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CISDs: Continuing Problems

CISDs: The Tension Remains Even Beyond Territoriality and Other Agenda's
A Brief Commentary by Roger F. Peters Phd RFD.

Doing Just Something May Not Be Enough
Interventions
Conclusion
References

As I prepare for a possible tour of duty in East Timor I am reminded that the principle concept for post trauma or critical incident stress intervention accepted by the ADF and promoted by me at the turn of this decade was the Critical Incident Stress Debriefing model. This model has been attributed to Jeffrey Mitchell, an educator with emergency services in Maryland, USA. More recently, this has become regarded as just one component of Critical Incident Stress Management (CISM). The CISM model aims to promote a more holistic approach, including specific procedures, training and especially an emphasis on prevention, in addition, a greater emphasis on peer support and techniques of defusing. Thus CISD in the CISM model is not a stand-alone technique but one of several strategies, all aimed at mitigating the psychological and emotional costs of working in emergency services. The CISD has nonetheless attracted extensive criticism, both here and overseas. The most repeated criticism has been the perceived failure by proponents of CISD to address several methodological problems that continue to make the technique difficult to empirically validate.

Wesseley, Rose, Bison (1999), conducted a meta analysis of the efficacy of brief psychological debriefing after trauma and his results appear to contradict the results from a previous meta-analysis study by Everly, Boyle and Lating (1998). Wesseley et. al. (1999) suggests that; "there is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorders after traumatic incidents. Compulsory debriefing of victims of trauma should cease". Again, that research is faulted, ie the studies selected are drawn from quite desperate groups. For instance, my understanding of CISD's is that it is technique developed for use among emergency service workers. Wesseley et. al. (1999) however, examined studies that included, primary victims of trauma who had been admitted to hospital, secondly, women with miscarriages, and thirdly so called "second level" victims, ie. relatives! While this meta-analysis challenges the intervention referred to as "debriefing", (which in these cases many of us would have considered debriefing an inappropriate intervention), I am not sure how nor do I believe these results can be extrapolated to suggest that CISD's don't work among emergency service workers. This seems to be a regularly found error or mistake.

In this way CISDs seem to have suffered a similar problem as EAPs. In a paper Peters (1999) [in preparation] I noted in relation to a study of EAPs by Kirk- Brown (1999). "Again, a comparison study that did little to add much to the needed research on cost benefit, effectiveness, etc. In fact, her paper could be faulted because of her failure to use homogenous groups, re, internal EAPs were not controlled for; nor capability of delivery or qualifications and counsellors included staff welfare, even counselling provided by Occupational Health and Safety staff, with overall less than 50% in fcat being registered psychologists. Her evaluation of external providers similarly failed to control the independent variable with no consideration for the differences in contract arrangements, eg. number of permitted sessions, fee base (per capita, annual fee, or fee for service etc), all of which can affect take up rates. For instance, in per capita base programs there is no incentive to promote return counselling, while for the service there is an incentive to prolong engagement with the client. Kirk-Brown's observation that they cancelled each other out can only be indicative of poor research, methodology, and even may betray a lack of understanding on her part about EAPs".

Similarly any "debriefing" seems to have become synonymous with CISD. However, like EAPs, CISDs are a particular strategy, an intervention with core components, delivered to a particular and quite unique population, ie emergency services. In addition, like a growing number of others, I have some considerable scepticism that the so-called "scientific method" is capable of actually validating or assessing the efficacy of this particular intervention. Bolen (1975) said, "By our insistence that the scientific method is the only means by which anything can be known, doors of perception are closed, the wisdom of the East is denied to us and our own world becomes one sided" (p 9).

However, is this difficulty in validating CISD the only basis of the tension? In 1996 I wrote a paper "CISD Territoriality, Ownership and other Agenda's". The general thrust of that paper was to suggest at that time it was clearly apparent that the debate about the efficacy of CISD/CISM was at least being in part fuelled by "human emotions such as envy, jealousy and pride"(p1). The academic debate seems to have continued and no doubt will for sometime. Meanwhile however, two important common law cases have since deemed post trauma intervention as being critical in demonstrating a duty of care, specifically in one case (see Howell vs SRA). In the other, Seedsman vs the NSW Police Service, it was essentially found that doing something by way of intervention only follows common sense.

The Seedsman case was also important because while the efficacy even validity of CISD intervention were predictably challenged; the judge deflected that argument, Judge Gouldring ruled that whether CISD worked was not really the issue. He suggested indeed that at least something should have been done and that a fair man should have known that some counselling intervention was critical so as to assist police deal with their difficult role, ie foreseeability. Moreover, his Honour pointed out that while the common law claim for damages appeared to be against the Police Service, it was in fact an action against the NSW State Government. He pointed out that other Government agencies at that time; eg DOCs were conducting interventions, so that knowledge was more generally available to the Government. Thus the second element, ie a failure in their duty of care was established. Forseability and a failure of duty of care are of course both pivotal points on which this case and any case like it will turn.

This idea of "intervention of some kind", was covered in Judge Gouldring's summation when he said; "Police Culture and Support, I have alluded to the attitude of police to individual officers' emotional reactions. All the witnesses were quite emphatic; they were not encouraged, at any time or in any environment to show their emotional reactions, or even distress. Such an attitude or culture is, of course, totally uncongenial to the atmosphere of discussion and mutual support seen as necessary as a precaution to avoid or reduce the levels of stress imposed on those in counselling roles. Introduction of the type of case conferences or supervised supervision as was common in welfare agencies would have been unwelcome to police. Nevertheless, even in the early 1980's the state of knowledge was that this technique was essential to stress management in the organisations where staff was exposed to the types of stress I have mentioned. Difficulty in introducing measures is no excuse for failure to do so if doing so is a reasonable way of avoiding unnecessary risk of injury.

I consider that I am entitled to take judicial notice of the fact that any police work is likely to be stressful. Any person who joins the police service must expect that from time to time he or she will be exposed to personal danger and to gruesome and disturbing sights and experiences. These are unfortunately, part of the policeman's or police woman's unhappy lot. Some of these situations will inevitably cause stress, and to some extent the one-to-one, on the job training traditionally given to detectives had the effect of enabling them to develop coping mechanisms. These usually took the form of distancing themselves emotionally from the people whom they had to deal with. It may not have been ideal, but detectives who were slowly exposed to the stark brutality of aspects of police work were then able to cope with most of the stress this caused.

To summarise, the State of NSW had a duty to prevent the risk of psychiatric disorders in police involved in the investigation of child abuse. In the early 1980's, that risk was foreseeable. The State was, or ought to have been, aware that police involved in such work would necessarily be exposed to traumatic invasions of the physical integrity of children; and placed in situations where, in the course of interviewing child victims of physical and sexual abuse and their families, and preparing them to give evidence, they would be necessarily placed in a position where they would be expected to provide a significant degree of support and counselling. The State was aware that other State employees engaged in analogue support and counselling roles, which required training in the 4 elements identified by Dr Adams and other witnesses to which, I have referred. That awareness, for the reasons I have been given, is attributable to the State in its role as employer of police. The State was, or ought to have been, aware that failure to do this would expose the police officers concerned to the risk of the extreme stress, and if such stress was sustained, to the risk of consequential psychiatric disorder.

Was There A Breach of Duty? I have found that the defendant, or at least senior police, should have known that where otherwise untrained police are exposed to sustained stress, means of preventing injury should involve the establishment of proper procedures for training and support mechanism. The evidence was that the police did nothing."


Doing Just Something May Not Be Enough

In the case of Cahill vs SRA the employer did do something, but it was ruled that the EAP provider, an agent of the SRA did not try hard enough. Again consequently, the employer's failure to meet their duty of care was established. This was a complex case but in fact raises the very questions that have been raging in this debate for the last 10 years, or ever since Christine Dunning sued and was countered sued by Jeffrey Mitchell over "ownership" issues relating to the CISD model.

The question could be put, would it have made any difference if Cahill had been counselled or provided with a CISD immediately afterwards? If some recent research from the Netherlands is accurate then the exposure to CISD could cause adverse longer-term reactions (Carlier et. Al, 1998). However it is puzzling and difficult to understand how an intervention developed for emergency service workers, one that has been embroiled in so much controversy, is not only being regularly recommended for occupational groups that it wasn't designed for, but worse still maybe regarded by some employers as now mandatory! In fact, if Bisson (1997) is to be believed then workers who are offered but do not opt for debriefing are the least likely to develop post trauma pathology. Indeed Cahill was several times offered counselling and assistance but rejected it. The successful claim for damages in this case turned on two points; firstly, that a common response to traumatic incidents is avoidance and knowing this the employer should have tried harder.

Again a good amount of criticism in relation to the lack of post trauma intervention was made in the Ombudsman's report on "Police Stress" (1999). This was levelled at the inadequate services provided, poorly thought out interventions and the lack of follow-up, in other cases the absence of any services at all. However, the Police Service has been criticised before, so why has there been a reluctance to change, especially after the costly finding in the Seedsman case? This is regarded by some as a type of organisational denial, even an acceptable risk, both of which may have replaced the search for the objective identification of causal factors (Graham, 1981: McCammon & Allison, 1995). Emergency services professionals continue to work in a culture that encourages emotional denial. Paton & Violanti (1996), Graham (1981) argue that the operation of this cultural norm has prevented those affected admitting emotional vulnerability and instead, they often transfer blame to the organisation, rendering the latter a scapegoat rather than a causal factor. In the case of the NSW Police Service while they often fail to provide the service, there is also resistance by many serving members to access the services available.

A concept that is gaining interest is what Dunning (1999) refers to as "resilience". This is described as "an active process of self-righting, learned resourcefulness and growth: the ability to function psychologically at a level far greater than expected given the individual's capabilities and previous experience" (Paton, 1999).

Paton (1999) goes on to say that "The resilience paradigm is proactive and provides an overarching framework for conceptualising, planning and implementing trauma mitigation strategies. Dunning (1999) describes resilience as comprising dispositional, cognitive, and environmental components. Dispositional resilience reflects how personal characteristics (eg. hardiness) affect judgement. The cognitive component is concerned with the individual's sense of coherence and meaning. Training strategies discussed above are designed to facilitate understanding the relationships between occupational experience and traumatic stress reactions and to develop coping strategies that promote adjustment" (p14). I have recently adopted this philosophy into a program for the Joint Investigation Teams, and police officers that work with adult victims of abuse. However, as Dunning (1999) says, the most important elements in any intervention must involve changes to organisational design and management. Then organisations should develop strategies, create practices, procedures as well as a culture that can mitigate the adverse consequences of police work. Dunning (1999) believes only in this way will the potential for recovery and post-traumatic growth be maximised.


Interventions

There have been a number of interventions introduced to assist following critical incidents, CISD is just one. Another, again so often criticised is Eye Movement Desensitisation and Reprocessing Therapy (EMDR). Brief Cognitive Therapy likewise, has gained growing support following several studies that have found significant results pointing to its efficacy. For instance Foa et. al. (1995) and Bryant et. al. (1998) investigated this particular intervention. Bryant et al (1998) also examined CBT (with a waitlist control), while using supportive counselling as a comparison. Participants in both studies met the criteria for PTSD (except for duration) or Acute Stress Disorder at study commencement. The CBT intervention included education about common reactions, anxiety management, in vivo and imaginal exposure, and cognitive restructuring. Both studies provided strong support for CBT interventions in terms of facilitating recovery and even claiming to prevent the development of longer-term problems such as PTSD.

Returning to CISD's, where methodology continues to be problematic. Avery et al (1999) says, "scant consideration has been given to the contradiction inherent in first stating that CISD is not a therapeutic intervention and then proffering unsubstantiated claims of its efficacy in terms drawn from clinical practice. They then go on to say "With such an inauspicious start it should come as no surprise to anyone that true to the traditions of clinical disciplines that seek rationales for therapeutic practice through symptom outcome evaluations, priority has been given to considerations of clinical efficacy. Evidence thus gathered has not substantiated claims made for CISD. The counter-response has been to criticise systematic studies for inadequate methodological rigour. Mitchell and Everly (1998) seem impervious to the monumental irony of stipulating unrealisable methodological improvements as a precondition for decisive evidence when it was the manner in which they promoted CISD in the first place that led to the adoption of these particular research methodologies" (p 22).

Avery (1999) then rather eloquently concludes, "Given that Mitchell & Everly took the lead in recommending CISD during the 1980's it may help raise the standard of the debriefing debate if they were to explain the evidence based rationales for publicly advocating "early intervention" in general and then give account of how this evidence base in turn gave rise to designated protocols for delivering CISD and other CISMS."


Conclusion

What Cahill vs SRA, Seedsman vs NSW Police and the substantial literature that discuss trauma interventions all tell us is that: a) we should be doing something, and; b) trying harder. The problems seem that we are caught in various tensions. The first is that we continue to be challenged by empiricists to constantly scientifically prove the value of any intervention. This is problematic because it excludes the possibility that anything that can not be empirically "proven" is of any worth. Mitchell once said (I am sure tongue in cheek) "We haven't empirically validated funerals, do we stop doing those?" Again I share the sentiments of Bolen (1975) who said "The psychological split needs healing through an inner union, allowing flow between left and right hemispheres, between scientific and spiritual, masculine and feminine, yin and yang." (P9).

The second area of tension that continues to be as I have suggested earlier is a problem that is as much about ownership as anything else. The difficulty this can cause is rather self evident in general terms but especially so when research is manipulated, contrived or simply fabricated to support, one's own passionate belief. This problem in research is well understood but never more problematic than in CISM. Aside from the limitations or as I have suggested before the arrogance of empiricism, the profession can certainly do without the spite that seems to at times be overwhelming in debating these matters. For practitioners the challenge is how to separate that research which is simply based on polarisation of camps. It seems to me that there are devotees on sides that seem quite blind to the inconsistency of their positions, however when professional bodies likewise become polarised, and its little wonder that the credibility of our profession is threatened.

A third area in need of urgent address is the problem that in part stems from the lag between research and practice. For instance most organisations by now have heard about a need for trauma intervention. With a highly marketable product, (it is simple, it is relatively cheap and its quick) CISDs have become a first choice intervention by employers. Add to this the reinforcement that has been seen by burgeoning costs of workers compensation, threat of common law, there now remain few large organisations that do not have some post trauma procedure. Yet, due to the controversy in relation to the validity of CISD/CISM one of the messages that may be filtering through to organisational users is that they may be best to sit out and wait a final verdict.

There are two further issues here. The first is that if the only reason that a intervention is acted on is due to a financial imperative, (risk exposure), it may opt for a cheap, poorly designed, inadequately staffed, worse still poorly executed program. Certainly, there may be an absence of follow through. This may have the affect of causing more distress than having done nothing at all. Some bank debriefing could prove particularly vulnerable to this error. One reason for poorly serviced programs of intervention (EAPs can experience the same fate) is that there was not a real commitment to the intervention in the first place, simply a commitment to reduce risk exposure. Let there be no doubt CISDs are being seen by many organisations as a quick fix veiled by the sentiment that it's "the responsible thing to do". For instance at the time of writing this report, I was called by an educational facility to conduct a CISD for staff. The staff had found on returning on Monday that a student had been killed in a MVA over the weekend. Is that what Mitchell had in mind when he developed the protocol? We did provide two counsellors, (trained in grief) but we certainly didn't conduct a CISD. Organisations and practitioners alike seem to miss the fact that CISD was not designed for non-emergency workers. As indicated earlier in this commentary, to place all debriefing into one category and then move from not only the variations in model and approach but also across population groups, is to fail to understand the fundamentals of psychotraumatology. I have always found it quite paradoxical that when we teach trauma we talk about the first phase being "shock", ie when our senses shut down to incoming, especially new information, yet we still conduct immediate "debriefs". One further problem in committing ourselves to poorly timed, poorly executed CISDs, is that they may not only be ineffective but also increase the chances that they will be regarded more generally as poor or inappropriate interventions, when infact in some alternative circumstances they may be otherwise quite effective.

I have always been struck with the Garden of Gethsemane story. You will recall that Jesus Christ had asked his disciples to pray, while he faced the trauma of hearing that he would be killed. On return to the garden he finds his disciples asleep. He rebuts them, asking "Could you not watch with me but for one hour". My own concern is that we do not do enough watching and supporting. Perhaps this ministry of Co-passion may be more effective than talking "at" someone, especially if that support is not later available when needed. People who have been traumatised need support, an opportunity to talk, they should be followed up at regular intervals and there should be an emphasis on the early identification of any continuing clinical pathology. My opinion is that PTSD is probably not preventable by any intervention, however early identification can lead to arrest and manageable recovery. In all of this the issues of secondary gain must be carefully assessed, ie workers compensation, spiteful litigation and of course victims compensation, all of which may frustrate our clear understanding of this phenomenon, indeed an area worthy of some further discussion, but perhaps another time.


References

Bisson, J. (1997) Is Post Traumatic Stress Disorder Preventable? Shadowfax Publishing and Journals Oxford Ltd.

Bolan, J.S. (1982) The Tao of Psychology - Synchronicity and the Self Harper San Francisco.

Bryant, R.A., Harvey, A.G., Dang, S.T., & Basten, C. (1998) Treatment of Acute Stress Disorder: A comparison of cognitive behaviour therapy and Supportive Counselling. Journal of Consulting and Clinical Psychology, 66. 862-866.

Carlier, I.V.E., Lamberts, R.G., van Uchlen, A.J. & Gersons, B.P.R (1998) Disaster Related Post Traumatic Stress in Police Officers: A field study of the impact of debriefing. Stress Medicine. 14. 143-148.

Chemtob, C., Tomas, S., Law, W. & Cremniter, D. (1997) Post Disaster Psychosocial Intervention: A field study of debriefing on psychosocial distress. American Journal of Psychiatry 154, 415-417.

Dunning, C. (1994) Post intervention strategies to reduce police trauma: A paradigm shift. In J. M. Violanti. And D. Paton. (eds) Police Trauma: Psychological Aftermath of Civilian Combat. Springfield III.: Charles C. Thomas.

Davies, H.T.O., & Crombie, I.K. (1998). Getting to Grips with Systematic Reviews and Meta-analyses. Hospital Medicine, 509, 12. 955-958.

Foa, E.B., Hearst, I.D., & Perry, K.J. (1995). Evaluation of a Brief Cognitive Behavioural Program for the Prevention of Chronic PTSD in Recent Assault Victims. Journal of Consulting and Clinical Psychology, 63, 948-955.

Howell Vs State Rail Authority (1998) The Supreme Court of NSW, Common Law Division, Case Number 400071/93, Albury.

Matthews, L.R. (1998) Effect of Staff Debriefing on Post Traumatic Stress Symptoms After Assaults by Community Housing Residents. Psychiatric Services, University of Sydney.

Mitchell, J.T. & Everly, G.S. (1998) Critical Incident Stress Management., A New Era in Crisis Intervention. Traumatic Stress Points. Fall 1998.6-1.

Paton, D. & Violanti, J. (1996) Traumatic Stress in Critical Occupations: Recognition, Consequences and Treatment. Springfield III.: Charles C. Thomas.

Peters, R.F. (1996) CISD's Territoriality, Ownership And Other Agenda's. ACISA conference, Perth W.A. 1996.

Police Association of NSW Research and Resources Centre (1997) Seedsman vs the State of NSW. District Court of NSW.

Wessely, S., Rose, S., Bisson, J. (1999) Brief psychological interventions (debriefings) for treating immediate trauma related symptoms and preventing post traumatic stress disorder (Cochrane review). Cochrane Library, 2 1999. Oxford Update Software

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