Critical Incident Stress Debriefing and Law

Critical Incident Stress Debrieﬁng and Law Enforcement: An Evaluative Review

Abigail S. Malcolm, MS Jessica Seaton, MS Aimee Perera, PsyD Donald C. Sheehan, MA Vincent B. Van Hasselt, PhD

Emergency and disaster mental health may have century-old foundations, but its development as a field is far from complete (Everly, 1999). One of the more popular tactical interventions within the field is the Critical Incident Stress Debriefing (CISD) model of small-group crisis intervention, developed by Jeffery T. Mitchell (sometimes referred to as the ‘‘Mitchell Model’’). CISD is but one intervention that falls within the strategic array of crisis interventions collectively referred to as Critical Incident Stress Management (Everly & Mitchell, 1999; Sheehan, Everly, & Langlieb, 2004). With the advent of CISD came a burgeoning number of case studies, personal accounts, and clinical research reports all focused on the efficacy of CISD. The purpose of this paper is to examine and critique the literature specifically addressing the Mitchell Model of CISD with law enforcement. Suggestions for directions that future research on CISD with police officers might take are discussed. [Brief Treatment and Crisis Intervention 5:261–278 (2005)]

KEY WORDS: CISD, CISM, law enforcement, debrieﬁng, group crisis intervention.

High impact events, such as the Oklahoma September 11, 2001, attacks, tax the resources City Bombing, the 1993 World Trade Center of civilians and emergency responders alike Bombing, the Pan Am Disaster, and the (National Institute of Mental Health [NIMH], 2002). The response to these events and the

From the Center for Psychological Studies, Nova South resultant research revived an interest in the field eastern University (Malcolm, Seaton, Perera, Van Hasselt) of emergency mental health. A former Baltimore and the Law Enforcement Communication Unit, Federal County firefighter developed the most influen Bureau of Investigation Academy (Sheehan). Contact author: Vincent B. Van Hasselt, Professor, Center tial intervention, to date, for emergency re for Psychological Studies, Nova Southeastern University, sponders in the wake of critical incidents. 3301 College Avenue, Fort Lauderdale, FL 33314-7796. E-mail: [email protected]. Mitchell (1983) created Critical Incident Stress doi:10.1093/brief-treatment/mhi019 Debriefing (CISD) in the 1970s to help emer Advance Access publication June 29, 2005 gency responders quickly recover from a ª The Author 2005. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].

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traumatic incident. CISD (sometimes referred to Wessely & Deahl, 2003). Moreover, CISD was as the ‘‘Mitchell Model’’) is a formalized seven- designed as a small-group crisis intervention phase group discussion pertaining to a critical within the overarching strategic CISM contin incident, disaster, or traumatic experience. uum of care (Everly & Mitchell, 1999). Later, Mitchell collaborated with Everly and developed the strategic Critical Incident Stress Management (CISM) system, ‘‘a comprehensive, Critical Incidents and Critical Incident integrated multi-component crisis intervention Stress Debriefings system’’ (Mitchell & Everly, 2001). CISM rep resents an effective, strategic continuum of A ‘‘critical incident’’ has been defined as care approach to crisis intervention (Sheehan, a stressful event that is so consuming it over Everly, & Langlieb, 2004; Wagner, 2005). whelms existing coping skills (Kureczka, 1996). As CISM developed during the 1990s, over A more functional definition describes a critical 350 crisis response teams were created. The incident as an event that has the potential to International Critical Incident Stress Founda interfere with a person’s normal management of tion (ICISF) is composed of these teams. ICISF everyday stress. The Mitchell Model carefully members are trained to understand the basic differentiates between a critical incident and physiology and psychology of stress, stress a crisis response. Again, a critical incident is the management, and traumatic stress. Knowledge event itself, which is ‘‘critical’’ due to its about traumatic stress allows CISM members to potential to engender dysfunction. A crisis facilitate the appropriate CISM component in response is defined as the actual presentation the acute crisis phase. Table 1 delineates the of an individual whose coping resources have core components in the functional integration been overwhelmed by the incident and there is that CISM uses to adapt interventions for the evidence of impairment (Caplan, 1964). appropriate incident. One approach to address reactions of CISM continues to expand on its original emergency responders to critical incidents is model by incorporating new research and debriefing. Unfortunately, many researchers strategies from the fields of emergency mental have used the term debriefing to encompass health, psychology, faith interventions, mili a variety of incident–response interventions. tary procedures, and individual CISM team This paper uses the terms CISD to refer to the experience (Everly, 2003a, 2003b; Everly & Mitchell Model and debriefing to refer to all Langlieb, 2003). It is imperative to understand other descriptions of crisis intervention in the that the comprehensive, multifaceted, inte literature. grated nature of CISM was designed for the CISD consists of a group of emergency needs of emergency responders, their families, responders, all of whom were involved in the and their organizations (Everly & Mitchell, same critical incident, and the CISD intervention 1999). CISM was not developed to replace team members deployed for service. In law psychotherapy or to interfere with the natural enforcement, the CISD team consists of at least recovery of human resiliency. Rather, CISM one peer, who is a law enforcement officer, and was designed to facilitate a triagelike process, at least one mental health professional. The CISD for a nonpsychiatric population, in the face of is composed of seven stages. The first stage, a critical incident as a means of returning the Introduction, takes the time to describe the individual and/or the organization to levels of process, rules of CISD (i.e., confidentiality), and prior functioning (Everly & Mitchell, 1999; expectations. During the Fact Phase, the second

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TABLE 1. Core Components of CISM

Intervention Timing Activation Goal Format

1. Strategic planning Precrisis Crisis Set expectations, Groups, teams, phase anticipation improve coping, stress organizations management 2. Demobilizations and Shift Event Inform, consult, and Large groups/ staff consultations disengagement driven allow psychological organizations decompression; stress management 3. Assessment of need Anytime postcrisis 4. Defusing Postcrisis Symptom Symptom mitigation Small groups (within 12 hr) driven triage, possible closure 5. CISD Postcrisis Symptom or Facilitate psychological Small groups (1-10 days, event driven closure, triage, symptom 3-4 weeks mitigation mass disasters) 6. Individual crisis Anytime Symptom driven Symptom mitigation, Individual intervention 1:1 anywhere return to functioning, referral if needed 7. Family CISM Anytime Symptom or Foster support and Families/ event driven communications, organizations symptom mitigation, closure if possible, referral if needed 8. Community and organizational consultation 9. Pastoral crisis intervention Anytime Symptom driven Mitigate Individuals, ‘‘crisis of faith,’’ families, group assist in recovery 10. Follow-up referral Anytime Symptom driven Assess mental status, Individual/families assess needed care

Note. CISM ¼ Critical Incident Stress Management; CISD ¼ Critical Incident Stress Debriefing. Adapted from Everly and Mitchell, 1999 (p. 21); Everly and Langlieb, 2003. stage, officers are asked to say who they are and taught different ways of dealing with critical what their role was in the incident. The next incident stress in their lives (Teaching Phase). stage (Thought Phase) asks the officer to share Finally, the Reentry Phase encourages officers to his or her first thoughts after the incident. The discuss any other issues and ask questions. Most Reaction Phase, the fourth stage, explores the importantly, this phase focuses on returning the personal reactions surrounding the event. In officer to duty. Each stage represents a gradual the fifth stage, the Symptom Phase, signs and step designed to return the emergency re symptoms of critical incident stress are discussed sponder to his/her precritical incident level of and normalized. In the next stage, the officers are functioning (Mitchell, 1991).

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Case Example: Oklahoma City model of crisis intervention. However, CISD is not without its detractors, and there is exis On April 19, 1995, at 9:02 a.m. a bomb exploded tent research contradicting the case study and destroyed the Alfred P. Murrah federal support for the Mitchell Model (see reviews building in Oklahoma City, OK. One hundred by Bledsoe, 2004; Rose, Bisson, & Wessely, and sixty-eight people were killed and more 2002; Wessely, Rose, & Bisson, 2000). Contro than 500 were wounded in the blast (Ottley, versy has always been associated with new 2003). Although the immediate and long-term interventions, and further empirical research is effects on emergency responders included required to ascertain the effects of the CISD on anxiety, depression, suicide, increased alcohol reducing harm from critical incidents. How consumption, sexual misconduct, increased di ever, although there is a modicum of research vorce rates, and Posttraumatic Stress Disorder concerning the specialized area of emergency (PTSD), levels of these anticipated problems mental health, several studies offer evidence of were lower than predicted (Owen, 1999; the utility of CISD for law enforcement Plumberg, 2000; Raymond, 1999). personnel. Many of these articles are personal In the wake of this tragedy, researchers have accounts, of police officers themselves, and are dubbed the aftermath of Oklahoma City primarily subjective and anecdotal reports. The a ‘‘good’’ disaster, indicating that the general studies discussed below were selected based on outcome surpassed what might be expected their (a) empirically oriented focus and (b) following a terrorist attack (Owen, 1999). The attempt to ascertain the heuristic value of CISD implementation of the strategic CISM system in law enforcement populations. (and more specifically, CISD via Project Heart land and the Oklahoma Critical Incident Stress Management Network) helped to manage the Research Findings harmful aspects of traumatic stress (Klinka, 1996, 1999). Contributing to the success of 1. Robinson and Mitchell (1993) evaluated the outcome was the cooperation and collabo the impact of 31 debriefings on two ration among the multidisciplinary team of groups: emergency services personnel emergency response workers (firefighters, law (including 13 police officers) who enforcement officers, emergency medical sup participated in 18 of the 31 debriefings port, clergy, and volunteers). According to City and hospital and welfare staff who Manager Brown (1995), the team effort of the participated in 13 of the 31 debriefings. workers set a new standard in the face of The investigators developed their own disaster, named, ‘‘The Oklahoma Standard.’’ evaluation questionnaire, asking The Oklahoma City response followed the CISM participants to rate the impact of the model, including CISD for police, and proved critical incident and the value of the that if followed properly, it is an effective way debriefing using a 5-point scale (1 ¼ to minimize the impact of a critical incident. none;5¼ great) and their perceived impact of the event on other personnel and family. Additional open-ended Review of Research questions (i.e., reasons this critical incident had an impact on them, other Subsequent research from the Oklahoma aspects of their lives that were affected City Bombing provided support for the CISD by their recall of the critical incident

264 Brief Treatment and Crisis Intervention / 5:3 August 2005 CISD and Law Enforcement including family and signs of stress) (d) the 96% of emergency responders were included to collect subjective data who noted decrease in stress symptoms (e.g., 40% of emergency service attributed part of their improvement to personnel indicated that their families the debriefing, particularly because the were impacted by their own critical debriefing provided an opportunity to incident). Then, following any of the 31 talk about the incident. debriefings, they mailed the 2. Nurmi (1999) assessed the impact of questionnaire to persons who consented CISD on police, firefighters, and nurses to being a participant in their study 2 involved in the 1994 rescue of the ferry weeks postdebriefing. Sixty percent of Estonia off the coast of Finland. Nurses all the individuals who participated in did not receive CISD because it was not the 31 debriefings consented and hospital policy, whereas the police and responded to the questionnaire. firefighters did take part in debriefings. The hospital and welfare staff rated All three groups were assessed using the the impact of the critical incident, at the Impact of Event Scale-Revised, the Penn time of the event, an average of 3.3 Inventory, the SCL-90-R, and a specially compared to 2.2 for the emergency developed Perceived Satisfaction with service personnel. When the evaluation CISD questionnaire. Nurmi found the questionnaire was administered, both nurses to be significantly more groups showed a significant reduction distressed than police officers and in their average rated impact of the firefighters based on the differences in event, although the emergency service outcome using the abovementioned personnel showed a larger decrease. measures. Responses of the latter two CISD was not only rated as valuable but groups on the Perceived Satisfaction also viewed as responsible, at least, in questionnaire revealed that a majority part, for a reduction in stress symptoms (81%) found the debriefing to be useful. (e.g., fatigue, tearing, sleep 3. Bohl (1991) examined police officers in disturbances) for both groups. Southern California using the State-Trait Additionally, both groups rated the Anxiety Inventory, the Beck Depression debriefing as considerably valuable to Inventory, and the Novaco Provocation themselves and other personnel (a range Scale. All officers had experienced of 3.8–4.5). Subjective data also were a critical incident 3 months prior to the compiled about the broader effects of assessment. Also, 40 underwent a brief the critical incidents and the psychological intervention as per debriefings. For example, the evaluation departmental policy. A second group of showed that (a) the type of critical 31 officers did not receive any incident impacts the prevalence of intervention, again, due to department reported stress symptoms, (b) over 50% policy. Bohl found that the officers who of the participants stated that the event participated in the brief intervention caused them to recall prior critical showed a statistically significant incidents, (c) the most common sign of decrease in their rates of stress symptoms stress in emergency service personnel (e.g., depression, flashbacks, and anger). was cognitive (e.g. sleep disturbance, 4. Smith and de Chesnay (1994) evaluated preoccupation with the incident), and a CISD program with a South Carolina

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police department. Ten officers, from an 6. Carlier, van Uchelen, Lamberts, and agency of 100 employees, were Gersons (1998) studied trauma in Dutch interviewed by the primary investigator. officers who responded to a plane crash. The primary investigator contacted each The investigators selected their groups of the 10 officers following a debriefing from the 200 police officers who arrived that he himself had led. Each officer was at the crash site, of whom 45% were offered the opportunity to participate in debriefed and 55% were not. The the study or decline participation; they control group of nondebriefed officers all accepted the offer. A semistructured consisted of officers who, according to interview format allowed the Carlier et al. (1998), did not attend due participants to discuss any area of the to ‘‘operational reasons’’ (e.g., length of critical incident, the debriefing, and any service time on scene) or because related stress. Results indicated that 9 of officers chose not to (e.g., not on duty at the 10 officers felt that CISD was time of debriefing, volunteered to beneficial in helping to reduce their continue with service duty stress. uninterrupted). The investigators 5. Leonard and Alison (1999) assessed assessed 105 officer participants, 59 of groups of Australian police officers (N ¼ whom had not been debriefed and 60) who did (n ¼ 30) and did not (n ¼ 30) therefore comprised their control group. receive CISD following a shooting The investigators completed the testing incident. The evaluation packet at the police departments. They used included (a) a questionnaire asking for the structured interview for PTSD at details about the incident (e.g., prior both 8 and 18 months postdisaster. experiences regarding the shooting The 8-month assessment revealed that incident, appraisal of personal safety although some of the officers displayed during the shooting incident, support PTSD symptoms postdisaster, only two received from the department regarding met DSM-III-R criteria; there were no the shooting incident), (b) the Coping significant differences between the Scale (Carver et al., 1989), and (c) the research groups. Results were similar for State-Trait Anger Expression Inventory. the 18-month postdisaster evaluation. They found that the CISD group had 7. Carlier, Voerman, and Gersons (2000) more shots fired and more people killed described their intervention as the or injured in the incident, had scored Mitchell Model of CISD and higher on active coping, and were administered debriefings immediately significantly less angry than the non- after an unspecified trauma. The CISD group, on all measures. Leonard experimental group of officers (n ¼ 86) and Alison suggested that officers in the had been recruited for participation non-CISD group may have reported following their CISD. One control group elevated anger and poor coping skills of officers (n ¼ 82) did not receive the due to the fact that CISD was not offered debriefing due to operational reasons, to them; of the 30 officers who did not which were not stated in the article. receive CISD, it was stated that they Another ‘‘external control group’’ either refused CISD or were ‘‘overlooked (n ¼ 75) consisted of officers who by the Department.’’ experienced a previous traumatic event

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prior to the institution of debriefing patients, bank tellers, law enforcement offerings within the department. officers). The majority of the group The pretest and 24-hr postincident crisis intervention ‘‘debriefings’’ test phases involved administration of applied to emergency services, and the Spielberger State-Trait Anxiety military personnel yielded positive Inventory to debriefed and outcomes. However, the debriefings nondebriefed officers but not to the applied to individual medical and external control group. One week surgical patients led to no significant postincident, the investigators assessed change and, in some cases, indicated the debriefed and nondebriefed groups negative outcomes. using the Self-Rating Scale for PTSD and 9. Young (2003) focused on the the Peritraumatic Dissociative effectiveness of debriefings with law Experiences Questionnaire. The enforcement populations. The external control group was assessed overarching goal of this study was to with the Impact of Events and the assess the effect of periodic stress Peritraumatic Dissociative Experiences debriefings (debriefings were based on Questionnaire. The debriefed and non- the Mitchell model of CISD) on officers’ debriefed groups were again evaluated levels of depression and PTSD 6 months posttrauma using the symptoms. The author suggested that structured interview for PTSD, the the lack of statistically significant Anxiety Disorders Schedule-Revised, findings in this study reflected on the additional DSM-IV-related issues (e.g., debriefings’ lack of focus on internal dissociation, history of psychiatric police department stressors (e.g., illnesses), and several open-ended supervisors, administrative duties). It questions regarding perceived support, was not suggested that the results satisfaction with the debriefing, and indicated a negative effect from the stress. debriefings; in fact, subjectively, police The investigators found no significant viewed the debriefings as helpful and differences between groups in positive (Young, 2003). psychological symptoms, number of 10. Sheehan et al. (2004) utilized the sick days taken, or rate of returning to application of best practices to provide work. However, 98% of the officers law enforcement with practical, yet reported satisfaction with the debriefing empirically based, information sessions. regarding the issue of law enforcement 8. The NIMH (2002) reviewed 17 studies response to critical incidents and critical (see Table 4) that used self-described incident stress. Their study surveyed 11 psychological debriefings to address organizations, including federal, state, groups and individuals following and city agencies, and ascertained their various disasters and traumatic events. response to major critical incidents (e.g., The review evaluated articles for Waco, 9/11). Using both interviews and standards of research design that were written descriptions, the authors cited met, were unmet, or raised other how these agencies structurally concerns. Reviewed articles included responded to large-scale disasters and a wide range of populations (medical relayed their findings to offer tactical

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TABLE 2. Concerns for CISD Research With Law Enforcement

Assessment concerns CISM/CISD speciﬁcs Culture as a Variable

Measurements Deﬁnitions and terminology Culture of cops Control group Proper application of CISD Acceptance of CISD Overlapping culture concerns Potential for randomized studies Overlapping assessment concerns

Note. CISM ¼ Critical Incident Stress Management; CISD ¼ Critical Incident Stress Debrieﬁng.

and stylistic response options for other CISD in the field of emergency mental law enforcement agencies. While this health and implied an increased need for study supported the use of postincident critical evaluation of relevant literature, crisis intervention, such as CISM, specifically in reference to the a resounding conclusion from all application of CISD to specialized agencies reviewed in the article focused populations (e.g., emergency service on the lack of preincident responses. workers). The overall conclusion of this The authors suggested increased review supports the use of CISD; attention to applying a comprehensive however, the author is rightfully careful approach in response to major critical to specify the effectiveness of CISD incidents, including (a) preincident when applied with emergency service education, (b) preincident training, and workers and as part of a comprehensive (c) early-warning screening. response program. 11. Meta-analysis findings of Roberts, Everly, & Camasso (2005) included the Discussion: Practical Scientific effect size of multicomponent CISM. Suggestions The high-average, 2.11, effect size for multicomponent CISM provided The pattern of disparate findings in the arti statistical significance and practical cles reviewed above mirrors CISD research comparability that most notably in general (Wagner, 2005; Wessely & Deahl, supports the use of debriefings within 2003). Specifically, the reports above have a comprehensive, multifaceted, many of the same terminological and research integrated continuum of crisis design shortcomings as other CISD investiga intervention. In sharp contrast, the tions (Everly, Flannery, & Mitchell, 2000; studies of one-shot relatively brief Everly & Mitchell, 2000). Because in this paper debriefings had low overall effect sizes we focuse on the variable of law enforcement and were not statististically significant. culture, concerns we have identified regarding This study offers federal, state, and local research on CISD with this population are agencies a backbone of strong research illustrated in Table 2. to develop crisis intervention programs, including law enforcement. Assessment 12. Wagner (2005) approached the issue of CISD effectiveness within the field of Overlapping Culture Concerns. Although emergency services, including law each area in Table 2 identifies specific issues enforcement, with a review of literature. in the research, the overlapping aspect of these Wagner addresses the controversy of observations deserves attention. For example,

268 Brief Treatment and Crisis Intervention / 5:3 August 2005 CISD and Law Enforcement conducting research using police officers symptoms they are examining (e.g., State-Trait sustains its own inherent challenges due to Anger Scale, Beck Depression Inventory). shift work, unwillingness to disclose, and However, if they wish to examine the efficacy lack of validated measurements. An investi of CISD, researchers must be sure to (a) assess gator knowledgeable about police culture with psychometrically sound instruments and would likely inquire about how methodology (b) generalize from symptom-specific evalua was adjusted for a 24-hr occupation or how tion tools (e.g., Robinson and Mitchell, 1993, researchers gained access and trust within any used a Likert-type scale to measure perceived given department. However, before addressing effectiveness; Nurmi, 1999, developed a Per law enforcement culture, psychosocial instru ceived Satisfaction questionnaire). In addition, ments used in the studies require scrutiny with several of the articles reviewed mentioned regard to their potential threat toward the occupational records (e.g., absenteeism, sick strength and validity of their findings. and family leave, disciplinary history). How ever, none implied that these type of data Measurements. One of the critical issues in reflect the impact of CISD. It is important to assessment is balancing objective and sub note that one of the primary goals of CISD is to jective measurements. Police officers must return the officer to a premorbid (i.e., pre appear as if they are in control, well-adjusted, critical incident) level of functioning, which and calm. Therefore, a reliance on objective includes getting back to work without man measurements, particularly those which are dates or discipline (Wessely & Deahl, 2003). face valid (e.g., Beck Depression Inventory), Assessment issues regarding law enforcement will not accurately assess police officer stress. and CISD are not strictly police culture con Similarly, dependence on personal interviews cerns. Indeed, they are relevant to research on to assess the effectiveness of CISD does not CISD in general. However, assessment of law produce unequivocal results. enforcement carries its own challenges and must This lack of useful and valid assessment tools be addressed when conducting CISD research permeates CISD research in general. Specifi with this population (Sheehan & Van Hasselt, cally, there is an overreliance on self-reported 2003). Table 3 outlines suggestions specific to measurements and a lack of objective assess this problem pulled from previously reviewed ment (NIMH, 2002). In addition, there is studies. a paucity of evaluation tools validated on police officers: a notable exception is the Law Control Groups. Robinson and Mitchell Enforcement Officer Stress Survey (LEOSS; (1993) discussed the complexity, but under Van Hasselt, Sheehan, Sellers, Baker, & Feiner, scored the importance, of creating adequate 2003). However, a mixture of measurements control groups for CISD investigations. Much provides a more well-rounded assessment to CISD research does not have a control condition balance out the anticipated ‘‘cop culture’’ that includes police officers. The lack of such concerns. It is also important to note that most controls makes it difficult to generalize the fa valid assessment devices that measure psycho vorable findings of Robinson and Mitchell and logical symptoms will not answer questions of Nurmi (1999) to police officers. In contrast, about the perceived effectiveness of CISD. If Smith and de Chesnay (1994) only used police investigators intend to examine how CISD officers for the in-depth personal interviews; affects particular psychological symptoms, however, they did not include a control group they must employ instruments specific to the to confirm their subjective results.

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TABLE 3. Suggestions for Clinical Assessment With Law Enforcement

Research-speciﬁc suggestions Cop culture-speciﬁc suggestions

1. A combination of subjective and objective 1. Face valid instruments should not be used as the assessment tools serves both informative and only type of assessment tools within any given study, qualitative purposes certainly not with police ofﬁcers 2. The use of a mixed battery of assessment tools 2. The use of record checks (absenteeism, sick should be consistently administered throughout the leave, family leave) provides some of the most valid study to the same sample, in the same order and assessments of police ofﬁcers response to any given under the same conditions event and should be used in combination with other assessment tools whenever, ethically, possible

Creating adequate control conditions that (1998) incorporated a control condition of ethically control the variables of interest officers who were not involved with the de between groups is problematic. However, there briefing due to operational reasons. Without are basic differences, which, if addressed, clarification, the utility of a control condition would make the experimental control in law that includes officers who were disregarded by enforcement/CISD research more reliable: (a) their own department, declined the interven increased use of law enforcement officers in tion, or were not offered the opportunity is control groups, (b) improved awareness of questionable. cop culture in the selection of control groups Future research regarding CISD and law within an individual law enforcement agency, enforcement may not be able to completely ad and (c) improved attention to departmental dress individual and departmental differences differences in the selection of control groups affecting control groups. However, awareness between various law enforcement agencies. of how these issues could impact the validity of For example, many of the articles reviewed research findings lead to the following sugges here describe the demographical differences tions: (a) improve assessment batteries given to within and between the groups; there was both groups (to rule out significant personality no mention of departmental differences (Bohl, differences), (b) conduct comparative studies 1991; Carlier et al., 2000). Departmental differ contrasting departments that mandate CISD/ ences that could weaken the utility of control CISM versus departments that do not (to lower groups include (a) law enforcement agencies the significance of departmental disparities), that do or do not employ CISD/CISM, (b) and (c) continue to make efforts to include law agencies that make CISD standard operation, enforcement in control groups if results are to and (c) agencies where the command staff may be generalized to police personnel. offer CISD but fail to support the CISM model. Overlapping with departmental disparities, CISM/CISD: Specific Concerns with there may also be individual differences Law Enforcement Research between officers who choose to attend versus those who decline or are not offered the Definitions and Terminology. Apersistent CISD. Leonard and Alison (1999) created issue in CISD research concerns terminology and a control group from officers who were application. The nonspecified application of either ‘‘... overlooked by the Department or various debriefing models and the misleading refused the debriefing.’’ Similarly, Carlier et al. definitions of debriefing constitute the most

270 Brief Treatment and Crisis Intervention / 5:3 August 2005 CISD and Law Enforcement consistent flaw in CISD research, in general, and by trained CISD team members would be more work with police officers, in particular. Begin internally valid and reliable than debriefings ning with the event itself, an operational performed by other individuals. Some of the definition of a critical incident would undoubt articles presently reviewed describe their edly enhance any study focusing on CISD debriefing as CISD (Carlier et al., 1998, 2000; (Everly & Mitchell, 2000). For example, Nurmi Leonard & Alison, 1999; Nurmi, 1999; Robin (1999) explained the sinking of the Estonia, and son & Mitchell, 1993; Smith & de Chesnay, that description left no doubt about the capacity 1994). However, given the frequent termino for it to have been labeled a critical incident. The logical confusion and the importance of both NIMH (2002) review found that many studies in clinical and statistical significance, it is crucial the area did not define the ‘‘traumatic expo that individuals performing the CISD are sure.’’ Or, the event that was eliciting the properly trained. Nurmi (1999) and Robinson debriefing was itself unclear. A formal definition and Mitchell (1993) are the only two inves of a critical incident initiates the process of tigations to note that their debriefers were designating the model of debriefing being trained according to the Mitchell Model. When analyzed in the study. training standards are clarified, there is a clearer When CISD is the focus of an investigation, link between intervention and outcome of the the researchers should credit the intervention debriefing/CISD. as the Mitchell Model as Carlier et al. (2000) Most of the reports reviewed here justified did in their report. There is an extant body their description of CISD and explained how of work that accuses debriefings of being they identified with the Mitchell Model (Carlier ineffective and even harmful to participants et al., 2000; Leonard & Alison, 1999; Nurmi, (Bisson & Deahl, 1994; Bledsoe, 2004; NIMH, 1999; Smith & de Chesnay, 1994; Wagner, 2002; Wessely et al., 2000). Although contro 2005). Bohl (1991) explained that she used her versy fuels empirical integrity, there seems to personal model of debriefing that was adapted be a simple answer to this debate about the from the Mitchell Model. CISD is a flexible validity of CISD. Careful review of the articles intervention but not interchangeable with any that indicate a lack of efficacy reveals numerous strategy that bears a likeness to debriefing debriefings conducted in one-on-one settings, (Mitchell, 2003). Nurmi (1999) and Leonard and with hospital patients, and with ill-defined Alison (1999) consistently used the term CISD methods of crisis intervention. These debrief in their articles, avoiding confusion between ings do not follow the CISD guidelines, the CISD and other interventions described as Mitchell Model, or the ISCIF standard of care. debriefings. However, although Smith and de Although these articles appear to show a lack of Chesnay (1994) described their group pro effectiveness for the completed debriefings, cedure as CISD, it was difficult to ascertain if they do not have external validity relative to they were actually using the Mitchell Model. CISD as designed by the ICISF (Bisson & Deahl, Similarly, Young (2003) cited that the debrief 1994; Everly & Mitchell, 1999; NIMH, 2002; ing in the study was based on the Mitchell Wessely et al., 2000). Model; however, the description of the debrief ing and its outcome appeared disparate. Termi Proper Application of CISD/CISM. CISD nological clarification is critical in research to team members ostensibly practice the standard avoid the ongoing confusion concerning CISD ized Mitchell Model small-group CISD. There and other interventions mistakenly referred to fore, it can be assumed that CISD performed as debriefings.

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CISD was originally created to address the that none of the CISM components are meant emergency mental health needs of public to be administered as a solitary means of health responders, such as firefighters, para addressing critical incidents stress (Wessely & medics, law enforcement officers, teachers, and Deahl, 2003). Kureczka (1996) purports that nurses (Mitchell & Everly, 2001). CISD has preincident stress education (a CISM compo never been suggested for civilians, medical nent) is the most important element in patients, and other nonemergency responders addressing critical incident stress in police who are facing long-term stressors or severe officers. Volkman (2001) discussed the evolu mental health problems. The NIMH (2002) tion of CISM in the ‘‘blue culture’’ and the review offers a comparison model for other importance of training, stress management, types of CISD research. It shows how this and CISD in law enforcement populations. approach is ineffective when used with non Unfortunately, there is no literature, to date, emergency responders. An examination of that addresses the heuristic value of CISD Table 4 reveals that debriefings are not helpful within the appropriate CISM model. Indeed, for medical patients compared to the near 70% the only mention of the CISM model being positive outcome rate of debriefing efficacy followed in any of the studies we reviewed when administered to law enforcement officers, were from (a) the Roberts et al. (2005) emergency responders, and military personnel. presentation (who reported a high average In addition, the negative-outcome studies effect size of multicomponent CISM from their involving police and other emergency re meta-analysis), (b) the Sheehan et al. (2004) sponders included the reports by Carlier et al. article (they reported best practices (1998, 2000), reviewed earlier. for response mass disasters and noted that The NIMH (2002) review also indicates most agencies failed to provide a continuum of a number of concerns with CISD research, care beyond one-dimensional crisis interven including (a) inadequate random assignment, tion), and (c) the Wagner (2005) review article (b) lack of comparison groups, (c) overemphasis (which made specific recommendation for the on self-report measures, (d) inattention to multicomponent usage of CISM with emer preintervention measurement, and (e) an un gency responders). Fortunately, current liter defined exposure/critical incident. More impor ature has ascertained this weakness in CISD tantly, the NIMH (2002) review highlights other research and has begun the process of problems, such as control groups that opted out improvement with suggestions for research for operational reasons, debriefing interventions and practical applications for law enforcement that were not defined, and intervention groups agencies (Sheehan et al., 2004). that contained more severe injury and symp toms rates than control conditions predebrief Potential for Randomized Studies. Experi ing. In addition, none of the studies reviewed in mentally rigorous research requires randomized NIMH (2002) discussed the application of controls and assignment to interventions. a comprehensive CISM that included debriefing Robinson and Mitchell (1993) noted the dif as a necessary tool within a more comprehensive ficulty in obtaining a baseline (precritical plan of stress management. incident) level of functioning; the current Finally, CISD was designed within the controversy concerning randomized studies in integrated system of CISM (Everly & Mitchell, CISD highlights this problem. Although most 1999; Roberts et al., 2005; Sheehan et al., investigations did not employ a random 2004). The literature on CISM clearly states ized control trial, there appears to be a false

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TABLE 4. Comparison of Debrieﬁng Effectiveness According to Study Group Participants

Study group Studies Effectiveness Concerns

Individual Studies Medical patients Hobbs, Mayou, Harrison, and Negative outcome PD group had more Worlock (1996) severe injury Mayou, Ehlers, and Hobbs Negative and no change 1. PD group had more (2000), 3-yr follow-up study outcome severe injury 1. PD not defined Lee, Slade and Lygo (1996) No PD effects 2. Self-report Mx 3. ? Exposure Disaster/robbery Bisson, Jenkins, Alexander, and Negative outcome 1. PD group had more Bannister (1997) severe Sx 2. PD not defined and was supplemented Conlon, Fahy, and Conroy Positive outcome 1. PD not defined (1999) 2. Low stat power Rose, Brewin, Andrews, & Kirk Positive and no-change 1. Self-report Mx (1999) outcome 2. Low response rt. LEO/related Carlier, Voerman, and Gersons Negative-outcome positive 1. PD self selection (2002) subjective 2. Retrospective data collection 3. Low PTSD Deahl, Gillham, Thomas, No change and negative 1. PD not Mitchell Searle, and Srinivasan (1994) outcome 2. Self-report Mx 3. No pre-Mx Deahl, Srinivasan, Jones, Positive outcome 1. Unclear/? exposure/ Thomas, Neblett, and Jolly baseline (2000) 1. Self-report Mx Eid, Johnsen, and Weisaeth Positive and no-change 2. No pre-Mx (2001) outcome 1. Self-selected PD Jenkins (1996) Positive outcome 2. Self-report Mx Group Studies Medical patients Amir, Weil, Kaplan, Tocker, Positive and no-change 1. SCL-90 Mx of and Witztum (1988) outcome pathology, not acute Sx 2. Low stat. power 3. No control group 4. Self-report Mx Disaster/robbery Chemtob, Tomas, Law, and Positive outcome 1. Self-report Mx CISD Cremniter (1997) LEO/related Carlier et al. (1998) Negative outcome 1. Opted out of PD operational reasons 2. Retrospective data collection Shalev, Peri, Rogel-Fuchs Positive outcome 1. Self-report Mx Ursano, and Marlowe (1998) 2. Low premorbid Sx

Note. From National Institute of Mental Health (2002), Tables 1–4, pp. 40–63. CISD ¼ Critical Incident Stress Debriefing; PD ¼ psychological debriefing; Mx ¼ measure(s); Sx ¼ symptom(s); stat ¼ statistical; rt ¼ rate; LEO/related ¼ law enforcement officer, military personnel, or related profession.

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consensus in the literature that random the incident or were law enforcement officers ized studies are not possible when using CISD themselves; these individuals were part of the (Carlier et al., 2000). Even opponents of CISD cop culture they were investigating (Nurmi, admit that such studies are possible and would 1999; Smith & de Chesnay, 1994). Although improve extant work in the field (Wessely & research methods may hinder investigators Deahl, 2003). from being part of the CISD team, it may be Critical incidents are unpredictable, and useful to break the ‘‘outsider’’ role by having withholding intervention is unethical. How a CISD team member or police officer introduce ever, with increasing focus on officer assess the research team. Further, research teams ment at hiring, there seems to be the possibility would greatly benefit from a detailed prestudy of collecting baseline data for a longitudinal debriefing to explain their presence and to study of CISD effectiveness within police allow officers to ask questions. personnel (Hibler & Kurke, 1995). Similarly, However, even if research teams are able to with the prevalence of disparate debriefing avoid having their presence serve as a cultural models (Bohl, 1995; Dyregov, 1998), there is deterrent, investigators must address how the the potential for comparing interventions by police culture affects their work. In addition, utilizing adequate research designs. the presence of supervisors during CISD must also be addressed as an influencing factor. A heightened sensitivity to police culture may Law Enforcement Culture also impact decisions regarding the location of Police Culture. Volkman (2001) describes the CISD, media involvement in the critical several cultural characteristics of police offi incident, any political/bureaucratic issues that cers: (a) pride and perfectionism, (b) rigidity, (c) arise, the presence of a CISM peer who is also emphasis on bonding between officers (i.e., ‘‘us police officers, and the timing of the CISD vs. them’’ mentality), (d) development of relative to their shift work. All these variables language unique to the profession (e.g., using play a salient role in routine police work and dispatch codes), and (e) focus on safety and will impact evaluation and intervention. security, both at work and at home. Although police culture cannot be explained in a list Acceptance of CISD/CISM. Volkman (2001) of themes, writings addressing this closed contends that police culture is on the verge of culture concur that the same cultural forces accepting CISM as an opportunity to break their that create the effective role of an officer code of silence and improve stress management often work to destroy the same officer: process practices. In addition, many of the articles and action oriented, structurally organized, discussed here reported a subjective acceptance cohesion and loyalty, rigidity, ‘‘code of si of CISD by police officers, often in the face of lence,’’ and a sense of duty (Kirschman, 1995; nonsupporting data. Researchers in this area Paoline, 2001; Volkman, 2001). It is particularly need to address the acceptance of CISD/CISM challenging then to enter this closed culture as within the law enforcement community. an outsider and ask officers to divulge personal However, many efforts focus on proving the information that reflects the human vulner efficacy of CISD before providing evidence of abilities their occupational role often works its acceptability in the law enforcement pro hard to repress or deny. In fact, some of the fession. Investigators must be cognizant of the articles reviewed here were authored by acceptance of CISD and its impact on the individuals who were present at the time of efficacy of CISD itself. Several of the articles

274 Brief Treatment and Crisis Intervention / 5:3 August 2005 CISD and Law Enforcement reviewed above mentioned that officers did not terminology continue to plague the majority of participate in CISD due to operational reasons CISD research, regardless of the population of or because the department did not allow their interest. Finally, the application of solid re use (Bohl, 1991; Carlier et al., 1998). Although search and assessment methodology poses chal individual differences in the acceptance of CISD lenging problems when working with special are difficult to rule out, departmental policies populations and multifaceted interventions. influencing its acceptance are not, and could CISD with law enforcement clearly warrants easily be avoided. increased investigative attention in the future. However, the existing literature, albeit limited, Overlapping Cultural Concerns. As men appears to support the use of group CISD with tioned earlier, the assessment of police officers is emergency personnel (Everly, Boyle, & Lating, greatly influenced by their culture and ap 1999; NIMH, 2002; Sheehan et al., 2004; proach to testing. However, simple descriptions Wagner, 2005; Young, 2003). Although im of the assessment tools, with reference to their proved research would undoubtedly enhance relevant strengths and weaknesses when being confidence in CISD application, such work must used with emergency responders, address the be well defined, based on sound design issue. Only one of the articles we reviewed principles, and generalizable to the population offered such a description (Nurmi, 1999). With of interest. In addition to the three overlapping the exception of the LEOSS, there are few concerns mentioned above, there are other evaluation methods validated specifically for complex and challenging questions that war police. Meanwhile, it would improve the rant attention in CISD research with law quality of research to take the extra effort and enforcement. For example, are there occupa address the challenge of clinical assessment tionally specific criteria to consider when with law enforcement personnel. Similarly, although research in general has struggled addressing the CISD Reentry phase, which with the voluntary aspect of creating control impacts return to preincident levels of func groups, this is particularly problematic in work tioning? Does acceptance of CISD from depart with law enforcement professionals due to the ments and supervisors affect the impact of the closed culture, discussed earlier. procedure? Does application of CISM in a de partment strengthen the outcome of CISD? We have examined basic guidelines and Conclusions and Considerations for considerations based on extant research in an Future Research effort to instigate and encourage continued study of CISD in law enforcement. The evolving CISD and CISM have gained considerable needs in the field of emergency mental health recognition over the past two decades as stake require an adherence to standardized, empiri holders in the field of emergency mental health, cally driven procedures and careful delineation and the research continues to grow. The focus of variables that may ultimately affect the here highlighted three overlapping concerns in outcome in this important area. the study of CISD in law enforcement. The culture of law enforcement continues to be Acknowledgment a challenge for all research regarding police personnel; CISD investigation is no exception. Preparation of this paper was supported, in part, Similarly, definitions and applications of CISD through a Nova Southeastern University President’s

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Faculty Scholarship Award (Grant 338339) to the Carlier, I. V. E., Voerman, A. E., & Gersons, last author. Portions of this paper were presented at B. P. R. (2000). The influence of occupational the Council of Police Psychological Services Con debriefing on post-traumatic stress ference in Fort Lauderdale, Florida (2003), and the symptomatology in traumatized police officers. World Congress on Stress, Trauma, and Coping in British Journal of Medical Psychology, 73, 87–98. Baltimore, Maryland (2005). Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: A References theoretically based approach. Journal of Personality and Social Psychology, 56, 267–283.

Amir, M., Weil, G., Kaplan, Z., Tocker, T., & Chemtob, C. M., Tomas, S., Law, W., & Cremniter, D.

Witztum, E. (1998). Debrieﬁng with brief group (1997). Postdisaster psychosocial intervention: A

psychotherapy in a homogenous group of ﬁeld study of the impact of debrieﬁng on noninjured victims of a terrorist attack: A psychological distress. American Journal of prospective study. Acta Psychiatrica Psychiatry, 154, 415–417.

Scandivavica, 98, 237–242. Conlon, L., Fahy, T. J., & Conroy, R. (1999). PTSD Bisson, J. I., & Deahl, M. P. (1994). Psychological in ambulant RTA victims: A randomized debriefing and prevention of posttraumatic controlled trial of debriefing. Journal of stress. British Journal of Psychiatry, 165, 717–720. Psychosomatic Research, 46, 37–44. Bisson, J. I., Jenkins, P. L., Alexander, J., & Deahl, M. P., Srinivasan, M., Jones, N., Thomas, Bannister, C. (1997). Randomized controlled trial J., Neblett, C., & Jolly, A. (2000). Preventing of psychological debriefing for victims of acute psychological trauma in soldiers: The role of burn trauma. British Journal of Psychiatry, 171, operational stress training and psychological 78–81. debriefing. British Journal of Medical Psychology, Bledsoe, B. (2004, January). CISM debunk. 73, 77–85. Retrieved May 26, 2005, from http://www. Dyregov, A. (1998). Psychological debriefing: An bryanbledsoe.com/cismdebunk.htm effective method? Traumatologye, IV:2, Article Bohl, N. (1991). The effectiveness of brief 1. Retrieved June 12, 2003, from http://www. psychological interventions in police officers fsu.edu/;trauma/art3v4i2.htm after critical incidents. In J. T. Reese, J. M. Eid, J., Johnsen, B. H., & Weisaeth, L. (2001). The Horn, & C. Dunning (Eds.), Critical incidents in effects of group psychological debriefing on policing (pp. 31–38). Washington, DC: U.S. acute stress reactions following a traffic Department of Justice. accident: A quasi-experimental approach. Bohl, N. (1995). Professionally administered International Journal of Emergency Mental critical incident debriefing for police officers. Health, 3, 145–154. In M. I. Kurke & E. M. Schriver (Eds.), Police Everly, G. S. (1999). Emergency mental health: An psychology: Into the 21st century (pp. 169–188). overview. International Journal of Emergency Hillsdale, NJ: Erlbaum. Mental Health, 1, 3–7. Brown, D. (1995). Oklahoma City, April 19, 1995. Everly, G. S., Jr. (2003a) Pastoral crisis Public Management, 77, 6–9. intervention in response to terrorism. Caplan, G. (1964). Principles of preventative International Journal of Emergency Mental psychiatry. New York: Basic Books. Health, 5, 1–2. Carlier, I. V. E., van Uchelen, J. J., Lamberts, R. D., & Everly, G. S., Jr. (2003b) Psychological Gersons, B. P. R. (1998). Disaster-related counterterrorism. International Journal of posttraumatic stress in police officers: A field Emergency Mental Health, 5, 57–59. study of the impact of debriefing. Stress Medicine, Everly, G. S., Boyle, S. H., & Lating, J. M. (1999). 14, 143–148. The effectiveness of psychological debriefing

276 Brief Treatment and Crisis Intervention / 5:3 August 2005 CISD and Law Enforcement

with vicarious trauma: A meta-analysis. Stress miscarriage: A preliminary study. British Journal Medicine, 15, 229–233. of Medical Psychology, 69, 47–58. Everly, G. S., Flannery, R. B., & Mitchell, J. T. Leonard, R., & Alison, L. (1999). Critical incident (2000). Critical Incident Stress Management stress debriefing and its effects on coping (CISM): A review of the literature. Aggression strategies and anger in a sample of Australian and Violent Behavior, 5, 23–40. police officers involved in shooting incidents. Everly, G. S., & Mitchell, J. T. (1999). Critical Work & Stress, 13, 144–161. Incident Stress Management (CISM): A new era Mayou, R. A., Ehlers, A., & Hobbs, M. (2000). and standard of care in crisis intervention. Ellicott Psychological debriefing for road traffic accident City, MD: Chevron Publishing. victims: Three-year follow-up of a randomized Everly, G. S., & Mitchell, J. T. (2000). The controlled trial. British Journal of Psychiatry, debriefing ‘‘controversy’’ and crisis 176, 589–593. intervention: A review of the lexical and Mitchell, J. T. (1983). When disaster strikes ...the substantiate issues. International Journal of critical incident stress debriefing process. Emergency Mental Health, 2, 211–225.

Hibler, N. S., & Kurke, M. I. (1995). Ensuring Journal of Emergency Medical Services, 8(1), personal reliability through selection and 36–39. training. In M. I. Kurke & E. M. Scrivener (Eds.), Mitchell, J. T. (1991). Law enforcement Police psychology into the 21st century. Hillsdale, applications of critical incident stress teams. NJ: Erlbaum. In J. T. Reese, J. M. Horn, & C. Dunning Hobbs, M., Mayou, R., Harrison, B., & Worlock, P. (Eds.), Critical incidents in policing (1996). A randomized control trial of (pp. 201–211). Washington, DC: U.S. psychological debriefing for victims of road Department of Justice. traffic accidents. British Medical Journal, 131, Mitchell, J. T. (2003, February). Crisis intervention 1438–1439. and CISM: A research summary. Retrieved May Jenkins, S. R. (1996). Social support and debriefing 26, 2005, from http://www.icisf.org/articles/ efficacy among emergency medical workers after cism_research_summary.pdf a mass shooting incident. Journal of Social Mitchell, J. T., & Everly, G.S. (2001). The basic Behaviour and Personality, 11, 477–492. critical incident stress management course: Basic Kirschman, E. (1995). Organization consultation to group crisis intervention (3rd ed.). Ellicott City, law enforcement: An essay from the field. In MD: International Critical Incident Stress

M. I. Kurke & E. M. Scrivener (Eds.), Police Foundation.

psychology into the 21st century. Hillsdale, NJ: National Institute of Mental Health. (2002). Mental Erlbaum. health and mass disasters: Evidenced-based early Klinka, K. (1996, March 31). Many seek comfort at psychological intervention for victims/survivors of Project Heartland. Oklahoman. Retrieved June mass violence (NIH Publication No. 02-5138). 12, 2003, from http://archives.oklahoman.com Washington, DC: U.S. Government Printing Klinka, K. (1999, April 11). Murrah bombing’s effects long-term, study ﬁnds. Oklahoman. Ofﬁce.

Retrieved June 12, 2003, from Nurmi, L. A. (1999). The sinking of the Estonia: http://archives.oklahoman.com The effects of critical incident stress debriefing Kureczka, A. W. (1996). Critical incident stress in on rescuers. International Journal of Emergency law enforcement. FBI Law Enforcement Bulletin, Mental Health, 1(1), 23–31. 65(213), 10–16. Ottley, T. (2003, July 16). Bad day dawning. In Lee, C., Slade, P., & Lygo, V. (1996). The influence The Timothy McVeigh story: The Oklahoma of psychological debriefing on emotional bomber (chap. 1). Retrieved June 12, 2003, from adaptation in women following early http://www.crimelibrary.com/serial9/mcveigh/

Brief Treatment and Crisis Intervention / 5:3 August 2005 277 MALCOLM ET AL.

Owen, P. (1999, January 3). Recovery ongoing for Sheehan, D. C., & Van Hasselt, V. B. (2003). Murrah rescuers. Oklahoman. Retrieved June 12, Identifying law enforcement stress reactions 2003, from http://archives.oklahoman.com early. FBI Law Enforcement Bulletin, 72(9), Paoline, E. A., III. (2001). Rethinking police culture. 12–17. New York: LFB Scholarly Publishing LLC. Smith, C. L., Jr., & de Chesnay, M. (1994). Critical Plumberg, D. (2000, April 16). Rescuers live with incident stress debriefings for crisis management in memories—Many didn’t seek help in dealing post-traumatic stress disorders. Medicine and Law, with stress. Oklahoman. Retrieved June 12, 13, 185–191. 2003, from http://archives.oklahoman.com Van Hasselt, V. B., Sheehan, D. C., Sellers, A. H., Raymond, K. (1999, November 20). Officers’ Baker, M. T., & Feiner, C. (2003). A behavioral- misdeeds blamed on stress. Oklahoman. analytic model for assessing stress in police Retrieved June 12, 2003, from http:// officers: Phase I. Development of the Law archives.oklahoman.com Enforcement Officer Stress Survey (LEOSS).

Roberts, A. R., Everly, G. S., & Camasso, M. J. International Journal of Emergency Mental (2005, February). Meta-analysis of 36 crisis Health, 5(2), 77–84. intervention studies: Plenary address. Paper Volkman, P. (2001). Law enforcement perspectives presented at the 8th World Congress on for CISM enhancement. Ellicott City, MD: Stress, Trauma, and Coping, Baltimore. Chevron Publishing. Robinson, R. C., & Mitchell, J. T. (1993). Wagner, S. L. (2005). Emergency response Evaluation of psychological debriefings. service personnel and the critical incident Journal of Traumatic Stress, 6(3), 367–382. stress debriefing debate. International Rose, R., Bisson, J., & Wessely, S. (2002). Journal of Emergency Mental Health, 7(1), Psychological debriefing for preventing

post-traumatic stress disorder (PTSD). Cochrane 33–41.

Review. The Cochrane Library, 2002. Wessely, S., & Deahl, M. (2003). Psychological

Rose, S., Brewin, C. R., Andrews, B., & Kirk, M. debriefing is a waste of time. British Journal of (1999). A randomized controlled trial of Psychiatry, 183, 12–14. individual psychological debriefing for victims Wessely, S., Rose, R., & Bisson, J. (2000). Brief of violent crime. Psychological Medicine, 29, psychological interventions (‘‘debriefing’’) for 793–799. trauma-related symptoms and the prevention of Shalev, A. Y., Peri, T., Rogel-Fuchs, Y., Ursano, R. post traumatic stress disorder (Cochrane J., & Marlowe, D. H. (1998). Historical group Review). In The Cochrane Library (Issue 3). debriefing after combat exposure. Military Oxford, UK: Update Software. Medicine, 163, 494–498. Young, A. T. (2003). An examination of the Sheehan, D. C., Everly, G. S., & Langlieb, A. effectiveness of period stress debriefing with (2004). Current best practices: coping with major law enforcement personnel. Dissertation critical incidents. FBI Law Enforcement Bulletin, Abstracts International: Section B: The Sciences & 73(9), 1–13. Engineering, 64, 2902.

278 Brief Treatment and Crisis Intervention / 5:3 August 2005