Trauma Management and Intervention - Essay Example

TRAUMA MANAGEMENT AND INTERVENTION Background The ominous clutches of trauma hang on gravely into people's lives. Both those who are directly involved in a traumatic incident and those who responded to the emergency and the caregivers are all tortured and anguished. And even society itself is wronged when random and senseless misfortunes are experienced by those among us who are no more vulnerable than we are. A random sample of women from the United States, lifetime exposure to traumatic events was 69%, with exposure to crimes including sexual or aggravated assault or homicide of a close friend or relative at 36% (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Considering the frequency and pervasiveness of trauma, and knowing that it goes beyond time and borders, it is essential for everyone to have full comprehension of the psychological, emotional, and spiritual impact trauma imposes on people, and the treatment methods for repairing the damage. COGNITIVE INTERVENTIONS OF TRAUMA There are varied degrees or levels of cognitive interventions available to trauma victims. It is essential to note though that not everyone exposed to a critical incident will need all four levels of intervention. Not everyone who came through a critical incident will experience the same level of vulnerability. Some victims will feel safer and more in control and some will perform better at a cognitive level than others (Mc Farlane, 1994). Level one - crisis intervention, level two - debriefing, level three - social responsiveness, and level four - structured sensory intervention. The value of crisis intervention was established as early as 1944 by Eric Lindemann (1944). In this level, the most important task is to restore a sense of safety and control, either for the victim or for the responding to the incident. It is initiated immediately after a critical incident and continues for two-to-three days. It consists of organized responses (protocols), dissemination of information, and attending to the emotional needs of those involved. How important is it to have an organized protocol In the midst of trauma, normally cognitive functions are overwhelmed and most of the times disappear because of trauma's sensory nature. In a sense, protocols exist so people don't have to think in the midst of chaos, yet still act appropriately. Protocols, in other words, are the result of an orderly "thinking things through" before they happen, so that appropriate actions are immediate. "A time of crisis is not conducive to improvisation. Prior preparation and orientation of staff members regarding management of a crisis will greatly assist those expected to assume leadership roles and, initiate actions appropriate to the time of need" (Webb, 1986, 476). The second level is debriefing. In research, evaluating the outcome differences between those exposed to debriefing and those who are, those groups who participated in debriefing reported having shorter duration of reactions and less intense reactions. Debriefing can accelerate symptom reduction (Hokanson & Wirth, 2000; Everly & Mitchell, 2000; Eid., Johnson, & Weisaeth, 2001). Debriefing is generally reserved for the most exposed. There are four possible ways to be exposed, 1) as a surviving victim - victim of physical/sexual abuse, other assaults, community violence, critical injuries, catastrophic situations, etc., 2) as a witness to any potential trauma-inducing incident; violent or non-violent - murder, suicide, assault, car fatality, bus tragedy, house fire, drowning, etc., 3) being related to the victim - as a family member friend, or peer. ("Being related" can also include one's perceived similarity to or personal identification with victims.) Milgram and associates (1988) found in their study following a tragic school bus accident that "personal involvement" with the victims, rather than the incident itself, increased the level of prevalence. 4) Verbal exposure - Saigh (1991) found that listening to the details of traumatic experiences, traumatic stress reactions can be induced. This is especially true for professionals responsible for intervention with traumatized children. People who are exposed to repeated media coverage of details and survivors, understandably still may be vulnerable to trauma reactions. Level three, social responsiveness, is not a formal intervention for persistent reactions, however, it happens in tandem with debriefing. It applies itself to the general population who needs to do something to feel better. These activities are spontaneous. In most cases, they begin three or four days following the critical incident, but can begin earlier. They are sensory in nature, in the sense that participants are actively involved in doing something in response to the trauma experienced. For instance, after the 9/11 incident, blood drives were instigated, monies were gathered, letters written, pictures drawn that were then sent to victim's families and students in the attack area, vigils were held, and community forums addressing cultural and religious issues triggered by the attack were organized. It is this kind of response at a sensory level that helps return a sense of control and power to those who were left feeling defenseless following exposure. They can help to empower not just individual victims and/or participants, but the whole community. They can likewise provide the opportunity to teach people about the value of life, respect for diversity, generosity of spirit, care for others, and how to pool resources, act as a team and work together to support one another in a time of crisis. They generate a social conscience as well as help teach everyone difficult but enlightening lessons. They help restore a sense of hope. They become a way to help the "negativity" and "impotence" survivors can be left with immediately following exposure (Rowlands, 1998). They assist in "gaining control of the intense emotions and sense of helplessness that follow community disaster" (Austin, 1992). For immediate survivors, the outpouring of support helps to validate the value of the sacrifices made by their loved ones (van der Kolk, 1996). The fourth level, structured sensory intervention, may not help individuals with more intense or severe levels of trauma reactions. For some, it may even delay reactions. This lind of intervention responds to those victims who are experiencing PTSD weeks following exposure, even months or years later and to those who may not fulfill the criteria for PTSD but are, in fact, experiencing one or more trauma-specific reaction and/or delayed grief reactions (traumatic grief). Further, this level of intervention can actually be used with those who have been exposed to a singular incident or chronic multiple trauma situations. The restoration of a sense of safety and power is a primary concern in the program. The activities are primarily sensory, as trauma is experienced at a sensory level, not a cognitive level, however, the structure of the intervention, directs those sensory experiences into a cognitive framework, which can then be reordered in a way that is manageable and can provide empowerment (Steele & Raider, 2001). This intervention "is structured because with structure comes a sense of control and safety" (Steele & Raider, 2001, p. 63). Trauma-specific questions are used to help the victim give their experience a language, to tell their story. Sensory activities are used to help the victims make us a "witness" to what the experience was like. Once those tasks are completed, the victim can now think differently about what happened. STRESS INCIDENT, CRITICAL STRESS INCIDENT DEBRIEFING & CSI MANAGEMENT Incident Stress Critical incident stress has been called by many names in the past, including; shellshock, combat fatigue, traumatic stress and most recently, posttraumatic stress (Kates, 2000). This kind of stress has been depicted as being a normal reaction to an abnormal event. It is a type of stress encountered at incidents that are capable of causing serious injury or death (Mock, 2000). It is characterised by a very intense arousal subsequent to a traumatic stressor or trauma. Traumatic stress overwhelms the body's coping mechanisms, leaving individuals feeling out of control (Everly & Mitchell, 1998). This stress can occur in victims, witnesses, responders, family members and others. By its nature, posttraumatic stress may represent one of the most severe and incapacitating forms of human stress known (Volpe, 1996). At any given time, estimates have it that 15-32% of all emergency responders will be dealing with a reaction to posttraumatic stress, subsequently there is a 30-64% chance that they will have a reaction to it during their lifetime (Mock, 2000). In addition, law enforcement officers have a 20-30% chance of developing Posttraumatic Stress Disorder during their careers (Brumback, 1999). With that, exposure to one critical incident does not mean a responder will have a stress reaction (Pulley, 2000). For example in law enforcement, one incident may cause a stress reaction in one officer, but not in another officer who witnessed the same thing. It may take an officer being exposed to several traumatic incidents before he/she has any type of reaction. Nevertheless, if ignored or left untreated, this stress can lead to Posttraumatic Stress Disorder (Kates, 2000). Public safety administrators have started to recognise the need to help the responders with their emotional well-being. They realise that a physically and emotionally fit employee is more productive and efficient. They are beginning to ask their commanders, "What assistance is available for emergency responders who are experiencing this harmful critical incident stress" Critical Incident Stress Management (CISM) stands for an all-inclusive system of interventions, which are crafted with the objective to prevent and/or alleviate the unpleasant psychological reactions that usually comes with public safety functions. According to the International Critical Incident Stress Foundation (2000), CISM interventions are particularly directed towards the alleviation of posttraumatic stress reactions. CISM works to decrease the effects of critical incident stress early on, before reactions become deeply imbedded in the psyche and emotional set-up of an individual. CISM is devise to be "comprehensive." By using the term comprehensive, it means the CISM program runs the entire three phases of the crisis spectrum: the pre-crisis phase, the acute crisis phase, and the post-crisis phase (Everly & Mitchell, 1998). It is founded on the belief that crisis intervention techniques should have multiple components to achieve maximum effectiveness. Adapted from Everly & Mitchell, 1997 The most common type of intervention in use today is the one referred to as debriefing. Debriefings are group meetings or discussions about a traumatic event (Mitchell & Everly, 1998). Critical incident stress debriefing, or CISD, has been organisationally formalised for law enforcement and emergency services by Jeffrey Mitchell and his colleagues (Mitchell & Bray, 1990; Mitchell & Everly, 1998). The "Mitchell model" of CISD is now implemented in public safety departments throughout the United States, Britain, and other parts of the world. Using the Mitchell model, following a critical incident, there are several elements a supervisor can use to decide if he/she will provide a debriefing for personnel. These include situations wherein: (1) many individuals within a group appear to be distressed after a call; (2) the signs of stress appear to be quite severe; (3) personnel demonstrate significant behavioral changes; (4) personnel make significant errors on calls occurring after the critical incident; (5) personnel request for help; (6) the event is unusual or extraordinary (Miller, 1999). The composition of a CISD normally includes the presence of one or more mental health professionals and one or more peer debriefers, i.e. fellow police officers or emergency service workers who have been trained in the CISD process and who may have been through critical incidents and debriefings themselves. A conventional debriefing takes place within 24-72 hours after the critical incident, and comprises of a single group meeting that lasts approximately 2-3 hours. Shorter or longer meetings are determined by the circumstances (Mitchell & Everly, 1998). The debriefing is completely confidential, and is viewed as a tool to assist the reduction of human suffering. The debriefings are structured group meetings that accentuate the airing out of emotions and discussion of other reactions to a critical event. The formal CISD process consists of seven standard phases: Introduction - In this phase, the team leader introduces the CISD process and approach, motivates participation from the group, and sets the ground rules by which the debriefing will operate. Basically, these guidelines entail matters of confidentiality, attendance for the full duration of the group, however with non-forced participation in discussions and the establishment of a supportive, non-critical atmosphere. Fact Phase -- During this stage, the group is asked to concisely describe their job or role during the event and, from their own viewpoint, some facts regarding what happened. Normally, a few individuals provide core facts while others fill in the missing details (Pulley, 2000). The basic question is: "What did you do at the scene" Thought Phase - It is in this phase that emotional aspects are being touched. The CISD leader asks the group members to discuss their first thoughts during the crucial event: "What went through your mind after you came back from auto-pilot" Reaction Phase -- This point of the activity is designed to move the group participants from the predominantly cognitive level of intellectual processing into the emotional level of processing. Questions like "What was the worst part of the incident for you" triggers the emotional outpouring. This is the most intense phase of the process. Critical Incident Stress Phase -- listening to others talk about their feelings during this segment of the debriefing will be beneficial in and of itself. Many participants will discover that the reactions they had or are currently experiencing are similar to the feelings and reactions of their peers. Symptom Phase -- This phase begins the movement back from the predominantly emotional processing level toward the cognitive processing level. Participants are asked to describe their physical, cognitive, emotional, and behavioral signs and symptoms of distress which appeared (1) at the scene or within 24 hours of the incident, (2) a few days after the incident, and (3) are still being experienced at the time of the debriefing: "What have you been experiencing since the incident" is the main question that must be answered and elucidated in detail. Teaching Phase -- Information is exchanged about the nature of the stress response and the expected physiological and psychological reactions to critical incidents in this stage of the process. Here, the process of critical incident stress, stress reactions, and techniques to decrease stress are explored and extensively discussed. This serves to regulate the stress and coping response, and also provides a basis for questions and answers: "What can we learn from this experience" Re-entry Phase -- This is a wrap-up, in which any additional questions or statements are addressed, referral for individual follow-ups is made, and general group solidarity and bonding are reinforced. This is the time to ask "How can we help one another the next time something like this occurs" and "Was there anything that we left out" Timing and appropriateness are exceedingly vital for a successful debriefing. The consensus from literature supports scheduling the debriefing toward the earlier end of the recommended 24-72 hour window (Pulley, 2000). To keep the focus on the event itself and to reduce the potential for singling-out of individuals, some authorities recommend that there be a policy of mandatory referral of all involved personnel to a debriefing or other appropriate mental health intervention (Horn, 1991). However, in some scenarios, mandatory or enforced CISD attendance may lead to passive participation and resentment among the assigned personnel, and the CISD process may quickly become a boring routine if used indiscriminately after every incident, thereby diluting its effectiveness in those situations where it really could have helped. Departmental supervisors and mental health consultants must use their common sense and knowledge of their own personnel to make these kinds of judgment calls. The efficacy of CISD has been empirically validated through qualitative analyses, as well as through controlled investigations (Everly & Mitchell, 1997). However, CISD is not meant to be the cure all for every officer. It may satisfy the needs of some officers, and only start the healing process for others. CISD debriefers are trained to recognise and identify those officers who may need additional assistance. After the formal debriefing is complete, the debriefers will stay behind and have a talk with those officers who want to speak to them on a one-on-one basis. Other issues about CISD focus on how the intervention may exacerbate anguish. When CISD is provided in a group format, attendees have different degrees of familiarity with each other and the group is led by a team trained in CISD. The team includes formally trained mental health professionals as well as, in most cases, a layperson who works in the same field, or someone familiar with individuals affected by the PTE. Although the idea of including peer support personnel seems sensible, this feature has been censured strongly because it can, in theory, create dual relationships and may make some attendees feel unsafe, which may be counter-therapeutic and possibly unethical. Formally, the goal of including peer support personnel in a CISD team is to enhance the team's credibility and legitimacy in terms of particular work cultures. It is quite possible that this feature is very important in many work contexts, although it also seems likely that it constrains the extent to which emotionally salient or inadvertently incriminating experiences are shared for some. Another concern about how CISD is implemented is that if individuals are mandated or subtly coerced by their employers to attend a debriefing session, it raises the possibility that choice and control are taken from some traumatised people, which is likely to create frustration, anger, and resentment, as well intensify the experience of victimisation. It should be noted that the formal CISD literature highlights the fact that debriefing attendance is voluntary. However, volunteer status may be affected by work cultures not known to CISD personnel. For instance, overt and strong support from supervisors and administrators may impact decisions about participation. A related criticism of CISD is that an individual who is reluctant to reveal personal information may feel disgraced and pressured by the group's expectations. In this context, sharing of personal experiences may have harmful, rather than helpful, consequences (Young & Gerrity, 1994). One of the confusing issues in the implementation and execution of CISD is the process whereby an individual (or group of individuals) is found to be appropriate for CISD. Again, formally, CISD is designed only for use with emergency service workers (fire fighters, rescue personnel, emergency room personnel, police officers, etc.), although the CISD training also describes CISD as appropriate for witnesses to critical events and bystanders who suddenly become helpers by virtue of their being in a particular place at a particular time. The literature underscores that "direct victims" of critical incidents, family members of those seriously injured or killed, and those seriously injured in trying to respond to an incident require more extensive treatment and should not attend a CISD. These so-called "direct victims" are dealt with in unspecified ways within the broader treatment framework of CISM. Nonetheless, it is not clear whether those who practice CISD apply the intervention only to individuals secondarily exposed to trauma (Dyregrov, 1999). One of the predominantly appealing qualities of the CISD framework is the special attention given to the distinct needs of workers at risk for exposure to others' direct trauma and suffering, targeting the intense strain and stress of emergency and disaster relief activity. It also responds to the need for organisations to address the needs of their workers and to maintain cohesion and morale. A good example would be the Red Cross workers responding to grief stricken and horrified family members of victims of the terrorist attacks in New York City and at the Pentagon on September 11, 2001. The psychological burden of such work is extensive, and the CISD framework has provided a systematic structure to address the emotional needs of helpers in organisations such as the Red Cross. Nevertheless, a few have contended that advocates of debriefing fail to identify sufficiently the natural resiliency of emergency care workers and their capacity to find adaptive individualised and personal ways of managing their reactions to the stressful demands of their duties. In the CISD framework, the types of events that constitute "critical incidents" warranting CISD are unclear, and it is uncertain how, within a given occupation or work-system, "direct victims" of trauma are actually screened. In like manner, the CISD model assumes that direct or primary victims are inappropriate for CISD because some measurable physical, cognitive, or emotional quality of the "victim" experience makes the CISD process inadequate or unsuitable. If that viewpoint is to be taken in, then operationally defining what represents direct exposure becomes crucial. It appears that the distinction between a primary and a secondary victim within the CISD framework hinges superficially on whether there is physical injury, which is inappropriate, given the vast literature about the long-term consequences of psychological trauma. It has been maintained that initiatives to categorically distinguish direct (primary) and indirect (secondary) victims will be difficult if the intervention is intended to address psychopathological responses. If early intervention is to afford individuals who do emotionally challenging emergency work an opportunity to maintain group cohesion, as well as share and receive information about adaptive coping, then focusing on emergency workers seems an appropriate goal. On the other hand, if the intervention is to target pathological responses to trauma, then it does not appear justified to determine eligibility for early intervention in terms of one's type of involvement in the trauma. References / Readings Austin, L. (1992). Responding to disaster: A guide for mental health professionals. Washington, D.C., American Psychiatric Press, Inc Eid, J., Johnson, B., & Weisaeth, L. (2001)."The effects of group psychological debriefing on acute stress reactions following a traffic accident: A quasi-experimental approach." International Journal of Emergency Mental Health, 3, pp. 145-153. Everly, Jr. G.S. & Mitchell, J.T. (2000). "The debriefing "controversy" and crisis intervention." International Journal of Emergency Mental Health, 2, pp. 211-225. Hokanson, M. & Wirth, B., (2000). "The critical incident stress debriefing process for the Los Angeles county fire department: Automatic and effective." International Journal Of Emergency Mental Health, 2, 4, pp. 249-257. Lindemann, E. (1944). "Symptomatology and management of acute grief.". American Journal of Psychiatry, 101, pp.141-148. Mc Farlane, A.C. (1994). "Helping victims of disasters." In Freedy, J.R. & Hobfoll, S.E. (Eds.) (1994). Traumatic Stress: From theory to practice. New York. Plenum. Miligram, N., Toubiana, Y., Raviv, A., & Goldstein, I. (1988). Situational exposure and personal loss in children's acute and chronic stress reactions to a school bus disaster. Journal of Traumatic Stress, 1, 339-351. Rowlands, M. (1998). "Trauma memory and memorials." British Journal of Psychotherapy, 15, 1 Saigh, P.A. (1991). "The development of posttraumatic stress disorder pursuant to different modes of traumatzation." 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Law enforcement traumatic stress: Clinical syndromes and intervention strategies. Available: http://www.aaets.org/arts/art87.htm Everly, G. S. & Mitchell, J. T. (1992). "The prevention of work-related Post-Traumatic Stress: The critical incident stress debriefing process (CISD)." Paper presented at the Second APA/NIOSH Conference on Occupational Stress, Washington, D.C., November. International Critical Incident Stress Foundation, Inc. (2000). CISM information pamphlet. Ellicott City, MD: Chevron Publishing Corp. Mitchell, J. T. (1991). Law enforcement applications for critical incident stress teams. In J. T. Reese, J.M. Horn & C. Dunning (eds.). Critical incidents in policing Washington, DC: USGPO. Read More