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Ethically Treating PTSD Resulting from Terroism and other Traumas

Section 5
Critical Incident Stress Debriefing After A Line Of Duty Death
By Carol Fizer

Question 5 | Test | Table of Contents

Carol Fizer worked with rescue workers at the World Trade Center following the September 11th attacks. She is an Independent Clinical Social Worker in the greater Boston area. Carol trained with the International Critical Incident Stress Foundation and Smith College School for Social Work.

A debriefing is essentially a highly structured conversation, which moves from the cognitive to the affective and back to the cognitive level, from person to person around the group. This is done in a series of seven steps:

1. Introduction – this is when the leader tells the group its focus and set the group boundaries. “We are here to talk about Sean’s death in the fire on Monday.”

2. Fact Stage – the leader asks each participant his or her recollection of the trauma. “How did you know something wasn’t right, that Sean was missing?”

3. Thought Stage – the leader focuses on the cognitive reaction. “What was the first thought that came into your mind when you realized that he had not come out of the building?”

4. Reaction Stage - there is more sharing of feeling about the trauma and is usually the most extended in time. “What’s it like to lose a member of your Engine? How is the firehouse doing?”

5. Symptom Stage - the leader asks directly whether group members have had any unusual thoughts or feelings since the event. “What has been going on internally since Monday? Has anything been unusual for you?”

6. Teaching Stage - in this stage the leader tries to normalize symptoms and offer self-help steps. “What you all are feeling, the anger, the sadness, is what happens when someone close to you dies. I want to make suggestions about how you can help yourself feel better.” Specific steps to reduce stress are offered at this point. They include using less alcohol and caffeine, emphasizing the need for exercise and a balanced diet, encouraging communication with friends, and doing activities which feel good or whatever is stress reducing.

7. Reentry Stage - the leader wraps up the group, but leaves open the door for future contact. “Thank you all for being here when you would rather be at home. I know this has been a tough thing to talk about, but it helps. Please feel free to contact us if there is anyway we can be of help in the next days or weeks.” At this point, the group leader may ask to talk privately to targeted group members, for example, someone who is drinking more than usual, or has stopped taking his or her medication and is showing signs of decomposition, or has been reluctant to participate in the group. The remainder of this article contains a narrative as to how I applied the Seven Steps to a group of firefighters.

It had been five days since the trauma took the lives of two firefighters, Sean and Michael, experienced veterans of the department whom all the rest looked up to. There had been two funerals and life had gone on as “normal” in the firehouse, but the chief, James, had heard more than the usual complaints of not sleeping, arguing with family members, meetings at the local bar, and a general sense of tension among the men. James’ attempts to talk about Michael and Sean’s death had been met with a wall of silence. At that point James decided to call the local County Critical Incident Stress Team. As its Mental Health Coordinator, I discussed various options with him and set a time for the next morning to debrief the group of ten firefighters from the house who were all at the fire. We did not include firefighters from other houses since this group had a unique relationship with the two dead men. It was best not to meet in the firehouse, so we met at the Community Center. James arranged for transportation. I contacted Randy, a County Critical Incident team member and a firefighter, who has been trained in Critical Incident Stress Debriefing. Randy works in another town, and we ran through the plan for the debriefing.

Beginning the Meeting: I walked into the meeting room to see nine tired-looking men and one woman. They ranged in experience from young newcomers of the department to seasoned veterans of thirty years. The mix was about half and half. There was minimal conversation, but a lot of cigarette smoking and coffee drinking. Randy, the peer leader, and I worked out who should take the lead. I leapt in with a brief introduction that we were here because of Sean and Michael’s death. I briefly explained that everything that was said was confidential, that we were here for them, and what was happening to them. There was some grumbling from an older man about “psychological crap,” which I just chose to ignore.

Something was Wrong: We initiated a round-robin style group discussion by giving each person the opportunity to speak about when they first realized something was wrong. Each person gave his or her perspective. The general consensus in the group was that during the fire quite a bit of time elapsed before fellow firemen realized Michael and Sean were missing. In fact, it had been at least fifteen minutes after the building evacuation was called since there was so much confusion between the four different companies.

First Thoughts: A second round focused on the first thoughts which popped into their minds after realizing that the two were missing. The responses ranged from who was going to tell their wives to what they would do without them. Several men said nothing.

Sadness, Guilt and Anger: Feelings started to emerge and the conversation focused on how hard it was to go to the funeral and go to work without Sean and Michael. There were feelings of guilt when no one realized that Sean and Michael had been caught in a quick burn. Sadness for their families surfaced, and Julia cried as she talked about seeing the kids at the funeral. The guilt emerged and the focus switched to what could have been done differently. I gently reminded the group that this was not an operational critique, and again talked about how sad it was to lose someone in this way. Ralph turned away, hiding his tears. There was an immediate group response in terms of several people talking about their sadness. The group stopped. I asked what was going on that had stopped everyone in their tracks. A younger firefighter said he really thought their deaths were stupid, they had been doing something risky and left them with this mess. The group tentatively talked about their anger for the guys “who left us.” The group went back and forth between sadness, guilt, and anger, until they all seemed somewhat relieved.

Behavioral Changes: I summarized the feelings they had talked about and moved on to ask them about changes in their behavior and feelings during the past week. I heard complaints of sleeplessness, preoccupation with how “we could have done it differently,” and fears about the “next time the bell rings.” Another person kept wondering whether it could be himself the next time. A joke about nightly trips to the bar made me concerned about Jon’s increased drinking as a response to the situation. Randy addressed the feelings and behavior as a normal reaction to a major loss in their lives that not only affected their work lives, but also their personal lives. “It’s like losing a family member, so you are going to feel this way.” I interjected specific, concrete ways of handling these types of uncomfortable feelings…for example, talking to buddies and family members, as well as doing the activities that help them feel good. These were stressed as ways to get through the next week. The group then spontaneously planned a memorial for Sean and Michael. The group decided to hang Sean and Michael’s pictures in the kitchen, a place where they both liked being. As we ended, I thanked them all for being there and left the door wide open by giving them each our cards for further assistance if they or their families needed it. We said goodbye. As the group lingered to talk, I approached Jon, the person who joked about drinking. He quickly told me that he had not been to an AA meeting, but promised to go at the end of his shift. I told him I would check in with him the next day.

The Seven Stage Critical Incident Stress Debriefing, described by Mitchell in his 1983 article, has been shown to help individuals, like this group of firefighters, move from a traumatic situation back to work life. The debriefing is a group crisis intervention, a healing conversation, not psychotherapy and, when used correctly, shows the potential for reduced symptomatic behavior.

This is a brief overview of debriefing (CISD) which used with other interventions (CISM) can be potentially powerful in helping a wide variety of populations through traumatic situations with a reduced potential for long range symptoms.

NOTE: sentences and phrases are in bold type, in each Section of this Manual, for the purpose of highlighting key ideas for easy reference.

Peer-Reviewed Journal Article References:
Carsky, M. (2020). How treatment arrangements enhance transference analysis in transference-focused psychotherapy. Psychoanalytic Psychology. Advance online publication. 

DeTore, N. R., Gottlieb, J. D., & Mueser, K. T. (2021). Prevalence and correlates of PTSD in first episode psychosis: Findings from the RAISE-ETP study. Psychological Services, 18(2), 147–153.

Hasselle, A. J., Howell, K. H., Bottomley, J., Sheddan, H. C., Capers, J. M., & Miller-Graff, L. E. (2020). Barriers to intervention engagement among women experiencing intimate partner violence proximal to pregnancy. Psychology of Violence, 10(3), 290–299. 

QUESTION 5: When a client’s condition indicates that there is a clear and imminent danger to the client or others, the certified counselor must do what? To select and enter your answer go to Test.

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