A SCIENTIFIC APPROACH TO THE DEVELOPMENT OF A RELIABLE EVIDENCE BASE
At STAGE-28 we take a bottom-up approach that generates research data from the people in the field doing hazardous, distressing work and staying safe while they do it. STAGE-28 online assessments enable any department or organisation to design and undertake its own research, answer their own questions and develop their own policy. See here for further information.
As advocates of critical incident stress management (CISM which includes critical incident stress debriefing CISD) from our positive experience in emergency response and disaster work in the USA, UK and Australia, it is puzzling to read objections. The controversy over psychological debriefing persisted for over 20 years despite the following observations:
With warnings against psychological debriefing expert recommendations were to wait four weeks to assess for posttraumatic stress disorder (PTSD) then offer cognitive behaviour therapy (CBT), eye-movement desensitisation reprocessing (EMDR) and medication (NICE, 2005) as ‘evidence-based’. Ironically, the guidelines recommend against debriefing in favour of providing support during the first four weeks, despite CISM representing several forms of support (Mitchell, 1983), and being listed as ‘evidence-based’ by SAMHSA. SAMHSA stands for the Substance Abuse and Mental Health Services Administration, the mental health arm of the US Government’s Department of Health and Human Services.
Figure 1. Screenshot of the SAMHSA listing of CISD as ‘evidence-based’ in 2017
Studies critical of psychological debriefing were randomised controlled trials (RCTs) and so eligible for inclusion in the 2002 Cochrane Review Psychological debriefing for preventing post traumatic stress disorder (PTSD). However, CISD was never designed to prevent PTSD, only to provide support and mitigate post incident distress making the basis of the review a spurious one. The only RCT of CISD (Tuckey & Scott, 2014) was undertaken with firefighters and so demonstrated the internal and external validity lacking in the Cochrane Review’s critical studies. The outcome was firefighters in the CISD condition reporting better quality-of-life and reduced alcohol consumption than controls, and few PTSD symptoms. The information on Tuckey & Scott was not accepted by NICE committees in 2013, 2015 or 2016 and failed to have the warning removed in the 2018 Guidelines.
References and readings are below, including Tamrakar, Murphy and Elklit (2019) and their paper Was Psychological Debriefing Dismissed Too Quickly?: An assessment of the 2002 Cochrane Review.
Note blue highlighted references below find positive outcomes for CISD applied in homogenous teams as it was designed. The most recent studies were published in 2009, 2014 and 2019.
References and Reading
Adler, A., Bliese, P., McGurk, D, Hoge, C., & Castro, C. (2009). Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: Radomization by platoon. Journal of Consulting and Clinical Psychology, 17 (5), 928-940.
Bisson, J. I., Jenkins, P. L., Alexander, J., & Bannister, C. (1997). Randomised controlled trial of psychological debriefing for victims of acute burn trauma. British Journal of Psychiatry, 170, 78-81.
Campfield, K. M., & Hills, A. M. (2001). Effect of timing of critical incident stress debriefing (CISD) on posttraumatic symptoms. Journal of Traumatic Stress, 14, 327-340.
Conlon, L., Fahy, T. J., & Conroy, R. (1999). PTSD in ambulant RTA victims: A randomized controlled trial of debriefing. Journal of Psychosomatic Research, 46, 37-44.
Gamble, J., Creedy, D., Moyle, W., Webster, J., McAllister, M., & Dickson, P. (2005). Effectiveness of a counseling intervention after a traumatic childbirth: A randomized controlled trial. Birth, 32, 11-19.
Hobbs, M., Mayou, R., Harrison, B., & Worlock, P. (1996). A randomised controlled trial of psychological debriefing for victims of road traffic accidents. British Medical Journal, 313(7070), 1438-1439.
Lee, C., Slade, P., & Lygo, V. (1996). The influence of psychological debriefing on emotional adaptation in women following early miscarriage : A preliminary study. British Journal of Medical Psychology, 69 (Pt 1), 47-58.
Marchand, A., Guay, S., Boyer, R., Iucci, S., Martin, A., & Saint-Hilaire, M.-H. (2006). A randomized controlled trial of an adapted form of individual critical incident stress debriefing for victims of an armed robbery. Brief Treatment and Crisis Intervention, 6, 122-129.
Mayou, R. A., Ehlers, A., & Hobbs, M. (2000). Psychological debriefing for road traffic accident victims: Three-year follow-up of a randomised controlled trial. British Journal of Psychiatry, 176, 589-593.
Rose, S., Brewin, C.R., Andrews, B., & Kirk, M. (1999). A randomized controlled trial of individual psychological debriefing for victims of violent crime. Psychological Medicine, 29, 793-799.
Sijbrandij, M., Olff, M., Reitsma, J. B., Carlier, I. V., & Gersons, B. P. (2006). Emotional or educational debriefing after psychological trauma: Randomised controlled trial. British Journal of Psychiatry, 189, 150-155. doi: 10.1192/bjp.bp.105.021121
Tamraker, T., Murphy, J., & Elklit, A. (2019) Was psychological debriefing dismissed too quickly? An assessment of the 2002 Cochrane Review. Crisis, Stress and Human Resilience: An International Journal. 1, 146-155.
Tuckey, M.R. and J. Scott (2014), Group criticial incident stress debriefing with emergency services personnel: a randomized controlled trial, Anxiety, Stress & Coping: An International Journal, 27, 38-54.
Wu, S., Zhu, X., Zhang, Y., Liang, J., Liu, X., Yang, Y., Miao, D. (2011). A new psychological intervention: “512 Psychological Intervention Model” used for military rescuers in Wenchuan Earthquake in China. Social Psychiatry and Psychiatric Epidemiology. doi: 10.1007/s00127- 011-0416-2
Mental Health and Wellbeing in a Health and safety Framework
Hayward, R. & Durkin, J. (2020). Occupational Health and Safety: In Crisis, or in Charge? In R. Burke and S. Pignata (Eds.), Handbook of Research on Stress and Well-Being in the Public Sector (pp. 275-293). Cheltenham: Edward Elgar Publishing
The concept of psychological well-being amongst first-responders in emergency service work has relied upon a medical perspective within a patient- or victim-based framework where psychiatric language informs how mental health is discussed. However, emergency services’ workers encounter a range of physically, cognitively and emotionally demanding stressors, not as victims, but as members of cooperative teams willing to encounter such stressors. If traumatic incidents form an attractive part of emergency work the medical view of an unwitting victim in need of expert help is inadequate. By taking an occupational health and safety perspective, a greater explanatory power may be available because pre-incident, operational and post-incident factors will be considered. In this model, prevention and intervention will take on a greater number of forms, tap into different resilience, recovery, and well-being processes and predict more positive outcomes than the medical model. Hence a novel, dynamic picture emerges with well-being and resilience, rather than mental disorder, at the forefront of health and safety planning. The importance of camaraderie, teamwork and the resultant culture of trust inherent in staying safe during critical incident exposure is imperative to well-being and resilience. In this chapter, the nature of prevention and intervention processes are considered and explored within two contexts: 1. in South Australia, where large areas of the state are protected by volunteers and professional emergency services’ personnel as members of communities confronted by critical incidents; and, 2. in London, UK where terrorist incidents and the multi-fatality Grenfell Tower fire were attended by professional police officers supported by a specialist peer-support team. Two aspects of well-being in emergency services will be highlighted and explored within the differing contexts of South Australia and London. Theoretical processes that underpin individual well-being and team-functioning will be considered within an occupational health and safety framework. As such, symptoms of mental disorder will be reinterpreted as reactions to psychological shock and the 28-day ‘watchful waiting’ period required for psychiatric diagnosis seen as a fruitful period within which psychological function can be restored in first responders and their well-being assured.