Psychological-Educational Debriefings and Outcome Assessment: A point of view
Toby Snelgrove, Ph.D.
In 1942, America experienced the worst single-building fire in the country’s history. Four hundred and ninety three people perished in a devastating fire at the Coconut Grove nightclub. Linderman (1944) and his associates from the Massachusetts General Hospital played an active role in helping the family and friends who had lost family and friends in the fire. Through their work they recognized that many of the surviving family members do not do what we often do with a less traumatic loss – talk, emotionally process, learn about self-care, and, for those in need, get access to professionals. Essentially, the traumatic nature of the incident may short-circuit what naturally happened following death – natural grieving and healing. By not starting this grieving process, there was concern that maladaptive responses would occur resulting in negative psychological and physiological symptoms. Thus began the “crisis intervention” movement (Aguilera, 1994), a proactive mental health intervention designed to prevent the shock of an event and ignorance about self-care from resulting in dysfunctional states.
In the late 70’s Jeffrey Mitchell discovered that emergency service workers, including himself, who attended such gruesome and emotionally distressing incidents could benefit from a similar process (Mitchell, 1983). The CISD was designed as a “talking ritual” that gave emergency service workers who pride themselves in emotional invincibility, a structure to ‘talk out’ their experience (Mitchell & Everly, 1993). Essentially, this structured group process gave emergency services workers “permission” to talk about their thoughts and feelings following a visually or emotionally disturbing event (Snelgrove, 1999). So powerful was this “permission to talk” that an indiscriminate groundswell of support grew amongst many emergency workers (Ostrow, 1996; Gist, Lubin & Redburn, 1998).
Unfortunately, Mitchell’s enthusiasm for the process found him making claims including that his 7-step debriefing process mitigated post-traumatic stress disorder. “The CISD process is considered one of the most important mechanisms to reduce the potential impact of Post Traumatic Stress Disorder (PTSD) (Mitchell & Everly, 1993, p.61). This claim resulted in two things: (1) Devotees with a strong motivation to do debriefing due to its alleged efficacy, and (2) the curiosity of researchers about the accuracy of his claims.
It should be noted that the concept of debriefings is not new. For example, it is common practice for organizational development interveners and educators during participant learning activities. Its role is to process the psychological aspect of an organizational assessment or, in the later case, educational simulations, prior to reflecting on the instructive aspect of the activity. (Schmuck & Runkel, 1972).
The application of a debriefing was not necessarily to give workers or students permission to share their feelings. Rather, it was designed to provide a structure for open and constructive communication (Katz & Kan, 1966). Through this healthy exchange of possibly differing points of view (e.g., “I find these this company policy punishing and irritating!”) and/or subjective experience “I felt totally helpless when your team left us all to ourselves!”), employees or students were able to become solution focused with their concerns and/or reflect on educational learnings resulting from an activity. These outcomes are very similar to observed benefits of psychological-educational debriefings following shocking events (Robinson & Mitchell, 1993).
The value of an organizational development or educational debriefing rests in increased organizational productivity or in the expressed opinions of the participants (i.e., opinions expressed during the event or through follow-up survey feedback). It is designed to treat a social-psychological problem: Did the activity surrounding this organizational problem or learning goal create sufficient personal and/or inter-personal issues that the organization or learning activity will be negatively affected? Through these open communication activities, issues are identified and dealt with. These outcome goals are significantly different to Mitchell’s claim that a similar group process mitigates a potential psychiatric disorder, PTSD.
Not surprisingly, there has been great controversy about the efficacy of group debriefings (Avery, King, Bretherton, & Orner, 1999). So in question is the efficacy of debriefings that some are considering ceasing it as post-trauma intervention (Orner, 1997). The main focus has been on whether CISD, and more recently CISM, mitigate the symptomatology of acute stress disorder (see Bisson & Deahl, 1994). One of the good outcomes of this debate has been a more rigorous assessment of the use of group interventions following traumatic events. It is forcing us to ask the questions: “To whom are we offering debriefings, based on what assumptions, with what outcome goals?” Unfortunately, to question or promote its efficacy has created a strong emotional reaction with a polarization of views (See Orner, 1997; Mitchell & Everly, 1997; Gist et al., 1997; Gist, R., Lubin, B., Redburn, B. G.,1998). Consequently, in my opinion, the real value of these talking rituals may be lost.
My position on psychological-educational debriefings, and other proactive trauma interventions, is that they should be viewed as health-promotion interventions. They should not be seen as a treatment for acute stress disorder. In fact, they should only be used when the problems are cognitive-behavoural in nature (e.g., retrospective guilt) and social-psychological (e.g., withdrawal resulting in negative myopic thinking). Secondly, they should be viewed as culture enhancing process. As Turnbull (1972) has argued, traumas can create chaos in cultures. Work environment often are caught by surprise and are somewhat disorganized in response to a tragedy. This is particularly true when traumas occur in organizations already challenged by organizational conflict. Organized activities such as debriefings can create a structure that provides both a healthy outlet of emotions and frustrations as well as direction for re-building a foundation for the work culture.
For example, if a colleague was seriously injured at work, those that helped or watched are often shocked with what they saw. Some may feel inadequate for what they did or didn’t do in spite of having done their best. Others may feel a need to connect and talk the incident out with colleagues but often do not have a mechanism to do so. Others may feel a need to change something in the workplace in response to the incident. They are not “traumatized” by the incident. Rather, they are shocked, sad, frustrated, confused, etc. They may also be frustrated with the organization and its position on safety.
The traumatized individual would most likely need individual counselling to work through the potential traumatic stress reactions. His colleagues, on the other hand, most likely need a chance to talk out the incident, support each other, learn from their experience, and, when relevant, an opportunity to contribute to changes that would result in lowering the probability of such an event occurring again. Talking out the incident in a group setting would only be the case, however, when reviewing of the incident – the narrative stage – would not result in autonomic hyper arousal causing intense emotional reactions that constitute an exacerbation (helpless flooding) as opposed to a catharsis (emotional release resulting in acceptance and resolution). Such experiences, though emotionally evocative, do not result in cognitive restructuring (van der Kolk & Ducey, 1989). Cognitive organization, I will argue, is one of the goals of a psychological-educational debriefing.
Hodgkinson & Stewart (1998) state that there are six primary objectives of a debriefing:
- Ventilation if impressions, reactions, and feelings.
- Promotion of cognitive organization, through clear understanding of both the events and reactions.
- Decrease in the sense of uniqueness or abnormality of reactions, achieving normalization through sharing.
- Mobilization of resources within and outside the group, increasing group support, solidarity and cohesion.
- Preparation for experiences such as symptoms or reactions which may arise.
- Identification of avenues of further assistance if required.
Based on self-reports following debriefings, emotional bonding is also often a byproduct of theses groups. Even trauma related group therapies stress the importance of emotional attachment achieved through social interaction: “Contemporary research has shown that as long as the social support network remains intact, people are relatively well protected against even catastrophic stresses” (van der Kolk, McFarlane & van der Hart, 1996, p. 432). One of the central components of workplace trauma interventions is to provide this work community a structure to individually and interpersonally process the impact of a shocking event. One aspect is the availability of individual therapy. Another is provision of group activities designed to contribute to the healthy response to an incident – family helping family.
I have argued earlier there are six significant potential needs individuals may have following shocking events. Cultural rituals, such as funerals and wakes, often meet these needs. However, workplaces often do not provide a structure where individuals can receive support and direction:
- Contact/Social support. Have they had an opportunity to connect and receive social support from those they respect? Collegial and community support during stressful time contributes to better psychological outcomes (e.g., Shalev, Schreiber, and Galai,1993; Fulletron & Ursane, 1994; Fullerton, C. S., Ursano, Kaao, & Bhartiya,1992a, 1992b).
- Venting and emotional processing. Have they had an opportunity to talk out the incident in their work family? We are emotionally based animals. The interpersonal exchange contributes to emotional processing (Rachman, 1980; Greenberg, Rice & Elliott, 1993).
- Normalizing. Do they understand that the reactions they may be having are understandable given what they have been through? Individuals can become quite distressed by strong reactions following a shocking event. Education regarding the normalcy of their reactions is a key element in build strong self-efficacy (van der Kolk, McFarlane, & van der Hart, 1996).
- Meaning making. If the incident has resulted in a deconstruction of their idea of who they are, their profession, their beliefs about life, or whatever, have they had an opportunity to decide what meaning this will have and make decisions regarding their future? We are meaning making animals and cognitive restructuring is often a key element in personal recovery and growth (Horowitz, 1976;Janoff-Bulman, 1992).
- Education and direction. Have they received information regarding potential symptoms and symptom management, availability of in-house and outside resources, and other post-care information? An important aspect of self-care is knowledge of how to care for oneself. Persistent or delayed onset symptoms should be an indication of the need for professional follow-up. Knowledge of this will more likely result in proactive self-care. If story telling is not appropriate due to the level of individual distress, didactic debriefings are recommended (Dunning, 1988).
- If there was a loss, has there been an opportunity to grieving the loss? Some events are shocking. Others result in death or other losses. When this is the case human need to grieve (Raphael, 1993; 1986).
If we are to properly assess the efficacy of psychological debriefings, we must go beyond individual post-traumatic symptomatology. Few would argue that a 3 hour groups session would most likely have significant impact on the long-term psychological readjustment of an acutely traumatized individual. People like to connect after a trauma, many feel better and think more rationally following a community diaologue, those who are sevely traumatized need professional care, and most will take care of themselves better after some education. I argue that we should view workplace trauma interventions such as group debriefings as health promotion activities. We need to assess to what extent this view is true and which interventions contribute to individual and inter-personal recovery.
Aguilera, D.C., (1994). Crisis Intervention: Theory and Methodology. 7th ed. St. Louis: Mosby.
Avery, A., King, S., Bretherton, & Ortner, R. (1999). “Deconstructing psychological debriefings and the emergence of calls for evidence-based practice.” Traumatic Stress Points, 13(2), 6-8.
Bisson, J. I., Deahl, M. P. (1994). “Psychological debriefing and prevention of posttraumatic stress.”British Journal of Psychciatry, 165, 717-720.
Dunning, C. (1988). “Intervention strategies for emergency workers.” In M. Lystad (ed) Mental Health Responase to Mass Emergencies. New York: Brunner, Mazel.
Fullerton, C. S. & Ursano, R. J. (1994). “Health care delivery in the high-stress environment of chemical and biological warfare.” Military Medicine, 159(2), 54-59.
Fullerton, C. S., Ursano, R.J., Kaao, T., & Bhartiya, V. (1992a) “The chemical and biological warfare environment: Psychological responses and social supports in a high stress environment.” Journal of Applied Social Psychology, 22, 1608-1623.
Fullerton, C. S., Ursano, R.J., K ao, T., & Bhartiya, V. (1992b) “Community Bereavement following an airplane crash.” Paper presented at the annual conference of the International Society of Traumatic Stress Studies, Amsterdam
Gist, R., Lohr, J. M., Kenardy, J. A., Bergmann, L., Meldrum, L., Redburn, B., Paton, D., Bisson, J. I., Woodall, S. J., & Rosen, G. M.. (1997). “Researchers speak on CISM.” Journal of Emergency Medical Services, 22,(5), 27-28.
Gist, R., Lubin, B., & Redburn, B. G. (1998). “Psychosocial, ecological, and community perspectives on disaster response.” Journal of Personal and Interpersonal Loss, 3, 25-51.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating Emotional Change: The Moment-by-Moment Process. New York: Guilford Press.
Horowitz, M. (1976). The Stress response Syndromes. New York: Jason Aronson.
Janoff-Bulman, R (1992). Shattered Assumptions: Towards a new psychology of trauma. New York: Free Press.
Katz, D., & Kahn, R. (1966). “Communication: The flow of information.” Chapter in D. Kats & R. Kahn The Social Psychology of Organizations. New York: John Wiley & Sons, pp.223-226.
Linderman, E., (1944). “Symptomatology and Management of Acute Grief”. American Journal of Psychiatry, 101, 141-148.
Mitchell, J. (1983). “When disaster strikes: The critical incident stress debriefing process“. Journal of Emergency Medical Services, 8, 36-39.
Mitchell, J. T. & Everly, Jr., G. S. (1993) Critical incident stress debriefing: An operations manual for the prevention of trauma among emergency service and disaster workers. Baltimore, MD: Chevron.
Orner, R. (1997). “Emergency Service May Abandon Critical Incident Stress Debriefing.” Traumatic Stress Points, Winter, 1997, 5.
Ostrow, L.S. (1996). “Critical Incident Stress Management: Is it worth it?” Journal of Emergency Medical Services, August, 29-36.
Rachman, S. (1980) “Emotional Processing.” Behaviour Research & Therapy, 18, 51-60.
Raphael, B. (1993) The Anatomy of Bereaavement. New York: Basic Books.
Raphael, B. (1996) When Disaster Strikes. London: Hutchison.
Robinson, R., & Mitchell, J. (1993). “Evaluation of psychological debriefings.” Journal of Traumatic Stress, 6(3), 367-382.
Saturen, S. L., Martell, R. T., & Derr, B. (1972). Handbook of Organization Development in Schools. Portland, Oregon: National Press Books
Shalev, A. Y., Schreiber, S., & Galai, T. (1993). “Early psychological responses to traumatic injury.”Journal of Traumatic Stress, 6(4), 441-450
Snelgrove, T.N.F. (1998). “Debriefing under fire: Comments from a provider.” Trauma Lines , 3(2), 3,11.
Snelgrove, T.N.F. (1999). “Trauma Interventions: If it’s not broken, don’t fix it.” Traumanews, 8(1), 1-2, 10.
Taylor, S. T. (1989). Positive illusions: Creative self-deception and the healthy mind. New York: Portland House.
Turnbull, C. M. (1972). The Mountain People. New York: Simon and Schuster
van der Kolk, B., & Ducey, C. P. (1989) “The psychological processing of traumatic experience: Rorschach pattenrs in PTSD.” Journal of Traumatic Stress, 2, 2 h59-274.
van der Kolk, B., McFarlane, A. C., & van der Hart, O. (1996). “A general approach to treatment of posttraumatic stress disorder.” Chapter in B.S. van der Kolk, A.C. McFarlane, & L Weisaeth.Traumatic Stress: The Effects of Overwhelming Experience of Mind, Body, and Society. New York: Guilford Press. Pp. 417-440.