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| About CISD |
| By Dr. Susan Jones |
| Published: 09/03/2018 |
Have you heard that Critical Incident Stress Debriefing may be causing more harm than good to our staff?
There are studies that state that the Critical Incident Stress Debriefing approach, labeled as the Mitchell Model, is not helping our staff after a critical incident, and that it is even harming their recovery! I rejected this notion at first because I was trained in the Mitchell Model in 1995 by my agency. I went through this training because a few years earlier I was involved in a critical incident and was a recipient of this intervention. However, as I kept hearing that this approach may cause harm, I examined the research closely. This examination revealed that there are a variety of studies which indicate that stress debriefing actions taken after critical incidents were either, at best, doing no good, or were even causing harm. Studies that Show that the Intervention Does Not Help or Harm Participants Deahl (2000) stated that the intervention may offer a sense of support, but may also delay diagnosis for people in need of additional treatment. He concluded that the use of psychological debriefing is harmful, and that the overenthusiasm about the intervention may mask real symptoms. Sijbrandij, Olff, Reitsma, Carlier, and Gersons (2006) were more critical of the method when they concluded that individuals who had significant PTSD symptoms prior to intervention, and who went through a debriefing, actually showed more PTSD symptoms at 6 weeks than those who did not go through a debriefing. This study looked at a single session psychological debriefing, not the Mitchell Model. Van Emmerick, Kamphuis, Hulsbosch and Emmelkamp (2002) found that a single-session debriefing did not improve the natural recovery from trauma, and that, in fact, those who had no intervention actually showed higher improvement rates than those who received it. Devilly, Gist and Cotton (2006) were more specific on the harm done by a debriefing. They concluded that the debriefing process may re-traumatize individuals and provide details to the group that alter their perception of the event. They also speculated that the “medicalization” of this model may encourage individuals to see themselves as ill, which may negatively affect natural reactions to trauma. This research study also indicated concerns about timing. If a team follows the Mitchell recommendations of intervention between 24-72 hours after the incident, the process may actually interfere with the individual’s own coping strategies. In other words, the intervention can get in the way of strategies that individuals may be able to employ on their own, and it may actually decrease their chances of recovery. What the Research Measures When looking at the research on this topic, a primary concern revolves around labels and definitions. What I found was that the research studies used different labels to identify critical incident debriefing, including group debriefings and psychological debriefings. A clear issue with the review of this literature is that the Mitchell Model is not what is being evaluated in every case. Instead, a mix of other types of interventions, which have been labeled critical incident response, have been the subject of research. Some of this research even includes individual contact with staff after an incident (Ehlers and Clark 2003), which is clearly not what the Mitchell Model entails. Rose, Bisson, Churchill and Wessely (2009) concluded that the use of individual debriefing is not recommended, but they did not make any recommendations regarding the use of a group debriefing. Another concern brought forward by Deahl, Martin, Srinivasan, Jones, Neblett, and Jolly (2001) questioned the measurement of outcomes. Most of the studies measured the reduction of PTSD symptoms, but these authors found that the method improved the individual’s coping process in other ways, for instance, in a reduction in the use of alcohol. Move Away from the Mitchell Model In more than one agency, critical incident teams have moved away from a formalized, structured, group debriefing in line with the Mitchell Model, to a process of contacting staff individually. I witnessed this change in approach when a tragedy occurred in my agency. In response to this tragedy, executive staff decided that they needed to send someone to help the on-site staff deal with the incident. The person who had been in charge of our team had retired, and there had been no effort to assign this leadership role to another person. Consequently, I was contacted and ordered to get a group of people out to the affected facility immediately. I was surprised, to say the least, that I was being directed to send a team out, even though the incident had just occurred. I tried to explain that according to our training, we should not respond until at least 24 hours after the incident. I tried to explain that this training model was very specific on mandatory attendance, group structure, confidentiality, and support by a mental health clinician. None of this mattered. I was directed to just “send staff out there” to help because “we had to do something.” After the “team” arrived at the facility, I began to get phone calls from the individuals who had been sent to do a debriefing. They were at this outlying facility just wandering around talking to staff. No one had approved their request for a debriefing, mandatory or otherwise, and no one at the facility would listen to them as they explained how this was supposed to work. They were told to just go talk to people, on post, individually. And so that is what they did. After that tragic event, an official leader was chosen for this team and the Mitchell Model was out, just that quickly. The team retained the title of critical incident response, but in essence it was really some type of a peer response team. They would provide individual support, while staff remained at the facility, and often remained on post. This seamless transition from a structured model to a wandering peer support resource was not questioned by anyone in the agency. In fact, the new leader of the team often referred to the team as a “positive peer support group that assists others in dealing with normal reactions to abnormal situations.” As I talked to corrections professionals in different agencies, I found that many agencies had moved away from a formal debriefing process that followed the Mitchell Model to something else. In many cases, this something else was very similar to the individual approaches that resembled a peer-support type team. Devilly, Gist, and Cotton (2006) examined options for organizational action after a traumatic event, and suggested that immediate support is appropriate, and it should be through relationships that are already in place. This seems to suggest that a traditional peer support program, made up of people that staff knows and works with, is a better approach than bringing in strangers from other parts of the agency. Risk of Doing Nothing Devilly, Gist and Cotton (2006) went further in their statements by concluding that continued use of psychological debriefing may increase risk to employees. If providing a psychological debriefing increases risk to the employee, it follows that it will then increase liability to the agency. However, there seems to be a need to “do something” to help employees who are hurting or feeling vulnerable. Thus, the risk of doing nothing may seem to decision-makers to be more pressing than doing something that could cause harm. In Defense of Mitchell Everly, Mitchell and Flannery (2000) have clarified that the debriefing process was never intended to be the only intervention offered to employees. Additionally, Everly and Mitchell (2000) have identified substantive issues related to the Mitchell Model by suggesting that questions regarding who provides the crisis intervention and to whom, as well as what specific situations are appropriate for this method, must be answered. Other researchers have suggested different concerns or motives for the controversy regarding the use of the Mitchell model. Kaplan, Iancu, and Bodner (2001) found that some mental health providers supported debriefings because it addresses a sense of helplessness they may feel. Dyregrove (1998) concluded that the debate over the method has been invented by the psychiatric professional elite who are merely protecting their turf. Steps Forward This review of the research does not provide a clear-cut plan for the responsible corrections leader. In fact, it may actually lead to more questions than answers. So, what does the responsible leader do now? If providing debriefings may actually harm employees, it must stop. However, the evidence is not that clear. The fact that researchers have evaluated several different types of interventions, and labeled them all as debriefing is not helpful. If the Mitchell approach is problematic, then research that reviews and evaluates outcomes after a debriefing must focus on debriefings that adhere to the Mitchell process. Lumping psychological debriefings, individual contacts, and other types of group debriefings under one label is not an appropriate way in which to evaluate the model. If the Mitchell Model is chosen as the method to continue to offer staff support, then the model should be followed. Making alterations to the debriefing protocols based on staffing limitations or on what feels more comfortable is not recommended. The model defines attendance protocols, confidentiality protocols, time frames for implementation, and training for facilitators. These guidelines should not be ignored. What can be inferred by this research, however, is that individual contacts by people with whom the traumatized staff member has no existing relationship are not helpful. A peer support approach, staffed by familiar people, may in fact be more helpful for staff who are processing a tragedy. When using such an approach, staff members can reach out to this same peer support person later, if needed. Finally, what outcomes should be measured? Corrections staff who are traumatized by an event or loss may have already been exposed to other events that have led to the existence or likelihood of PTSD symptoms. Therefore, is the measurement of PTSD symptoms an appropriate measure? Perhaps there is a different outcome that is more appropriate when measuring the effectiveness of any type of intervention for traumatized staff. Use of negative coping mechanisms, days absent from work, stress measurements, or even effects upon relationships may provide a better evaluation of the intervention. For now, there is no clear answer, so corrections leaders are left to determine the needs of their employees based upon their own judgement. The tried and true mechanics of leadership must be relied upon: know your staff, be accessible to all levels of employees, and provide a wide spectrum of resources so that staff can access support when needed. Hopefully, more clear and specific research will be able to confirm or refute the efficacy of the Mitchell Model, and provide a clear answer about what should be done after a critical incident.
This article as been reprinted with permission from the July 2018 Issue of Correctional Oasis, a monthly e-publication of "Desert Waters Correctional Outreach". Dr. Susan Jones retired from a warden’s position within the Colorado Department of Corrections. She worked in a variety of corrections positions in Colorado for 31 years, including: community corrections, correctional officer, sergeant, lieutenant, manager, associate warden and warden. Dr. Jones research interests have focused on the issues that correctional employees face on a daily basis. Visit Dr. Jones's Facebook page "A Glimpse Behind the Fence". |
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