PTSD Scenario: Trauma and Prevention

Fred W. is a professional counselor who provides some services for an Employee Assistance Program on an outpatient basis. He receives an urgent call from the intake coordinator at one of the EAPs for which he provides services, asking if he can have an immediate session with an employee from one of the client companies of the EAP. The employee is a teller at a bank at which a robbery has occurred, and she has been very much shaken up by the incident. The robber came to her window and showed her a gun inside his coat, demanding all the money at her window and telling her she was going to get shot if she made any attempt to halt the robbery or tell any of the other people in the bank. This was the employee’s first week on the job, and even though she had been trained in how to handle a robbery, she was having a hard time calming herself down after the incident.

Because none of the other employees in the bank even knew that the robbery was occurring, no one else was affected by the incident in any immediate way. Fred is asked to meet the employee, and is given the choice of meeting with the employee at the bank alone or with other employees present, or in his office with either the employee and her manager, or just the employee.

How should Fred approach the decision about how to structure the meeting with the employee and how should he approach addressing the trauma with the bank employee?

The Preventive Approach to PTSD

The National Council of Disability places emphasis on minimizing stress reactions and preventing normal stress reactions from developing into PTSD when they do occur. (National Council on Disability, 2009)

There is still much debate on whether PTSD is preventable. Proponents of the preventive approach argue that with swift mental health care, PTSD can be prevented by forcing the individuals to confront the trauma immediately or shortly after the traumatic event.

The next section will offer some information and background on this model, with discussion to follow on the current research results.

Critical Incident Stress Debriefing (Mitchell Model)

Models of psychological debriefing have emerged from various sources dating back to World War I. (Mirzamani, 2006) Psychological debriefing (PD) has been described as an intervention conducted by trained professionals shortly after a catastrophe and is considered a preventative measure because it forces the individual to face the trauma head on, process the trauma, and thus, perhaps curtail the development of PTSD. (Mirzamani, 2006)

Many providers and response agencies have adopted the Critical Incident Stress Management (CISM) model also known as the Mitchell Model. CISM was created by a former firefighter in the 1970s, and is a formalized seven-phase group discussion pertaining to disaster, critical incident, catastrophe, or traumatic experience. (Everly & Mitchell, n.d.)

The seven cores or phases are outlined by Everly & Mitchell (n.d.) as:

1. Pre-crisis preparation. This includes stress management education, stress resistance, and crisis mitigation training for both individuals and organizations.

2. Disaster or large-scale incident preparedness, including development of school and community support programs, including demobilizations, informational briefings, “town meetings,” and staff advisement.

3. Defusing. This is a 3-phase, structured small-group discussion provided within hours of a traumatic emergency or crisis for purposes of assessment, triaging, and acute symptom mitigation.

4. Critical Incident Stress Debriefing (CISD) This is a structured small group discussion, usually provided 1-7 days post-crisis and designed to mitigate acute symptoms, assess the need for follow-up, and, if possible, provide a sense of post-crisis psychological closure.

5. One-on-one crisis intervention/counseling or psychological support throughout the full range of the crisis spectrum.

6. Family crisis intervention and organizational consultation.

7. Follow-up and referral mechanisms for assessment and treatment, if necessary.

Clinicians who provide services within this model are required to be thoroughly trained in the model, and will typically collaborate with organizations who have in place procedures and protocols for incident response should a critical incident occur. Airlines, city and county police, fire departments, and other private and public entities whose employees work with known safety risks are likely to have the necessary infrastructure in place for CISM services.

The model is designed to work in a collaboration between designated representatives from the organization who are trained to be peer facilitators and mental health clinicians who provide the clinical components of the intervention services. Much of the focus of the clinical work is concerned with leading the Defusing and CISD small group discussions.

The Defusing is a rapid response approach where initial assessment about the impact of the traumatic event can be discerned and preliminary determinations can be made about who might need one-on-one clinical services. The model is set up to work best within a system where referral resources have already been identified and are available as soon as they are needed.

Because some people who are involved in a traumatic incident may have delayed responses to the trauma, the Defusing is usually followed by a formal CISD process. This small group intervention is another opportunity to evaluate who has been negatively affected by the trauma and connect individuals to appropriate referral resources. The CISD also includes a formalized and structured trauma processing approach, where the incident is reviewed, beginning with a fact based – and emotionally distanced – presentation of what happened.

As the session moves forward, the clinical leader of the session gradually introduces some of the emotional material from the traumatic incident, allowing participants to slowly process their emotional reactions in a controlled and emotionally safe environment. The clinician has been trained to monitor the level of affect that gets generated, and slow down the emotional processing if the level of anxiety or fear begins to become too difficult. The theory is that this controlled exposure, first to the facts of the traumatic incidents, then to the responses to the traumatic incident, allows participants to have an opportunity to make sense of the incident and re-establish a sense of psychological mastery and control.

The principles behind CISM are similar to the other models of treatment that have been presented. However, the model is utilized close to the time of the incident, in a highly structured way, and with the participation of many or all of the people who had the same shared experience. Because there can be a broad range of responses, the more reactive trauma survivors may be supported and encouraged by the degree to which less reactive survivors seem to get through the incident without developing symptoms of PTSD.

A thorough program of CISM will include follow up – as needed - with the survivors of the traumatic incident for several weeks or longer pursuant to the incident, as well as the capacity to make available a full complement of family and individual therapy services that can be used over time.

Over the past several years, some criticism has been leveled at the CISM model, with the effectiveness of the model being called into question in some very public forums. (Kagee 2002) ( Jacobs 2004) The developers of the Mitchell Model have responded to this criticism by asserting that the research has evaluated only certain elements of the model, taken out of the context of the approach as an integrated model.

Each side presents empirical supportive evidence to back up their assertions, leaving the question of effectiveness not fully resolved.

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