Defusing / Debriefing & Psychological First Aid
John D. Weaver, LCSW
Defusing is the term given to the process of talking it out - taking the fuse out of an emotional bomb (explosive situation). It involves allowing victims and workers the opportunity to ventilate about their disaster related memories, stresses, losses, and methods of coping, and be able to do so in a safe and supportive atmosphere. The defusing process usually involves informal and impromptu sessions. A DMH worker might witness an emotional interchange between a victim and another staff member and, soon afterward, approach one or both of them and open a dialogue. This will, in turn, help folks release thoughts and feelings that might not otherwise be expressed. Suppression or repression of this kind of highly charged material might lead to the development of any number of stress-related physical and/or mental illnesses.
Greeting a victim who is waiting in line at a disaster service center and offering a snack or a drink, or playing a game with a child in an emergency shelter, or making a purchase from a clerk at a store in a disaster area, or even ordering a meal while in the field, can be enough of an opportunity to open a dialogue with someone who is anxious to tell his or her story. Running into a coworker at the copy machine offers the same chance. So does going out to eat with other staff members. Although informal and immediate, the defusing often becomes a mini-debriefing and can follow the same format discussed in the next section. Because the allotted time is often too brief, the defusing session is simply a starting point. Further intervention is often required and this can be anything from offering ongoing support (e.g., briefly touching base with the persons/groups in the coming days/weeks) to scheduling and providing formal debriefing sessions.
The psychological debriefing (PD) is often a good first step for helping people process their direct involvement with traumatic events. The PD is a formal meeting, done individually or in small groups. It is generally held shortly after an unusually stressful incident, strictly for the purpose of dealing with the emotional residuals of the event. Any location that is large enough to accommodate the group, and which can be secured so as to assure privacy, is appropriate for use. This session may require a block of time that is several hours in length, particularly if a process such as Mitchell's (1983) formal Critical Incident Stress Debriefing (CISD) model is used.
Whenever possible, everyone involved in the crisis should attend the debriefing(s). Many organizations recommend or even require attending defusing or debriefing sessions, whenever certain types of incidents occur. The American Red Cross (ARC) formerly offered defusing, as necessary, throughout a person's tour of duty at a disaster scene and offered debriefing before leaving for home. Once ARC workers got home, their local ARC Chapters often offered them another debriefing (if that area had an active DMH team). At the morgue following the 1994 crash of Flight 427 near Pittsburgh, volunteer trackers and scribes (persons who escorted the remains of the 132 victims through the I.D. process) were offered graphic pre-briefings (a form of stress inoculation). They were also required to attend debriefings at the end of their shifts. Many expressed their gratitude and all seemed to value the opportunity to be debriefed.
The original Mitchell process was designed for first responders (police, fire fighters, emergency medical technicians, etc., to help them overcome the emotional aftereffects of critical incidents (e.g., line-of-duty deaths). Sessions were usually held within the first 24-72 hours after the traumatic event, with follow-up sessions as needed. Given the nature of disasters, we do not always identify all of the victims that quickly. Fortunately, the debriefing process is still beneficial, even when the sessions are held long after the event. Most mental health professionals have not been taught about defusing and debriefing and report being amazed at how helpful these simple but powerful tools become in their day-to-day practices.
There are now several debriefing models. Organizations like the National Organization for Victim Assistance (NOVA) may favor a model which they teach their volunteers and staff members. While the various models differ in the number and type of phases (or stages), they all get at the same basic elements that Mitchell's original process sought to examine. This is done to help people cope with the sights, sounds, smells, thoughts, feelings (replaced by thoughts and reactions in the revised Mitchell Model), symptoms, and memories that are all part of a normal stress reaction to a traumatic event. Toward the end of this document there is a sample handout based upon the original Mitchell model. Some of the other, more current models (including the Multiple Stressor model formerly utilized by the Red Cross) are presented below:
MULTIPLE STRESSOR DEBRIEFING MODEL
Phase 1 - Disclosure of Events
Phase 2 - Feelings and Reactions
Phase 3 - Coping Strategies
Phase 4 - Termination [see Armstrong, Lund, McWright, Tichenor (1995), p. 85]
MITCHELL MODEL CISD (original process)
Stage 1 - Introduction
Stage 2 - Fact Phase
Stage 3 - Feeling Phase
Stage 4 - Symptom Phase
Stage 5 - Teaching Phase
Stage 6 - Re-Entry Phase [see Mitchell (1983)]
MITCHELL MODEL CISD (current revision of process)
Stage 1 - Introduction
Stage 2 - Fact Phase
Stage 3 - Thought Phase
Stage 4 - Reaction Phase
Stage 5 - Symptom Phase
Stage 6 - Teaching Phase
Stage 7 - Re-Entry Phase [see Everly (1995), pp. 288-289]
MASS DISASTER / COMMUNITY RESPONSE VARIATION OF CISD
Stage 1 - Introduction
Stage 2 - Fact Phase
Stage 3 - Thought Reaction Phase
Stage 4 - Emotional Reaction Phase
Stage 5 - Reaffirming Phase
Stage 6 - Teaching Phase
Stage 7 - Re-Entry Phase [see Everly (1995), pp. 289-290]
Whatever model you use, allow lots of time for folks to ventilate, especially during the initial stages/phases when facts, thoughts, and feelings are being discussed. Encourage expression of the most vivid or graphic, negative images and memories. Think of it as cleaning out an emotional wound before allowing it to try to heal with foreign material still on the inside. Improper procedure with a cut might promote infection. Improper procedure here will mean the emotional wound can be easily reopened by future stressful events and it will lessen the ability to avert PTSD. Facilitators should not, however, push people to reveal anything that is still too upsetting for them to discuss. Forcing things may cause additional harm by making people re-experience the traumatic event at a time when healthy denial may be a better approach.
Normalize the participants’ experiences. Teach them about stress reactions and provide stress inoculation about anniversary reactions and other problems that they will eventually face. Offer lots of support and try to anchor a positive image and outlook for their successful recovery. Help them recognize the resiliency of the human spirit and have them expect post-traumatic growth rather than PTSD. End by thanking them for coming and joining in the debriefing process - shake their hands and/or give a hug as each person leaves the session.
Guidelines for Organizing Debriefings
The following material was designed to help DMH workers facilitate formal community debriefing sessions held in the days or weeks following a disaster event. Remember that the American Red Cross DMH Team, the county and/or state mental health offices, the area's CISM Team, and other local agencies may also be available to help when mutual-aid is needed. In my area, the CISM Team commonly works with first responders and ARC works with the community (e.g., folks who tried to fight a fire before the volunteer fire company arrived.
Try to find a site that allows separate breakout rooms, so that a large group can be divided into smaller ones. Churches, schools, and other, similar buildings usually are good meeting places. Sunday evenings are often good times to meet, as participants generally have fewer scheduling conflicts. When working with two (or more) groups, try to locate a neutral spot in the building where the group that finishes first can go to await the arrival of the other group(s) and the end of their sessions. This same spot is a good place to use for offering simple snacks and/or drinks before and after the session.
Try to get someone from the group of persons who have requested the debriefing to help with preparations by having that person invite the appropriate participants and select the logical meeting place. This screening will also help assure confidentiality. As the invitations are being made, it is best to try to get a fix on how many persons might attend and how many small groups may need to be formed. A good rule of thumb for the size of each small group is 8-12 persons, with two facilitators per small group.
To maintain confidentiality and eliminate problems with interruptions, it may be helpful to have someone extra there to watch the door. This person can intervene with any persons who find it necessary to leave the session in the middle. He or she can also stop anyone who is late (or uninvited) who might be attempting to enter the area once the process has begun. Take along the appropriate educational handouts.
When entering a large room and taking seats, persons will often form logical subgroups. Use this phenomenon to help in allocating space needs and for assigning victims and facilitators to the smaller work groups. Try to also have people assigned to subgroups by exposure level. Otherwise one group member, who talks about the worst sights, sounds, etc., may upset others who, until then, had had less traumatic experiences and memories of the event.
It is important to separate participants into groups by trauma-exposure level. If folks had low levels of exposure to the nastiest sights, sounds, smells, etc., you need to avoid exposing them to that new stress via the debriefing. It is also a good idea to handle workers and victims in separate groups (to avoid publicly airing any sensitive relief organization issues) and to keep workers and supervisors in different groups (each may not be comfortable sharing with the other present). Facilitators should try to sit on opposite sides of the group circle, to allow maximum ability to monitor group dynamics and each other.
While participants are not required to speak, it is a generally a good idea to try to draw everyone into the conversation and to do so as quickly as possible. I generally have members of my groups begin by going around in a circle for introductions. I then go around the circle again for each person to respond to the fact phase (and possibly do so again for the feeling phase). After a few times around, a more natural and free-flowing group process can be allowed to take place. By doing this in this way, I find that shy people are more likely to participate and persons with overbearing personalities are less likely to monopolize the session.
PD sessions represent an initial crisis intervention step that can be very helpful in assisting, assessing and supporting individuals and groups that have experienced trauma. Bear in mind, however, that victims and witnesses may further benefit from short-term cognitive-behavioral therapy (CBT) sessions (e.g., Stein, Jaycox, Kataoka, Wong, Tu, Elliott, and Fink, 2003) and some people may need to receive even more comprehensive treatment. The following is a sample handout that I developed, based upon the original version of the Mitchell CISD model (see Mitchell, 1983). I use this in my community debriefing sessions. It serves as a road map for the meeting, and helps guide both the facilitators (some of whom may be new to debriefing and need a cheat-cheat) and the participants through the session. A similar handout can be developed around any of the debriefing models.
I have found that using this adult-learning approach works very well for all parties. It makes it especially easy to redirect conversations whenever someone is trying to move through the process too quickly. For example, if someone begins talking about symptoms while the rest of the group is still working on facts, you can acknowledge the comment, and state that the concerns will be addressed in the upcoming "symptom phase" of the discussion. You can even point it out on the handout and then return the group's focus to the desired spot in the process. Remember that debriefing is not meant for use as a single, stand-alone intervention. It is, however, a good way to structure the initial crisis intervention, psychological first aid, and triage efforts in the aftermath of workplace violence
DEBRIEFING SESSION HANDOUT
This session has been scheduled to help everyone come to terms with the thoughts and feelings that arose out of the recent tragic situation that you all faced. The format for the session is based upon the Critical Incident Stress Debriefing (CISD) model put forth by Jeffrey Mitchell (1983).
(Fill in the name of the sponsoring organization) has provided the workers who will serve as facilitators for today's debriefing. The session will probably last from one to two hours and it will cover these six areas:
Initial Phase - introductions, a discussion about confidentiality, an explanation of the purpose of the session, and a review of some other guidelines for the session. Some general rules in addition to the need to maintain confidentiality are:
- Please speak only for yourself.
- There is no rank during the session.
- No press and no outsiders are allowed in the session (if anyone feels he or she does not belong in the session, please speak up about it right away).
- Once we begin, there will be no break until we end the session.
- No beepers and no phone calls, or other interruptions are allowed.
- This will not be a time of investigation or critique.
- Feel free to ask questions any time.
- Please plan to stick around for the whole session.
- No one has to talk, if they do not want to do so.
Fact Phase - review of what actually happened during and after the incident (e.g., what each person heard, saw, smelled, touched, thought, and did).
Thought Phase - review of the thoughts each person had at the time of the incident and in the time since the incident.
Reaction Phase - review of the reactions each person had at the time of the incident and in the time since the incident.
Symptom Phase - examination of the physical and psychological aftereffects of the incident.
Teaching Phase - used to remind everyone that the symptoms they are experiencing are normal responses to the abnormally stressful situation they have faced.
Re-entry Phase - this is the time to wrap-up, answer any questions, and develop a plan for any future action that may be needed.
We hope this debriefing will be helpful to you, as you continue with the normal recovery process. The facilitators welcome your questions and/or feedback about the session.
The Controversy About Debriefing
Debriefing has certainly had its share of detractors. Gist and Woodall (1998), for example, view debriefing (and its many supporters) as a social movement rather than true social science. They cite many studies that found a lack of efficacy and question whether debriefing may actually exacerbate distress. Nevertheless, debriefing programs and related support services got to the point that they become the standard of care for the initial assessment and management of stress reactions resulting from traumatic events.
Everly and Mitchell (1999) have noted that the critical research done up to that time had often been sloppy in its design. Some studies mixed apples and oranges by blending results obtained from interventions offered by practitioners with varied levels of skill and training, and possibly using different debriefing models. Other studies involved improper application of debriefing, using it as a freestanding intervention rather than as one component of a complete Critical Incident Stress Management (CISM) program. They noted that similar difficulties commonly arise whenever researchers attempt to study the efficacy of psychotherapy using randomized experimental designs. Everly and Mitchell (1999) suggest that the only way to get an accurate picture of the effectiveness of these interventions is to allow a broader research approach, including the use of nonrandomized designs and survey research.
A National Institute of Mental Health (NIMH) workshop on mass violence concluded that early intervention in the form of single one-on-one recitals of events and emotions evoked by a traumatic event do not consistently reduce risks of later post-traumatic stress disorder or related adjustment difficulties (NIMH, 2002, p. 2). Beyond that comment on the potential failings of one-shot debriefing with no follow-up, though, the same workshop concluded that early, brief, and focused psychotherapeutic intervention can reduce stress in bereaved spouses, parents, and children and selected cognitive behavioral approaches may help reduce incidence, duration, and severity of acute stress disorder, post-traumatic stress disorder, and depression in survivors (p. 2). Thus, do no harm. A good rule of thumb is to use debriefing carefully and do so as part of a broader crisis intervention program that includes options for ongoing education, social support and, when necessary, ongoing psychotherapy.
For those interested in more on this debate, Litz, Gray, Bryant, & Adler (2003) offer one of the most complete overviews and critiques of the debriefing controversy and the current state of research to better address whether debriefing is helpful or harmful. Another has been written by McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Remember that debriefing is not meant for use as a single, stand-alone intervention. While it is a very good way to structure the initial crisis intervention, psychological first aid, and triage efforts in the aftermath of traumatic events, many victims and helpers may benefit from short-term cognitive-behavioral therapy (CBT) sessions. For one example of such CBT programs, see Stein, Jaycox, Kataoka, Wong, Tu, Elliott, and Fink (2003). Some people may need to receive even more comprehensive and ongoing treatment.
Because of the controversy, the American Red Cross has revised its DMH training class and has stopped teaching/using defusing and debriefing. Instead, emphasis is again being placed on offering psychological first aid for emotional support.
Psychological First Aid
Kirk (1993) details the Danish Red Cross efforts to supplement its regular first aid training programs with psychological first aid (PFA). In 2006 the American Red Cross began offering its own Psychological First Aid: Helping Others in Times of Stress course. The twelve principles of its PFA program are:
- Making a connection
- Helping people be safe
- Being kind, calm, and compassionate
- Meeting people’s basic needs
- Giving realistic assurance
- Encouraging good coping
- Helping people connect
- Giving accurate and timely information
- Making a referral to a Disaster Mental Health worker
- Ending the conversation
- Taking care of yourself
These principles allow all responders to focus their “awareness, attitudes, and actions” to support survivors and helpers. In 2012 theRed Cross added a digital disaster volunteer program which now offers educational information and PFA support via social media (see article in TNSWO http://lnkd.in/N9g_KR).
There are other PFA models, including the one used by the Medical Reserve Corps, the National Child Traumatic Stress Network, and the National Center for PTSD. The core actions of that model are:
- Contact and Engagement
- Safety and Comfort
- Information Gathering: Current Needs and Concerns
- Practical Assistance
- Connection with Social Supports
- Information on Coping
- Linkage with Col laborative Services
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