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Journal of Mental Health (2001) 10, 3, 351362

A field study of critical incident stress debriefing versus


critical incident stress management

DAVID RICHARDS

School of Nursing Midwifery and Health Visiting, University of Manchester, Manchester,


UK

Abstract
This prospective field trial compared two post-trauma support systems following armed robberies
Critical Incident Stress Debriefing (CISD) as a stand alone group intervention and integrated Critical
Incident Stress Management (CISM) delivered to two groups of raided employees. Morbidity was
measured using two measures of post-traumatic stress and a general health measure. Morbidity in both
groups was equivalent at day 3 and one month post-raid. The CISM group had significantly less post-
trauma morbidity at follow-up (312 months post raid) compared to CISD alone supplying evidence
for the superior efficacy of postdisaster interventions when these are delivered in an integrated CISM
format. Calls to cease debriefing are premature and integrated CISM systems should now be the
subject of randomised controlled studies.

Introduction (OBrian & Hughes, 1991) to 30.6% (Kulka,


et al., 1990); in survivors of natural disasters,
The effect of traumatic events on psycho- 28% in flood victims (Green et al., 1990) to
logical wellbeing is well established. Epide- 59% of tornado survivors (Madakasira &
miological studies have suggested that the OBrien, 1987) and after terrorist attacks,
prevalence of Post-Traumatic Stress Disor- where 50% of survivors had PTSD 6 months
der (PTSD) in the general population is be- after the event (Curran et al., 1990).
tween 1% and 3% (Davidson et al., 1991; Crime victims are also vulnerable, with the
Helzer et al., 1987). Disaster survivor studies prevalence of post crime PTSD estimated as
estimate that 22% to 50% of victims suffer 5.5% for American men and 11.5% for women
from PTSD (Curran et al., 1990; Raphael, (Norris, 1992). Sexual crime consistently
1986). In one study 46% of motor vehicle produces high psychological morbidity of up
accident victims suffered from PTSD plus a to 47% PTSD in those assaulted (Rothbaum
further 20% with sub-syndro mal PTSD et al., 1992). In a study of 4,008 American
(Blanchard et al., 1995). Other studies have women (Resnick et al., 1993), 69% had expe-
shown high levels of PTSD after traumatic rienced at least one traumatic event during
events, for example: in war veterans, 22% their lives and of these 17.9% met lifetime
Address for Correspondence: Dr David Richards, Senior Lecturer, School of Nursing Midwifery and Health
Visiting, University of Manchester, Coupland III, Oxford Road, Manchester M13 9PL, UK. Tel: 0161 275 7589;
Fax: 0161 275 7566; E-mail: David.A.Richards@man.ac.uk

ISSN 0963-8237print/ISSN 1360-0567online/2001/030351-12 Shadowfax Publishing and Taylor & Francis Ltd
DOI: 10.1080/09638230020023868
352 David Richards

and 6.7% met current PTSD criteria, giving a traumatic experiences in a group setting. It
total population PTSD prevalence of 12.3% attempts to accelerate recovery before harm-
lifetime and 4.6% current. European studies ful stress reactions have a chance to damage
of crime victims on this scale are absent but the performance, careers, health and families
smaller scale studies tend to concur with of victims (Busutill & Busutill, 1997). It is
those from the US. For example, Fisher & recommended that CISD be incorporated into
Jacoby (1992) found that 23% of bus crews an integrated system of pre-incident training,
subject to violent assault developed PTSD initial post-incident defusing, group debrief-
compared to no cases in a control group of ing and further counselling, referred to by
non-assaulted crews. Brewin et al. (1998) Mitchell & Everley (1997) as Critical Inci-
found that 20% of crime victims met criteria dent Stress Management (CISM).
for PTSD 6 months after their trauma. Unfortunately, the evidence base is gener-
The last 15 years have seen significant ally characterised by a lack of robust control-
advances in the development of treatments led evidence for the efficacy of early inter-
for PTSD. Major controlled studies have ventions in traumatic stress CISD or CISM.
demonstrated the efficacy of a range of treat- The efficacy of CISD in particular is a matter
ments, particularly those based on cognitive of debate. Recently, several randomised con-
behavioural approaches (Foa et al., 1991; trolled trials have demonstrated that, when
Keane et al., 1989; Marks et al., 1998). The CISD was carried out with individual trauma
main techniques studied have been (a) pro- victims rather than in groups it produced
longed exposure, where the patients re-expe- either no improvement compared to controls
rience their traumatic memories until habitu- (Brewin et al., 1998; Hobbs & Adshead,
ation and emotional processing are complete; 1996) or, had the potential to cause signifi-
(b) stress inoculation training, where patients cant harm to those debriefed (Bisson et al.,
are instructed in symptom management tech- 1997). These studies have led to claims that
niques; and (c) cognitive restructuring, where CISD is an ineffective crisis intervention
patients are helped to consider alternative technique which should be discontinue d
interpretations of the incident itself, the world (Avery & Orner, 1998; Wessley et al., 1998).
and their own self image. Mitchell and others (Mitchell & Everley,
Early intervention or crisis intervention 1997) have criticised these studies on the
services (Raphael, 1986) have been devel- grounds that they sacrifice internal validity
oped with the explicit aim of reducing the for experimental control, participants are self-
initial psychological impact of trauma and to selected, CISD timing is outside that recom-
prevent the development of long-term mor- mended and debriefers appear inadequately
bidity. A common organisational response to trained.
traumatic stress has been the development of However, there are also methodologica l
Critical Incident Stress services including, as objections to those studies which purport to
a major component, Critical Incident Stress show CISD delivered in a CISM framework
Debriefing (CISD) based on Mitchells work in a positive light (e.g. Bohl, 1991; Chemtob
(Mitchell, 1983) with emergency service per- et al., 1997; Robinson & Mitchell, 1993)
sonnel. CISD is defined as a meeting of those including participant self-selection, variable
involved in a traumatic event which aims to intervention timings and a lack of control
diminish the impact of the event by promot- comparison groups. Essentially, the debate
ing support and encouraging processing of hinges on the degree to which trade-offs
Field trial of CISM v. CISD 353

between experimental purity and realistic Sample


field trial methodologies are acceptable and
Intervention 1: CISD alone, 225 people;
valid and which research approaches pro-
intervention 2: integrated CISM, 299 people.
duce the most reliable, generalisable find-
There were no differences between the groups
ings. As noted by Chemtob et al. (1997),
on age, gender or employee grade. The mean
despite the desirability of randomised con- age per group was 31.40 years (SD 8.33) for
trolled trials, post-event environments re- CISD alone v. 32.50 years (SD 9.60) for
quire special sensitivity which may preclude CISM. The sample was overwhelmingly
randomly withholding treatment from a con- female (91.80% v. 88.00%) with 80.5% in
trol group. lower paid clerical grades (82.3% v. 79.1%)
Despite the debate, there are no published and less than 20% overall in supervisory or
studies where the single-shot CISD used by management grades (17.7% v. 20.9%). The
the negative effect studies is compared di- raid experiences were remarkably similar.
rectly with an integrated CISM system cited While all the employees had been directly
by the positive effect studies. This paper confronted by the raider or raiders, no fire-
reports the results of a field trial of CISD arms had been discharged, there were no
delivered as a stand alone intervention com- physical injuries and none of the incidents
pared to an integrated CISM system with involved hostage taking.
victims of armed robbery.
Interventions
Method
Intervention 1: CISD alone
A prospective field trial of CISD alone This was a structured group meeting of all
compared to CISD integrated within a CISM employees working in a raided branch and
system was conducted with victims of armed closely followed the Mitchell model of de-
robberies working in a major financial serv- briefing a seven stage process where par-
ices company in the UK. Concerned by ticipants are encouraged to talk about the
increasing levels of crime in the early 1990s incidents facts, their thoughts, their emo-
the company had rapidly introduced a single tions and stress reactions, followed by symp-
intervention CISD response, which operated tom education and re-entry or session clo-
for 16 months before a more comprehensive sure. CISD took place in the branch environ-
CISM system could be developed. Thereaf- ment a mean of three days after the robbery,
ter, a CISM system of pre-raid training, CISD was conducted by DR or one other trained
and additional individual repeat assessment debriefer and lasted 1.5 2 hours.
and advice sessions one month post-raid was Intervention 2: CISM
introduced. This developmental change in CISM was an integrated programme of (a)
service delivery, therefore, afforded an op- pre-trauma training, (b) CISD and (c) indi-
portunity for a pragmatic, field trial where the vidual follow-up.
constraints of providing a routine service to a (a) All employees working in customer fac-
sensitive post-event environment allowed ing environments were given a pre-raid
neither randomisation nor a no-treatment training programme based on stress in-
control condition to be introduced. However, oculation training (SIT) principles
routine outcome measures and protocol based (Meichembaum, 1985). Staff were trained
interventions facilitated comparative outcome in groups, facilitated by the branch man-
evaluation of the two interventions . ager, and shown videos of real and en-
354 David Richards

acted robberies together with instruction they were in no need of further assistance. In
on procedural and anxiety management the CISM condition, pre-raid training was
coping strategies. Each employee was timetabled as part of the overall training
given an individual workbook, which con- structures used to deliver other training such
tained information and exercises on cop- as financial product training. No employees
ing with robberies. The training took raided in the CISM condition had previously
place in four monthly parts with home- refused to take part in the training.
work exercises between each training ses-
sion. Measures
(b) CISD was identical to that delivered in the All raided employees completed standard
CISD alone group. health questionnaires at day 3 post-raid, im-
(c) Each raided employee received an indi- mediately before the start of the CISD. Ques-
vidual counselling session, lasting between tionnaires were also collected 1 month after
0.5 and 1 hours, 1 month after the robbery. the raid and at 3, 6 and 12 months post raid.
In this session the same debriefer assessed The Impact of Events Scale
the employees recovery and identified The impact of events scale IES (Horowitz
any ongoing difficulties. Individually tai- et al., 1979) is a 15-item scale measuring both
lored advice and guidance was given, intrusive and avoidant symptoms of post-
structured around a cognitive-behavioural / traumatic stress. Respondents were asked to
problem focused model of intervention . rate on a 0, 1, 3, 5 scale how often 15 state-
For example, employees with sleep diffi- ments such as I had waves of strong feeling
culties were advised on sleep hygiene; about it or I tried not to talk about it were
those experiencing nightmares instructed true for them. Scores above 26 are regarded
on nightmare relief; avoidant employees as indicating significant clinical psychopa-
given advice on prolonged exposure. thology (Corneil et al., 1994).
Note: All interventions were delivered as The Post-traumatic Stress Scale
part of the companys standard support pro- The post-traumatic stress scale PSS (Foa
cedure. The company had a history of pro- et al., 1993) is based on the DSM (III) R
viding employee care and counselling after diagnostic criteria for PTSD (APA, 1987). It
raids. As raids increased in frequency, em- asks respondents to score on a 0, 1, 2, 3 scale
ployees expected to be given support and how troubled they are by symptoms such as
almost no one refused to take part in either distressing dreams or avoiding activities
CISD or CISM. Employees worked in close and situations which remind you of the event.
knit teams where supporting ones colleagues The General Health Questionnaire - 28
was seen as a key element of the occupational (GHQ-28)
culture which typified the day to day working The GHQ-28 (Goldberg & Hillier, 1979) is
environment. While refusal to participate a 28 item measure of psychological distur-
was always an option, only five people de- bance consisting of four, seven-item sections
clined to take part in CISD and two people in which relate to psychosomatic symptoms,
the initial CISD element of CISM. Of the 299 anxiety symptoms, social functioning and
people in the CISM condition offered indi- depression. Scoring is 0, 0, 1, 1 for each item.
vidual counselling one month after the raid, A score of four or above is regarded as
50 declined stating that they did not feel they indicating a significant level of psychiatric
needed to be seen by the debriefer again as caseness
Field trial of CISM v. CISD 355

Results t=0.38, NS). Therefore, the following tables


present data from day three, 1 month post-
raid and a composite follow-up score where
Calculation of follow-up scores
each individua ls follow-up score was com-
Because of declining response rates to ques- puted by taking the mean score from those
tionnaires at 3, 6 and 12 months a composite they returned at one or more of the 3, 6 or 12
measure of follow-up was computed. Re- month points.
peat measures t-tests determined the point
Outcome at CISD, 1 month and follow-
where there was no significant difference
up
between measures over time. In all meas-
ures, this point was reached 3 months post- Table 1 details the mean scores, standard
raid, when scores remained stable at subse- deviations and responder numbers to all three
quent time points (IES: 3 month x 6 month, questionnaire measures at day three, 1 month
t=1.30, NS; 3 month x 12 month t=0.14, NS; and follow up points. Data is presented for
PSS: 3 month x 6 month, t=1.04, NS; 3 month the complete sample (n=524) and the smaller
x 12 month t=0.09, NS; GHQ: 3 month x 6 sample (n=217) for whom data is available
month, t=0.95, NS; 3 month x 12 month from all three time points.

Table 1: Outcome measures post raid for both intervention groups at day 3, 1 month and follow-
up, total sample and sample of respondents who returned data at all three time points.

Measure Subscale Total sample Sample with complete data set


CISD alone CISM CISD alone CISM
Day 3 Immediately post-raid
n=225 n=299 n=75 n=142
IES Intrusion 17.44 (9.17) 18.25 (9.05) 18.79 (8.29) 18.60 (8.89)
Avoidance 14.17 (9.14) 15.26 (9.66) 14.16 (8.59) 15.46 (9.58)
Total 31.61 (16.45) 33.52 (16.52) 32.95 (15.10) 34.06 (16.34)
PSS 13.87 (9.57) 15.38 (10.71) 14.39 (8.35) 15.52 (10.85)
GHQ 7.33 (6.53) 7.92 (6.57) 8.24 (6.14) 7.71 (6.59)
1 month post raid
n=114 n=249 n=75 n=142
IES Intrusion 4.77 (6.52) 6.05 (7.00) 4.48 (6.44) 5.31 (6.22)
Avoidance 3.68 (6.66) 5.08 (7.72) 3.60 (6.25) 4.17 (6.55)
Total 8.46 (12.00) 11.13 (13.83) 8.08 (11.43) 9.48 (11.72)
PSS 4.40 (6.11) 5.42 (7.00) 4.63 (6.17) 4.85 (6.00)
GHQ 1.86 (4.00) 2.07 (4.36) 1.99 (4.19) 1.68 (3.88)
Follow-up
n=106 n=152 n=75 n=142
IES Intrusion 5.02 (6.81) 2.50 (4.55) 4.04 (6.24) 2.40 (4.22)
Avoidance 3.90 (6.79) 2.67 (5.66) 3.08 (5.60) 1.77 (4.57)
Total 8.92 (12.97) 4.31 (8.57) 7.12 (11.17) 4.17 (8.49)
PSS 4.40 (6.11) 2.75 (5.01) 3.85 (6.40) 2.52 (4.69)
GHQ 1.47 (3.77) 1.26 (3.14) 1.48 (3.93) 1.02 (2.73)
356 David Richards

Initial symptom severity was high with x time F=0.06, ns. On two out of the three
mean scores on both the IES and GHQ above outcome measures, therefore, the main ef-
the cut off points, which would indicate clini- fects of time and group x time demonstrate
cal concern. However, by 1 month post-raid, the superior outcomes for employees receiv-
symptoms had reduced considerably and re- ing CISM over CISD alone when initial symp-
mained low in both intervention groups at tom severity is controlled for. Furthermore,
follow up. At day three and 1 month, scores independent sample t-tests at each time point
in the CISD alone group were marginally reveal that the mean differences between the
lower than the CISM group. However, at groups were only significant at follow up
follow up the CISM group scored lower on all (IES: t=3.43 p<0.01; PSS: t=2.55, p<0.05,
measures. GHQ: t=0.49, ns) and in favour of the CISM
In the sample of employees for whom data group. This was true only for specific post-
is available at all three time points (n=217), trauma symptoms. GHQ scores were not
scores for 1 month and follow up measures significantly different between groups at any
were entered into repeat measures analyses time.
of covariance ( ANCOVA) with day three scores
entered as covariates to control for initial Clinical cases
post-robbery symptom severity, yielding the The mean symptom scores for the sample
following results. IES: group F=0.76, ns; as a whole (reported above) are well below
time F=22.43, p<0.001; group x time F=10.76, those considered clinically significant. How-
p<0.01. PSS: group F=1.68, ns; time F=20.57, ever, a proportion of employees continued to
p<0.001; group x time F=5.14, p<0.05. GHQ: experience raised levels of symptoms above
group F=0.57, ns; time F=3.89, p<0.05; group a clinical threshold. Figure 1 illustrates the

80

67.2
64.5

60
CISD alone
Percentage cases

CISM

40

20 15.7
12.3 11.3
5.3

0
Day 3 1 month Follow up

Figure 1: Percentage of employees with significant clinical symptoms on the IES


Field trial of CISM v. CISD 357

percentage of employees with significant day 3 of employees who returned 1-month or


clinical symptoms over time, as defined by a follow-up questionnaires with those who did
score of 26 or more on the IES (Corneil et al., not. Using independent samples t-tests, two
1994). At day three post raid more than two comparisons were made comparing initial
thirds of employees were in this category. scores for employees who returned measures
However, by 1 month these rates fell to at 1-month compared to those who did not
15.7% (CISM group) and 12.3% (CISD alone return measures and a similar comparison for
group). The numbers of employees with those employees who returned questionnaire s
clinically significant post-trauma symptoms at follow-up compared to those that did not.
at the follow up point reduced by two thirds In each case the dependent variable was the
to 5.3% in the CISM group but remained initial symptom score at day 3.
almost unchanged in the CISD alone group at Table 2 shows that CISD and CISM re-
11.3%. At the follow-up point there was a sponder and non-responder groups suffered
trend for this difference to approach signifi- similar levels of initial post raid morbidity.
cance (Fishers exact one tailed significanc e Of the two traumatic stress measures that
test - 0.061). show a significant advantage of CISM over
CISD at follow up, there is a tendency in the
Treatment of missing data PSS - though not the IES - for the CISD non-
Despite the size of the data set, the declin- responders to be less symptomatic than those
ing response rate at the 1-month and follow- that did return questionnaires. It is conceiv-
up assessment points is of concern. Although able, therefore, that the advantage of CISM
there were no differences between the groups over CISD may be accounted for in part by
on gender, age, employment grade or raid questionnaire responder bias in favour of
experience, the subset of employees who more symptomatic CISD responders. In con-
returned 1-month and follow-up question- trast, however, as can be seen from Table 1,
naires may be unrepresentative of the origi- the mean differences between the CISD and
nal sample because they suffered either more CISM groups at follow-up are actually less in
or less initial post-traumatic stress symp- the sample of respondents with data from all
toms. This problem was addressed as fol- three time points compared to the total sam-
lows. ple at follow up. The significant group mul-
Imputing the missing data by the usual tiplied by time ANCOVA result at follow up is,
methods such as the last value carried for- therefore, based on a conservative reading of
ward method would add no value to the the data.
analysis given that, there are too few data
points post-intervention. That is, for most Discussion
non-respondents, this would require carrying
forward the baseline score 3 days post rob- CISD v. CISM
bery to the 1- month and follow-up points. This pragmatic comparative field trial of
However, in order to test the proposition that two interventions designed to support and
the difference at follow-up between CISD ameliorate symptoms of post-traumatic stress
and CISM was due to non-responder bias, an after armed robbery demonstrates that supe-
analysis of the immediate post-raid morbid- rior outcomes may be achieved with a struc-
ity of responders and non-responders was tured CISM package of care compared to a
undertaken by comparing the mean scores on stand alone CISD intervention. The incorpo-
358 David Richards

Table 2: Comparison of initial symptom scores at day 3 for employees returning subsequent
questionnaires compared to those that failed to return questionnaires at 1 month and
follow-up

Measure Initial scores at day 3 - ns, means (SD) t -value p


n Returned n Not returned
IES 1 month CISD 111 32.32 (15.90) 114 30.91 (17.00) 0.64 0.52
Measures CISM 247 34.12 (15.93) 52 30.64 (18.97) 1.24 0.22
Follow-up CISD 101 33.45 (15.26) 124 30.11 (17.27) 1.54 0.13
Measures CISM 152 33.78 (16.26) 147 33.24 (16.82) 0.29 0.78

PSS 1 month CISD 111 13.83 (8.67) 113 13.90 (10.41) 0.06 0.95
Measures CISM 247 15.53 (10.50) 52 14.64 (11.73) 0.55 0.58
Follow-up CISD 101 15.14 (9.44) 123 12.82 (9.58) 1.81 0.07
Measures CISM 152 15.45 (10.68) 147 15.31 (10.77) 0.11 0.91

GHQ 1 month CISD 111 7.50 (6.32) 114 7.18 (6.76) 0.37 0.71
Measures CISM 247 7.96 (6.48) 52 7.75 (7.07) 0.21 0.84
Follow-up CISD 101 8.25 (6.48) 124 6.59 (6.50) 1.91 0.06
measures CISM 152 7.65 (6.46) 147 8.21 (6.70) 0.74 0.46

ration of the initial CISD alone procedure Brewin et al. (1998) also suggested that inter-
into an integrated CISM system of pre-raid ventions of 48 hours in length might be
training and a short, focused mental health delivered to the 20% of trauma victims who
advice session one month after a raid to are in danger of developing chronic PTSD.
robbery victims produced significantly im- The results from the current study indicate
proved recovery rates in terms of mean symp- that in the context of an integrated CISM
tomatology. There was also a trend to signifi- system, significant improvement may be
cance for clinical caseness. Employees in the gained with even smaller investments of thera-
CISM group were less traumatised at later pist time and that these can indeed be achieved
follow-up and the proportion of clinically by intervening 1 month after a trauma.
significant cases was less than half the number
in the CISD alone group. Limitations
The timing of the extra individual session The results of this study are limited by its
in CISM deserves comment. A number of non-randomised field trial methodology. A
studies have suggested that at 1-month post more robust trial would have involved ran-
trauma it is possible to identify victims who dom allocation to the two groups with a no
will go on to develop chronic disorders and intervention control. This trade-off between
therefore, it is at this time that one should experimental rigour and pragmatic investi-
offer effective interventions. Rothbaum et gation is familiar to those working in post-
al. (1992) found that 1 month after a rape event situations where the nature of the serv-
trauma it was possible to distinguish between ice delivery contract and employees expec-
women who would recover and those who tations for post-incident care render no-treat-
were likely to develop chronic PTSD, a feat ment controls unethical and impractical
impossible closer to the time of the trauma. (Chemtob et al., 1997). Indeed, given that the
Field trial of CISM v. CISD 359

two interventions being compared were de- Efficacy of CISD alone


livered during consecutive periods of opera-
The specific impact of CISD as a stand
tion of the Societys trauma support service,
alone intervention is difficult to determine
other differences over time may have been
from this study. The levels of spontaneous
responsible for the results reported. While recovery are impossible to assess directly, as
this is impossible to rule out it is, however, the current study did not include a control
somewhat unlikely as the two groups were group. However, levels of long-term mor-
very similar in demographic profile and sta- bidity are considerably lower than expected
tistically indistinguishable in their symptom from other recent studies of crime victims.
profiles at the initial CISD point. Further- Such normative data allows benchmark com-
more, the author knows of no significant parisons to be drawn. For example, Brewins
organisational or other factors existing dur- recent study (Brewin et al., 1998) showed
ing the time when CISM was being delivered that crime victims debriefed individually had
compared to the CISD alone period which mean scores which were twice as high on the
may have accounted for the observed differ- IES 6 months post-event compared to the
ence in effect. follow up morbidity levels in this study, even
A further caution is that this study does not in the CISD alone group. Furthermore, fol-
purport to investigate the individual impact low up caseness in Brewins study was also
of the interventions included in CISM pre- double that of the CISD alone group in this
raid stress inoculation training (SIT), CISD study. This suggests that group CISD alone
and individual follow-up counselling. These may indeed have reduced morbidity below
were developed from the authors extensive that expected following traumatic criminal
experience in the cognitive behavioural treat- events with even greater improvements from
ment of PTSD and anxiety disorders (Richards the CISM intervention .
& Rose, 1991; Richards et al., 1994). It is However, caution should be exercised when
certainly possible that the effect of some of undertaking such comparisons. As suggested
these elements (in particular SIT and indi- by recent controlled studies (Bisson et al.,
vidual follow-up sessions) may have been 1997; Brewin et al., 1998; Hobbs & Adshead,
due to attention from the traumatic stress 1996) it may be that the interventions in
counselling service per se rather than as a either condition had no effect whatsoever.
result of their specific content. Several other factors may account for the low
A final limitation is the loss of data at one long-term morbidity in this study. First,
month and follow-up points. Although non- although the implied threat in an armed rob-
significant, there was a trend for the CISD bery is very severe the actual nature of the
questionnaire non-responders at follow-up to assault is predominantly psychological with
have lower morbidity immediately after the little actual physical injury. Physical injury
raid. Had these people returned follow-up has been found to be associated with greater
measures it is conceivable that the difference long-term psychological morbidity (Brewin
found between CISD and CISM may have et al., 1998; Resnick et al., 1993) so the lack
been less marked. However, in contrast, the of physical injury in raids may lead to low
significant ANCOVA result was found in the long-term morbidity in this specific popula-
more conservative follow-up results obtained tion. Secondly, Building Society branches
from the smaller sample of respondents who are small, close knit workplaces where em-
returned data at all three time points. ployees work regularly together with a small
360 David Richards

number of other people, supporting each other tarily entering into potentially traumatic situ-
and often socialising together. Social sup- ations. Thirdly, while both Bisson et al.
port has been identified as a major protective (1997) and Brewin et al. (1998) argue against
factor post-trauma, enhancing the opportuni- the provision of immediate services for all
ties for recovery (Joseph et al., 1992, 1997). victims suggesting instead a symptom moni-
Experiencing and recovering from traumatic toring system to pick up cases at one month
incidents together with ones colleagues in a post-trauma such a strategy is unlikely to
pre-existing supportive environment may lead engage victims in therapy unless initial con-
to better outcomes. tact has been made with victims earlier.
It is certainly possible, however, that the Evidence for the last point is unexpectedly
design of CISD as implemented in this study provided in Brewin et al.s own study (Brewin
1.52 hours long, in groups and as such et al., 1998), where less than 10% of those
much closer to the model proposed by Mitchell crime victims initially approached came for-
(1983) may have had more of a therapeutic ward into the study, despite being offered an
effect than the short, individually focused intervention not normally available to the
intervention procedures used in the published general public. Given the choice, the trauma-
negative effect randomised controlled stud- tised do not readily volunteer for assistance.
ies (Bisson et al., 1997; Brewin et al., 1998; CISD might work best as part of the inte-
Hobbs & Adshead, 1996). Certainly, the grated CISM approach proposed by Mitchell
level of clinically significant cases in this (Mitchell, 1983, Mitchell & Everley, 1997)
study even at 1-month post-trauma was by allowing the therapist or counsellor to
considerably lower than that found in similar build a rapport and establish competence.
victim populations in the UK. When coupled with the positive experience
reported by the majority of those debriefed,
Is CISD an appropriate early interven- CISD (and/or the SIT pre-trauma training)
tion? may lead to enhanced compliance with sub-
Whereas many studies have concentrated sequent interventions at one month post-
on long-term psychiatric morbidity, research- trauma or later. Indeed, in this study, even
ers, policy makers and service managers when CISD alone was offered as a standard
should remember that the potential beneficial intervention, the response rate to postal moni-
effects of CISD can also be measured in toring questionnaires (51% of those origi-
many other outcome domains. First, CISD is nally debriefed) was five times that of Brewin
a highly valued people management tool in et al. (1998). The effect of CISM was to
organisations, which suffer repeatedly from increase this engagement rate to 83% when
traumatic incidents. Studies have shown that employees were offered a visit from the
it is appreciated by both the traumatised and debriefer one month post raid.
their managers (e.g. Flannery et al., 1991;
Shapiro & Kunkler, 1990; Turner et al., 1993). Conclusion
Secondly, doing nothing in response to a
traumatic event is not an option for managers Despite its necessary methodological com-
where expectations of appropriate post- promises, this study has shown that embed-
trauma care are part of the implicit bargain ding CISD within an integrated CISM sys-
between employers and employees which tem can significantly reduce the levels of
facilitates employees repeatedly and volun- long-term morbidity in crime victims com-
Field trial of CISM v. CISD 361

pared to both a stand alone CISD intervention Busuttil, W. & Busuttil, A. (1997). Debriefing and
and morbidity levels reported elsewhere. The crisis intervention. In D. Black, M. Newman, J.
Harris-Hendricks. & G. Mezey (Eds.), Psychologi-
debate on the effectiveness of CISD itself is cal Trauma: A Developmental Approach, pp. 238
unresolved but it would be unwise to heed the 249. London: Gaskill.
calls to cease CISD on the basis of studies, Chemtob, C.M., Tomas, S., Law, W. & Cremniter, D.
which apply CISD alone in an inappropriate, (1997). Postdisaster psychological intervention: A
field study of the impact of debriefing on psycho-
individualised manner. Even if CISD alone
logical distress. American Journal of Psychiatry,
is clinically ineffective, it may serve to in- 154, 415 417.
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with subsequent interventions. This study, Shapiro F. (Ed.), Eye Movement Desensitization
therefore, provides important evidence, which and Reprocessing: Level 1 Basic Workshop Manual,
p.39. Pacific Grove, EMDR Institute.
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systems. Rather than the watered down, R. & Rocke, L.G. (1990). Psychological conse-
internally invalid procedures currently being quences of the Enniskillen bombing. British Jour-
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Davidson, J.R.T., Hughes, D., Blazer, D.G. & George,
must now be studied in empirically rigorous
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randomised controlled trials. Such studies community: An epidemiological study. Psycho-
are sorely needed before policy makers should logical Medicine,21, 713 721.
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