At present the debates in this area are continuing. To make some sense of the discussions and debates that are occurring the following is an outline of these issues.
Are Critical Incident Responses Preventive or Not?
The preventive effect, that has been attributed to formalised critical incident responses, to avoid longer term difficulties from manifesting themselves has not been verified empirically (Health Innovation Management Services, 2004; McNally, et. al., 2003; Gist & Devilly, 2002; Kaplan, et. al., 2001; Smith & Suda, 2001; Carlier & Gersons, 2000; Deahl, 2000; MacFarlane, 2000; Morris, 2000; Raphael, 2000; Raphael & Wilson, 2000; Shalev, 2000; Stallard, 2000;
2000; Yamey, 2000; Gist & Woodall, 1998; Gist & Woodall, 1998; Kenardy, 1998; Paton, et. al., 1998; Pfefferbaum, 1997; Hobbs, et. al., 1996; Kenardy, 1996; Ostrow, 1996; Paton, 1996: Deahl, et. al., 1994; Watts, 1994).
There is no proof that indicates that the palliative effect of formalised critical incident responses is any better than alternative interventions such as: “…psychological first aid, education, information, group support, focussed counselling, practical assistance and so forth” (Raphael, 2000; p.354) or cognitive reframing and psychological distancing (Armstrong, 2000; Gist & Woodall, 2000; Shalev, 2000; Stuhlmiller & Dunning, 2000; Gist & Woodall, 1998; Paton, 1996; Stallard & Law, 1993; Yule, 1992; Carter and Brooks, 1990). As Stuhlmiller & Dunning (2000, p.26) state:
The demand to “let go” or vent when a traumatized person is desperately trying to maintain a sense of composure is in itself mechanisms reinforced. It would appear that debriefing reinforces a sense of lack of control, of vulnerability, of damage. Another important alternative is that talking to those people whom one knows and trusts is an important component for many as it contributes to maintaining the support systems that already available (McNally, et. al., 2003; Taylor, 2002; Campfield & Hill, 2001; Carlier & Gersons, 2000; Chemtob, 2000; Gist & Woodall, 2000; MacFarlane, 2000; Morris, 2000; Raphael, 2000; Stuhlmiller & Dunning, 2000; Wilson & Raphael, 2000; Weisæth, 2000; Ayalon et. al, 1998; Eyre, 1998; Gist & Woodall, 1998; Foa & Meadows, 1997; Ostrow, 1996; Paton, 1996; Paton & Long, 1996). Taylor, (2002, p.107) writes that helpers: “…should try to connect people with their family and support groups and with their cultural and religious networks”.
A Growing Field or a Business?
A further complication is highlighted by the confusion between the original purpose of critical incident responses and the widespread growth of the ‘debriefing business’ (McNally, et. al., 2003; Summerfield, 1995). There are those who question why a model developed for emergency workers is now being applied as a method that has utility as a generic response in any and every circumstance and they are especially wary about its use with adolescents
(Chemtob, 2000; Raphael & Wilson, 2000; Stuhlmiller & Dunning, 2000; Wraith, 2000). Morris (2000, p.321), in exploring this further, advocates the following caution:
In the absence of demonstrated effectiveness for wide population use it is perhaps safest to consider the application of debriefing only in the contexts for which it was originally developed: for stress (not psychological trauma) in emergency service workers.
Mitchell, in particular, has been accused of making critical incident responses a business (Gist & Woodall, 2000; Ostrow, 1996). He was accused of developing a concept that was based on the “Barnum Effect” (after Barnum, of circus fame) where:
A sound basic idea has an attraction all of its own. But if carefully wrapped and cleverly marketed, it can easily become much more than it ever was or ever should have been. Given the illusion of science and precision, through claims of theoretical roots and empirical evaluation, it readily transforms into something with a life and momentum all its own (Gist & Woodall, 2000; p.5).
In response, Mitchell contends that the responses he developed are, by nature, versatile if delivered in the right way:
Clearly crisis intervention techniques can be used in a variety of settings. The comprehensive crisis intervention system called CISM has many applications such as businesses or industries, emergency service organizations, schools and communities (Mitchell & Everly, 2000; p.76).
This ambivalence in viewpoints confirms the need to step back from what is happening and examine what is the best way forward.
The Short Term Nature of the Debriefing Response
Responses have often been one-off sessions for those who have been involved in an incident. Questions have been asked about how a one-off intervention can be measured as effective for participants when gauged against what may be seen to be naturally occurring processes of healing and recovery (McNally, et. al., 2003; Leadbetter, 2002; Taylor, 2002; Rose, et. al., 2001; Armstrong, 2000;
1998; Raphael et. al, 1995). One of the major difficulties with researching this involves methodological considerations. As McNally et. al (2003, p.45) state:
Although the majority of debriefing survivors describe the experience as helpful, there is no convincing evidence that that debriefing reduces the incidence of PTSD, and some controlled studies suggest it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretations of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of the trauma.
The Timing of the Response
There is no empirical evidence that indicates an agreed upon optimal time for a response (Campfield & Hills, 2000; Kaplan, et. al., 2001; Pfefferbaum, 1997). In reality, a whole range of response times is advocated.
On the one hand researchers and writers in this field of practice argue that any intervention needs to be as soon as possible after the event (Annan, 2003; Carlier & Gersons, 2000; Shalev, 2000; Mitchell & Everly, 1996; Robinson & Mitchell, 1993, Stallard & Law, 1993; Poland & Pritchard, 1992; Yule, 1992; Dyregrov, 1998; Talbot, 1990; Burges Watson, 1987; Raphael, 1986; Horowitz, et. al., 1980). Shalev (2000, p.21) adds that recent psychophysiological findings indicate that the “…immediate aftermath is of critical significance” as memories may be consolidated during that time.
On the other hand others say that this immediate response is too soon and should not be conducted in the first two days (Newman, 2005; Rayner & Giarratano, 2002; Bryant & Harvey, 2000). Newman (2005) adds that we should not rush in as people need to be protected by natural opioids that manifest themselves after a shock or trauma.
Still others have indicated preferred times for intervention: Kenardy et. al (1996) advocate 24-48 hours; Paton (1996), Everley (1995), Robinson & Mitchell (1993) and Mitchell & Everley (1996) believe the response needs to be within 24 to 72 hours; Busuttil (1995) suggests 48 to 72 hours after the incident; and then there are those who suggest a longer time span again, maybe up to a few
months after the incident (Lovell, 2000; MacFarlane, 2000; Raphael & Wilson, 2000; Stuhlmiller & Dunning, 2000; Taylor, 2000; Foa & Meadows, 1997).
In light of the responsibility to provide the best possible outcomes for those affected by critical incidents this area of timing responses needs some firmer empirically based guidelines to enable these outcomes to eventuate.
Mandatory Responses
Initially responses were seen to be mandatory. This raised the issues of coercion, informed consent and legal liability (McNally, et. al., 2003) and early proponents have changed this so that only a general information session is mandatory. There is concern, however, that many of the responses that are offered in schools are still mandatory (Rayner & Giarratano, 2002; Kaplan, et. al., 2001; Armstrong, 2000; Stuhlmiller & Dunning, 2000):
Mandatory, inescapable mental health treatment is generally only associated with those found criminally insane or in need of protection of self or society. To refuse to participate, even when voluntary, creates problems associated with the recovery of civil, or workers’ compensation damages. It is inconceivable that the traumatized person is placed in a position of being compelled to receive a therapeutic modality that the provider cannot even guarantee has benign, at best, or positive results (Stuhlmiller & Dunning, 2000; p.27).
Again, if looking at what is best for those affected, then this debate needs to be resolved, especially for teenagers who have different developmental needs than adults and may need more sensitive input than older people who have more coping and emotional resources.
Responses that are Effective for All
Mandatory responses do not have the necessary flexibility given that incidents happen in different settings, communities, cultures and contexts. What is offered in one situation may be counterproductive in the next. This would suggest that responses to incidents needs to be flexible and individually tailored so that the needs of those affected are best met (Rayner & Giarratano, 2002; Calhoun & Tedeschi, 2000; Chemtob, 2000; Stuhlmiller & Dunning, 2000; Wilson & Sigman, 2000; Paton, 1996; Lichtenstein et. al, 1995; Rivers, 1994).
Gist and Woodall (2000, p.90) would agree with this adding that any response needs to be the: “…least formal, least intrusive, and more conservative of available options”.
Further to this, Stuhlmiller and Dunning (2000, p.14) suggest that: “Treatment of all exposed is excessive and ignores the healing effects of natural coping strategies”. This is confirmed by Foy (cited in Butler, 1996; p.44) when he says that: “If people don’t label themselves as abnormal, some will naturally recover if they give themselves six weeks to settle down biologically”.
The provision of debriefing to this particular population is a further consideration. There are variables specific to this age group that need to be considered as part of any response. Wraith (2000) specifically names some of these as being: an inability to have their needs met because of the usual expected compliance to adult expectations; a likelihood that they may find it harder to disengage; that issues of confidentiality will be qualitatively different to that of adults; that adults will need to have different expectations, use suitable modalities, and be aware of the more limited experience-base that is brought to the event, and, in fact, need to be very skilled.
In addition to this, Calhoun and Tedeschi (2000) accentuate the need for safety within the process to allow the young people to participate and express themselves freely.
When providing responses, then, it is necessary to remain cognisant of these special features of adolescents. Stallard (2000, p.222) advocates the recognition of the importance of a fit for adolescents:
Older children, as reported by Casswell (1997) may be more interested in exploring abstract issues that challenge their internal cognitive schema and causal attributions. Debriefing with this age group may need to focus more upon the cognitive and emotional stages thereby allowing causal attributions to be appraised.
The other aspect that we also need to remain cognisant of is that adolescent populations, indeed any population involved in a critical incident, are not all culturally homogeneous. Western-trained traumatologists have been accused of
being ‘culture-blind’ (Silove, 2000; p.339). A response plan, then, that is reliant on a template may not be effective as more flexible responses. (Annan, 2003; Coggan et. al, 2001; Papalia et. al, 2001; Stewart, 2001; Summerfield, 2001; Ober, et. al., 2000; Perren-Klingler, 2000; Silove, 2000; Weisæth, 2000; Stewart, 1999; McCarthy & Hermannson, 1998; Gilliland & James, 1997; Paton & Sylvester, 1996; Wellington, 1996; Lichtenstein, et. al., 1995; Ridling, 1995; Rivers,1995; Klingman, 1993; Dale, 1992). An example of this comes from Summerfield (1995) who questions the use of Western psychological techniques on the world stage when debriefing techniques are used as a panacea rather than analysing the particular situation. Another comes from Perren-Klingler (2000, p.3) who suggested that:
In many cultures, religion offers models or rituals for working through distress after threatening experiences, and facilitates the integration of what has happened. In the so-called first world, where religion plays a less salient role in this respect, psychology and psychiatry have assumed the task of supporting the survivors when difficulties arise in dealing with the aftermath of violence. The consequences are not, however, necessarily positive.
Yet another example comes from Eränen & Liebkind (1993; p 958):
Fatalistic, externalized belief attributions (for example, it is God’s punishment) may result in learned helplessness and the failure to learn alternative ways to cope with the aftermath of a disaster (Caporale, 1987). On the other hand, where the culture emphasizes a belief in an internal locus of causation and effective coping, disaster impacts might be less pathological and lead to more adaptive forms of post-disaster learning and future preparation.
Weisæth (2000, p.48) illustrated this necessity to remain cognisant of culture after he observed a group a Fijian soldiers in South Lebanon processing an artillery barrage:
Among their traditional ways of coping with severe stress, the Fiji culture has the ceremonial use of kawa (sic) drinking, a mild intoxicant, in intense group settings. Observing the obvious value that the interactions in the group had in coming to terms with what had passed made us drop ideas about GSD (Group Stress Debriefing) because we realized that they had their own
have disturbed their own way of working through.
While this example is not related specifically to adolescents in schools it does highlight the need to be focused on what is best for the young people at the time of the incident. Some believe that this indicates that each individual needs to be assessed in their own right and in their own time so that the best possible outcomes are achieved (Smith & Suda, 2002; Armstrong, 2000; Wraith, 2000; Manning, 2000; Stallard, 2000; Violanti, 2000; Weisæth, 2000; Wraith, 2000; Paton & Sylvester, 1996; Raphael, et. al., 1995; Carter & Brooks, 1990). It has been colourfully suggested that:
Forcing issues or squeezing everyone, like toothpaste, through a common intervention orifice, is unlikely to be successful for everyone and for some who could actually benefit the most and indeed (sic), for others, as this paper concludes, may actually be harmful (Manning, 2000; p.2
These then are the issues that are still being debated and developed. The next section looks at the outcomes that may be expected from adolescents, not just after a critical incident and the ensuing response, but as a result of the way they approach problem solving in their lives.