Designing an Effective Debriefing Session Daniel W. Clark, Ph.D. Critical Concepts Consulting www.CriticalConcepts.org

WSH/PCO drdan@criticalconcepts.org Overview Crisis Intervention Critical Incidents & CISM tools CISD, Defusing, CMB Recommendations WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Crisis Intervention Peer Support Critical Incidents WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Crisis intervention Crisis intervention practice roots can be found in military psychiatry, community mental health, and suicide intervention initiatives. WSH/PCO drdan@criticalconcepts.org

Lessons learned from the military “Nothing could be more striking than the comparison between the cases treated near the front and those treated far behind the lines…As soon as treatment near the front became possible, symptoms disappeared…with the result that sixty percent with a diagnosis of psychoneurosis were returned to duty from the field hospital (p. 994).” Salmon (1919, NY Med J) WSH/PCO drdan@criticalconcepts.org

Principles of Crisis Intervention Proximity Immediacy Expectancy Simplicity WSH/PCO drdan@criticalconcepts.org

Crisis Incident Stress Management (CISM) WSH/PCO drdan@criticalconcepts.org

Critical Incident Stress Management (CISM) Comprehensive Integrated Phase Sensitive Multi-component WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Critical Incident In a career where day to day you respond to the abnormal events in other people’s lives; A critical incident is the one that, for whatever reason, is abnormal even for experienced personnel. Baby Jessica, child’s head falls off in your arms, overwhelming disaster like OKC or NY Trade Towers bombing WSH/PCO drdan@criticalconcepts.org

Types of Interventions Tools Pre-Incident Education Critical Incident Stress Debriefing Peer Support (Individual Consults) Defusing Crisis Management Briefings Rest Information Transition Services Pastoral Crisis Intervention WSH/PCO drdan@criticalconcepts.org

Types of Interventions Tools On Scene Support Services Specialty Debriefings Significant Other Debriefings & Support Follow Up Services Mental Health Referral Services Community Assistance WSH/PCO drdan@criticalconcepts.org

Critical Incidents The LE Terrible 10 Line of Duty Death Serious line of duty injury Suicide of a co-worker Disaster / Multi-casualty incident LEO shooting OKC, 19 APR 1995 WSH/PCO drdan@criticalconcepts.org

Critical Incidents The LE Terrible 10 Events involving kids Relatives of known victims Prolonged incident - Especially with loss Excess media interest Any Significant Event Baby Jessica Rescue - 16 OCT 1987 WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Intensity of Impact Personal Relevance Duration Sense of Loss Previous History Guilt Disruption Social Support Coping Skills Relevance - ‘just like…’ Duration - more time=more trauma Previous History - ‘reminds me of…’ Guilt - esp. in “failed” endeavors Social support - when lacking, say in shooting like Trooper Linn’s or Trooper Sweet Coping skills - sufficient for this stressor? WSH/PCO drdan@criticalconcepts.org

Peer Support/ Individual Crisis Intervention WSH/PCO drdan@criticalconcepts.org

Individual Crisis Intervention Positives ‘Been there, done that’ Credibility Rapport Negatives May be too close May over-identify with peer WSH/PCO drdan@criticalconcepts.org

Individual Crisis Intervention Communication Skills Awareness of Acute Stress Symptoms Intervention Protocol Referral Options WSH/PCO drdan@criticalconcepts.org

Crisis Management Briefing WSH/PCO drdan@criticalconcepts.org

Crisis Management Briefing “…a group psychological crisis intervention designed to mitigate the levels of felt crisis and traumatic stress in the wake of terrorism, mass disasters, violence, and other “large scale” crises.” IJEMH v2(1) p. 53-57 (2000) WSH/PCO drdan@criticalconcepts.org

Crisis Management Briefing Goals Supply facts about the incident Allow psychological decompression Provide stress management info WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Defusing WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Defusing Defusing means to render something harmless before it can do damage. A small group intervention applied within hours of a critical incident. WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Goals of Defusing Stabilization of the traumatized group Restore unit cohesion Restore unit performance Assessment tool to determine if group members need something else in addition to the defusing As mentioned earlier unit cohesion and unit performance are the most important things that a defusing can stimulate. WSH/PCO drdan@criticalconcepts.org 23

WSH/PCO drdan@criticalconcepts.org Defusing An interactive group process Same day (up to 8 hours after incident ends) Has little effect or no effect after 12 hours Group must be homogeneous If opportunity is missed, provide one-on-one support followed later by CISD Be very clear here. The defusing is extremely time limited. It was designed for intervention in the heat of the moment. The trauma membrane begins to form shortly after the trauma in a very vulnerable time for the person. People cannot tolerate vulnerability for very long. Soon the trauma membrane is intact and the person is more protected. The trauma membrane can also block help from entering. That is why early intervention is so important. It gives people direction and lays out the road map toward recovery before the membrane is fully formed. The can help the person to sort out some thing while the trauma membrane is in effect and their recovery process is made a little easier because they have received messages such as, “You are not alone.” “Someone cares about you.” “Here are some steps that may help you as you try to recover.” Lindy developed the concept of the trauma membrane. WSH/PCO drdan@criticalconcepts.org 24

WSH/PCO drdan@criticalconcepts.org Defusing In some cases, a defusing may be all the group needs. In other cases a CISD should follow If reactions are intense or suppressed and if there appears to be unfinished business, then a CISD is indicated a few days later. When a CISD is necessary, it is generally made stronger by holding the defusing first. 5-phase CISD is taught in the Advanced Group course. The usual follow-up to defusing is individual support and CISD for the group. In some cases the CISD is not necessary. That is not a goal of defusing. It is a by-product. In other words an accidental benefit of a defusing is that it might be all that is necessary in a small number of cases. WSH/PCO drdan@criticalconcepts.org 25

Clues that a CISD should follow a Defusing Absence of appropriate emotion Excessive emotion Expression of inappropriate emotions A sense of unfinished business Withdrawal and inability to communicate during the defusing The immediate follow-up to defusing are individual support. The next step is to set up a CISD. WSH/PCO drdan@criticalconcepts.org 26

Criteria for Homogeneous Group Group members have a relationship with each other before the traumatic event They have a shared history They have spent considerable time together prior to the event They have experienced the same traumatic event. If you do not have a homogeneous group then defusing and CISD are never used. Homogeneous group is the “Sine qua non” of group in interactive groups. “Sine qua non” means “without which there is none”. No homogeneity, then no interactive group process. WSH/PCO drdan@criticalconcepts.org 27

WSH/PCO drdan@criticalconcepts.org Defusing: 3 phases Introduction – Introduce team; lay out the guidelines; lower anxiety about the process Exploration – Allows a brief discussion of the experience. A brief “story” of the event Information – Provide information, normalize, teach, guidance, summarize key points The easiest way to get the exploration phase going is to say something like this, “My team mate and I were not here when this happened. It would be helpful if you could give us an overview of what happened. We do not need a great deal of detail. We are more interested in the big picture of the event. Perhaps you could tell us what happened first and then next after that and so on.” WSH/PCO drdan@criticalconcepts.org

Critical Incident Stress Debriefing WSH/PCO drdan@criticalconcepts.org

Critical Incident Stress Debriefing (CISD) A structured GROUP discussion concerning a critical incident First described by Mitchell (1983) for use with homogeneous groups of emergency services personnel Requires a team approach Peers play an absolutely vital role in CISD. The process can be a little complex, however, and a CISM trained mental health professional is required. Ironically, the mental health professional’s main objective is use their skills to keep the process from turning into therapy. H.E.R.D. means Historical Event Reconstruction Debriefing. It is used by the Israeli armed forces as a Debriefing. It consists of an extremely detailed, blow, by blow description of one’s involvement in a traumatic event. It is based on a historian’s interview of soldiers in World War II. The Israelis say they get the most benefit from telling the story. They do little teaching in the process unlike the approach that is used in CISD which spends time teaching group members how they can get out of the stressful conditions. WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org CISD Goals Mitigate distress Facilitate psychological normalization and psychological “closure” Set appropriate expectations for psychological / behavioral reactions Serve as a forum for stress management education Identification of external coping resources Psychological triage and referral The most important goals of a CISD are to a) mitigate the impact of the traumatic event by lowering tension, b) facilitate the recovery process for normal people who are having normal reactions to an abnormal event, and c) to identify individuals within the group who might benefit from additional support or, in a few cases, a referral for psychotherapy. WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org CISD Team Minimum: Two CISM trained team members. At least one mental health clinician. Peer driven, clinician guided** Other team member(s) may be “peer support personnel,” spiritual leader, another mental health, or physical health, professional. All team members must be trained in the small group process - CISD! WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org CISD Considerations Convenient time Neutral location All involved operations personnel invited Ideal group size is 3-20 Homogeneous groups (with regard to traumatic exposure/ psychological toxicity) Ideally, one team member for every 5-7 participants - minimum of 2 WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org CISD Considerations Strict Confidentiality No breaks Timing is important Location and physical environment Large scale, significant incident** Circumstances out of the ordinary** Closed circle format WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Physical Format MHP Door Peer WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Physical Format MHP Door Peer WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Physical Format MHP Door Peer WSH/PCO drdan@criticalconcepts.org

Physical Format Peer MHP Peer Avoid tables, distractions, dispatch speakers, equipment, And CPR training dummies. Try to avoid snacks until after. These are impediments to communications! Participants are not necessarily equally placed around the room, but the CISM team members are strategically placed. WSH/PCO drdan@criticalconcepts.org

CISD Structure: 7 Phases Introduction (C) Fact (C) Thought (C A) Reaction (A) Symptom (A C) Teaching (C) Re-Entry (C) WSH/PCO drdan@criticalconcepts.org

Phases of a CISD COGNITIVE AFFECTIVE INTRODUCTION RE-ENTRY FACT TEACHING THOUGHT SYMPTOMS REACTION AFFECTIVE

WSH/PCO drdan@criticalconcepts.org Recommendations WSH/PCO drdan@criticalconcepts.org

Recommendations Consider For more “routine” incidents, use a Defusing For more extraordinary or significant incidents, use a CISD. WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Recommendations The majority of individuals exposed to a traumatic event will not need formal psychological intervention. 2. The focus should be upon the individual more so than the event; assessment is essential. Assessment is an on-going dynamic process, rather than a once and done. 3. Normalization of the crisis response is encouraged, but should never lead one to dismiss serious crisis reactions. WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Recommendations 4. Unless the magnitude of impairment is such that the individual represents a threat to self or others, crisis intervention should be voluntary. 5. Be careful not to interfere with natural recovery or adaptive mechanisms. 6. Individuals should be encouraged to talk about or relive the event only if they are comfortable doing so. 7. When in doubt, seek assistance/supervision. WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Recommendations 8. The risk of adverse outcome is associated with all human intervention and helping practices including medicine, surgery and counseling. Improper, inadequate training is the greatest risk factor associated with crisis intervention. Training and supervision may be the best way to reduce the risk of adverse outcome. WSH/PCO drdan@criticalconcepts.org

Recommendations Avoid Saying! “I know how you feel.” “It’s not so bad.” “This was God’s will.” “God won’t give you more than you can handle.” “Others have it much worse.” “You need to forget about it.” “You did the best you could.” “You really need to experience this pain.” Confrontation WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Questions?? WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Questions? WSH/PCO drdan@criticalconcepts.org

WSH/PCO drdan@criticalconcepts.org Daniel W. Clark, Ph.D. Washington State Patrol 1405 Harrison Avenue NW Suite 205 Olympia, WA 98502 (360)-586-8492 wsp-psych@att.net Critical Concepts Consulting 2103 Harrison Avenue NW Suite 2183 Olympia, WA 98502-2607 (360)-786-0292 drdan@criticalconcepts.org WSH/PCO drdan@criticalconcepts.org