Is Critical Incident Effective?

Nicholas Marney, MD, Sandeep K. Johar, DO, and E. Jackson Allison, Jr., MD, MPH

As this crisis intervention program undergoes scientific scrutiny, its efficacy has been called into question. These authors explore the discrepancies behind study findings that vary widely.

tress is very much a part of tential to interfere with their ability to to address potential problems within the human experience, and function either at the scene or later.3 the precrisis, acute crisis, and postcri- there are probably as many This critical incident stress may cause sis phases of critical incidents.4,5 This Sdifferent types of stress reac- these professionals to become sec- system consists of eight components: tions as there are potential stressors. ondary victims of trauma, the psy- preincident intervention; demobili- Stress reactions may be influenced chological impact of which can range zation and staff consultation or, for by a person’s knowledge and experi- from work-related burnout to post- larger groups, crisis management ence, as well as by his or her level of traumatic stress disorder (PTSD).1 briefing; defusing; critical incident physiologic and emotional , In order to help such profession- stress debriefing (CISD); individual but traumatic experiences are long als cope with critical incident stress, crisis intervention; pastoral crisis in- remembered by the individuals in- JT Mitchell provided a formal frame- tervention; family crisis intervention volved.1 work known as critical incident stress and organizational consultation; and Across the stress continuum, management (CISM).4 The effective- follow-up and referral for assessment certain traumatic events have the ness of CISM has been the focus of and treatment. (Table 1).5 potential to affect those involved tre- many studies, the findings of which None of these components is a mendously. These events are referred have varied greatly. As a result, con- stand-alone process; all are meant to to as critical incidents, and the state flicting research has shown CISM be provided as part of an integrated of cognitive, physical, emotional, and to be beneficial, ineffectual, or even package of interventions.2 One com- behavioral arousal that accompanies harmful. ponent, however, has received more them is known as critical incident This article aims to address the attention and professional scrutiny stress.2 efficacy of CISM in preventing the within the field of mental health than Certain professionals whose work development of psychological symp- the others: CISD. involves responding to serious inci- toms from exposure to critical inci- The concept of CISD evolved dents and disasters—such as emer- dent stressors in secondary victims of in an attempt to combat the effects gency medical technicians (EMTs), trauma, such as support staff mem- of associated firefighters, police officers, and health bers of organizations whose goal is to with the experiences of emergency care providers—frequently face sit- help those who have experienced a workers, and it has since been used uations that elicit unusually strong traumatic event. We discuss the com- in the treatment of other profession- emotional reactions and have the po- ponents of the CISM program and als exposed to critical incident stress. summarize favorable and unfavorable Like the umbrella CISM program to research regarding its value. We then which it belongs, CISD is predicated Dr. Marney is a second-year emergency medi- analyze methodologic flaws in all on the assumption that exposure cine resident at The Brody School of Medi- cine, East Carolina University, Greenville, NC. studies discussed and make recom- to critical incident stress may elicit Dr. Johar is a third-year emergency medicine mendations for future crisis interven- symptoms that go beyond what the resident at State University of New York (SUNY) tion programs and further research. individual can manage effectively on Upstate Medical University, Syracuse, NY. Dr. Allison is the chief of staff at the Asheville VA his or her own. Medical Center, Asheville, NC; an adjunct profes- A multicomponent system Typically, the formal CISD is led by sor of emergency medical care at Western Caro- CISM refers to an integrated, multi- a qualified mental health practitioner lina University, Cullowhee, NC; and an adjunct professor in the College of Health Professions at component crisis intervention system one to 10 days after the conclusion SUNY Upstate Medical University. that employs numerous technologies of the incident and consists of seven

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phases (Table 2). This structured group discussion was designed to as- Table 1. The components of critical sist a homogeneous group of people incident stress management1,5 after exposure to the same significant, traumatic event.2 It is not meant to re- Component Description place psychotherapy, nor is it meant to Preincident intervention Aims to strengthen potential vulnerabilities be used outside of the context of the and enhance psychological resiliency in CISM program. Unfortunately, several individuals at risk for psychological crises of the studies that purport to evalu- or trauma. Includes preincident prepara- ate CISM focus exclusively on CISD, tion, behavioral response preparation and which is one reason that the efficacy rehearsal, familiarization with common of CISM has been so hotly debated. stressors, stress management education, stress resistance training, and crisis Studies supporting efficacy mitigation. CISD following civil disturbance Demobilization and staff Provides an opportunity for temporary Wee and colleagues studied the effects consultation/crisis psychological “decompression” immedi- of CISD on EMTs following the 1992 management briefing ately after exposure to a critical incident. Los Angeles civil disturbances that For groups of 300 or more, crisis manage- erupted after a predominantly white ment briefing (held in a town-meeting jury acquitted four police officers ac- style) may be most appropriate to dissemi- cused in the videotaped beating of nate timely information. black motorist Rodney King. The au- Defusing Aims to assess, triage, and mitigate acute thors sent 66 surveys to emergency symptoms in a small group through a providers approximately two months three-phase, 45-minute, structured dis- after the riots. Of those responding, cussion provided within hours of a crisis. 42 had participated in a Mitchell-style CISD and 23 had not. Investigators Critical incident stress Focuses on psychological and emotional used the Fredrick Reaction Index- debriefing aspects of the event (as detailed in Table Adult (FRI-A) to detect the presence 2) in a seven-phase, structured, group dis- of PTSD symptoms and measure the cussion. Conducted one to 10 days after degree of their severity. Those respon- the incident. dents who participated in a CISD ses- Individual crisis Consists of one to three contacts with an sion reported fewer symptoms and intervention individual in crisis, with each contact last- scored significantly lower on the FRI- ing from 15 minutes to more than two A compared to those who did not par- 6 hours, depending on the nature and ticipate in CISD. severity of the crisis. CISD for firefighters Pastoral crisis Integrates traditional crisis intervention The Los Angeles County Fire Depart- intervention with pastoral-based support services. ment has one of the oldest CISM pro- Family crisis intervention Provides systems-level crisis intervention grams in the United States. In 1996, and organizational for both family and organizational mem- Hoakanson and Wirth conducted a consultation bers in a group setting, with a focus on survey of 2,073 Los Angeles County support and communication. firefighters to assess their attitude toward the CISD component of the Follow-up and referral Provided to individuals for whom acute program. The survey sought to deter- for assessment and crisis intervention techniques prove mine: (1) whether CISD participants treatment insufficient. found the debriefings helpful, (2) how soon after the debriefings they noticed

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significant symptom reduction, (3) Table 2. Phases of critical incident stress debriefing how stress symptoms after CISD com- pared with stress symptoms following Phase Intervention critical incidents of similar severity for Introductory Team members are introduced. Rules are explained. which they were not debriefed (par- Confidentiality and respect are discussed. Partici- ticularly in terms of time until sig- pants are assured that open discussion of feelings nificant symptom reduction), and is not to be used against them. This is not a scene (4) whether they would recommend critique. the debriefing process to others. Re- spondents reported significantly faster Fact Participants discuss the incident and their individual symptom reduction following inci- roles in it. dents for which they were debriefed, Thought Participants share what they thought while on scene. and the majority of those individuals reported that they would recommend Reaction Participants describe how they felt while on scene, the debriefing process to others.7 the worst aspects of the event, and how they have been feeling since the incident. the evidence against Symptom Participants report any unusual experiences that oc- Crisis intervention for curred at the time of the incident or since that time. road trauma Teaching Facilitator discusses commonalities, describes the Brom and colleagues randomly as- stress response syndromes, reinforces that they are signed 83 subjects who had been in- normal, and provides additional available resources. volved in moderate to severe traffic Reentry Facilitator answers outstanding questions, provides accidents in the Netherlands to an assurance, and suggests direction to take after the intervention or control group. The debriefing. Events, such as memorial services, may former, a CISM-like program that be planned. combined practical help, informa- tion, support, reality testing, con- frontation with the experience, and ing performed within one month of ing an intense trauma, physiologic appropriate referral for psychothera- trauma. Symptoms were assessed on arousal may promote susceptibility to peutic treatment, involved four con- the basis of widely accepted clinical suggestion in those who have expe- tacts over a six-month period. Using outcome measures, and data from rienced trauma.10 Through this pro- the Impact of Event Scale, Trauma psychological assessments were col- cess, they hold, the teaching phase of Symptom Survey, and Evaluation lected before and after the interven- CISD may inadvertently cause some Questionnaire, the intervention and tions. Five studies were randomized, of the very symptoms it is designed control groups were assessed at one controlled trials; one was a nonran- to alleviate. and six months after the accident. domized, controlled trial; and one in- In other words, CISD may make Although more than 90% of the sub- cluded no controls. trauma survivors hypersensitive to jects in the intervention group were After statistical analysis, the au- their own reactions to a traumatic content with the intervention, the thors concluded that non-CISD in- event. Learning what symptoms to two groups demonstrated no signifi- terventions and no interventions expect may increase self-directed cant differences in improvement at improved symptoms of PTSD but focus of attention, exacerbating or six months. Therefore, the effective- that CISD did not improve symp- bringing on symptoms. The notion ness of the psychological interven- toms. They went on to say that CISD that traumatic symptoms should re- tion could not be proven.8 has no efficacy and even may be det- ceive professional attention also may rimental to participants.9 cause survivors receiving CISD to Single-session debriefing after view such symptoms as maladaptive. psychological trauma A proposed explanation As a result, survivors who do develop Van Emmerik analyzed seven studies Herbert and Sageman have hypothe- symptoms may view such symptoms that involved single-session debrief- sized that, in the acute period follow- as beyond their control or ability to

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deal with them, thus beginning a outcome measures, it is difficult to discuss emergency services personnel stress reaction that could go on to dismiss such claims. as possessing a number of personal- fuel PTSD.11 Further compounding the confu- ity characteristics that are distinctive Furthermore, Gist and Woodall sion, in many of the reviewed studies, to those in their profession: a great suggest that, by participating in CISD, CISD is used as a stand-alone mea- need for control, an action orienta- trauma survivors may overlook or sure, which was never the intention tion, a high level of dedication, a need underutilize other mechanisms of of those who introduced it within the for immediate gratification, risk tak- support, such as coworkers, family context of crisis intervention. CISD is ing tendencies, and a strong need to members, and friends.12 meant to be used as one component be needed.14 As secondary victims of of the larger concept of CISM. Re- trauma, emergency services personnel flaws in Methodology search needs to focus on the effective- may find that these unique personality The literature pertaining to CISM and ness of CISM when all components traits and psychological needs make CISD has several methodologic flaws, are employed and not concentrate on them more amendable to the process most notably the lack of consistent effects observed one month after a of CISM than those in other profes- terminology. Many authors, such as single debriefing, as in the studies re- sions. As such, attempts to apply Van Emmerik, fail to differentiate viewed by Van Emmerik. CISM beyond this group could be ex- CISM and CISD and use the terms It is also difficult to find studies pected to produce variable results. “counseling,” “psychotherapy,” and of CISM or CISD that employ true “crisis intervention” as if they were randomization. Wee and colleagues, future RECOMMENDATIONS synonymous, grouping all under the as well as Hoakanson and Wirth, Despite discrepancies in the medical label of CISD.2 conducted studies based on surveys. literature, CISM has long been held Not only have investigators evalu- Their control groups were either to be efficacious in a wide variety ated distinct interventions as if they people who were not given the op- of crisis situations. As such, CISM were identical, but they have used portunity to undergo CISD or people should continue to be offered to sec- variable outcome measures to deter- who chose not to do so. It is difficult, ondary victims of trauma. Involve- mine their efficacy, thus making it of course, to deny individuals access ment in CISM, however, needs to be difficult to compare outcomes across to intervention for the purpose of voluntary. It is important for criti- different studies. In future CISM re- research. The priority of CISM is to cal incident teams to ensure that the search, investigators should evaluate provide assistance to secondary vic- individuals leading the debriefing sessions are trained mental health professionals and are well versed in the Mitchell model of CISM. In ad- dition, it is essential that participants The literature pertaining to CISM and CISD have easy access to all components of has several methodologic flaws, most no- CISM, including adequate follow-up tably the lack of consistent terminology. and proper referral if needed. Rescuers will continue to face critical incidents that cause them to become secondary victims of trauma. Additional empiric studies are nec- the formal CISM model and standard- tims of trauma, and randomization essary to examine further the effects ize outcome measures, allowing for is viewed by many as intentionally of CISM, but the program should be better comparison between studies. withholding such assistance. studied in its entirety, not through in- McNally and colleagues surmise that Finally, the fact that Mitchell’s in- vestigations narrowly focused on its some participants in crisis interven- tended target group for CISM is CISD component. ● tion studies who endorse CISD and secondary victims of trauma—spe- describe its helpfulness are expressing cifically, emergency services person- Author disclosures gratitude for the counselors’ efforts nel—raises the question: Can results The authors report no actual or poten- rather than reporting actual treat- achieved by this unique group be tial conflicts of interest with regard to ment efficacy.13 Without standardized generalized? Mitchell and Bray often this article.

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4. Everly GS Jr, Mitchell JT. Critical Incident Stress eds. Response to Disaster: Psychosocial, Community, Disclaimer Management (CISM): A New Era and Standard of and Ecological Approaches. Philadelphia, PA: Brun- The opinions expressed herein are Care in Crisis Intervention. 2nd ed. Ellicott City, ner/Mazel;1999:81–95. MD: Chevron Publishing Corporation; 1999. 13. McNally RJ, Bryant RA, Ehlers A. Does early psy- those of the author and do not neces- 5. Everly GS Jr, Mitchell JT. The debriefing “contro- chological intervention promote recovery from sarily reflect those of Federal Practi- versy” and crisis intervention: A review of lexical posttraumatic stress? Psychol Sci Public Interest. and substantive issues. Int J Emerg Ment Health. 2003;4(2):45–79. tioner, Quadrant HealthCom Inc., the 2000;2(4):211–225. 14. Bray GP, Mitchell JT. Emergency Services Stress: U.S. government, or any of its agen- 6. Wee DF, Mills DM, Koehler G. The effects of criti- Guidelines for Preserving the Health and Careers of cal incident stress debriefing (CISD) on emergency Emergency Services Personnel. Englewood Cliffs, NJ: cies. This article may discuss unlabeled medical services personnel following the Los An- Prentice-Hall; 1990. or investigational use of certain drugs. geles Civil Disturbance. Int J Emerg Ment Health. 1999;1(1):33–37. Please review complete prescribing in- 7. Hokanson M, Wirth B. The critical incident stress formation for specific drugs or drug debriefing process for the Los Angeles County Fire Department: Automatic and effective. Int J Emerg combinations—including indications, Ment Health. 2000;2(4):249–257. contraindications, warnings, and ad- 8. Brom D, Kleber RJ, Hofman MC. Victims of traffic accidents: Incidence and prevention verse effects—before administering of post-traumatic stress disorder. J Clin Psychol. pharmacologic therapy to patients. 1993;49(2):131–140. 9. van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM. Single session debriefing after REFERENCES psychological trauma: A meta-analysis. Lancet. 1. Pulley SA. Critical incident stress management. 2002;360(9335):766–771. eMedicine web site. http://www.emedicine.com 10. Herbert JD, Sageman M. “First do no harm”: /emerg/topic826.htm. Updated March 21, 2005. Ac- Emerging guidelines for the treatment of post- cessed March 6, 2007. traumatic reactions. In: Rosen G, ed. Posttraumatic 2. Mitchell JT. Crisis intervention and critical inci- Stress Disorder: Issues and Controversies. West Sus- dent stress management: A defense of the field. sex, UK: Wiley; 2004:213–232. International Critical Incident Stress Founda- 11. Bootzin RR, Bailey ET. Understanding placebo, tion Inc web site. http://www.icisf.org/articles nocebo, and iatrogenic treatment effects. J Clin Psy- /Acrobat%20Documents/CISM_Defense_of_Field. chol. 2005;61(7):871–880. pdf. Published January 9, 2004. Accessed March 12. Gist R, Woodall SJ. There are no simple solutions 6, 2007. to complex problems: The rise and fall of Critical 3. Mitchell JT. When disaster strikes…the critical inci- Incident Stress Debriefing as a response to occupa- dent stress debriefing process. JEMS. 1983;8(1):36–39. tional stress in the fire service. In: Gist R, Lubin B,

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