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Rocky Mountain Region Disaster Mental Health Conference

February 11-14, 1999

Laramie, Wyoming


DAY 1 - Afternoon and Evening

Debriefing/Defusing, Mass Casualty And Airline Disasters,

Acute Psychological Intervention Following Traumatic Stressors: Empirical Findings

Julian Ford, Ph.D. Co-Director, Center for the Study of High Utilizers of Health Care Director of Behavioral Healthcare Outcomes Research Director of Outpatient Services Department of Psychiatry 6410 University of Connecticut School of Medicine University of Connecticut Health Center Julian Ford, Ph.D. presented a lecture on "Acute Psychological Intervention Following Traumatic Stressors: Empirical Findings." He discussed the efficacy of debriefing as the result of attendee evaluations and satisfaction surveys. Some of the positive themes and features identified included: enables self-identification of normal stress reactions; enables professional identification of problematic stress reactions and risk factors for clinical disorders; promotes psychological resolution of loss and fear; enhances psychological hardiness; promotes development of coherent trauma narratives; facilitates individual, family, group, and organizational planning for reasonable future preparedness; and enhances social support and group/team/agency cohesion. He discussed these in relation to a number of studies on Disaster Relief Personnel, Paramedics, Firefighters, Law Enforcement Personnel, Medical/Nursing Personnel, and Bank Personnel. Some important general findings reported by Dr. Ford included: * Two-thirds of the Exit Debriefings performed with Red Cross workers were found to be positive. * He made a distinction between PTSD, Shame PTSD and Guilt and Humiliation as factors. * Those workers involved in CISM appeared to do better at Posttest and at 3 month follow-up. * Those involved in CISD tended to do better on depression measures, etc. * Following violent incidents, those receiving defusing early on helped workers return to work. Dr.Ford also discussed debriefing studies using single-group Pre/Post-Design Evaluations involving Disaster Relief Personnel where the majority reported improvement 9 months posttest (Lundin & Bodegard, 1993); bank personnel with 60-80% reduced sick leave and reduced disability claims (Leeman-Conley, 1990); Army Quartermaster survivors of SCUD missile attacks who were 80% clinically improved 20-50% showed posttest symptom reduction (Perconte et al., 1993); and accident survivors (7 adolescent bus crash survivors) following a 2-session debriefing at 3 month follow-up showed reduced RCMAS, Birleson Depression Inventory no change/Mild deterioration on IES (Stallard & Law, 1993). Ford went on to discuss Multiple Group Design Evaluations under two conditions: Non- random Assignment and Randomized Assignment Trials. Under the Non-random Assignment conditions, he discussed the following: Campbell's (1992) study of Paramedics, Firefighters, and Law Enforcement using 3 stress symptom indicators, ETOH and perceived isolation at posttest following CISM vs no CISM. Bohl's (1988) study with CISD vs No CISD with a 3 month follow-up showing depression, anger and stress symptoms. Flannery et al (1996) study of Medical/Nursing Personnel where same day 1:1 defusings resulted in decreased sick leave, accident claims and staff turnover. Two studies were reported involved Disaster Relief Personnel: Kenardy et al (1996) where they did one multi-hour session vs no debriefing and did four follow-ups over a two year period; and Gist et al (1998) who studied single session debriefing vs no debriefing. Two studies were reported on that were done with military personnel: One (Ford et al, 1997) studied Persian Gulf ODS Soldiers at 3-9 months Post-war and used a Follow-up Only Control Group plus a Quasi-Control Group. They used 1-5 Session CBT/Family Therapy plus Large Group Debriefing vs Large Group Debriefing Only. The second study Ford reported on used No Debriefing vs Debriefing (Deahl et al., 1994). It involved British ODS Graves Duty Soldiers who were studied 6 months Post-war using a Quasi-Control Group and 9 month follow-up. Ford reported on two studies involving Disaster Survivors 2-6 weeks post. The first involved Single Multi-hour Debriefing vs No Debriefing using a Wait-list Control Design and Posttest IES (chemtob et al., 1997). The second study was a 2 session Visual-Kinetic Dissociation/Relaxation vs Delayed Treatment. It used a Multiple Baseline Design and Posttest IES (Hossack & Bentall, 1996). Under the Randomized Assignment Trials conditions, Ford discussed the following studies with (a) Positive Findings and with (b) Null/Negative Findings: (a) Family members of emergency service patients were studied using a 20 Minute Debriefing vs No Debriefing using a projective test measuring Anxiety as the posttest measure (Bunn & Clarke, 1979). In another study of family members of emergency service patients 2-10 session of Supportive Counseling constituted one group. Another group received a 60 minute Debriefing Interview, and a third group received No Debriefing. Posttest measures were Langner Psychiatric Screen, Langsley Work Problems, Bradburn Positive/Negative Affect, Traumatic Neurosis Symptoms, Quality of Social Support, and Hospital LOS (Bordow & Porritt, 1979). In a study on Rape Trauma one to two weeks post, 4 Session CBT vs Waitlist or Posttest Only, the Posttest at 3.5 month followup used the PTSD Symptom Scale and BDI (Foa et al., 1997). A study one month post was reported on accident/assault acute stress disorder patients in which 5 session CBT vs 5 session supportive/problem solving counseling were used. A second part studied 5 session CBT, 5 session PE Alone and 5 session Supportive/Problem Solving Counseling. A 6 month follow-up was done (Bryant & Harvey, 1998). (b) The null/negative findings studies reported were: Accident survivors studied 1+ month post. The study used 3-6 Session Debriefing vs No Debriefing and posttest IES (Brom, Kleber & Hofman, 1993). Crime victims were studied less than one month post. This study used a one session Education, Education plus Debriefing and an Assessment Only Control Groups. A 6 and 11 month followup was done using PTSD Symptom Scale, IES and BDI (Rose et al., 1998). A study of burn survivors was reported. It was done 2-19 days post and used 1:1/Couple 0.5-2 hour Debriefing and No Debriefing. It reported 3 and 13 month follow-up using Hospital Anxiety & Depression Scale and IES (Bisson et al., 1997). A study of miscarriage survivors, 2 days post, was reported. It used 1:1 60 minute Debriefing vs No Debriefing and used a 4 month followup using the IES, Hospital Anxiety & Depression Scale (Lee et al., 1996). Motor vehicle accident survivors were studied 1-2 days post. They studied Usual Care vs a one hour Debriefing. They did a 4 month followup using IES, BDI (Hobbs et al., 1996). An additional study using Usual Care vs a one hour Debriefing (Hobbs & Adshead, 1996) was also reported. Posttest at 1 and 3 month followup used IES, BDI and SEQ. Dr. Ford identified some of the critical issues in evaluating acute psychological interventions. These included: * Debriefee self-selection (e.g. overrepresentation of resilient copers who are mildly symptomatic but are possibly at long term risk); * Intervention timing and staging (e.g. premature acute biopsychosocial intervention and risk of peritraumatic imprinting); * Intervention focus (e.g. emotion abreaction vs processing - anger and dissociation vs fear and integration); * Evaluation focus (e.g. symptom reduction vs social integration; risk elimination vs symptom management; single session "fix" vs matching to appropriate level and type of care over time). Some of the potential explanatory models Dr. Ford discussed included: * Exacerbation of psychiatric impairment; * Acute stress disorder; * Peritraumatic dissociation; * Acute PTSD symptom severity; * Information processing fragmentation; * Emotional/cognitive suppression. As a result of the above reviews, Dr. Ford discussed some clinical implications suggested by them. He suggested matching the intervention to the nature and phase of post-traumatic impairment. Intervention models he discussed included: * Biopsychosocial focusing for acute impact; * Cognitive-behavioral remodulation for acute peritraumatic reconstitution (fear/grief, anger, dissociation); * Cognitive-interpersonal-systems facilitation of remoralization and reintegration for peritraumatic readjustment; * Cognitive-narrative therapy for Recovery/chronic PTSD (e.g. fear reactivation processing); * Trauma reactivation integration-assimilation-differentiation therapy (TRIAD) for renewed psychological development/complex PTSD (e.g. self-regulation restoration). On a final note, Dr. Ford talked about what he termed the "White Bear Phenomena" - the more you try not to think about a white bear, the more you will think about a white bear. This has implications for the treatment of intrusive and recurring disturbing thoughts related to trauma. ****************************************************************************************************************
DISCUSSION AND COMMENTS (If you wish to make comments or enter a discussion about the above presentation, topic and/or materials, please email:
Your comments will be posted here and others can respond.): ****************************************************************************************************************

Mass Casualty and Airline Disasters

Gerard A. Jacobs, Ph.D. Director, Disaster Mental Health Institute Professor, Clinical Psychology Training Program University of South Dakota In an evening presentation, Gerard Jacobs, Ph.D. discussed "Mass Casualty and Aviation Disasters". The majority of his presentation focused on the Aviation Disaster Family Assistance Act of 1996. The role of the National Transportation Safety Board (NTSB) was outlined, including the responsibilities of the designated organization (Red Cross) for working with the families of air disaster victims. The general Red Cross Plan was discussed from the initial response of the local chapter through to the rapid response by the Aviation Incident Response Team (AIR Team). The AIR Team response ensures consistent high quality follow through in the following functional areas: * Administration * Mental Health * Mass Care * Staffing * Logistics * Physical Health The AIR Team Mission was presented and discussed: "The American Red Cross AIR Team is dedicated to ensuring the best care and support possible in the immediate aftermath of an aviation disaster for survivors; the families of those on the aircraft; and the rescue, recovery, and affiliated support personnel, as authorized by the Aviation Disaster Family Assistance Act of 1996, and the disaster services policies and procedures of the American Red Cross. The AIR Team will utilize local resources as much as possible, provide opportunities for mentoring, and will assist in building the disaster response capability of the affected unit(s)". (American Red Cross, 1997). AIR Teams have hand selected supervisory personnel, follow a detailed response plan, receive specialized training, are on-call for one month at a time, and provide training for local chapter personnel in distant areas. It is the local chapter that prepares for the initial 8-24 hour period. They are tasked with selecting in advance a Family Assistance Center with adequate facilities and to coordinate in advance lodging for airline and Red Cross personnel. Dr. Jacobs discussed the cooperative preparation necessary nationally, including interactions, cross-training and sharing of response plans between the airlines and the Red Cross. There are a number of Response Sites which would be established: * Administrative - includes Job Headquarters and Staff Processing Center. The Job Headquarters is where the Job Director and function offices will be located. * The Staff Processing Center (SPC) is designed to effectively screen, prepare identification for, train, and generally manage all those interested in participating in the disaster response. * Personnel who work in secure locations will report to the SPC for each shift. After the daily briefing, the workers will be transported to the secure site. At the end of each shift, the workers will be transported back to the processing center for defusing/debriefing before departing for the day. Response Sites include the Family Assistance Center and the Rescue/Recovery/ Morgue. * The Family Assistance Center is set up to provide a safe environment in which families can grieve and/or wait in privacy for information about their loved ones. Mental Health Services are made available for survivors and their families, hotel staff, support staff, and those on the ground who may have been impacted. * Some additional sites which may be provided with Mental Health Services include: ~ Rescue Teams ~ Crash Site ~ Command Post ~ Aircraft Reconstruction Site ~ Morgue Dr. Jacobs also referred to the procedures and sites served by Mental Health Professionals following the Oklahoma City bombing. A final report of the APA Task Force on the Mental Health Response to the Oklahoma City bombing is available from: Jan Peterson APA Practice Directorate 750 First Street Washington, D.C. 20002-4242 Finally, Dr. Jacobs reviewed and discussed the Goals of Intervention, the American Red Cross DMHS Interventions, and transition to long term care. He also emphasized the importance of Self-care for all workers. ****************************************************************************************************************
References DISCUSSION AND COMMENTS (If you wish to make comments or enter a discussion about the above presentation, topic and/or materials, please email:
Your comments will be posted here and others can respond.): ****************************************************************************************************************