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Critical Incident Stress Debriefing: Helpful, Harmful, or Neither?

        Dear Editor:
        Critical incident stress debriefing (CISD) was developed as a therapeutic technique to be used with first responders after exposure to an excessively stressful or horrific critical incident (CI), the primary goal being to facilitate adaptive coping mechanisms following the CI. Although CISD has a long history and is used in many settings, research studies examining its effectiveness have not supported its continued use. Knowing this, I was particularly concerned after reading “Pediatric emergency department staff preferences for a critical incident stress debriefing” by Clark et al.
        • Clark P.R.
        • Polivka B.
        • Zwart M.
        • Sanders R.
        Pediatric emergency department staff preferences for a critical incident stress debriefing.
        The authors infer in their introduction that research evidence supports the use of CISD for health care providers to decrease negative effects of exposure to a CI. However, research evidence does not support this position. In fact, most researchers have determined that CISD is, at minimum, not helpful. In addition, authors of a meta-analysis, 2 systematic reviews, and a comprehensive literature review on the effectiveness of CISD in preventing negative symptoms following a CI reached the same conclusion: CISD does not improve recovery from exposure to a CI.
        • van Emmerik A.A.
        • Kamphuis J.H.
        • Hulsbosch A.M.
        • Emmelkamp P.M.
        Single session debriefing after psychological trauma: a meta-analysis.
        • Rose S.
        • Bisson J.
        • Churchill R.
        • Wessely S.
        Psychological debriefing for preventing post traumatic stress disorder (PTSD).
        • Bledsoe B.E.
        Critical incident stress management (CISM): benefit or risk for emergency services?.
        World Health Organization
        Psychological debriefing in people exposed to a recent traumatic event.
        Furthermore, the authors of the systematic review and literature review also agree that evidence exists that CISD may actually increase the risk for developing posttraumatic stress disorder.
        • Rose S.
        • Bisson J.
        • Churchill R.
        • Wessely S.
        Psychological debriefing for preventing post traumatic stress disorder (PTSD).
        • Bledsoe B.E.
        Critical incident stress management (CISM): benefit or risk for emergency services?.
        World Health Organization
        Psychological debriefing in people exposed to a recent traumatic event.
        It is for these reasons that the World Health Organization recommends that “Psychological debriefing should not be used for people exposed recently to a traumatic event as an intervention to reduce the risk of post-traumatic stress, anxiety or depressive symptoms.”
        World Health Organization
        Psychological debriefing in people exposed to a recent traumatic event.
        These important and high-strength studies were lacking from the article by Clark et al.
        • Clark P.R.
        • Polivka B.
        • Zwart M.
        • Sanders R.
        Pediatric emergency department staff preferences for a critical incident stress debriefing.
        Unfortunately, much of Clark and colleagues’ review of the literature relies on lower-strength research and nonscientific literature that supports the use of CISD.
        Most research on the effectiveness of CISD is quite old by research and publishing standards, an issue not addressed by Clark et al. Regardless, existing meta-analyses, systematic reviews, and literature reviews need to be addressed in the manuscript when more recent studies are not available, especially when they refute the presupposition of the study. Certainly, more high-quality and rigorous research on this topic needs to be conducted and published. In addition, research has been conducted since the referenced review articles were published, yet none of these are cited in the text.
        • Adler A.B.
        • Litz B.T.
        • Castro C.A.
        • et al.
        A group randomized trial of critical incident stress debriefing provided to U.S. peacekeepers.
        • Tarquinio C.
        • Rotonda C.
        • Houllé W.A.
        • et al.
        Early psychological preventive intervention for workplace violence: A randomized controlled explorative and comparative study between EMDR-Recent Event and Critical Incident Stress Debriefing.
        I believe it is important to note that authors of a soon-to-be-published quasi-experimental study, “Impact of crisis intervention on the mental health status of emergency responders following the Berlin terrorist attack in 2016,” found that those first responders who participated in CISD following their response to a terrorist attack had lower scores on measures of quality of life and higher scores on depressive symptoms.
        • Wesemann U.
        • Mahnke M.
        • Polk S.
        • Bühler A.
        • Willmund G.
        Impact of crisis intervention on the mental health status of emergency responders following the Berlin terrorist attack in 2016. Disaster Med Public Health Prep.
        Although this study would not have been available to Clark et al for their study, it is 1 more piece of evidence showing that CISD is not helpful and may be harmful.
        Those recommending or using CISD in emergency departments need to be fully aware of the evidence refuting the use of CISD and the harm it may do. It was my hope that Clark et al would have addressed the evidence suggesting that CISD is not effective and why it continues to be used, but the article instead appears heavily biased in favor of CISD. CISD may be a sacred cow that needs to be put out to pasture.—Christian N. Burchill, PhD, MSN, RN, CEN, Nurse Scientist II, Office of Nursing Research and Innovation, Cleveland Clinic, Cleveland, OH; E-mail: burchic@ccf.org

        References

          • Clark P.R.
          • Polivka B.
          • Zwart M.
          • Sanders R.
          Pediatric emergency department staff preferences for a critical incident stress debriefing.
          J Emerg Nurs. 2019; 45: 403-410
          • van Emmerik A.A.
          • Kamphuis J.H.
          • Hulsbosch A.M.
          • Emmelkamp P.M.
          Single session debriefing after psychological trauma: a meta-analysis.
          Lancet. 2002; 360: 766-771
          • Rose S.
          • Bisson J.
          • Churchill R.
          • Wessely S.
          Psychological debriefing for preventing post traumatic stress disorder (PTSD).
          Cochrane Database Syst Rev. 2002; 2CD000560
          • Bledsoe B.E.
          Critical incident stress management (CISM): benefit or risk for emergency services?.
          Prehosp Emerg Care. 2003; 7: 272-279
          • World Health Organization
          Psychological debriefing in people exposed to a recent traumatic event.
          • Adler A.B.
          • Litz B.T.
          • Castro C.A.
          • et al.
          A group randomized trial of critical incident stress debriefing provided to U.S. peacekeepers.
          J Trauma Stress. 2008; 21: 253-263https://doi.org/10.1002/jts.20342
          • Tarquinio C.
          • Rotonda C.
          • Houllé W.A.
          • et al.
          Early psychological preventive intervention for workplace violence: A randomized controlled explorative and comparative study between EMDR-Recent Event and Critical Incident Stress Debriefing.
          Issues Ment Health Nurs. 2016; 37: 787-799https://doi.org/10.1080/01612840.2016.1224282
          • Wesemann U.
          • Mahnke M.
          • Polk S.
          • Bühler A.
          • Willmund G.
          Impact of crisis intervention on the mental health status of emergency responders following the Berlin terrorist attack in 2016. Disaster Med Public Health Prep.
          (In press.)

        Linked Article

        • Pediatric Emergency Department Staff Preferences for a Critical Incident Stress Debriefing
          Journal of Emergency NursingVol. 45Issue 4
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            There are significant and negative psychological effects that can occur in nursing staff caring for pediatric patients experiencing critical incidents. Debriefings can provide relief from the stressors caused by critical incidents. Adapting a pre-existing critical incident stress debriefing (CISD) process to ED staff is 1 way to provide staff debriefing.
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        • Response to Burchill Letter
          Journal of Emergency NursingVol. 45Issue 6
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            Thank you for this opportunity to reply to the letter, “Critical incident stress debriefing: Helpful, harmful, or neither?” based on our manuscript, “Pediatric emergency department staff preferences for a critical incident stress debriefing.”1 We are grateful to the author of this letter for their valuable feedback.
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