February 11-14, 1999
Laramie, Wyoming
CONFERENCE PROCEEDINGS
DAY 1 - Afternoon and Evening
Debriefing/Defusing, Mass Casualty And Airline Disasters,
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
ford@psychiatry.uchc.edu
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.
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References
DISCUSSION AND COMMENTS (If you wish to make comments or enter
a discussion about the above presentation, topic and/or materials, please email:
odoc@mailcity.comYour comments will be posted here and others can respond.):
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Gerard A. Jacobs, Ph.D.
Director, Disaster Mental Health Institute
Professor, Clinical Psychology Training Program
University of South Dakota
jjacobs@usd.edu
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.
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References
DISCUSSION AND COMMENTS (If you wish to make comments or enter
a discussion about the above presentation, topic and/or materials, please email:
odoc@mailcity.comYour comments will be posted here and others can respond.):
****************************************************************************************************************
EMAIL: odoc@mailcity.com
