce the exposure to traumatic events for everyone in a given population.” (Sones, Thorp &
Rasking 2011, pg. 80). The example used by Sones, Thorp, Rasking was the use of an educational program for women to inform them of the risks in order to decrease the rate of sexual assaults.
The secondary prevention known as Selective prevention, is designed for individuals who are at risk of developing the PTSD disorder, who have not exhibited any of the symptoms associated with it. Sones, Thorp, and Rasking wrote that “For PTSD, selective prevention efforts could target individuals who have been exposed to a traumatic stressor or life event, and are therefore at greater risk for developing the disorder”. (Sones, Thorp & Rasking 201, pg. 80). A Critical Incident Stress Debriefing 22 psychological counselling session would be a secondary measure used to treat a traumatized person who may not yet be exhibiting symptoms associated with PTSD.
The third identified prevention is Indicated, or known as Tertiary. The indicated prevention is designed for those who may show some signs of the PTSD disorder but the criteria has not been fully met to diagnose PTSD. Indicated is designed in a way that, according to Sones et. al., “targets individuals who are exhibiting subclinical symptoms of the disorder, although full criteria have not been met” and “For PTSD these efforts target those traumatized persons who are beginning to exhibit symptoms of PTSD such as sleep disturbance” (Sones, Thorp & Rasking
2011, pg. 80). The interventions may or could be directly targeted to those individuals meeting criteria for acute stress disorder (ASD), ultimately being used as a prevention for reoccurring
PTSD symptoms (Sones, Thorp & Rasking 2011).
The Need for Early CISD
Acute stress is a sudden onset of stress due to a critical event. Stress plays a significant role in the psychological state of humans. In highly stressful situations, demands become too extreme and the stress produces a heightened state of physical, emotional, cognitive and behavioral arousal (Cane & Ter-Bagasarian 2003). The traumatic events pose significant psychological threats to the affected person and compromises the ability to control emotional and other life outcomes.
ASD and PTSD share similar qualities, depending on the level of stress encountered.
Acute stress also occurs within the first month following the traumatic event and the stress generally lasts between two days and two weeks. Some of the outlined symptoms of ASD listed by Cane & Ter-Bagasarian are “the signs and symptoms of acute stress disorder experienced by a person during or after the traumatic event are a subjective sense of numbing, or absence of Critical Incident Stress Debriefing 23 emotional responsiveness; a reduction in awareness of his or her surroundings (derealization); a feeling of detachment or estrangement from himself or herself (depersonalization); and blocking of traumatic events from his or her memory (dissociative amnesia)” (Cane & Ter-Bagasarian
2003, pg. 61).
Just like PTSD, a person with ASD may reexperience traumatic events due to certain surrounding stimuli that will trigger the event. To be diagnosed with ASD, the symptoms “must have caused clinically significant distress” (Cane & Ter-Bagasarian 2003, pg. 61) beyond general anxiety or sadness, and has significantly affected or impaired the functioning or ability of a person to complete normal tasks (Cane & Ter-Bagasarian 2003). The effects of ASD are notably similar, however if the effects continue beyond a single month period PTSD should be considered as the next diagnosis, and PTSD cannot be diagnosed prior to a one month period.
The requirements of PTSD diagnosis require time to evaluate to determine if it is PTSD or another acute stress issue. To diagnose PTSD, you must wait “at least a month following the trauma— which means that one cannot diagnose PTSD during the first month after the exposure.
Acute PTSD is considered if the symptoms last more than a month and up to 3 months” (Zohar,
Sonnino, Cwikel-Hamzany, Balaban & Cohen 2011, pg. 301). Another notable issue is that both
ASD and PTSD can cause a disability which is permanent, and psychological distress along with general absenteeism and accidents within the work place (Cane & Ter-Bagasarian 2003). It’s important to remember that ASD and PTSD have similar attributes and physical signs.
Current Problems with Applying the Concept of CISD to Police Officers
There are inherent obstacles posed in policing that make that application of mental health services a difficult task. The personality factors of a police officer are generally adaptive type that help the officer cope with feelings, but they do impede recognition factors post incident, and Critical Incident Stress Debriefing 24 they reduce the willingness of the officer to seek mental health treatment. Officers are seen as masculine and strong individuals by the public community they serve and by their fellow co- workers. At any sign of weakness, it will deter an officer from stepping forward after a critical incident due to the police officer belonging to the culture unique to the job. The “Police culture promotes police officers as invulnerable and heroic protectors, and the police identity is built on principles of self-reliance, toughness, control, strength, vigilance, quick and effective problem- solving, discipline and resilience” (Brucia, Cordova, Ruzek 2016, pg. 121).
This adaptation of culture begins early in the police officers career, possibly beginning at the police academy. The police academy is a para-military structure with superior officers and instructors that teach and maintain a structured system for the subordinate officers. These subordinates follow a rigid and guided training session, and behavior code instituted by the agency (Brucia, Cordova, Ruzek 2016).
Further factors that hinder proper mental health services or the treatment of PTSD for police officers is that “The socialization process also promotes the thin blue line, separating police officers from civilians. Though the intention of the thin blue line is to promote fraternalism, it can result in decreased social support from non-law enforcement friends and detachment from psychologically distressed colleagues and superiors” (Brucia, Cordova, Ruzek
2016, pg. 122). The fear is that distressed officers may be rejected from fellow officers or other superiors in the law enforcement field. Brucia, Cordova, and Ruzek note a specific quote from a study of a senior investigator saying “We’re getting the welfare department in tomorrow for any officers who want to talk about this murder. They’ll be using the room past my open office door.
If I see you walk down that corridor, don’t bother coming back” (Brucia, Cordova, Ruzek 2016, pg. 122). These aspects of the police culture make identifying the need for critical incident stress Critical Incident Stress Debriefing 25 debriefing difficult, and makes it difficult for an officer to step forward to seek any needed mental health interventions. The police culture is fundamentally hyper-masculine due to the instilled principles of policing and “renders officers unwelcoming of psychological weakness, unpredictability, uncontrolled emotions, and the perceived inability to cope” (Brucia, Cordova,
Ruzek, 2016, pg. 122).
Additional areas of concern are that officers learn to become distrustful of others, which in turn would lead to difficulty in establishing a rapport or trust with a counselor providing mental health services. Police officers may be dissuaded from seeking the treatment because of perceived threats of being labeled weak, unfit to perform his or her duties, or other consequences that would hinder their professional career. Officers have reported that they feel isolated from the department, punished for reporting their feelings, and degraded through a different work assignment or change of duty (Brucia, Cordova, Ruzek 2016). These factors may lead an officer to refuse to admit to post incident stress and prevent that person from seeking needed treatment.
Models of Approach
The Mitchell Model, created by Jeffrey Mitchel in 1983, consists upon 7 phases of treatment. Irving and Long in 2001 used the Mitchell Model in a study following a critical incident. The seven phases of the Mitchell model adapted by Irving and Long are instrumental in providing CISD following an incident.
As noted earlier, the seven phases of the Mitchell Model are the introduction phase, fact phase, thought phase, reaction phase, symptoms phase, teaching phase, and re-entry phase. Irving and Long used this model of approach on a group of three civilian females in 2001. The results indicated by Irving and Long state that “at the 6-month point, the three women considered debriefing to be beneficial and that it gave them some strength and hope for the future. Several Critical Incident Stress Debriefing 26 themes emerged from their evaluations. All three participants found the experience to be cathartic. The debriefing facilitated the participants to present a detailed account of their traumatic experiences connecting facts, thoughts and feelings. The recognition of such connections helped to alleviate the fear of being overwhelmed by powerful feelings” (Irving &
Long 2001, pg. 312). While the Mitchell Model showed some success with this particular study, it was noted that further studies are needed to prove that the intervention of debriefing would prove effective.
Malcom Et Al, describes the use of the Mitchell Model for the CISD, with the use of first responders in the article Critical Incident Stress Debriefing and Law Enforcement: An Evaluative
Review. From the CISD plan created by Mitchell, they developed a comprehensive CISM system. Within the CISM are 10 components of intervention with separate goals of achievement for each phase identified by Malcom. The components consist of intervention, timing, activation, goals, and format. The CISM System is comprised of the following 10 components, these components make up the Mitchell Model of CISM (Malcom, Seaton, Perera, Sheehan, Van
Hasselt 2005).
1) Strategic Planning: this is the pre-crisis phase with the goal of setting expectations
improved coping, and stress management.
2) Demobilization and Staff Consultations: this is in the shift disengagement phase
with the goal to inform, consult, allow stress management and psychological
decompression
3) Assessment of Need
4) Defusing: post crisis phase, with the goal of symptom mitigation. Critical Incident Stress Debriefing 27
5) CISD: post crisis phase, with the goal of facilitating psychological closure and
symptom mitigation.
6) Individual Crisis: Individual, done one on one: anytime with the goal of symptom
mitigation, return to functioning and referral to other sources if needed.
7) Family CISM: anytime, with the goal of fostering support and communication,
symptom mitigation, possible closure, and referral if needed.
8) Community and Organizational Consultation
9) Pastoral crisis Intervention: anytime, with the goal of mitigating and assisting in
recovery.
10) Follow-up Referral: anytime, with the goal of assessing mental status.
The case study first used was the Oklahoma City bombing incident to test a group of individuals who experienced the critical incident. Robinson and Mitchell conducted a study of
31 individuals, evaluating the impact of the debriefing on two specific groups; hospital and welfare staff, and emergency personnel which had consisted of 13 police officers. The investigators created a questionnaire to rate the impact of the incident and to value the debriefing using a scale of 1 -5, using 5 as great, and to rate the impact perception on their family.
Following the 31 debriefings they mailed a questionnaire to those willing to participate further approximately 2 weeks following the initial debriefing. Sixty percent agreed to participate in the second questionnaire as a further follow-up measure. The results from those second questionnaires proved positive. The results indicated that “When the evaluation questionnaire was administered, both groups showed significant reductions in their average rated impact of the event, although the emergency service personnel showed a larger decrease” (Malcom, Seaton,
Perera, Sheehan, Van Hasselt 2005). Critical Incident Stress Debriefing 28
In addition to the findings, both groups rated the debriefing sessions as valuable in a range of 3.8- 4.5. They note that 50 percent of the participants stated the critical event caused them to recall previous incidents, the most common stress was cognitive for emergency personnel, and 96 percent of the emergency responders noted a decrease on stress because of the ability to talk about the incident and the incident details (Malcom, Seaton, Perera, Sheehan, Van
Hasselt 2005).
Types of Coping Framework
Avoidance coping is a mechanism that is an effort to avoid dealing with a particular stressor. The coping factor is the attempt of the mind to protect oneself from psychological damage. PTSD is the precursor to avoidance and the sufferers of PTSD attempt to avoid the trauma and not cope with the problem. Avoidance, “reflects a person’s decision to remove oneself from a perceived threat. This might be accomplished through filtering out or ignoring information (i.e., discounting or reducing the importance of the stressor) or psychologically distancing oneself from the stressor by objectively identifying and understanding the source of stress” (Anshel & Brinthaupt 2014, pg. 677).
On the other hand, approach coping strategies focuses on a different way to deal with stress head-on. Examples of such include obtaining knowledge, venting the emotions, or seeking other information (Anshel & Brinthaupt 2014). The approach coping strategy “focuses on the person’s thoughts or behaviors following stressful appraisals of an event for the purpose of reducing or managing the stressful event” (Anshel & Brinthaupt 2014, pg. 677).
The results reported by Anshel and Brinthaupt were that the study showed that coping skills can be implemented effectively with police officers to help manage the stress levels. The use of approach-avoidance coping had an appearance, or promotional appearance, of the ability Critical Incident Stress Debriefing 29 to have effective coping skills for law enforcement. The study however, was limited due to the number of its participants but it did show successful results across both genders, and with police officers suffering from similar stress of PTSD and other acute stress issues (Anshel & Brinthaupt
2014).
Summary
In Summary, the early implementation of a CISD program for police officers following an officer involved shooting will allow for needed mental health services to combat issues of
PTSD. The debriefing process of a CISD program after experiencing a traumatic event has shown effective by the participants involved. The research has also indicated that sessions of
CISD post-incident will allow for the relief of stress, fear, and anxiety and has been reported favorably by the participants involved. The studies also show that debriefing sessions in CISD allow the affected person to suffer less from the effects of PTSD by normalizing the critical incident thorough talking about the incident methodically, and by encouraging the mind to spontaneously recover when CISD is applied appropriately. This paper will hope to support that
CISD, when applied properly after a critical incident, will reduce the effects of PTSD in an OIS.
CHAPTER III. METHODOLIGICAL STRATEGIES
Different strategies to combat issues of stress, and to prevent PTSD after a critical incident have been developed to assist those officers and first responders in need. Five different examples have been listed of how to identify, initiate, and maintain CISD or CISM.
Immediate Single-Session Approach
Debriefing typically occurs within a few hours to a few days following the critical event.
The incident debriefing is also administered to all of those exposed to the trauma events. During the debriefing sessions those that are the victims are encouraged to talk about their experiences Critical Incident Stress Debriefing 30 and share their personal thoughts or feelings. Those individuals involved are also offered psychological education or services (Sones, Thorp, & Rasking, 2011). The most common form of the single-session approach program that is used is the CISD program (Sones, Thorp &
Rasking, 2011).
The single-session approach of CISD is a secondary style of psychological prevention.
This style invites all of the victims of the critical incident or event to participate in a session that lasts up to four hours. This is provided by the CISD team to normalize the stress responses
(Sones, Thorp, & Rasking, 2011). During the single-session approach, the “team teaches coping skills, encourages participants to share their experiences and emotional reactions, and offers additional resources for those who may need it” (Sones, Thorp, & Rasking, 2011, pg. 82). The victims are invited to the debriefing regardless of PTSD risk factors that may affect them. Those who may have more severe symptoms may not attend in a way to avoid the trauma. This avoidance is a “hallmark of psychological trauma” (Sones, Thorp, & Rasking, 2011, pg. 82). Due to the style of this session, in the single-session approach there is little time for the development of familiarity with others, and it may pose some ethical implications if victims are mandated to attend the session (Sones, Thorp & Rasking, 2011). The single-session may not provide enough sufficient opportunities that may be required for some victims (Sones, Thorp, and Rasking,
2011).
Brief-Delay Multiple Session Approach
The brief-delay approach is a multi-session program that will usually occur within the first few weeks to the first few months following the incident. These sessions are more structured than the initial debriefing programs, such as the CISD or single-session approach.
These sessions follow more rigid guidelines and are not designed to have open discussion Critical Incident Stress Debriefing 31 amongst the others involved or discussed with others involved as in the single-session style.
This type of intervention targets those who are at higher risk of developing PTSD (Sones, Thorp,
& Rasking, 2011).
The trauma-focused cognitive behavioral therapy (TFCBT) has the most amount of empirical support to prevent PTSD (Sones, Thorp, & Rasking, 2011). This program is effective in psychoeducation, cognitive restructuring, and exposure therapy. Along with the TFCBT, the memory structuring intervention may be implemented. This is a two-session approach intervention with the belief that memories are fragmented, and rely on emotional information
(Sones, Thorp, & Rasking 2011).
In the first session, the therapist helps the affected individual provide a detailed narrative of the event, and includes emotional, sensory, and factual information. This is written down and then read out loud with a therapist. The victims are also encouraged to share this with coworkers or other supportive persons (Sones, Thorp, & Rasking 2011).
In the second session, the written information is read again. The victim and therapist collaborate with the results, and the reported reactions of the coworkers and supporters after the victims’ reading of the events to those participating individuals. The therapist then recommends additional sources of support based on the reported reactions from the victim (Sones, thorp, &
Rasking, 2011).
Emotional Processing Theory
The Emotional Processing Theory was developed in 1986 by E. B. Foa and M. J. Kozak.
This theory was developed to conceptualize anxiety and its disorder, and to develop effective treatments including that of PTSD (Psychother J.C., 2006). It is noted in the article Emotional
Processing Theory (EPT) and Exposure Therapy for PTSD, that “fear is represented in memory Critical Incident Stress Debriefing 32 as structures that are made up of associated stimulus, response, and meaning elements designed as a program to avoid or escape danger” (Psychother J.C., 2006, pg. 62). The fear stimulus would connect to behavioral and psychological response elements, such as running away or increased heart rate. It would also connect to other meaningful elements, such as the fear of dying (Psychother J.C., 2006). When an effected person is in the environment and matches the fear elements, it is activated and “the activation spreads throughout the network” (Psychother
J.C., 2006, pg. 61). Foa and Kozak state that the pathological fear is underlying of the anxiety disorders. The pathological fear structures differ from that of the normal fear structure, in the fact that they involve excessive response elements which may be resistant to modification procedures, and “the associations among the different elements do not accurately represent reality” (Psychother J.C., 2006, pg. 61). The article notes that to apply the emotional processing theory to PTSD, the fear structure must include excessive stimulus, response elements, and pathological meaning elements (Psychother J.C., 2006).
The Emotional Processing Theory believes in an effective treatment that “involves an optimal level of activation of the fear structure targeted for treatment” (Psychother J.C., 2006, pg
62). It also states that too little or too much activation may impede the treatment (Psychother
J.C., 2006). As emotional processing theory is applied to PTSD, those affected by PTSD have fear structures of trauma survivors that include dysfunctional cognitions. The first noted fear is that the PTSD sufferer believes that the world is completely dangerous. Secondly, he or she feels that they are totally incompetent in handling the situational stress (Psychother J.C., 2006). Foa and Kozak report that the psychological intervention requires that the fear structure be activated, and the information incompatible with the elements must be presented into the fear structure of the person. This is to replace pathological elements of fear with realistic elements (Psychother Critical Incident Stress Debriefing 33
J.C., 2006). The treatment is “engaging the victim with the avoided daily activities and the traumatic memory to disconfirm the pathological elements of the feat structure” (Psychother
J.C., 2006, pg. 62).
Over-Engagement
The Emotional Processing theory suggests that over-engagement will prevent the information processing that will disconfirm pathological elements, and impede the modification of the fear structure (Psychother J.C., 2006). While the theory suggests this, there has been no empirical evidence suggesting that this may occur. However, the mechanisms of over- engagement that may relate to the treatment have not been fully examined to make a determination of its effects (Psychother J.C., 2006).
It is believed that the over-engagement will occur when the persons fear structure
“become so activated during the exposure that the patient is unable to focus on new information to incorporate into the fear structure” (Psychother J.C., 2006, pg. 63). It is imperative that the affected person is reminded of the rationale for exposure, help the patient stay grounded to the present, and have the affected person write the event down and avoid a verbal recount of events
(Psychother J.C., 2006).
Under-Engagement
The Emotional Processing theory also suggests that the if the fear structure isn’t sufficiently activated, the modification may not or cannot occur (Psychother J.C., 2006). The under-engagement may happen during an imaginal type of exposure. During imaginal exposure, feelings and thoughts of the event are recounted. Studies have lent support “to the hypothesis that fear activation is necessary for exposure therapy to be successful in reducing anxiety symptoms” (Psychother J.C., 2006, pg. 62). The article Emotional Processing Theory (EPT) and Critical Incident Stress Debriefing 34
Exposure Therapy for PTSD, notes that studies have shown that heart rates increase during times of “fear-relevant imagery” and a relation between reported stress by the victim and heart rate increase on activation (Psychother J.C., 2006, pg. 62).
The article also notes that unless the victim of the traumatic event does not display signs of distress when recounting the experience, he or she does not benefit from the exposure therapy.
Steps to increase victim engagement during times of under-engagement are to remind the patient of the reason for the exposure, encourage the victim to keep his or her eyes closed, speak in a present tense when including details and feelings, use probe style questions to encourage the exposure of the distressing thoughts and feelings, and attempt to role play the event if the other steps are unsuccessful with the victim keeping his or her eyes closed, and continuing to use present tense to include the emotional details, thoughts , feelings, and actions. (Psychother J.C.,
2006).
These methodological strategies are steps to take, in a specific order, to combat psychological effects from the exposed trauma. The theories provide treatment options to attack the critical incident effects to reduce the fears and anxiety that may cause PTSD, or another long term psychological trauma. Each style of approach provides commonalties of discussion as an important factor, followed by more intensive treatment options with psychologists and mental health services for those more severely affected. Multiple public safety agencies have policies and procedures in the administering of CISD and CISM following a critical incident. Five examples from public safety agencies consisting police departments, a correctional institute, and fire department will be discussed in the next section. The selected agencies have developed
CISD and CISM plans to initiate with the first responders following a critical incident. Each agency developed a plan unique to their specifics departments. Critical Incident Stress Debriefing 35
CHAPTER IV. ANALYSIS OF COMPARISON OF CISD PROGRAMS
Strategies are used to develop CISD programs for police officers and first responders.
The concepts of those strategies noted earlier are used in conjunction with the developed policies and procedures from the listed below agencies. Police departments and other public safety agencies have put together different methods or polices that are specific to their own departments for CISD following a critical incident. The procedures that were developed target the individuals that were either directly and indirectly effected by the critical incident to include police officers, firefighters, emergency medical technicians, and others that may have been on scene of a critical incident. Five CISD models and policies will be put forward, as an example to establish a foundation which the best practices model will prioritize CISD and CISM. These five example models are Op5 from the Grand Rapids Police Department and Kent County Sheriff’s Office,
CISD from the Los Angeles Fire Department, CISM and Peer Support model from the Peoria
Police Department in Arizona, Post Trauma Staff Support Program from the State to Texas
Department of Public Safety, and the Peer Stress Program from the Multnomah County Sheriff
Department in Oregon.
Op5 from the Grand Rapids Police Department and Kent County Sheriff’s Office
The Op5 is a pilot program that was developed by the Robertson Research Institute to be implemented for law enforcement officers. Dr. Joel Robertson who is the founder and CEO of the company stated that the understanding of the brain is vital in terms of understanding how to eliminate blocks of the mind that are impacted by daily unavoidable activities (Robertson, 2016).
The Robertson Research Institute and the Mercy Health System, initiated the study with the
Grand Rapids Police Department and Kent County Sheriff’s Department to measure not only the mental well-being of the officers and employees, but also the physical and emotional well-being. Critical Incident Stress Debriefing 36
An article published by the Grand Rapids Business Journal stated that “Robertson Research
Institute, the local research arm of Nevada-based Robertson Wellness, partnered with Grand
Rapids-based Mercy Health to launch a pilot program called 0p5 with the Grand Rapids Police
Department and the Kent County Sheriff's Department. The goal was to improve officers' quality of life and long-term health” (Nichols, 2016, pg. 3). The intention of the pilot program is to develop plans and “provide deputies with the insight they need so they are able to develop coping techniques that improve their wellbeing and health” (Robertson, 2016. Pg. 9).
The Op5 program consists of 8 weeks of study, examining what Robertson calls the 5 cards that being the brain, body, physiological reward center, environment, and belief system
(Robertson, 2016). In this pilot program, 45 law enforcement officers combined between the
Grand Rapids Police Department and the Kent County Sheriff’s Department participated.
Robertson lead the program by teaching officers how to manage stress response. This was done by identifying response factors to stress such as sweaty palms, increased heart rate, aggression, or scattered thoughts called yellow flags. Once these signs have been identified, each officer was given a unique prescribed method to relieve the anxiety that is specific to each participant,
(Robertson, 2016). The program also includes online physiological sessions that applies a personal strategy assessment by the Roberson Wellness group, including “group workshops, and some 1-on-1 sessions involving a personal strategic plan” (Roberson, 2016, pg. 11)
The pilot study resulted in positive test results for the officers. For example, Officer’s impression of the program was that 88% gained insight and 81% felt heathier”, and “Officer compliance was at 0.68, where 0.5 is minimally compliant and 0.75 is highly compliant”
(Robertson, 2016, pg. 14). Also noted was that officers showed an average increase to their personal health, work performance, and their relationship inhibitors of 14 per officer, which is an Critical Incident Stress Debriefing 37 improvement to 6.5 (or 54%) over the 8-week trial period (Robertson, 2016).
Due to the outcome resulting favorably, the Grand Rapids Police Department and Kent
County Sheriff Department, which employs around 800 police officers in each department, has initiated the Op5 program as the model of stress reduction for their department, and will continue to analyze the results over the course of an additional year.
CISD from the Los Angeles County Fire Department
The CISD debriefing process by the Los Angeles County Fire Department (LACoFD) is one of the oldest developments in the country. The LACoFD debriefing program was implemented in 1986, based on the International Critical Incident Stress Foundations (ICISF) model. The program follows three main criteria of the crisis which are the pre-crisis phase, the acute crisis phase, and the post-crisis phase. Furthermore, the three phases encompass ten components of “pre-incident education, demobilizations, on-scene support, defusing’s, Critical
Incident Stress Debriefings (CISD), individual counseling, significant other support, specialty debriefings, follow-up, and a strong peer firefighter support program” (Hokanson & Bonnita,
2000 pg. 249) with intentions of lowering the negative effects created from critical incident induced stress.
Between 1986 and 2000 over 500 CISD’s have been conducted within the department with fours specific goals; reduction of impact from the traumatic event, to accelerate the recovery process, to normalize the stress response, and provide for education in stress coping techniques. The LACoFD has a series of components in the CISM program that focus on defusing, CISD, and individual peer support. The LACoFD requires all personnel to attend a
CISD after each critical event in an effort to reduce and educate staff about stress (Hokanson &
Bonnita, 2000). Critical Incident Stress Debriefing 38
CISM Peer Support model from the Peoria Police Department
The City of Peoria Police Department in Arizona has a policy for stress management following a critical incident. The policy was developed to provide police officers with needed peer and psychological support following any critical incident. The peer support and critical incident stress management is a team of individuals that are comprised of sworn police officers, civilian department staff, trained mental health professionals, and other support members that are selected on the basis of their knowledge, training, and abilities to effectively deal with the critical incidents (City of Peoria Police Department, 2006).
The critical incident support team consists of four core roles and member are assigned positions based on qualifications. First, there is a team leader. The team leader has, at minimum, completed an advanced course of CISM. Second, the general team members consisting of sworn police staff and civilian staff that must successfully pass the basic course of CISM. Third, is the
CISM and Peer Support Team members. These members are from other agencies that will be available if the team leader requests additional resources to assist. Fourth, the team will have one of the police departments’ chaplains assigned (City of Peoria Police Department, 2006).
The team will provide emotional, spiritual, and psychological support to the officers involved and assist their families with making needed arrangements. The CISM/Peer Support
Team will be activated automatically by the Bureau Lieutenant for incidents of officer involved shootings, line of duty deaths, serious duty injuries, major disasters, prolonged tactical operations, incidents involving child deaths, and other serious incidents involving other Peoria departments. The team may also be activated for incidents upon request with the approval from the Chief of Police (City of Peoria Police Department, 2006). At the conclusion of a critical incident the Bureau Lieutenant or the CISM/Peer Support Team Leader, may recommend that a Critical Incident Stress Debriefing 39 debriefing occur involving those involved directly or indirectly with the incident, and the debriefing will be held within three days of the incident. Participation will be voluntary unless mandated by the team leader. Two other duties and responsibilities of the team are to first, diffuse by providing support, education, and referral services. These diffusing sessions may be direct with a team member, or informal within one-on-one communication. Those sessions will remain confidential without knowledge of a supervisor if so desired as long as no illegal activity has occurred that needs to be refereed. If illegal activity is reported during the confidential session, that information is passed on and given to the department supervisors for review for dissemination (City of Peoria Police Department, 2006).
The second additional duty of the team is to conduct an annual review. The review will be of related operations due each October. The review is to determine if changes to the program or operating procedures need to be altered for future use (City of Peoria Police Department,
2006).
Post Trauma Staff Support Program State of Texas Department of Public Safety
The Post Trauma Staff Support Program is a two-tier program utilizing Unit Teams and
Regional Teams for the correctional officers in the State of Texas. Each of the facilities has a unit staff support team that is comprised of individuals selected by the facility warden. These individuals are the immediate responders following a critical incident to provide support to the affected employee. Each team has two employees, usually one male and one female, who hold the rank of at least a sergeant but typically is a department captain. They will train the team members, conduct team meetings each month, monitor the completion of incident logs, and serves in the capacity of a unit liaison to the regional team (Finn, 2006).
There are five regional support teams, one team for each of the five geographic regions in Critical Incident Stress Debriefing 40 the state. The teams consist of a department psychologist, regional director, chaplain, health service representative, and one open slot to be filled in a two-year term. Each of the team members are assigned a specific role such as a debrief leader, or a team leader. The regional teams are available for a crisis 24 hours a day (Finn, 2000).
The unit team leader, generally learns about the incident by word of mouth. The team leader then advises the facility administrator who will then authorize the leader to activate or summon the entire team. When the team is activated, they are relieved of their duty posts until advised when they may return to duty. Team members are identified by badges and provide the initial first aid to the officers. They do this by accompanying the affected individual to the hospital or medical facility and by talking with them (Finn, 2000).
The team members are in charge of multiple aspects. As a team, they provide information about symptoms that may occur after the critical incident, identify reactions that are normal for the situation, and assess the need for debriefing. The team members also distribute information about reactions and resources, assist employees with needed follow-up, provide assistance to access the employee assistance program, and help the affected employee with matters that are practical such as providing needed transportation or making contact with the appropriate resources (Finn, 2000). The regional team is responsible for scheduling a debriefing time, providing a private location for consultation, meets with the unit tea leader to review the incident, ensures that the affected employee is accounted for before the debriefing, arranges and initiates a debriefing for all post trauma program members that provide assistance (Finn, 2000).
The critical incident debriefing sessions during and after an incident, are mandatory.
The regional coordinator may refer an affected employee to a care provider through the employee assistance program, or the human resource department. The unit teams up to two Critical Incident Stress Debriefing 41 times per month, continue to be updated on events or changes to officers involved in an incident.
If anyone needs help the team will assign someone immediately and conduct a follow-up within three days (Finn, 2000).
Peer Stress Program Multnomah County Oregon Sheriff’s Department
The Multnomah County Sheriff’s Department’s Peer Stress Program serves the entire department which include 515 correctional officers, 450 civilian staff, and 100 road deputies that are spread across 5 jail facilities. After restructuring the Sheriff’s Office in the early 1980’s, there was low department morale and stress levels were at an all-time high. In 1987, the peer support program was developed. The peer supporters are divided into three area teams; substance abuse, trauma, and debriefing (Finn, 2000). The team members consist of correctional officers, law enforcement deputies, and civilian records division staff. Each of the teams have a team coordinator assigned. (Finn, 2000).
Under the sheriff department structure, there are three divisions that branch out. The
Sheriff is on the top of the hierarchy, underneath the sheriff it is divided by the correctional division, the law enforcement division, and the records division. There is one program manager that will oversee the peer supporters from each division. The sheriff gives each manager per division one day a week to work solely on peer support and follow-up (Finn, 2000). As noted above, the Multnomah County Sheriffs’ Office provides three teams (substance abuse, trauma and debriefing). The three teams have specific duties. The substance abuse team handles addiction issues such as alcohol and gambling, which are the most common addictions noted in the sheriff’s office. The substance abuse team refers those who come forward to the appropriate counselling sources to treat the specific abuse.
The trauma and debriefing teams are activated following every critical incident. The peer Critical Incident Stress Debriefing 42 team managers are contacted automatically from an emergency call list that is approved by the sheriff. The trauma team members prepare the officers for mandatory debriefing. This is to determine who may be in need of immediate psychological attention (Finn, 2000). The debriefing team meets with the involved officers in a secured area that is away from the incident area. The staff comes to the debriefing without their phones and portable radios. One of the trained team members will conduct the incident debriefing with the assistance of a provided department psychologist (Finn, 2000). All officers in need of psychological treatment will be referred to appropriate services by the department following the debriefing.
Comparison of Agencies
Comparing the agencies, all have a system in place to handle critical incident stress to protect their employee’s psychological well-being. The agencies mostly used in-house, trained staff to conduct the initial intervention methods immediately following the critical incident. The agencies have contingency plans for the affected person should the initial debriefing be insufficient to deal with the trauma, such as a referral process for the appropriate medical needs such as needing a psychologist.
The agencies have shown commonalities in use of terms and definition of critical incidents. The terms of CISD and CISM are common between all agencies, and are used as identifiers for critical incidents. Each agency has a system involving employees that are made up of trained teams, provide assistance to those in need of service, provide assistance in obtaining services, provide emotional support for the individual affected, provide resources to the families of the affected, and allow some level of confidentiality. The agencies all note that it is important that the affected receive needed psychological treatment and believe that CISD and CISM are vital functions for positive mental health recovery. Critical Incident Stress Debriefing 43
Using the available information from the noted strategies and the developed processes for
CISD, I will make recommendations for the implementation for an effective CISD program. The recommendations will be developed from the noted agency policies and programs as already discussed.
CHAPTER V. RECOMMENDATIONS FOR AN EFFECTIVE CISD PROGRAM FOR
POLICE OFFICERS FOLLOWING A SHOOTING
The early implementation of a CISD program for law enforcement officers allow for the needed mental health evaluations, and the initiation of debriefing sessions to reduce the effects of the suffered psychological trauma that may cause PTSD, or other acute stress symptoms.
Implement the CISD within 24-72 hours following the Incident
Treatment options are necessary because of the severe effects of PTSD. It was noted that PTSD is caused by an incident that that is so stressful that is will overwhelm the coping skills of a person (Malcom, Seaton, Perera, Sheehan, Van Hasselt, 2005). Because of this high level of severity encompassed in PTSD, it is important to begin those treatment options within an appropriate window of time to reduce the likelihood of PTSD and its symptoms, generally within
24-72 hours. The symptoms of stress, anxiety, and depression can be reduced by providing
CISD soon after the incident because those stressors may be identified, and the brain can begin to experience the normal process of closure (Christenson, 2017).
The recommendations for a best practice model for an effective CISD program would be the implementation of an early and immediate single-session approach following an OIS incident. Following the incident, police officers should begin a debriefing process within the first 24-72 hours after the shooting incident has occurred, if feasibly possible. The stressors are noticeable soon after the incident during the noted “Window of Opportunity” or the “Golden Critical Incident Stress Debriefing 44
Hours” as indicated earlier in the paper (Zohar, Sonnino, Cwikel-Hamzany, Balaban & Cohen,
2011). Though the intervention should be early, it should not be too early as to interrupt the spontaneous recovery efforts of the brain (Zohar, Sonnino, Cwikel-Hamzany, Balaban & Cohen,
2011). Facilitating a structured CISD, as mentioned earlier, may assist with a police officers’ ability to cope with the incident in a positive way (Plat, Westerveld, Hutter, Olff, Fings-Dresen,
& Sluiter, 2013).
Acute stress, is a sudden onset of stress due to a specific critical event and is similar to
PTSD. Cane and Ter-Bagasarian referenced the feelings of extreme stress as indicators that may lead to PTSD if not treated. The feelings of acute stress heighten the physical, emotional, and behavioral responses that pose significant mental and phycological setbacks that compromise the ability to cope if not treated (Cane & Ter-Bagasarian, 2003). Surrounding stimuli may also trigger negative psychological events if left untreated. The treatment should begin following the incident to monitor if acute stress or PTSD should be diagnosed. Treatment is dictated by the length of time of the effects following the incident, and is another reason to implement CISD as soon as feasibly possible to begin the documentation of the length of time. If PTSD is to be diagnosed, it cannot occur less than one month following the incident (Zohar, Sonnino, Cwikel-
Hamzanay, Balaban & Cohen, 2011). Both acute stress and PTSD can cause severe and permanent psychological damage to those affected if undocumented or untreated.
The critical incident trauma may be developed into PTSD, but it was shown to be reduced after participating in CISD and CISM programs. Those affected by PTSD after the traumatic event showed positive recovery efforts, suffered less from the effects of the experienced trauma, and showed to have a better general outcome as the example shown in the 0p5 program.
Robertson noted that those involved in the pilot study had increased general health, work Critical Incident Stress Debriefing 45 performance, and overall officer improvement (Robertson, 2016).
Sones et. al. stated that in order to combat PTSD, the event must be identifiable and specific to treat the individuals, and specific a debriefing plan can then be instituted for the involved person (Sones, Thorp, Rasking, 2011). This allows for revealing of the SAM’s and
VAM’s to identify the feelings and reoccurring symptoms, and to decide if the single-session or brief-delay session of approach would be necessary.
Form Small Groups to Begin the CISD Process
Providing an environment that promotes proper recovery efforts is imperative for police officers to be willing to seek treatment. The police culture, as discussed, is inherently difficult when posed with the fact that psychological treatment may be necessary. The feelings of being labeled weak, or that he or she has lost has lost control is a real threat to the officers’ credibility by their peers. The police culture demands that officers are in control, self-reliant, vigilant, and disciplined to handle stress (Brucia, Cordova, Ruzek 2016). Departments must promote a positive environment for those officers wanting to seek help to cope with the onset of stress from the critical incident. This can be done by implementing CISD or CISM programs, developing policies and procedures related to CISD, and by acknowledging the internal issues within the department.
Following the critical incident, the single-session approach should be initiated. The single-session allows for the individuals as a group to express their thoughts, feelings, and shared experiences of the incident to normalize the stress responses (Sones, Thorp, & Rasking, 2011).
This approach is brief, generally lasting less than 4 hours, and will teach needed coping skills and provide for additional needed resources. Monitoring progress should be conducted. If the officer involved is still not recovering, the brief delay multiple-session approach should be Critical Incident Stress Debriefing 46 considered. The brief-delay session is more structured and follow rigid guidelines that meets with a trained therapist, and is for those at a higher risk of PTSD, the brief-delay is a TFCBT therapy which holds the most amount of empirical support for those needing a more in-depth treatment option (Sones, Thorp, & Rasking, 2011).
The initial treatment sessions should be single person, or small-group focused if multiple persons are involved. This may determine those in need of treatment by witnessing who willingly participates, or it may act as an indicator that the officer(s) involved may not have any psychological suffering. The initial small group focus, is an indicator of possible acute stress by those who avoid the debriefing, and may be an indicator of severe trauma by someone who is actually suffering. This is a type of avoidance by the victim and should be noted (Sones, Thorp,
Rasking, 2011).
Complete the Phases of the CISD by Well-Trained Team Members
The single session debriefing efforts should be conducted by a qualified team member that is trained in CISD. An example of this was presented by the Texas State Department of
Public Safety, indicating that a qualified person trained in the area of CISD is important to begin the process (Finn, 2000). The qualified person should begin the debriefing process, with follow- up sessions to determine if additional mental health services are needed. The services should be confidential, and supported with a positive work environment. Avoiding the police culture such as the stigma of toughness, control, and invulnerability is key as noted by Brucia et. al. (Brucia,
Cordova, Ruzek, 2016). The confidentiality is so that the officer can feel safe, and unafraid to express feelings of the incident without the fear of retribution from police department, and fellow peers due to the potentially negative view of CISD by the police culture. A well-trained team member can assist in avoiding negative cultural issues within a police department. Critical Incident Stress Debriefing 47
Follow-up with the Affected Individuals
Following a CISD program, follow-up should be conducted periodically. Follow-up after the first month, third month, and one year should be done to monitor the progress of treatment.
These time increments coincide with the findings of the presented studies. ASD generally lasts from 2 weeks up to 3 months, and no sooner following the first one month period can PTSD be diagnosed (Zohar, Sonnino, Cwikel-Hamzany, Balaba, & Cohen, 2011). Additional treatment would be needed if PTSD is suspected. Following the 3-month mark, an additional review should be conducted to evaluate the sign and symptoms, evaluate if there is improvement, and to identify ASD as the inhibitor or if it may be PTSD. A one year review should occur to monitor the treatment progress as a whole.
After the initial follow-up is conducted, the implementation of the brief-delay multiple session approach should be considered for those still showing signs of stress. The multiple session approach is to be conducted by a specialized therapist to begin a structured session with more rigid guidelines. During this intervention, the therapist may engage the induvial to participate, and express their feelings and fears of the event by use of the TFCBT and memory structuring intervention (Sones, Thorp, & Rasking, 2011).
CHAPTER VI. SUMMARY AND CONCLUSION
The use of CISD and CISM have shown to be generally favorable by the participants involved. The debriefing efforts have also shown, by the studies presented in this paper, that emergency service personnel, specifically police officers have benefited from CISD or CISM.
This appears to be due to the ability of being able to express the traumatic memories, allowing for the normalizing of the recovery process, and promoting the recovery efforts if it is applied correctly. CISD is a promotion of positive mental health recovery as a type of medical Critical Incident Stress Debriefing 48 intervention for coping with the perceived critical mental trauma (Irving & Long 2001). It assists with the reduction of stress, fear, and anxiety that causes PTSD and ASD by expressing connective feelings that are overwhelming (Irving & Long 2001).
The early implementation of CISD program has shown that there is success in reducing the effects of PTSD, or depression symptoms for police officers when it is possible to do so in a timely fashion following the event (Sones, Thorp & Rasking 2011). The study referenced in the article Prevention of Post-Traumatic Stress Disorder also indicated the successful implementation of the Immediate Single-Session, and Brief Delay theories, depending on the individual (Sones, Thorp & Rasking 2011).
The studies presented in this research also indicate that the application of CISD and
CISM to those willing to participate showed better recovery than those who did not participate.
Providing these measures to those who are willing to participate appeared to be generally positive, as this gave an emotional outlet to those involved that were seeking psychological help.
CISD and CISM, and the follow-up components should be provided, or at minimum offered to all individuals involved in the critical incident who are willing to receive this assistance.
As an additional note, the implementation of further studies of groups of individuals in the immediate single-session approach following a critical incident, should be conducted and compared with the brief delay-multiple sessions approach to more accurately compare the immediate effects versus prolonged effects that have gone without treatment. This research would be fundamental so that it may be evaluated for its effectiveness on other groups of first responders that have been involved in an OIS or another similar critical incident.
Critical Incident Stress Debriefing 49
CHAPTER VII. REFERENCES
Anshel, M. H., & Brinthaupt, T. M. (2014). An exploratory study on the effect of an approach- avoidance coping program on perceived stress and physical energy among police officers. Psychology, 2014.
Bohl, N. (2013). Professionally Administered Critical Incident Debriefing for Police Officers. Police psychology into the 21st century, 169.
Brucia, Emily, Matthew J. Cordova, and Josef I. Ruzek. "Critical Incident Interventions: Crisis Response and Debriefing." Police Psychology and Its Growing Impact on Modern Law Enforcement (2016): 119
Caine, R., & Ter-Bagdasarian, L. (2003). Advanced practice. Early identification and management of critical incident stress. Critical Care Nurse, 23(1), 59-65.
Chopko, B. A. (2010). Posttraumatic Distress and Growth: An Empirical Study of Police Officers. American Journal Of Psychotherapy, 64(1), 55-72.
Christensen, R, (2017). Critical Incident Stress Debriefing. Dr. Christensen Inc.
Conn, S. M., & Butterfield, L. D. (2013). Coping with Secondary Traumatic Stress by General Duty Police Officers: Practical Implications. Canadian Journal Of Counselling & Psychotherapy / Revue Canadienne De Counseling Et De Psychothérapie, 47(2), 272- 298.
Finn, P., United States, Abt Associates, & National Institute of Justice. (2000). Addressing correctional officer stress: Programs and strategies. U.S. Dept. of Justice, Office of Justice Programs, National Institute of Justice.
Hartley, T. A., Sarkisian, K., Violanti, J. M., Andrew, M. E., & Burchfiel, C. M. (2013). PTSD Symptoms Among Police Officers: Associations With Frequency, Recency, And Types Of Traumatic Events. International Journal of Emergency Mental Health, 15(4), 241– 253
Hokanson, M., & Wirth, B. (2000). The critical incident stress debriefing process for the Los Angeles County Fire Department: Automatic and effective. International Journal of Emergency Mental Health, 2(4), 249-258. https://www.linkedin.com/pulse/law-enforcement-health-community-safety-robertson-efforts- marc-decker https://www.peoriaaz.gov/PoliceDepartment/administration/docs/policy_manual/3.13_CriticalIn Critical Incident Stress Debriefing 50
cidentStressManagementPeerSupport.pdf
Irving, P., & Long, A. (2001). Critical incident stress debriefing following traumatic life experiences. Journal Of Psychiatric & Mental Health Nursing, 8(4), 307-314 8p. doi:10.1046/j.1351-0126.2000.00388.x
King, K. (2015, Aug 19). Shootings in Newark surge --- increase of 45% breaks with statewide decline; removal of state police, drugs cited as reasons. Wall Street Journal Retrieved from http://search.proquest.com.ezproxy.uwplatt.edu/docview/1704928732?accountid=9253
Malcolm, A. S., Seaton, J., Perera, A., Sheehan, D. C., & van Hasselt, V. B. (2005). Critical Incident Stress Debriefing and Law Enforcement: An Evaluative Review. Brief Treatment & Crisis Intervention, 5(3), 261-278
Miller, Laurence. "Law enforcement traumatic stress: Clinical syndromes and intervention strategies." Trauma Response 6.1 (2000): 15-20
Nichols, M. (2016). 800 officers in line for stress relief. Grand Rapids Business Journal, 34(29), 1-1,6. Retrieved from http://search.proquest.com.ezproxy.uwplatt.edu/docview/1807686941?accountid=9253
Nieuwenhuys, A., Cañal-Bruland, R., & Oudejans, R. D. (2012). Effects of Threat on Police Officers' Shooting Behavior: Anxiety, Action Specificity, and Affective Influences on Perception. Applied Cognitive Psychology, 26(4), 608-615. doi:10.1002/acp.2838
Pender, D., & Prichard, K. (2009). ASGW Best Practice Guidelines as a research tool: a comprehensive examination of the critical incident stress debriefing. Journal For Specialists In Group Work, 34(2), 175-192 18p
Pia, F., Burkle, F. M., Stanley, S. A., & Markenson, D. (2011). ACFASP review: Critical incident stress debriefing (CISD). International Journal of Aquatic Research and Education, 5(1), 9.
Plat, M. J., Westerveld, G. J., Hutter, R. C., Olff, M., Frings-Dresen, M. H., & Sluiter, J. K. (2013). Return to work: Police personnel and PTSD. Work, 46(1), 107-111. doi:10.3233/WOR-121578
Psychother J.C. (2006) Emotional Processing Theory (EPT) and exposure therapy for PTSD. Journal of Contemporary Psychotherapy,36: 61-65
Psychotrauma and effective treatment of post-traumatic stress disorder in soldiers and peacekeepers. (2009). Journal of Occupational Medicine & Toxicology, 421-27. Critical Incident Stress Debriefing 51
Sones, H. M., Thorp, S. R., Rasking, M. (2011) Prevention of Posttraumatic Stress Disorder. Psychiatric Clinics of North America. 2011-03-01, Volume 34, Issue 1, Pages 79-94
Tuckey, M. R., & Scott, J. E. (2014). Group critical incident stress debriefing with emergency services personnel: a randomized controlled trial. Anxiety, Stress & Coping, 27(1), 38- 54. doi:10.1080/10615806.2013.809421
Walker, A., McKune, A., Ferguson, S., Pyne, D. B., & Rattray, B. (2016). Chronic occupational exposures can influence the rate of PTSD and depressive disorders in first responders and military personnel. Extreme Physiology & Medicine, 5, 8. http://doi.org/10.1186/s13728- 016-0049-x
Wojcik, J. (2012). Critical-incident response team helps workers cope. Business Insurance, 46(21), 6. Retrieved from http://search.proquest.com.ezproxy.uwplatt.edu/docview/1015628858?accountid=9253
Zohar, J., Juven-Wetzler, A., Sonnino, R., Cwikel-Hamzany, S., Balaban, E., & Cohen, H. (2011). New insights into secondary prevention in post-traumatic stress disorder. Dialogues Clin Neurosci, 13(3), 301-309