Critical incident stress management: A review of the literature with implications for social work

Introduction

The debates in the research literature surrounding the provision of psychological debriefing following critical events are many and varied. They include queries about which approaches and interventions should be used and what ‘best practice’ constitutes. Critical incident stress management (CISM) literature falls into a number of categories: evaluations of existing frameworks, their applications in differing contexts and reviews on the basis of personal experience, opinion and commentary (Lewis, 2003). Lewis (2003) further asserts that most literature on the subject of psychological debriefing consists of commentary stimulating debate within the field. Within this commentary three strands of opinion are evident: ‘Proponents of the intervention, critics of the intervention, and personal “war stories” with no empirical data’ (Lewis, 2003: 331). The purpose of the current article is to chart some of the major themes in the argument for and against psychological debriefing, in the hope that stimulating further reflection on the usefulness of various models clarifies the positioning of social work within these debates, to create new definitions in the process of critical reflection.

The literature on CISM is multi-disciplinary with nursing, fire services, police, emergency work, social work and allied health professions contributing to the commentary about CISM models and their value to practice and practitioners. The term ‘psychological debriefing’ is an umbrella term which covers a range of interventions. These interventions are typically short term and aimed at alleviating long-term distress focussed on preventing the development of post-traumatic stress disorder (Devilly et al., 2006). Critical incident stress debriefing (CISD) and defusing are specific approaches offered within the more generic term of ‘psychological debriefing’. These concepts are given different emphasis in some CISM models or the more recent notion of ‘psychological first aid’.

Search strategy

A search was run in the databases Cinahl, PubMed, Social Services Abstracts, PsychInfo and SSCI using the keywords ‘critical incident stress’ and ‘social work*’. A second broader search was also tried using the keywords ‘critical incident stress’. Publications were selected within the past 10 years to show recent developments in the field of CISM since Mitchell and Everley’s model of CISM developed from the late 1980s and was refined and elaborated throughout the 1990s and beyond. Seminal works in the field that were cited in the recent literature were then followed up to put the commentary and debates into their historical context. Those papers that were cited from the context of critical incidents encountered in the helping services were selected, as I discovered there was a broader literature about survivor narratives to a variety of disasters that were unrelated to the helping professions directly, so these articles were less relevant to the focus of this article.

Systematic reviews of meta-analyses were less frequently encountered; therefore, qualitative or mixed method evaluations were included alongside personal commentary that added to the debates about the efficacy of CISM and specific interventions within these models. The ‘personal war stories’, ‘proponents’ and ‘critics’ of CISD earlier mentioned by Lewis (2003) were all sought to show the range, depth and breadth of debate in the literature as it relates to the helping professions and in particular to social work. Selection of articles was made on the basis of titles involving these search terms, using Lewis’s (2003) debate typology of ‘proponents’, critics’ of CISM as the criteria for inclusion. Commentaries and ‘personal war stories’ (Lewis, 2003) were read as background to the main evaluations and systematic reviews of recent research. Articles written in English or available with an English translation were included as the author’s language was English.

Content analysis was undertaken and the results were analysed thematically. Once the articles were read and the content of each article analysed, each article was categorized as being primarily for, against or undecided in relation to the debate about the efficacy and effectiveness of CISM and related interventions. This analysis positioned each research article within the current debates in the literature about CISM. The majority of research publications reviewed either were supportive of existing models or gave an undecided view of the efficacy and effectiveness of CISM. Difficulties were identified in the majority of substantive studies reviewed, in conceptually defining CISM and related terminology, and due to methodological shortcomings of existing evaluative studies in the field.

Background

CISM has been described as a ‘comprehensive, multi-component, well integrated work-based programme that is designed to assist emergency service workers’ (Robinson, 2000: 92). The elements of critical incident stress debriefing within the CISD process include the detailed disclosure of facts, thoughts and emotional reactions and sensory material linked to the event or incident; coping factors involving education and traumatic stress, normalization of responses, anticipatory troubleshooting and planning for the future and group support factors where a reassuring and supportive environment is facilitated by a peer or leader (Lewis, 2003).

Mitchell, who developed the original model of CISD together with colleagues, counters critics’ arguments that CISD was always seen as insufficient as a ‘stand alone’ intervention by saying that as an intervention it was always envisaged by its authors to form part of a comprehensive, integrated approach or a part of CISM (Everly et al., 2001).

Historically approaches to CISM developed originally from an identified need within the military during war time to debrief from events encountered by veterans in the course of combat (Plaggemars, 2000). The thinking at that time was that group critical incident stress briefing as an intervention enables soldiers to return to the war zone by ameliorating ‘shell shock’ or post-traumatic stress disorder. Other historical influences include the development of crisis intervention models, the growth in knowledge about recovery from trauma and the specialization of therapies within psychology (Robinson, 2000). Herman (1992) discusses the shame and disbelief that historically has surrounded trauma that was relaxed with the return of Vietnam War veterans and the feminist movement of the 1970s. From this era onwards the rights of trauma survivors entered the public consciousness and their rights were acknowledged by the provision of appropriate services (Herman, 1992).

Recent developments

More recently, critics of CISM conclude that its primary intervention, CISD, does not prevent psychological conditions such as post-traumatic stress disorder and, furthermore, may be harmful if used indiscriminately (Boudreaux and McCabe, 2000; Devilly and Cotton, 2003). Current thinking is that CISD facilitators should not push people to reveal anything that is still too upsetting for them to discuss, as this may cause additional harm by encouraging participants to re-experience the traumatic event at a time when healthy denial and avoidance may facilitate recovery (Devilly and Cotton, 2003). The argument for early intervention in CISM as a preventative model is that the provision of such programmes usually involves three distinct approaches: first, involving waiting and screening those who are likely to need assistance; second, allowing natural social networks to operate to heal; and third, proactive early intervention (Robinson, 2004, summarizing Dyregrov, 1997). Devilly and Cotton (2003) assert that waiting and assessing to target interventions such as CISD to those who are deemed to need the intervention, is the ethical way forward to applying the practice of psychological intervention following critical incidents.

Definitions of CISM: Key elements

Several theorists have been influential in setting the framework for CISM approaches around which the debates about the efficacy of CISD have emerged subsequently. These theorists include Mitchell, Everly and Flannery and their founding work in the American context. In the Australian context, Robinson’s interpretations of CISD see the process integrated within a CISM programme in a less prescriptive, more holistic way. Robinson (2000, 2007) acknowledges that stress reactions invoked by a critical incident may vary significantly from person to person, determined by a range of factors including the nature of the incident, personality characteristics, value and belief systems, prior experiences of trauma and the quality of leadership and support systems in the organization (Robinson, 2000). In light of this, the process of debriefing requires a clear definition and structure that is able to be tailored to the individual as well as the work team. In this way a prescriptive, one-size-fits-all approach is considered detrimental to individual resilience as some individuals given the time and resources naturally ‘bounce back’ without any more formal intervention than spending quality time within emotionally sustaining relationships (Devilly and Cotton, 2004).

CISD as an intervention is considered best offered as part of a comprehensive programme of CISM that is integrated into the organization (Caine and Ter-Bagdasarian, 2003). Such a programme needs to involve the organization as a whole with teams and allied professionals rather than solely adopting an individual focus. However, although current evidence suggests that employers have a duty of care for employees in high risk occupations such as helpers in the acute and emergency services, confusion abounds about the most appropriate forms of intervention (Regel, 2007). Mitchell et al.’s (1983) model of CISM, and later developments, draw from crisis intervention which is deemed important when dealing with helping professionals. As professional helpers are likely to militate their own coping resources following a critical incident, there is a brief time immediately after the event when workers are more open to processing their own responses to distressing material encountered on the job (Robinson, 2000). If this opportunity is missed by too long a wait between the incident and opportunity for those helping professionals to process what happened and their responses, this opportunity can be lost irretrievably (Robinson, 2000). Timing of intervention is, therefore, critical which is an advantage of Mitchell et al.’s models of CISM. Within this overarching model, interventions such as CISD are offered on a team basis, ideally within 24–48 hours of the event (Donnelly and Siebert, 2009).

The organizational culture and context is thought to mediate responses to critical events (Devilly et al., 2006). There is a growing body of research that asserts that at the organizational level employers who accord priority to workplace strategies to improve the morale of employees contribute to job satisfaction and resilience (Devilly et al., 2006). For example, in critical care nursing, around a half of all employee turnover is thought to be due to work stress, much of which is unacknowledged by the employing organization (Caine and Ter-Bagdasarian, 2003). Therefore, Mitchell et al.’s model of CISM has been adapted and applied to a variety of organizational contexts where staff are dealing with life and death issues on a daily basis in an effort to improve staff retention and morale (Devilly et al., 2006; Lane, 1993). There is evidence that staff impacted by critical events manifest their distress in various ways. Those symptoms most frequently reported by hospital workers dealing with critical events such as death of a colleague through suicide include sleep disturbance and ‘intrusive thoughts about the victim’ (Plaggemars, 2000: 91). Cognitive reframing of such beliefs is part of the focus of the CISD as a multi-stage intervention.

However, though organizations increasingly offer various forms of psychological intervention, the cost often discourages organizations to offer a comprehensive CISM programme. As a consequence, employee assistance programmes tend to be left with the task of assessing those employees who are worst affected or who are referred by management following a critical event (Plaggemars, 2000). Alternatives to CISD as an intervention include the pared down option of ‘defusing’ and less formalized ‘peer support’. Both of these interventions are cited as having their value in the research literature, as they tend to be more cost-effective when compared with a more formal team debriefing intervention. The distinctions between CISD and defusing are less clearly defined in the literature, however, leading to difficulties comparing interventions as the elements of each approach offered within CISM models differ considerably. Yet critics of Mitchell’s claims to knowledge argue that:

It appears that anything involving intervention for distressed or victimised individuals could be considered critical incident stress debriefing as it is currently defined (or, rather, not defined). (Devilly and Cotton, 2004: 36)

Lane (1993) and Lewis (2003) also write with an emphasis on coping strategies and resilience in relation to CISD/CISM which combine strengths-based theories with CISM/CISD. Strengths-based theories are prevalent in recent directions in social work theories of practice and so are referred to as informing social work theory building around emerging definitions of CISM/CISD for social work as a profession (Tuckey, 2007).

Critical events

Definitions of critical events vary widely in definition in the articles reviewed. For example, from a social work perspective Bell (1995: 37) defines critical events as ‘traumatic events’. Citing Figley (1985), ‘traumatic events’ are defined as falling into the categories of ‘natural disasters’ such as earthquakes, ‘accidental catastrophes’ such as motor vehicle accidents and ‘human-induced catastrophes’ such as acts of terrorism. Lane (1993) defines critical incidents as being related to situations of death and dying encountered by health care professionals.

Devilly and Cotton (2004: 148) mention ‘terminology slippage’, referring to the generalizing of critical incidents to events that in their view are not traumatic, such as co-worker conflict in the workplace. In this way, Devilly and Cotton (2004: 144) conclude that:

Frequently and particularly in applied contexts, terms are being used without operational definitions and are often used interchangeably. This makes inspecting the evidence behind the claims a murky and very difficult task.

This ‘murkiness’ is evident in evaluations of workplace psychological debriefing in relation to ‘critical incidents’ such as restructuring and redundancy in the workplace. In one study reviewed, for example, psychological debriefing through employee assistance programmes was found to be effective in assisting employees to verbalize their issues and construct alternative meaning from experience following redundancy (Plaggemars, 2000). Whether organizational change and restructuring can be defined as a ‘critical event’ in the same sense as an unexpected death of a client or colleague, for example, remains problematic in the literature, however.

Support for interventions within CISM models

The majority of outcome studies suggest that those workers who participate in CISM programmes find it a valuable experience and in particular those programmes that include a CISD component (Tuckey, 2007). Those aspects that are positively commented upon following group psychological debriefing include the sharing of experiences which normalizes common responses (Tuckey, 2007). Other positive outcomes that have been reported include a reduction in alcohol abuse which has been identified as a co-morbid factor linked to traumatization among military personnel (Deahl, 2000; Deahl et al., 2001).

Evaluations of CISD

Positive feedback about the process of group debriefings as an intervention within CISM programmes has been documented in a variety of different contexts involving a diversity of ‘critical events’. For example, police officers involved in the 1995 Oklahoma bombing used group and individual interventions with clinicians specializing in law enforcement issues following the event (Horn, in Williams and Sommers, 2002). Horn (in Williams and Sommers, 2002: 314) noted that a prior history of trauma may either ‘sensitize or immunize officers to subsequent trauma depending on whether or not they had worked the earlier trauma’. Therefore, a range of interventions was needed to be available to officers on a voluntary basis. Services included residential workshops, one-to-one sessions, chaplaincy and EMDR therapy with positive feedback from participants (Horn, in Williams and Sommers, 2002). The success of the debriefing was considered to arise from using clinicians who were familiar with the context of police work and by offering an eclectic range of interventions which officers could select voluntarily from within a supportive workshop environment.

CISD has been used with employees undergoing job restructuring where redundancy is the outcome and has been found to have meaning-generating outcomes for the participants (Plaggemars, 2000). Downsizing-based CISD groups not only engender mutual and peer support, they can facilitate a productive adaptation to loss and change which may assist in the quest for another job or in transitioning into retirement (Plaggemars, 2000).

Whilst some reviewers of meta-analyses find mixed results as to the efficacy of CISD evaluations, they also find a number of secondary gains that participants are found to make through engagement with the debriefing process (Mitchell et al., 2003). These gains include individual benefits such as emotional ventilation, stress management and reassurance that the range of stress responses is normal to experience. Enhancement of the work group process, interagency cooperation and screening and referral for additional services were other secondary positive goals identified (Mitchell et al., 2003). One study of peer diffusers, for example, discovered that the involvement of peer diffusers in the workplace reduced lost employee time after critical incidents. Improved organizational culture and workplace health was noted as well as the diffusers’ transferring enhanced skills to other work tasks (Freeman and Carson, 2006).

Similarly, the ‘meaning-making’ functions of group CISD have been discovered when workers discuss the suicide of clients and colleagues as critical events (Plaggemars, 2000). For example, one mental health nursing study in Northern Ireland found that CISD had good outcomes with a group of three research participants. All found the individual and group debriefing process validated their experiences and offered hope for the future at the six-month follow up (Irving and Long, 2001). The usefulness of combining group CISD with individual psychotherapy is mentioned as ideally forming part of a comprehensive programme of CISM (Galliano, 2002; Irving and Long, 2001). Induction of new employees with stress management education that encourages adaptive responses to events in the workplace is seen as important in dealing with critical incidents in a preventative sense (Lane, 1993; McNab et al., 2003).

Riddell and Clouse (2004) warn that critics who argue that CISD is at best ineffectual or at worst harmful may be throwing the baby out with the bathwater as they fail to understand that debriefing is part of a broader approach to the psychosocial needs of persons affected by trauma to promote resilience. Mitchell (2004) has entered the debate to point out that the majority of criticisms about CISD refer to what is a single session of debriefing, not what the original model of CISM intended, as single session debriefing violates the guidelines of standards of CISM practice (Mitchell, 2003; Mitchell et al., 2003) .

Critique

Critics of psychological debriefing assert that its meaning is problematic as the concept is defined in various ways. This lack of conceptual clarity leads to further difficulties of application and the scope of use across various contexts (Arendt and Elklit, 2001; Regel, 2007; Tuckey, 2007) and uniformity of process (Regel, 2007). The aims of use also lack definition; therefore, greater conceptual clarity is needed to determine if the evaluation of a diverse range of approaches and interventions actually refer to the CISD as an intervention and integrates with the more comprehensive term, CISM (Van Emmerik et al., 2002). Regel (2007) argues, for example, that the umbrella concept of ‘psychological debriefing’ and ‘critical incident stress management’ are widely used in the UK despite various misconceptions and misunderstandings about the terms. Some see CISM as an intervention as being the same as counselling, and these confusions in terminology reflect misunderstanding that is translated into multiple interpretations as to what is done in practice (Regel, 2007; Van Emmerik et al., 2002).

Therefore, given this lack of clarity of terminology and application, the criteria for the evaluation of the effectiveness of psychological debriefing also lacks consensus in the literature (Lewis, 2003; McNab et al., 2003). One meta-analysis of 25 studies concludes four main criteria for success (Arendt and Elklit, 2001). These criteria include the definition of psychological debriefing’s purpose which is to prevent psychological disorders such as the development of post-traumatic stress disorders. However, there is a lack of consensus as to whether psychological debriefing and CISM have the same meaning (Devilly and Cotton, 2004). Second, there are queries as to whether the main aim of the umbrella term ‘psychological debriefing’ is primarily aimed at preventing post-traumatic stress disorder (Regel, 2007).

More recently the use of psychological debriefing is seen as a morale-boosting intervention, ‘a gesture of employer support, rather than a clinical intervention influencing distress and clinical symptomatology’ (Devilly and Cotton, 2004: 147). Other studies remain undecided about CISD’s efficacy as ‘there is still no consensus on whether single session debriefing can contribute to the prevention of symptoms of chronic post traumatic stress disorder’ (Van Emmerik et al., 2002: 769). The authors conclude in their meta-analysis of seven studies evaluating CISD as an intervention that ‘Critical incident stress debriefing has no efficacy in reducing symptoms of post-traumatic stress disorder and other trauma-related symptoms’ (Van Emmerik et al., 2002: 769). Robertson et al. (2004) and Bledsoe (2003) concur with these authors and conclude that CISD may be at best neutral in its after effects but for some may be harmful (Van Emmerik et al., 2002).

These findings are supported by evidence that single session debriefing is generally considered less helpful by the participants (Devilly and Cotton, 2003; Robertson et al., 2004; Tuckey, 2007). Devilly and Cotton (2003) argue that CISD as a one-off intervention may cause harm based on their review of randomized controlled trials. However, Robinson (2004) counters these criticisms by saying that Devilly and Cotton are operating on a number of common misunderstandings and a lack of evidence to support their assertions. CISD was never designed as a standalone intervention. Despite attempts by Mitchell to clarify the use of the terms ‘critical incident stress management’ as the model and ‘critical incident stress debriefing’ as the intervention, throughout the 1990s misunderstanding of these two concepts continued (Robinson, 2004).

There are problems reported with the randomized controlled trials reviewed by Devilly and Cotton which are considered to be methodologically flawed. For example, Robinson (2004) asserts that the studies chosen for review by Devilly and Cotton (2003) fail to acknowledge intervening variables throughout the study. The CISM models are blamed for traumatizing citizens through unsolicited helping efforts by the public, for example, after 9/11 (Devilly and Cotton, 2003). Further, there is an assertion that psychological debriefing has created an industry: Robinson (1994: 31) ‘paints a picture of exploitative, unethical behaviour’ that is unfounded. Gist and Devilly (2002) propose the way forward as a more structured, ‘stepped’ set of interventions that can be individually tailored, two to four weeks after the critical incident. This intervention would be offered on the assumption that brief cognitive therapy has efficacy in treating post-traumatic stress disorder in those populations deemed to be ‘high risk’. How ‘high risk’ is defined has yet to be elucidated, however.

Another randomized controlled trial of three levels of critical stress intervention among ambulance staff evaluated the effectiveness of three intervention strategies and attempted to correlate symptoms with the severity of incident and level of intervention (McNab et al., 2003). The authors discovered that requests for CISD among ambulance staff were uncommon, which could be related to the reluctance of unionized staff to self-refer to a co-ordinator who was unknown to them. The other possible explanation for the lack of uptake of CISD may be accounted for by the lack of awareness of critical incident stress by the ambulance workers (McNab et al., 2003). The authors conclude that caution is needed when providing psychological debriefing due to the paucity of well-designed evaluations of CISD (McNab et al., 2003).

Methodological issues

Evaluations of psychological debriefing interventions have been reviewed by evidence-based researchers, revealing a number of methodological shortcomings of the existing studies (Everly, 1999). These shortcomings involve the fact that sample sizes are often small, the studies are retrospective rather than prospective and there is an absence of control groups (Regel, 2007). The lack of uniformity of processes, timing variances in the delivery of specific interventions, low response rates and lack of generalizability across different contexts and traumatic events, confounds the evaluation of effectiveness (Everly, 1999). Furthermore, there is limited evidence that interventions after traumatic events such as psychological debriefing have preventative effects in terms of preventing post-traumatic stress disorder (Robertson et al., 2004).

What exactly is ‘effectiveness’ seems difficult to define with the symptomatology of post-traumatic stress disorder being the main outcome measure. Regel (2007) suggests that there is a gap in the research literature as there are no studies assessing the impact of other symptoms of traumatization which may involve other markers of social and occupational functioning such as alcohol and drug use. Robertson et al. (2004: 108) concur with this conclusion and call for ‘a broader range of outcome measures’ when researching the efficacy of CISD.

Despite the ongoing debate about definitions of CSIM models and the phases of intervention encompassed within these approaches, there is an opinion that through academic debate, progress is being made in defining the key concepts and elements (Flannery and Everly, 2004; Suveg, 2007). The challenge according to Flannery and Everly (2004: 327) is for standardized definitions of ‘critical events’ and intervention protocols to be developed. Reliable outcome measures that are tested by formally trained personnel who are inducted in the standardized procedures are required (Flannery and Everly, 2004). Whilst more rigorously conducted research using controlled experimental design is recommended, the ethical issue of withholding treatment to the control group is noted as a major obstacle in research using control groups (Devilly and Cotton, 2003; Flannery and Everly, 2004).

The implications for social work

The findings from the studies reviewed have implications for social workers as facilitators of CISM programmes, both for colleagues and with clients as part of clinical practice. Social work educators who prepare students for the many challenges they will face that are inherent in the practicum environment, and for qualified social workers who encounter critical incidents on the job, CISM programmes can provide a range of options supporting professional effectiveness, well-being and staff retention.

From a social work perspective, social workers working as critical incident stress debriefers quote numerous examples illustrating the efficacy of the group process for participants (Lane, 1993; Morrison, 2007; Prichard, 2004; Spitzer and Burke, 1993; Spitzer and Neely, 1992). Within organizations such as hospitals, social workers are seen as ideally qualified and positioned to offer CISM programmes in their employing workplaces as they are used to collaborating with a variety of emergency helping professionals (Lane, 1993; Spitzer and Burke, 1993; Spitzer and Neely, 1992). A holistic view of people; a focus on social justice establishing rights and responsibilities for all; an ability to respect difference and think broadly, influencing social change; and group work skills are among those characteristics and competencies that make social workers ideally suited to facilitate a range of critical incident stress interventions such as debriefing. Social work as a profession works on the margins of systems and with events that are routinely outside the usual range of human experience in contexts as diverse as child protection, health and welfare. In these contexts the experience of working intensively with grief, loss and unexpected crises are an everyday feature of the work. Social workers witness and work alongside their clients to support their resilience in the face of traumatic events. In a parallel way, social workers are returning to consider the needs of their colleagues and of the workforce in relation to CISM.

The mental health stigma is avoided by CISD being conducted by multi-disciplinary teams including peers within the participants’ own workplace (Prichard, 2004). It is vital that the facilitators who conduct the process are well trained and have credibility in the eyes of the participants (Maher, 1999; Prichard, 2004). The experience from those writing as critical incident stress debriefers is that being a trusted peer in the workplace fosters trust and flow in the group debriefing process (Lane, 1993; Maher, 1999; Prichard, 2004). This view contrasts with some CISM policies, however, where independent support via employee assistance programmes is deemed more effective to target those most in need and likely to respond to formal CISD as an intervention (Devilly and Cotton, 2004). Confidentiality can be compromised with less formal models of debriefing involving peer supporters. Specifically untrained peer supporters without adequate training in CISD and strong professional boundaries can inadvertently disclose personal information that can impact on promotional prospects and so affect the career development of colleagues in the workplace (Maher, 1999).

The credibility of the facilitators and their skills in group facilitation are reiterated in the social work literature on CISD with the relationship ideally establishing between the debriefed and the debriefers: ‘gentle, respectful interactions, clear verbal and non-verbal communication, clear co-leader leadership’ (Prichard, 2004: 57). The use of trained and registered clinicians is also highly recommended (Devilly and Cotton, 2003; Flannery and Everly, 2004; Suveg, 2007).

Adaptation to context

Selecting participants for CISM interventions is considered to be of vital importance as only those who have been present at the critical incident should be involved in the debriefing (Lane, 1993; Maher, 1999; Prichard, 2004). Therefore a targeted approach to those who need the help most is reiterated from a social work perspective along with adaptation of CISD to suit differing work contexts (Morrison, 2007). For example, one US study discovered that there was ‘limited applicability of the critical incident stress management model with a school age population’ for social workers in schools (Morrison, 2007: 771). A second shortcoming voiced by social workers was that CISD needed to be adapted to the cultural background of the participants, and students’ developmental needs needed to be taken into account (Morrison, 2007). Attending to cultural, ethical and gender variables are important in the application and operation of CISM programmes (Morrison, 2007).

Adapting the language of CISD as an intervention to the audience’s background, culture, gender and context is important to ensure that the organizational context surrounding the process is understood. Owing to a gulf in understanding the culture of the audience, an external debriefer risks offending and alienating, which may further traumatize those affected. In the case of working with children and young people in schools following a critical incident such as a sudden death of a classmate, for example, social workers working in schools need to adapt the language of the debriefing models to evolve age- appropriate interventions (Morrison, 2007). Providing families with the tools and information for working with their own children affected by a critical incident may be more appropriate ethically than debriefing students in class with a facilitator. The former approach was one used during the 22 February 2011 earthquake in Christchurch, New Zealand where teachers taught parents how to deal with traumatized students, in addition to various classroom interventions such as art therapy and creative writing to facilitate the expression of feelings amongst primary school students. An application of CISM models to work with families may, therefore, involve a systemic, strengths-based approach which capitalizes on naturally occurring support networks to use these resources as a first line of support and intervention following a critical incident rather than a formal debriefing by a trained facilitator.

Strengths-based models of CISM

Strengths-based models and approaches are considered to be needed to supplement existing models of CISM. Slawinski (2005) argues that promoting resilience needs to be the focus when considering psychological debriefing. She suggests combining strengths-based and ecological systems theories alongside CISM approaches and protocols to broaden the focus and the application of specific strategies such as psychological debriefing. Working with protective factors such as natural healing networks, cognitive coping strategies and self-esteem is suggested as these resources can be overlooked within CISM approaches. Furthermore, the combination of a strengths-based paradigm within ecological systems thinking may be more culturally sensitive as it can be adapted to the ways in which the individual already processes traumatic events within their social and community networks. Lim et al. (2000) suggest that when a critical event occurs a ‘circle of influence’ exists around each person who is directly affected, starting with the helping professionals involved in the critical event, their family, friends, workplace, school, neighbourhood and community, state and nation. Therefore, any intervention following a critical event needs to occur on each of these levels within CISM programmes. Adamson (2006) concurs with these findings in her research as she proposes adequate preparation of students in the rigours of practice. She discovered in her doctoral research that job context and in particular social workers’ interpersonal finesse in navigating complex and ambiguous situations in the workplace are the major variables in determining social work interns’ well-being in the workplace in the face of critical incidents. The rationale for this approach comes clearly from the evidence that:

a significant proportion of occupational stress comes not from specific events but from the environmental conditions that create ambiguities, tensions and conflict. Furthermore, these contextual pitfalls can undermine resilience in the event of critical incidents. (Adamson, 2006: 54–5)

The implication of this is that in social work education preparation is needed to prepare new social work graduates to deal with the rigours of the practice environment (Adamson, 2006). This finding suggests the need for induction programmes for new social workers to assist in their knowledge of different sections of the workplace. This knowledge can assist staff to access and use the range of services available.

A targeted approach

Screening of individuals and their post-trauma histories is needed to refer those considered to be more at risk of subsequent re-traumatization to appropriate debriefing and other services (Devilly and Cotton, 2004; Flannery and Everly, 2004; Suveg, 2007). For social workers the quality of their experiences in the organizational environment needs to be taken into consideration. For example, Regehr et al. (2004) conclude that social workers employed in the field of child welfare need to be mindful of the effects of long-term workplace stressors in relation to predicting how they will likely respond to critical events. If critical events occur in an environment where there are chronic or long-term stressors, the intensity of the responses are likely to be increased. Workplace chronic stressors for social workers include recording requirements, organizational change and working with difficult clients. Drawing on the cognitive self-development theory of McCann and Pearlman (1990), various protective factors enhancing resilience are identified (Regehr et al., 2004). These protective factors include support by colleagues, individual cognitive constructs such as safety/trust and power and control, and ‘incident factors’ which refer to the length of time since the event and number of traumatic events encountered over the past year (Regehr et al., 2004).

Of these factors promoting individual social worker resilience, the organizational context is considered the most important factor (Regehr et al., 2004). How well the organization operates in its day-to-day functioning suggests how effectively it will operate in a crisis mode, as well as being indicative of the quality of care provided to clients and the level of care and support given to workers (Gist and Taylor, 2008). This is a theme I discovered in researching vicarious traumatization and critical incidents among social workers working as sexual abuse therapists (Pack, 2004) and Maher (1999) identifies in the fire service. If the employing agency worked from an explicitly anti-oppressive position with management working collaboratively with workers, I discovered that this shared philosophy, clinical supervision and personal therapy enabled a smoother passage through critical events such as client suicide (Pack, 2004).

Conclusion

As there are many different interventions encompassed within CISM, there is the need for each of the many differing protocols to be more objectively evaluated by those not involved in the provision and facilitation of debriefings or co-ordinators of programmes (Lewis, 2003). It is recommended that the quality of the facilitation and the facilitators’ own training and supervision be examined by independent researchers (Lewis, 2003). Further research is needed to determine which groups and for which kinds of critical incidents and in what context (individual or group) psychological debriefing is likely to be beneficial to participants (Lewis, 2003). The role of context and, in particular, attention to the organizational setting is needed. Within and across organizations, contact with other CISM teams and programmes operating in the local area is recommended (Lane, 1993).

There is also an identified lack of research on the impact of debriefing on the debriefers themselves, in terms of the resources they need to continue to sustain themselves in this role. The role of employer support to screen individuals vulnerable to post-trauma responses via employee assistance programmes and trained peer supporters is another area for further research.

Attention to context, protective factors and strengths-based theories of resilience

The identification of protective factors such as social support and other personal resources need to be considered alongside a theoretically grounded model of risk factors such as the moderating influences of age, gender, ethnicity, marital/socio-economic status (Donnelly and Siebert, 2009). Additionally, the influence of occupational risk factors needs to bring a contextual understanding to guide facilitators towards what is ‘appropriate’ intervention. What seems clear is that there is insufficient evidence that the CISM model and CISD protocol within that model is harmful and should be immediately suspended (Wagner, 2005). Overall, those workers who participate find that having an opportunity to discuss the emotional aftermath of events encountered in their work to be very supportive personally and professionally.

Perhaps the debates in the literature about the effectiveness of CISM ultimately will be informative of ‘what works’ when assisting professionals who deal with critical events (however these are defined), through a process of integrating experience. From my review of the literature on models of CISM and CISD as an intervention, I note the existence of a conceptual ‘holding space’ out of which a more pragmatic definition of CISM models is forming. The new definition of ‘what works’ for social workers in CISM involves a process of closer integration between the personal and professional values that the individual brings to practice. Central to this emerging new definition of CISM is the process of reflecting on the context (field of practice and employing organization) surrounding the triggering critical event and from that point of reference, evolving a new meaning about the event, one’s identity as well as the context in which the incident has occurred. Inevitably, this reflection involves the social worker’s whole self, based in personal and professional beliefs and values. The support of management involving proactive leadership of work teams needs to be part of an integrated CISM policy for social workers, out of which a range of interventions such as group and individual debriefing is offered on a voluntary or ‘as needed’ basis.

As Hibler (2000: 227) states, ‘the history of science replays that in the evolution of ideas it is sometimes difficult to use existing or contemporary standard evaluation techniques to determine the effect of these “innovations”’. We need not be surprised then if the ‘lessons learned’ will take time to integrate and the evolution of guidelines for the use of CISM developed.