Crit­i­cal Inci­dent Stress Debrief­ing (CISD)* was orig­i­nal­ly devel­oped and deliv­ered in the 1980s in the US for emer­gency ser­vices work­ers after wit­ness­ing a num­ber of high-pro­file trau­mat­ic events involv­ing the Unit­ed States Postal Service.¹⁺²

The CISD com­po­nent was part of a com­pre­hen­sive, sys­tem­at­ic, and inte­grat­ed mul­ti-com­po­nent cri­sis inter­ven­tion, titled Crit­i­cal Inci­dent Stress Man­age­ment (CISM). These CISM pro­grams encom­pass many ele­ments, includ­ing pre-cri­sis edu­ca­tion, assess­ment, defus­ing, CISD and spe­cial­ist fol­low-up for ongo­ing psy­cho-log­i­cal sup­port if required. How­ev­er, con­tro­ver­sy arose when it was incor­rect­ly per­ceived that the CISD part of the mod­el would a) pre­vent post-trau­mat­ic stress dis­or­der (PTSD), and b) be deliv­ered as a stand-alone process.

Since around 1989, the terms Psy­cho­log­i­cal Debrief­ing (PD) and CISD have become inter­change­able, and rep­re­sent one part of a struc­tured, sev­en-step form of group cri­sis inter­ven­tion that usu­al­ly occurs with­in the first 24 to 72 hours after the inci­dent. It would gen­er­al­ly be deliv­ered to a group of peo­ple who have expe­ri­enced the same trau­ma, and it has very spe­cif­ic require­ments for the group make­up of this structure,³ which are often not achiev­able in a rur­al or remote con­text (e.g. homo­gene­ity of the group, mem­bers hav­ing approx­i­mate­ly the same amount of expo­sure to the trauma).

Nei­ther PD nor CISD were ever intend­ed to be a stand-alone psy­cho­log­i­cal treat­ment nor a form of coun­selling or psychotherapy.¹

Despite CISD being per­ceived as impor­tant after a trau­mat­ic event, there is evi­dence to sug­gest that it is not help­ful and does not improve recov­ery from expo­sure to a crit­i­cal inci­dent. A meta-analy­sis of sin­gle-ses­sion debrief­ing after a psy­cho­log­i­cal trau­ma found that those who received CISD did not have relief from PTSD symp­toms, whilst those who had non-CISD inter­ven­tions or no inter­ven­tion had improved PTSD symptoms.⁴

Anoth­er study on CISD with first respon­ders also found that there was no evi­dence that CISD was effec­tive in the pre­ven­tion of PTSD.⁵

In fact, the World Health Organ­i­sa­tion rec­om­mends that:

“Psy­cho­log­i­cal debrief­ing should not be used for peo­ple exposed recent­ly to a trau­mat­ic event as an inter­ven­tion to reduce the risk of post- trau­mat­ic stress, anx­i­ety or depres­sive symptoms.“⁶

Although con­tin­ued research is need­ed in this area, the results of these stud­ies and oth­ers sug­gest that reac­tions to trau­mat­ic events are nor­mal reac­tions to abnor­mal events, and that if a per­son has good men­tal health lit­er­a­cy around this, stays con­nect­ed to oth­ers, has a sup­port­ive work­place, and has a self-care régime, the major­i­ty of peo­ple will recov­er naturally.⁷

Let’s look at two hypo­thet­i­cal sce­nar­ios of work­place psy­cho­log­i­cal sup­port respons­es to crit­i­cal inci­dents. Both Geoff and Jack­ie are RANs and work in dif­fer­ent remote communities.

Sce­nario one:

Geoff respond­ed to and assist­ed with a vehi­cle rollover near the com­mu­ni­ty where he works, involv­ing a well-loved com­mu­ni­ty mem­ber and their grand­child. The child sus­tained seri­ous injuries and had to be medevac’d out. Unfor­tu­nate­ly, the well-loved com­mu­ni­ty mem­ber died at the scene.

The inci­dent deeply affect­ed all staff mem­bers at the clin­ic, and man­age­ment want­ed to help them. They organ­ised a CISD for all mem­bers of staff via their EAP; atten­dance was com­pul­so­ry. Two days after the inci­dent, an exter­nal con­sul­tant was flown in to con­duct the CISD. Geoff did not wish to attend as he was still try­ing to process what had occurred, along with all the dif­fer­ent emo­tions he was expe­ri­enc­ing. He wasn’t ready to share yet.

Dur­ing the CISD, some mem­bers were ready to share and talked about obser­va­tions and feel­ings that Geoff found con­fronting. This fur­ther con­fused him; he no longer felt safe to talk about what he was going through and was ques­tion­ing if his feel­ings were ​‘nor­mal’. Geoff with­drew into him­self, no longer talked to his col­leagues about any­thing oth­er than his day-to-day work, nor did he socialise with them. He felt com­plete­ly alone and was ques­tion­ing his san­i­ty and if he was wrong for feel­ing how he did.

Geoff’s symp­toms, such as hyper­vig­i­lance, poor sleep (includ­ing night­mares), lack of appetite, poor con­cen­tra­tion, and avoid­ing the place where the acci­dent occurred, con­tin­ued for weeks. His work­place had noticed these changes but told him the best thing to do would be to ​‘get back on the horse’ and get stuck into work. His col­leagues were unsure of what to say, so they said noth­ing. Geoff felt com­plete­ly iso­lat­ed; how­ev­er, he believed he had to be sto­ic and keep going whilst con­tin­u­ing to feel like this.

Three months lat­er, Geoff expe­ri­ences a minor frus­tra­tion at work and breaks down. Man­age­ment ter­mi­nates his con­tract, and he is required to leave the com­mu­ni­ty to seek new employment.

Sce­nario two: 

Jack­ie had a patient present to the clin­ic with severe head injuries and bleed­ing. The patient’s part­ner, who had inflict­ed the injuries, attempt­ed to fol­low them in. Staff were able to lock the door and all oth­er exits; how­ev­er, the part­ner banged on doors and win­dows, yelling to be allowed inside. The police were called. How­ev­er, they were attend­ing anoth­er inci­dent in a com­mu­ni­ty one hour away. They stat­ed they would attend as soon as pos­si­ble. How­ev­er, it would still prob­a­bly be an hour and a half or more before they could attend. Jack­ie tried her best to assess the patient amongst the con­tin­u­ing noise the part­ner was mak­ing out­side, and it was decid­ed the patient need­ed to be medevac’d out. Through­out, the part­ner con­tin­ued to bash on the clin­ic door and win­dows, throw­ing rocks at the build­ing and win­dows, yelling, and attempt­ing to gain access through win­dows and doors. Staff and the patient all feared for their lives should they gain access. The police arrived around two hours lat­er, arrest­ed the part­ner, and the patient was able to board the plane.

Once all staff were back at the clin­ic and safe, the team leader acknowl­edged what had hap­pened and assured every­one that what­ev­er they were expe­ri­enc­ing were nor­mal reac­tions to an abnor­mal event. The team leader then advised every­one they were free to speak with them or each oth­er should they wish to debrief, but if they didn’t want to talk about it, that was ok too. Jack­ie pulled them aside and asked if she could have an hour to go some­where qui­et and process what had hap­pened. Her team leader sug­gest­ed she go back to her accom­mo­da­tion and come back when she was ready. The team leader also advised that they would ring in an hour and check in on Jack­ie, which they did.

Over the next few days, the team leader checked in with each staff mem­ber to see how they were going and asked how they could sup­port them. Jack­ie stat­ed she need­ed a day off, as she hadn’t been sleep­ing well, and they dis­cussed dif­fer­ent self-care options Jack­ie could try. She tried some mind­ful­ness strate­gies, talked to friends back home on the phone, and caught up on lost sleep.

In the fol­low­ing weeks, Jack­ie felt strong enough to talk to oth­ers about the shared expe­ri­ence and was able to feel safe, heard and sup­port­ed in her work­place. Her symp­toms nat­u­ral­ly resolved, and after a few weeks, she noticed that she was func­tion­ing as usu­al before the incident.

After a crit­i­cal inci­dent, staff want to feel sup­port­ed and know that man­age­ment and the organ­i­sa­tion care about them. Peo­ple react dif­fer­ent­ly and indi­vid­u­al­ly to trau­mat­ic inci­dents, and these dif­fer­ences need to be respect­ed and respond­ed to with com­pas­sion. Don’t push some­one into a group debrief­ing if they don’t want to. Instead, pro­mote the avail­abil­i­ty of oth­er sup­ports and resources, such as the CRANAplus Bush Sup­port Line, Employ­ee Assis­tance Pro­grams, or their GP.

Around four weeks after the inci­dent, when peo­ple have had a chance to process the event, a reflec­tive prac­tice ses­sion for the team may pro­vide an oppor­tu­ni­ty to share insights and learn­ings, and pro­vide an emo­tion­al­ly sup­port­ive ele­ment. This must be done with everyone’s agree­ment, includ­ing those who wish to be excused. If peo­ple agree with this option, make sure you fol­low through.

The CRANAplus Men­tal Health and Well­be­ing team has devel­oped a suite of resources to sup­port indi­vid­u­als and work­places after trau­mat­ic events. There are tip sheets, a book­let, and an online learn­ing mod­ule avail­able on our web­site. Indi­vid­u­als are also encour­aged to con­tact one of our psy­chol­o­gists on the CRANAplus Bush Sup­port Line at 1800 805 391, where they can be sup­port­ed in a con­fi­den­tial, 1:1 envi­ron­ment at any time after the event, if they feel this may ben­e­fit their recovery.

At the end of the day, nur­ture a work­place cul­ture that is com­pas­sion­ate, respon­sive and sup­port­ive of each other’s men­tal health, even before a trau­mat­ic inci­dent occurs. It’s impor­tant to remem­ber that what a per­son expe­ri­enced after a trau­mat­ic event is not per­ma­nent, and recov­ery is like­ly with the prop­er support.

Be your authen­tic self when hav­ing any con­ver­sa­tions, and advo­cate for the needs of your team where possible.

We’re all in this together.

* CISD is relat­ed to psy­cho­log­i­cal trau­ma recov­ery and does not relate to clin­i­cal debrief­ing, which are those med­ical learn­ing con­ver­sa­tions that are used to review events to improve patient care, process­es and team­work that occur soon after a clin­i­cal event.

Ref­er­ences

1. Regel, S. (2007). Post-trau­ma sup­port in the work­place: the cur­rent sta­tus and prac­tice of crit­i­cal inci­dent stress man­age­ment (CISM) and psy­cho­log­i­cal debrief­ing (PD) with­in organ­i­sa­tions in the UK. Occu­pa­tion­al Med­i­cine, 57(6), p411-416

2. Davis, J.A. (2013). Crit­i­cal Inci­dent Stress Debrief­ing. Accessed 14 May 2024 at https://​www​.psy​chol​o​gy​to​day​.co…

3. Peter­son, T.J (2024). Crit­i­cal Inci­dent Stress Debrief­ing: How it works and what to expect. Choos­ing Ther­a­py. Accessed 14 May 2024 at https://​www​.choos​ingther​a​py​.co…

4. Van Emmerik, A.P., Kam­phuis, J.H., Hul­bosch, A. M. * Emmelkamp, P.M. (2002). Sin­gle ses­sion debrief­ing after psy­cho­log­i­cal trau­ma: a meta analy­sis. The Lancet, Vol 360 (9335).

5. Tuck­ey, M.R. & Scott, J.E. (2013). Group Crit­i­cal Inci­dent Stress Debrief­ing with emer­gency ser­vices per­son­nel: A ran­dom­ized con­trolled tri­al. Orig­i­nal man­u­script accept­ed 09 May 2013 for pub­li­ca­tion in Anx­i­ety, Stress, & Cop­ing.

6. World Health Organ­i­sa­tion (2012). Psy­cho­log­i­cal debrief­ing in peo­ple exposed to a recent trau­mat­ic event. Accessed 14 May 2024 at https://​www​.who​.int/​t​e​a​m​s​/ment…

7. Phoenix Aus­tralia. Your recov­ery: Help­ing your­self. Accessed 14 May 2024 at https://www.phoenixaustralia.o…