By Barbie Humble
If you aren’t going out into the field to do a formal critical incident stress debriefing (CISD) you can still use this approach with patients in your office. It can be used with anyone who has just had a recent exposure to a traumatic event.
Why We Use CISDs
CISDs are used after a traumatic event to prevent post traumatic stress and PTSD symptoms and increasing the mechanisms of psychological and emotion resilience. In the work place Critical Incident Stress Debriefings are used to off-set risk, mitigate fall out and enhance recovery and sustainability in the event of an acute or short term natural work place stoppage. Human Resource directors use debriefings with staff members to support their employees but also for liability reasons. CISDs are frequently used within professions where employees are exposed to acute trauma such as law enforcement, firefighters and military personnel.
When a traumatic event happens CISD providers and teams are put on call or in ready alert. We want to get in within 24 to 72 hours of the event. The further you get out from the 72 hour mark the less effective the CISD becomes. If an adult is exposed to a traumatic event 15% will be vulnerable to getting PTSD. People who experience dissociation immediately following or during the trauma are those at risk for developing PTSD. Dissociation during or following the event will impair the hippocampal ability to integrate the experience into a whole picture of what happened. As will the increase in cortisol and adrenaline. People with disorganized attachments are also a high risk for getting PTSD after trauma.
Many of the people you encounter in doing debriefings aren’t people who would typically make it into your office. First responders are typically ordered into CISDs. When I’m in the field I’m thinking this is the only shot I have at working with this individual.
Place As Resource
I got called on site to the headquarters of an insurance company that had been struck by a horrible tornado. Among many people I saw that day was a woman who could not leave the bathroom. When the tornado hit she sought shelter in the bathroom. Now she couldn’t stay out for longer than 5-10 minutes because she felt too fearful and vulnerable. So we did the debriefing in the bathroom. As her activation level decreased we moved out into the hallway and eventually throughout the office.
I’ve done debriefings in restrooms, under tables, in closets, in emergency vehicles, in the smoking area at offices, next to windows, away from windows, in garages, in churches. My favorite was at 2:00 am. I was debriefing a victim at a factory on third shift while we ate fresh made chips off the conveyor belt. He told the HR direction he wanted to do a debriefing because after the event he found that he couldn’t stop working. If he did his anxiety became too high. So, I started the debriefing there. Once his activation level dropped we moved further out into the factory until we entered the room where the trauma had occurred.
When I start a debriefing either with an individual or with a group I always ask where they feel the most comfortable and the least activated. You can SUDs the location. Then later in the processing we will move out into the place they are most activated and see if there is anything more to process. Note: if you have someone who has dissociated in response to the event, a resource place will help them be less activated.
Several years ago I was sent out on a team to work with folks at a very large tech company. My team mate was set up in a separate room so we didn’t get a chance to connect until after the day was over. Afterwards she said “you were busy all day, and I didn’t see anyone. What’s that all about?” I said, “look at what you and I are wearing.” I was wearing slacks and a sweater, she was wearing a dress, heels with some really nice pearls. In other words, be relatable.
When dispatch calls me they will tell me a little about what happened, who my contact person is and what I should wear and then they ask if I want to take the case. Know your audience. If you go into a law firm and are wearing jeans and sweatshirt they won’t want to work with you because they won’t feel you are credible. If you go into a factory and are wearing a suit they won’t approach you.
Onsite attunement starts with what you wear and how well you fit in. If people want to sit around and eat donuts and talk small talk prior to the debriefing (which there will be a lot of) you need to be able to hang and relate.
The Actual Debriefing
Earlier when we were trained the model used was similar to what is now called the Mitchell Model. It’s more of a psycho-educational. About 12-15 years ago a litigation issue arose when a CEO mandated everyone do a debriefing after a traumatic event. One of the participants sued the company saying they were traumatized from the debriefing. Make sure you ask if people want to participate.
If you are with a team I suggest working with groups of five people per clinician. You can get a splitter with five sets of headphones to attach to it. With a really cohesive group this works really effectively. Make sure before you start to ask the person where s/he feels the least activated and start in the area of the least activation. As you process and get SUDs to a 0 then incrementally move to the place of the most activation.
Use the same set up for individuals and groups. Participants are wearing headphones.
- Start with the patient’s narrative about what happened. The person tells their story of the event, what they saw, heard and did during the incident.
- Ask patients to conceptualize what they heard and saw, share their first thoughts focus on it from the beginning and slowly focus on the events as they unfolded. For example, David Grand uses the movie analogy. Ask the person to run the movie in their mind from right before the incident to now.
- What was the worst part of the event? Use SUDs scale.
- Once the SUDs is a 0 you can move to a more activating place again until the SUDS is a 0 again.
I use generally the same format with children but on site I prefer to use drawings. The sequence would look like this:
- Draw a picture of what happened.
- What were the things you heard and saw? Draw a picture of how things unfolded (all the while they are talking about their picture and what happened).
- Draw a picture of the worst part of the event. SUDs scale.
- If you started in a lower activation place, you may want to move to high activation place until SUDs is a 0.
Be creative with kids. When I worked with teams involved in debriefing those involved in the Columbine shooting I happened to have had my dog in the car. I went into the school which was an elementary school that had been on lock down during the incident. Moving through the school I noticed a lot of hyper-vigilance. I ran back to the car and got my dog. Everyone eased and we sat under tables while the children told the dog their stories.
Post-Debriefing Team Meetings
When working as part of a team, all team members should meet immediately following the debriefing. Review the sessions and assess difficulties or successes. CISD therapists are exposing themselves to highly intense information. It can definitely have an impact on you. It’s not atypical for team members to share info about themselves before and/or after a debriefing so that the rest of the team can be a resource to you.
On occasion the debriefer will need to be debriefed. Typically if the debriefer needs a formal debriefing it’s best to have someone provide that who has not been involved in the debriefing process. Having been trained in EMDR and now brainspotting I have performed debriefings on debriefers. We use the same set up and identify what the worst part of the debriefing experience was for them. Then we SUDs it and process. If you are doing a debriefing alone you can self-spot doing the same: what was the most disturbing part of the debriefing?
My interest in my practice is in psycho-neuro immunology. The amount of stress we expose ourselves to on a daily basis seeing patients let alone our exposure on CISDs are incredibly toxic to our systems. One of the things I do to manage the stress and protect my nervous system from the exposure is to use heart rate variability. I recommend this as a self-monitoring tool for other therapists.
Barbie Humble is a member of RMBI with over 20 years of experience working with children, adolescents, adults, and couples. She is the co-owner of In-depth Therapy & Associates and is trained in EMDR, Brainspotting, Mindfulness, Psycho-Neuro-Immunology and the neuropsychology of the brain.