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Handbook of Community-Based Clinical Practice$

Anita Lightburn and Phebe Sessions

Print publication date: 2005

Print ISBN-13: 9780195159226

Published to Oxford Scholarship Online: April 2010

DOI: 10.1093/acprof:oso/9780195159226.001.0001

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Critical Incident Debriefings and Community-Based Clinical Care

Critical Incident Debriefings and Community-Based Clinical Care

Chapter:
(p.529) 33 Critical Incident Debriefings and Community-Based Clinical Care
Source:
Handbook of Community-Based Clinical Practice
Author(s):

Joshua Miller

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780195159226.003.0033

Abstract and Keywords

Critical Incident Stress De-briefing (CISD) has emerged as an intervention in response to disasters. It is a structured group process for survivors and victims of disasters and other trauma-inducing events. De-briefings are usually considered part of a larger system of crisis responses to “critical incidents” known as Critical Incident Stress Management (CISM), which include more immediate responses known as “defusings,” briefings for management, and individual crisis intervention. CISD and CISM are community-based interventions and often rely on a peer or volunteer model of responders and facilitators. This chapter focuses on debriefings, the most widely used crisis intervention service in response to disasters. It describes what de-briefings are, summarizes research about their effectiveness, and considers how they are an essential component of a community-based system of clinical care.

Keywords:   CISD, mental health services, community-based clinical practice, crisis intervention, social work practice

Community-based clinical practice covers the spectrum of clinical interventions, from crisis intervention to long-term care of people with chronic conditions. In any community there will be disasters: a car crash that kills and injures high school students after a prom, the suicide of a psychiatrist at a local mental health center, a fire that consumes a sleeping child. Disasters can be due to “natural” causes (e.g., a hurricane, earthquake, flood) or caused by humans (e.g., murder, hijacking, sexual assault, police brutality). There are differences in the scale of disasters, with some affecting large groups of people, such as a tornado inflicting damage on a street or in a neighborhood. Some disasters affect the entire community (e.g., the murder of a mayor or city councillor) or even an entire country (e.g., the Columbine school shootings, the Oklahoma City bombing), or in some instances, the world (e.g., the attacks of September 11, 2001).

Critical Incident Stress Debriefing (CISD) has emerged as an intervention in response to disasters. It is a structured group process for survivors and victims of disasters and other trauma-inducing events (Everly & Mitchell, 2000; Miller, 2000). De-briefings are usually considered part of a larger system of crisis responses to “critical incidents” known as Critical Incident Stress Management (CISM; Everly & Mitchell, 2000), which include more immediate responses known as “defusings,” briefings for management, and individual crisis intervention. CISD and CISM are community-based interventions and often rely on a peer or volunteer model of responders and facilitators.

In this chapter I will focus on debriefings, the most widely used crisis intervention service in response to disasters. I will describe what debriefings are, summarize research about their effectiveness, and consider how they are an essential component of a community-based system of clinical care.

Debriefings

Debriefings were originally developed for soldiers and emergency workers; expanded to disaster relief workers, uniformed personnel (firefighters, ambulance drivers, and emergency medical technicians [EMT]), and law enforcement officers; and eventually adapted for use with survivors of direct trauma (Armstrong, O’Callahan, & Marmar, 1991; Dyregrov, 1997; Mitchell, 1983). Debriefings are offered by national disaster relief organizations (e.g., Red Cross), community-based volunteer groups, professional responders, and agency-based (p.530) teams, all of which utilize the services of mental health clinicians in partnership with trained volunteers and peer responders. A debriefing has a clear goal: to help participants to sufficiently process the consequences of a disaster and the consequent crisis-induced stress, and to enable them to continue with their jobs and remain engaged with their families and communities (Pueler, 1988; Raphael, 1986). One notable aspect of a disaster is that it affects more than one person. Therefore, de-briefings are designed to work with groups of people to process the critical event and resultant stress and to collectively provide mutual support, healing, and self-help.

Debriefings are led by a facilitator or a small team of facilitators, who guide the group through a semistructured set of questions. The typical format for a debriefing involves reviewing accounts of what occurred; reflections about cognitive, emotional, and physical reactions; psychoeducational teaching about typical stress responses and useful coping mechanisms; and eliciting ideas and plans for healing, self-care, and mutual aid and support (Miller, 2000). Individual participants may be referred for further assistance and treatment.

Although debriefings are provided by a variety of organizations to different target groups in varied situations, the similarities between models of de-briefings outweigh their differences. Warheit (1988) notes seven key components that are found in most models of debriefings:

  1. 1. The impact of the critical incident on survivors and response personnel is assessed;

  2. 2. Critical issues surrounding the problem, particularly relating to safety and security, are identified;

  3. 3. Ventilation of thoughts, emotions, and experiences occurs, and reactions are validated;

  4. 4. Future reactions and responses are anticipated and predicted;

  5. 5. The event and the response to it are thoroughly explored and reviewed;

  6. 6. There is an attempt to bring closure to the event and to connect people to community resources; and

  7. 7. The debriefing assists people with making a reentry back to their community or workplace.

It is interesting to note the common properties of debriefings because they are frequently marketed in different ways. One of the biggest differences is whether or not the debriefing is presented as a clinical intervention. Some are called “psychological” debriefings and are clearly seen as clinical interventions (Dyregrov, 1997; Raphael, 1986). However, when offered to uniformed personnel, the clinical aspects of debriefings are de-emphasized, perhaps due to the cultures of hardiness that are part of being a police officer or firefighter, and the accompanying stigma of receiving mental health services, which can be seen as a sign of weakness. With uniformed personnel, the aspects of debriefings that are stressed are the importance of talking with peers, who understand what the job is like, the need for self-care, and the importance of mutual support. When beginning a debriefing with uniformed personnel, the facilitator will often stress, “this is not therapy.” Yet the actual process and phases of debriefings offered by different organizations to different target groups are remarkably similar

Table 33-1 compares five different debriefing prototypes. Mitchell’s (1983) model was developed initially for use with emergency response personnel, while the National Organization of Victim Assistance (NOVA; Young, 1997) and the American Red Cross (1995) respond to a wide range of disasters and traumatic events. The community team model is based on the model used by the Community Crisis Response Team of Western Massachusetts (Miller, 2000), which offers debriefings to schools, local communities, and various formal and informal groups. Raphael’s (1986) psychological debriefings were also developed for workers and helpers responding to disasters. Although the name for a given phase may differ slightly and the amount of time spent processing that phase may also vary, the actual sequence of phases is very similar, moving from introductions, ground rules, and information about what happened to describing thoughts, feelings, and reactions. All models close with a focus on self-care, mutual support, and re-integration into the community and one’s life commitments and routines. This is called a “wave model,” moving from information and thoughts through feelings and eventually to self-care and normalization (Everly & Mitchell, 2000).

I have had direct experience with three models in my work with three volunteer teams: the Mitchell model, American Red Cross model, and the community team model. I have also used aspects of the NOVA model in my work for managed care (p.531) companies. I have found that the Mitchell and Red Cross models’ emphasis on creating a narrative is a very important place to begin. Much of this work, like therapy, is helping participants articulate their story of a disaster and its negative consequences and to then reconstruct a narrative of healing and efficacy. As part of this process, it is useful to help participants to get in touch with their thoughts and feelings. After disclosing the facts, it is helpful for participants to describe their cognitive reactions: thoughts at the time of the critical incident, as well as their present thinking about the event. Feelings are also important to reveal and process only if there is sufficient time! It is not helpful to encourage people to open themselves up if there is not enough time to process this or to move on to coping and self-care strategies. All the models that I have used place an emphasis on empowerment types of activities—normalizing and depathologizing typical stress responses, emphasizing self-care activities, and encouraging mutual support from group members.

Table 33-1. Comparison of Debriefing Models

Mitchell Critical Incident Stress Debriefing

National Organization of Victim Response Debriefing

American Red Cross Debriefing

Community Team Model

Raphael’s Psychological Debriefing

1. Introductions and Ground rules

1. Introductions and ground rules

1. Groundwork

1. Introductions and ground rules

1. Initiation into disaster role

2. Fact Phase

2. Cognitive level of experience.

2. Disclosure of events

2. Cognitive Phase

2. Workers own experience of disaster

3. Thought Phase

3. Sensory experience.

3. Feelings and reactions

3. Reaction phase.

3. Review of negative aspects and feelings

4. Feeling Phase

4. Emotions

4. Coping strategies

4. Self-care strategies

4. Review of positive aspects and feelings

5. Reaction Phase

5. What has happened since the event

5. Termination

5. Closing, rituals, follow-up

5. Relationships with workers and family

6. Normalizing, teaching phase.

6. Normalizing the experience

6. Empathy with others

7. Re-entry

7. Closure

7. Disengagement from disaster role

8. Integration of disaster experience

Armstrong, et al., 1991; Mitchell, 1983

Young, 1997

Armstrong, et al., 1991; American Red Cross, 1995

Miller, 2000

Raphael, 1986

The use of a particular model depends on the organization that is sponsoring the debriefings, the culture of the participants, and the nature of the critical incident. Emergency medical service teams respond to uniformed (fire, police, ambulance) personnel and usually subscribe to the Mitchell model. In my experience, such teams emphasize sticking to the format quite rigidly. In contrast, my work with a community team has involved taking a more flexible approach, adapting the debriefing to the audience and setting. Uniformed personnel regularly face harrowing situations and have developed cultures of strength and self-reliance. Weakness is something to be feared. When conducting debriefings with such groups, facilitators are encouraged to not ask “How did you feel?” but rather “What was the hardest part for you?” This is very different from conducting a debriefing with college counselors after a student commits suicide, where exploration of feelings is culturally compatible and indeed expected.

I once conducted a debriefing on behalf of a community team for a group of friends of a person who had been murdered. The debriefing focused a great deal on feelings and ended with a ritual suggested by the group that involved a group hug and a great deal of emotional expression. This would not have been appropriate with a group of firefighters or possibly even employees who had survived the attack on the World Trade Center.

(p.532) The nature of the critical incident also influences the process and emphasis of a debriefing. When I was working with survivors of the attack on the World Trade Center in New York, counselors would usually check in with people about their sensory impressions at the time of the disaster. Almost all participants had vivid sensations such as the smell of burning airplane fuel, the sound of the planes before they hit the building, the images of smoke and debris, the sound of elevators crashing in their shafts. These were powerful, deeply embedded images that were easily triggered by everyday city sights, sounds, and smells. People described breaking into a cold sweat upon hearing a siren or an airplane without realizing what the precipitating stimulus was. In contrast, when debriefing teachers and students at a driving school after two students died in a car accident, the sensory stimuli were not essential, but it was important to spend a great deal of time on the participants’ memories of the victims and their feelings of guilt for not having prevented the incident.

Ultimately, all the models follow the same ripple of the wave but have different points of emphasis, varying ways of phrasing questions, and different philosophies about how flexible or rigid the protocols should be. It is ultimately up to the facilitators and the organization they represent to try to offer a debriefing process that best fits the group of people requiring this form of crisis response.

Debriefings and Community-Based Clinical Care

Debriefings respond to vulnerable populations in immediate need of services, possibly preventing serious negative mental health and social consequences, and referring individuals to needed resources. Debriefings stress coping skills, social support, and interpersonal connections. They offer a place where individuals can create narratives about what happened and their own personal reactions. Often people find that there are others who have had similar experiences. They can also learn from those with different reactions. Ultimately, a group narrative is created that binds people together and creates a sense of shared experience.

The combination of peers working alongside clinicians as facilitators exemplifies community-based clinical practice. The presence of peers empowers participants as they see people like them (fellow firefighters, construction workers, residents of their community) with the skills and understanding to help them to cope with their grief and trauma. This demystifies and de-professionalizes the process, reducing the social distance between the helper and the helped, rendering the process more accessible and supporting the notion that participants’ reactions are normal responses to abnormal events. It is also empowering to peers to be able to help their colleagues, neighbors, and friends. And yet a debriefing conducted after events like Columbine, Oklahoma City, and September 11, 2001, requires clinical skill and judgment. Participants often have powerful, vivid recollections of the disasters, accompanied by strong, powerful affect. Other participants are dazed and numb and need help with getting in touch with their reactions through gentle probing or skillful group facilitation. Some participants have developed functional defense mechanisms, which a skilled clinician can discern and respect. There is also a need to assess during a debriefing who might be at risk of depression, chemical abuse, or self-destructive behavior; these participants might well require referrals for further treatment and clinical interventions.

Like other forms of community-based clinical practice, debriefings place a high value on client empowerment and emphasize assets, social support, mutual aid, and networking, and are consistent with resiliency and strengths-based approaches (Miller, 2003). Some models of debriefing also emphasize cultural competency (Young, 1997), which is a central tenet of all good community-based clinical practice.

Debriefings are offered to groups. This helps to bring people together and to create opportunities for learning from others and for mutual aid and support. Therefore, clinical group-work skills, such as listening skills and empathic capacity, enhance debriefings (Dyregrov, 1997). Additional clinical skills that enhance the effectiveness of debriefings are understanding how to pace a group, being able to tolerate silences, affirming and validating experiences, fostering interaction between group members, tracking affect and mediating, and resolving conflict.

Most debriefings are nested in a community context, whether the community is residential, professional, or one of intimate relationships, such as circles of friends. The death of a high school student (p.533) can result in debriefings within the high school community for teachers, administrators, and students or within the deceased’s residential community for relatives, friends, neighbors, and other affected families and individuals. The murder of a man by police in a synagogue can bring together communities of friends or members of the congregation. Therefore, it is important that debriefings are offered through a variety of services: community-based mental health teams, agency-based crisis intervention units, and local and national volunteer disaster response teams (Miller, 2000).

Using Principles of Community-Based Clinical Practice to Enhance Critical Incident Stress Debriefings

Although CISD is a community-based intervention, more consciously employing principles of community-based clinical practice (CBCP) can strengthen their efficacy. Principles of CBCP can be applied to debriefings in a number of ways:

  1. 1. Constructing debriefings ecologically;

  2. 2. Valuing strengths, resiliency, and group and community connectedness;

  3. 3. Conceptualizing debriefings with narrative theory;

  4. 4. Thoughtfulness about group process; and

  5. 5. Ensuring equal access for all members of a community.

Ecologically Constructed Debriefings

Theoretically, debriefings conceptualize the person in their environment, working with natural groups and systems, encouraging mutual aid and support, and taking a strengths perspective. Employing an ecological perspective (Germain, 1979; Germain & Gitterman, 1980, 1995) can further enhance the theoretical basis of debriefings. According to the ecological perspective, “both person and environment can be fully understood only in terms of their relationship, in which each continually influences the other within a particular context” (Germain & Gitterman, 1995, p. 816). While this is implicit in debriefing philosophy, it is useful to explicitly conceptualize debriefings through an ecological lens. The framework focuses on the fit between the person and environment (or group of people and the environment) and considers life stressors as well as stress. Ecological theory uses terms and concepts such as “relatedness,” “adaptations,” “competence,” “self-direction,” and “habitat and niche,” the last of which refers to a person’s physical and social environment (Germain & Gitterman, 1995). An ecological perspective provides concepts often missing from debriefing literature, such as types and manifestations of power, different aspects of time (individual, historical, and social), and the notion of a person having a “life course” (Germain & Gitterman, 1995). This conceptualization places disasters and debriefings in a larger ecological and historical context, offering a more nuanced view of human behavior. Debriefings become part of a larger social web, situated in a continuum of time that began before the disaster and will continue after the debriefing. Zinner and Williams (1999) conceptualize this as a contextualized timeline for group survivorship and community recovery with the following periods: pretrauma, trauma, primary intervention period, secondary adjustment period, and posttrauma period.

The events of September 11 offer a good example of how a more ecological approach to de-briefings might be valuable. Many people who escaped from the World Trade Center received debriefings offered by clinicians hired by managed care corporations and offered through employee assistance programs. This was both valuable and problematic. It was important for employees to receive services, and many of them did as a result of this service delivery model. It also fostered mutual support among colleagues. However, there was also an emphasis on getting back to work, and supervisors offered mixed messages about wanting their employees to take care of themselves while also wanting them to contribute to the corporation. Participants were also wary about revealing too much in front of their colleagues. This tension is structured into debriefings being offered by an employer, however well intended. However, workers inside the World Trade Center and people passing by who did not work for large corporations might not have received debriefings. An ecological model and systems of care approach would assess all the potential people directly affected by the World Trade Center disaster and try to map out different ways to reach and serve individuals, families, groups, and subgroups. It would consider conflicts (p.534) of interest arising from employer-generated services and consider various ways of reaching people—through neighborhoods, religious organizations, trade unions, and other formal and informal groups and systems. This does not negate the need for employer-offered services but rather offers a complementary, more varied and flexible service delivery system.

Strengths, Resiliency, and Group and Community Connectedness

The contextualized, developmental framework of an ecological approach fits well with the CBCP emphasis on strengths and resiliency (Saleeby, 1996; Weick, Rapp, Sullivan, & Kisthardt, 1989). A debriefing is a way of helping people move from a narrative of victim to one of survivor. A major function of debriefings, and perhaps a more important one than the ability to prevent posttraumatic stress, is to connect participants with one another. Palmer (1999), using a case-based research method, has concluded that the most important variable in resiliency is “human relatedness” with other individuals, families, community networks, and social support groups. Debriefings are exercises in human relatedness; an explicit goal is to create a group narrative of disaster and healing and to foster group cohesion and mutual support.

Gilgun (1999) has developed a model of assessing client risks and strengths, the Clinical Assessment Package for Assessing Client Risks and Strengths (CAPACRS), which uses a number of scales to assess risk and resiliency in children and families: emotional expressiveness, family relationships, family embeddedness in community, and peer relationships. While CISD encourages emotional expressiveness and utilizes peer relationships, more could be done to work with family groups and to understand how families and communities are intricately and mutually embedded (Miller, 2001).

Since connectedness with family and community is so important, debriefings could actively bring family and/or community members together for debriefings even when they have not directly experienced critical incidents. This process views the effects of critical incidents more systemically: even those not directly victimized by a disaster can experience forms of secondary trauma. Such de-briefings would allow families to understand the reactions that some of their members are experiencing while also fostering support and help from those less triggered and destabilized by critical incidents. Family debriefings respond to one of the problems with debriefing people solely by virtue of their shared exposure to critical incidents: while this group may have a special, shared understanding of the critical incident and its impact, they then have to adjust to being with family, friends, and colleagues who do not have this shared experience, and reentry problems can occur (American Red Cross, 1995). For example, spouses and children of those who survived the World Trade Center collapse were certainly affected by this event, yet they were not present for debriefings offered via employee assistance programs for the family member who directly escaped the disaster. Individuals who directly experience disaster frequently comment that their loved ones do not truly grasp or understand what they went through (Miller, 2002a), while relatives of the victim may be baffled and confused by the victim’s withdrawal and alienation. If a survivor is drinking heavily or isolating him- or herself, what is a spouse, partner, or child to make of this? This behavior can have recursive effects within the family as potential supports are withdrawn or even become antagonistic. Debriefing families together could mitigate such recursive effects. There may be a need to conduct debriefings with individuals who directly experienced the disaster, such as a work group that survived 9/11, and subsequently offer family debriefings as a follow-up.

The same is true of bringing together friends and other relevant members of the community who can support the victim and his or her family. Clinicians conducting debriefings could map out natural community groups, networks, and relationships before conducting debriefings as part of a pre-debriefing assessment process. Intentionally bringing a heterogeneous group of people together, including those who directly experienced the event and those who can offer support, could buffer and help contain the traumatic effect of the critical incident, while strengthening bonds between those directly and indirectly impacted by the tragedy. The guiding principal would be less about who experienced a critical incident and more about who can be supportive and helpful. It is also worthwhile to foster debriefing groups with potential for developing relationships that can continue after the (p.535) crisis. A strengths-based and resiliency approach suggests that there is value in bringing together people with differential exposure to crisis and disaster; they can learn from one another and as a group offer balance between hope and despair, optimism and pessimism.

For example, when there has been domestic violence in a community leading to murder, many different systems and groups of people are affected—people who knew the victim, social service and law enforcement personnel who tried to save the victim, teachers of the victim’s children, members of the church that the victim attended, and many more. Not only groups within the community but also the community itself may be affected by the event. If there had been previous domestic fatalities, this can become part of an ongoing community narrative about domestic violence. While it is certainly important to offer debriefings to people within a formal or informal group, say the teachers at the school the children attended, it might also be helpful to offer community debriefings that may bring together people who were more directly involved with people who are concerned and affected but less directly triggered by the tragedy. This could be done by holding open community meetings where debriefings are offered or by consciously inviting members from different groups and constituencies to expand and open the debriefing process. This would integrate the group-based process that debriefings traditionally follow with a community-oriented approach that taps and builds on community assets and resources.

Strengths- and relationship-based community practice also has implications for the role of the debriefing facilitators. An empowerment and strengths-based approach works best when there is minimal social distance between facilitators and those receiving help (Saleeby, 1996). Polio, McDonald, and North (1996) have developed a set of “practice principles” to guide strengths-based practice (that also incorporates the values of feminism) with “street” populations. One is that workers are sensitive to their professional privilege and the barriers that accrue from this; a second is that workers participate as group members rather than as leaders. Many debriefings are facilitated by trained professionals and offered by national organizations such as the Red Cross and the National Organization of Victim Assistance. Other organizations, such as the emergency medical services network, utilize a mixture of trained peers with a professional clinician as consultant. To further a strengths-based orientation, there should perhaps be a greater emphasis on the use of community-based teams of volunteers (Miller, 2000) or on a trainer-of-trainers model, where professional clinicians would have more of a training and consultation role with lay facilitators, rather than leading the debriefings. In my experience the ideal combination is to have a team of facilitators composed of peers and/or community volunteers with at least one professional clinician. This amalgamation both lessens social distance and stigma and also adds the skills of a professional responder to work with complex group dynamics and to assess for severe and unresolved stress reactions.

Whatever the mixture of facilitators, it is always helpful for this group to process their work together afterward and, ideally, to be debriefed by an outside facilitator. This follow-up is essential to understanding complex group dynamics and untangling knots that may have occurred within the facilitation team. It also presents the opportunity for facilitators to learn from one another. Perhaps most important, it aids facilitators with processing their own feelings and reactions and helps to prevent or at least respond to secondary traumatic stress. I have found that the potential for absorbing secondary trauma is always present, as it is in any clinical work. This is more likely to occur when the debriefing facilitator has a personal connection to the incident or the group being debriefed, or has personal analogues that are triggered by the critical incident or the stories of the debriefing participants. While firefighters conducting a debriefing can be more empathetic toward their colleagues, they may also be more prone to overidentifying with their guilt. If a clinician conducting a debriefing after a domestic murder and suicide experienced this with a client in the past, then any unresolved feelings from that earlier trauma might be reactivated. One of the paradoxes of 9/11 is that no one was immune from the trauma of the event, including the debriefing facilitators.

Conceptualizing Debriefings as Narratives

CISD is in essence the creation of individual and group narratives to understand, experience, explain, reconstruct, and transform traumatic incidents. Much has been written about the use of narratives (p.536) for healing purposes (Chambon, 1994; Laird, 1993; Riessman, 1993; White & Epston, 1990). Narrative theory encourages clinicians to pay attention to the structure of narratives and the metaphors that are used, which raises important questions when viewing debriefings as a narrative intervention and applying the principles of CBCP. Are the structures and sequences of debriefing narrative construction the most helpful? For example, do individual narratives find adequate expression and validation within the context of group debriefing frameworks? Are the metaphors employed in the psychoeducational sections of debriefings ones that foster empowerment and resiliency, or do they reflect a medical model or pathology-oriented vision of crisis and trauma (Stuhlmiller & Dunning, 2000)? Do the normalization and self-care responses, presented as psychoeducational guidelines in most debriefing models, permit enough space for the diversity and complexity of individual narratives of responses to trauma?

Exploring these questions and utilizing the lens of narrative theory may lead to critical assessments and revisions of the debriefing narrative process. A narrative conceptualization lends itself to continuing the healing and restorying well after the formal debriefing process. An example would be to suggest follow-up activities, such as directed journaling, which evolve from debriefings and continue the work of self-growth and healing. This raises the question of what would happen to the homework. Would there be a follow-up session (or sessions) to compare responses, or would the group be encouraged to share their reactions in self-led follow-up sessions? Or would journaling be viewed as a personal and individual process of healing? I do not have answers to these questions; rather, I suggest them for consideration as part of enhancing the efficacy of the debriefing process.

Group Process Considerations

Many community-based clinical practitioners are trained in group work and recognize the importance of careful attention to group process. In this section I will consider the tensions between the individual and group in debriefings, examine group structure, sequence, and timing, and explore the balance between a structured versus spontaneous group process.

Balancing the Needs of Individuals and Groups

The balance between individuals and groups is one that all group workers grapple with. Individuals seek both inclusion and differentiation (Brewer, 2001). The balance between the unique experiences and needs of individuals and the collective good of a group is implicit in debriefings and is built into most debriefing models. Debriefings involve the goal of helping and supporting individuals experiencing reactions to critical incidents, but debriefings also can have organizational goals, such as helping a group of workers regain their capacity to carry out their work responsibilities. Although these goals may correspond, at times they diverge, and clinicians should be mindful of potential conflicts of purpose. Confidentiality, although a stated rule for all debriefings, is also a contingent notion. When a work group is debriefed, there may be concerns about manifesting weakness or acknowledging that one is dealing with trauma by drinking excessively.

In an effort to respond to these tensions, there are often “support” facilitators who focus on individuals who may be particularly triggered or experiencing post–traumatic stress disorder (PTSD) and who assist with referrals for therapy and counseling, while “lead” and “assist” facilitators concentrate more on the group process (Miller, 2000). However, scanning for individual distress relies on picking up overt, observable cues. Allowing participants to self-identify unresolved issues or pressing needs, perhaps through offering exit interviews or having counselors available immediately after de-briefings, would help individuals whose needs were not met by a group debriefing. Community-based clinicians are cognizant of the importance of easy access, removal of roadblocks, and follow-up when people are seeking mental health services and could help debriefing facilitators and organizations strengthen this aspect of their intervention model.

Conflicts and splits within groups can affect feelings of safety and security by individual group members. If such fissures occur during debriefings, then models of conflict resolution and options for breaking into subgroups might enhance the debriefing process. Community-based clinicians know that one size does not fit all and that some occasions require creativity and flexibility.

(p.537) Consideration of Structure, Sequence, and Timing

Historically, debriefings have primarily been single events and conducted with groups. Debriefings are now seen as one aspect of a continuum of crisis intervention services ranging from predisaster preparations to follow-up activities, including referrals for clinical services (Everly & Mitchell, 2000). The structure and sequence of debriefings has been remarkably similar for most debriefing models (see Table 33-1), and yet it would be surprising if one model fit all groups at all times for all types of critical incidents. Are the current structure and sequence of debriefing the most effective for all groups at all times, or can different modules be developed that expand certain sections of the process and de-emphasize or eliminate others? Should the sequence always remain the same? When should debriefings optimally be offered?

Is there any reason that a group should be exposed to only one debriefing? Could debriefings take place at different intervals with different areas of emphasis? Why not have multiple debriefings that build on one another? Initial debriefings could focus on the crisis nature of the critical incident and follow the traditional debriefing structure. But subsequent debriefings might focus more on medium-and long-term effects of the critical incident, as well as evaluate the effectiveness of earlier interventions, leading to new support networks and coping strategies. Social workers in agencies with ongoing access to consumers could develop and evaluate a more sequential, developmental model of debriefings. Follow-up debriefings could be scheduled in advance or offered on an as-needed basis.

Fine-Tuning the Balance Between Formula and Spontaneity

Models of debriefings have for the most part followed a fairly scripted and formulaic structure (see figure 33-1), although Dyregrov (2000) has advocated for achieving a balance between following a predetermined format and spontaneity. Because paraprofessionals and peers are used in so many debriefing programs, and also in an effort to ensure the greatest benefit and the least amount of harm, there has been a tendency to present debriefings in a tightly structured, nearly invariant fashion (Miller, 2000). Although consistency is important, rigidity can limit effectiveness. There is a difficult balance to achieve between consistency and predictability with flexibility and creativity. Debriefings work well when there is a format and structure, but any group process that is responding to disaster and emotional distress must remain fresh and vital.

Ensuring Equal Access and Equitable Treatment

Another question deserving attention is who receives debriefings and who does not? Social exclusion and such forces as racism, sexism, homophobia, and many other forms of oppression isolate populations within communities. Differential opportunity structures limit access by some to employment, neighborhoods, health care, resources, and services. What barriers exist for marginalized populations who have experienced critical incidents to receiving debriefings, and how can they be overcome? For example, employees of large corporations located in the World Trade Center were more likely to receive CISM services than those working for small firms (Miller, 2002a, 2002b). Within the structure of debriefings themselves, what dynamics of power, privilege, and oppression are manifested, and how can they be confronted?

CBCP appreciates the power of societal inequities, differential privilege and access to services and resources, and institutionalized societal oppression. Such structural inequities do not disappear when disaster strikes. There has been surprisingly little written about this issue in the debriefing literature. Who receives debriefings, and who does not? Which facilitators and organizations offer de-briefings? Are there cultural biases built into debriefing models? Are social inequities and/or inter-group conflicts enacted in the actual debriefings? It is important to examine how durable relationships of power and powerlessness affect people, families, and communities before, during, and after a crisis.

Do Debriefings Help?

There has been disagreement and controversy over the effectiveness of debriefings. The research evidence thus far is inconclusive, incomplete, and at (p.538) times flawed (Bisson, McFarlane, & Rose, 2000; Deahl, 2000; Everly & Mitchell, 2000; Miller, 2003; Raphael, 2000; Raphael, Meldrum, & McFarlane, 1995). Researchers and practitioners have differed over what to study, how to conduct the research, and the meaning of results, all of which reflect theoretical differences over how to conduct meaningful research, disagreement over what de-briefings can realistically accomplish, and competition and turf wars. Deahl (2000) describes this as both a political and a professional issue:

The effectiveness of acute interventions to prevent PTSD or other long-term psychological sequelae has become increasingly politicized and more than a matter of science. The interpretation of a number of recent randomized controlled trials (RCTs) is keenly contested. Many workers in the field of psychological trauma clearly have powerful vested interests in promoting the efficacy of interventions, such as PD [psychological debriefing], that often they themselves have developed. (p. 931)

One issue of contention is whether research should focus on the ability of debriefings to prevent future occurrences of PTSD or whether a different evaluative measure, such as reducing stress or helping people to make meaning from a crisis, should be used (Deahl, 2000). In part this stems from the overuse of the term PTSD, when often people are suffering from acute stress disorder, chronic stress, secondary trauma that does not reach the level of PTSD, or nonspecific stress disorders (Miller, 2002b; Perrin-Klingler, 2000). Everly and Mitchell (2000) and Deahl (2000) caution against using inoculation against future PTSD as the standard for evaluation. Another area of disagreement is whether randomized controlled trials are the “gold standard” for evaluating debriefings (Bisson et al. 2000; Raphael et al., 1995) or whether there are other ways to study debriefings, such as observational or case studies (Deahl, 2000).

A range of methodological problems have occurred in efforts to evaluate the effectiveness of de-briefings: (1) different types of critical incidents (ranging from sexual assault to traffic accidents) have been compared; (2) there has been no standardized agreement about what constitutes a debriefing; (3) debriefings being researched were offered at different time intervals after a critical incident; (4) different recipient groups (emergency responders, soldiers, gravediggers, motorists, etc.) were compared; (5) there has been a lack of standard evaluative instruments and research methodologies; and (6) many evaluations have lacked randomly assigned control groups (Armstrong et al., 1998; Bisson et al., 2000; Chemtob, Tomas, Law, & Cremniter, 1997; Deahl, 2000; Everly & Mitchell, 2000; Raphael et al., 1995; Raphael, 2000). Studies have also neglected to adequately consider other variables, such as aspects of strength and resiliency, which are often independent of the debriefing although possibly more significant for future mental health (Gist & Woodall, 2000). People have differential responses to critical incidents depending on the nature of the catastrophe, their proximity and relationship to the disaster, history, strengths, and vulnerabilities, interpersonal and community supports, and the meaning they make of the event (Miller, 2002b), all of which make it difficult to measure the “success” of a debriefing. There have also been ethical concerns about forming control groups that do not receive treatment after a critical incident if there is a possibility that debriefings help (Deahl, 2000). Despite these inconsistencies, there does seem to be agreement by those who have reviewed the literature on two key points: (1) there is no conclusive evidence that de-briefings help prevent future PTSD for those exposed to severe critical incidents, and (2) many of those who receive debriefings report finding that they are helpful (Bisson et al., 2000; Carlier & Gersons, 2000; Chemtob et al., 1997; Deahl, 2000; Everly & Mitchell, 2000; Miller, 2003; Raphael, 2000).

The controversy over the efficacy of debriefings is not unlike that surrounding the utility of other forms of psychotherapy. Both those who provide and those who receive debriefings report finding them to be helpful, but it has been less easy to conduct research clearly demonstrating that debriefings lead to measurable positive outcomes.

Suggestions for Future Research and Dissemination

Most research conducted about debriefings has been evaluative, outcome oriented, focusing on consumer satisfaction, job performance, and reduction of traumatic symptoms (Armstrong et al., 1998; Bisson et al., 2000; Chemtob et al., 1997; (p.539) Deahl, 2000; Everly & Mitchell, 2000; Raphael et al., 1995; Raphael, 2000; Walker, 1990). This approach is valuable and should continue. Community-based clinical practitioners can contribute to this research and design and implement experimental studies that utilize randomized control groups, which for some will always remain the “gold standard.” However, a number of qualitative research methodologies would also be applicable to debriefings and consistent with the principles of CBCP: phenomenological (Seidman, 1991), narrative (Riessman, 1993), and action (Urehara et al., 1996).

It is not only the outcome of debriefings that should be evaluated but also the process itself. De-briefings are acts of constructing and reconstructing a group narrative of tragedy and disaster, so how this occurs and why these are important topics for research in addition to evaluating debriefing outcomes. How do participants experience debriefings, and what is it about the process that they find helpful? This has implications both for the method and for how to improve outcomes. Phenomenological research seeks to understand the experience and meaning of participants: What led up to the debriefing, what was their experience of the debriefing, and what meaning do they make of the debriefing (Seidman, 1991). These questions could be explored, perhaps, through post-debriefing interviews.

Narrative research relies on a textual analysis, which could result from a transcription from a debriefing. This would contribute to a better understanding of the construction of disaster narratives and the reconstruction of healing narratives. Case studies would be valuable for this enterprise (Deahl, 2000), although issues of confidentiality would need to be carefully considered.

Deahl (2000) raised the important question of the ethics of having control groups that do not receive debriefings if the intervention might be helpful. This problem is in some ways addressed by the tradition of action research, which conceptualizes research as a collaborative process that empowers people, with clear positioning of the researcher, who works toward a social goal (Reason, 1994). In this paradigm the researcher would be embedded in the group, and research would be conducted in collaboration with participants, not by an outside, “objective” researcher.

Empowerment-based practice involves less hierarchy between those who are being helped and those who do the helping, and the same should hold true for research. Community-based clinical practitioners can both conduct research and train others in how to conduct their own research. Observing, recording, tracking, coding, interviewing, analyzing, and understanding the experience and meaning of debriefings for both consumers and facilitators are all research activities that clinicians can employ during and after debriefings to better understand the process and to guide future development. They are also activities that community volunteers and disaster relief workers can be trained to do.

Conclusion

This chapter has considered debriefings from the perspective of CBCP. Clinical disaster relief work brings together citizens, volunteers, relief workers, and a myriad of professionals in the service of the community. Communities are best served when de-briefings and other disaster relief services respect the natural relationships and connections that existed before the crisis and there is an appreciation of community assets and the human capacity to heal and prosper when confronted with adversity. Community-based clinical practitioners recognize that clinical services occur in the context of communities and organizations. Critical incident stress debriefings are interventions that are founded on empowerment and resiliency and that utilize peer and lay facilitators, as well as community-based clinicians. They exist on the interstice of clinical interventions and mutual aid groups and embody the values and intentions of community-based clinical practice.

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(p.542) A patchwork, partially constructed vision may strike exactly the balance between humility and boldness that’s needed in these unpredictable times … we may proceed best, as Mary Catherine Bateson writes, “by improvisation, discovering the shape of our creation along the way, rather than pursuing a vision already defined.” So long as we stay open to new information, learning as we go, not allowing ourselves to be distracted by the search for absolute certainty, we can continue to work toward goals we can feel proud of. We can conduct what Gandhi called “experiments in truth,” or as the priest who founded the Spanish Mondragon co-ops once said, “build the road as we travel” (pp. 303–304).

—P. R. Loeb, Soul of a citizen: Living with conviction in a cynical time.