EVIDENCE-BASED CRITICAL INCIDENT STRESS DEBRIEFING: APPROACHING A MILESTONE?
By John Durkin Ph.D. – ICISF Member and Approved Instructor
As published in LifeNet, members’ newsletter of ICISF in June 2016
By the time you read this article I hope there has been a positive shift in the clinical reputation of Critical Incident Stress Debriefing (CISD) because it may now be recognized as ‘evidence-based’ standing alongside psychological trauma therapies. As an article written by a psychologist based in the UK you might wonder how this possibility came about. Here is what went before…
GETTING THE JOB DONE
I grew up hearing “If you want a job doing well, do it yourself”, which told me not to be disappointed in experts who perform badly. When I joined the fire service I worked with others who seemed to work by a similar mantra. During operations I saw how a determined mind could manipulate poor equipment and cooperative colleagues into improvised solutions. I saw stupid orders from domineering officers turn into relatively safe and workable plans by the time they reached the firefighters. It seemed that as long as we knew what had to be done it would, somehow, get done. If failure was down to equipment or officers we rarely blamed either one if we could blame ourselves first. So getting injured, despite a failure of both equipment and orders, saw me blame myself for it by simply doing as I was told.
This kind of self-talk is probably familiar to many in fire, emergency and medical services, especially when they feel wedded to a successful outcome. I noticed those who blamed the tools, the conditions and everybody but themselves somehow found themselves exonerated, compensated and (too often) promoted. When I recovered from injury it was to a job which, with my now unreliable memory for procedures, orders and safe-practice, terrified me. Afraid of getting somebody hurt I sought a way out that did not look like cowardice. I took a two-year job away from operations, surely long enough to get myself well. However, returning to duty was as cautious and frightening as it had been the first time. In desperation I saw my doctor and various mental-health professionals, the best of whom did not make me feel worse. When the experts gave up it was clear who was to blame: “It must be me”.
I stopped caring whether or not tomorrow came. I found myself tackling unfinished business as if there was little time left to live. The anxiety of being mortal was replaced by consoling thoughts of having lived a good-life and loved being a firefighter. I remember the day it all began to change because it was one of the worst. I finally left the fire service with posttraumatic stress disorder (PTSD) and spent all I had on a building project. Unable to plan it properly I ran out of money and realized the futility of what I was trying to accomplish. I seemed to be trying to prove that I could still succeed at something. I wept. Then I picked up the phone and called the nearest university. I asked how I could enroll on a psychology degree given my lack of qualification. To my amazement after writing an essay and attending an interview I was accepted. Suddenly life had meaning again. Upon graduation I sought the counsel of Professor Mark Williams regarding my fascination for psychological trauma research and the inherent vulnerability embedded in a PTSD diagnosis. He suggested I “..put one foot in front of the other and keep doing that until something stops you.” That was 1997, and I’m still doing it.
I then undertook a Master’s degree in psychological research methods and completed crisis intervention training with the International Critical Incident Stress Foundation (ICISF). I became an Approved Instructor around the time of the 9/11 attacks, and visited New York’s fire and police departments to see if a British ex-firefighter and psychologist was of any interest to them. It was. I learned greatly from Bill Genet and his colleagues at the Police Organization Providing Peer Assistance (POPPA) and the peers and counselors at the Fire Department of New York (FDNY) with whom Malachy Corrigan arranged meetings and always welcomed me. I was then eager to inform London’s authorities of lessons-learned given the predictions of terrorist attacks there. Nobody listened. In 2005 the 7/7 attacks happened immobilizing London, and everybody had to learn what I already knew. Why I was ignored I did not know, but I heard the words again: “It must be me.”
By the time of the attacks in London I had already trained four fire departments in Individual and Group Crisis Intervention and had the fire service rehabilitation centers nearest to London on standby to accommodate CISDs in the way I’d participated at POPPA. Nothing happened. Then the reason became apparent. Psychological debriefing (including CISD) was, according to an expert body of psychologists and psychiatrists, somehow harmful. Nobody listened to me with my 9/11 experience, yet everybody was listening to them, with no 9/11 experience. I knew the value of CISD and I still wanted the job doing well, and these were the experts I knew not to trust so I needed even more authority. I enrolled on a Ph.D. program.
JOINING THE EXPERTS
Now I’m a Ph.D. I joined the same committee of experts that warned against debriefing and informed them of Michelle Tuckey and Jill Scott’s (2014) randomized control trial (RCT) of CISD. The RCT is the quality-standard that justifies the label of ‘evidence-based’ for an intervention. I made the case to move CISD from ‘Do-Not-Do’ to ‘Recommended’. It failed. At a later meeting I bombarded the committee with evidence supporting CISD and argued we should remove the warnings and in keeping with the role of the committee, recommend it as ‘evidence-based’. I thought my argument had been accepted and a grave injustice was to be corrected. When, after some weeks, nothing had happened I insisted on an explanation and was told that the changes will not be considered until late-2018. I hadn’t succeeded after all, and with little faith in the changes occurring even when the committee reconvenes in 2018 I’d failed. The voice returned: “It must be me”.
Then I wondered about the USA where, despite no formal warning against CISD, a shadow seems to hang over it. I targeted SAMHSA whose website states:
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.
I saw that for an intervention to be recognized as evidence-based with SAMHSA a formal, staged application has to succeed through the National Registry of Evidence-based Programs and Practices (NREPP). In January this year I decided to apply.
The first stage of the application required the submission and discussion of at least one RCT to represent the strongest evidence, backed-up by the most relevant studies. The second stage would see ICISF involved to have the relevant program information available to NREPP. The third stage would be the decision on its status and seeing it listed as evidence-based. To avoid raising false hopes I made the initial application without informing ICISF because if it was rejected only I would know. However, it succeeded and went to the ‘program information’ stage that required ICISF involvement. Jeff Mitchell assisted generously with that and now we are at the third and final stage – we await the decision.
Having CISD listed as evidence-based with SAMHSA probably has great implications for the field of crisis intervention, and I will leave others to speculate on those. For me, with CISD categorized alongside clinical therapies I hope to finally confound our critics, raise our confidence in how we support our colleagues and inspire future research to maintain this newly-acquired status for CISD. At the 2015 World Congress I announced at the Approved Instructors meeting that I intended to make this application, and here it is with one step to go. On reflection it was that firefighter’s determination to see the job done (and well), being motivated never to quit unless stopped and wondering if I was the reason nobody listened. Now we may be approaching a milestone in the fortunes of CISD that will safeguard and strengthen the principles established in peer-support and crisis intervention for the next generation. I saw the critics of CISD as experts who performed badly and so did the job myself. It’s still a little early to know, but I hope I did it well.