Journal of Mental Health (2001) 10, 3, 351362

A field study of critical incident stress debriefing versus

critical incident stress management

DAVID RICHARDS

School of Nursing Midwifery and Health Visiting, University of Manchester, Manchester,

UK

Abstract
This prospective field trial compared two post-trauma support systems following armed robberies
Critical Incident Stress Debriefing (CISD) as a stand alone group intervention and integrated Critical
Incident Stress Management (CISM) delivered to two groups of raided employees. Morbidity was
measured using two measures of post-traumatic stress and a general health measure. Morbidity in both
groups was equivalent at day 3 and one month post-raid. The CISM group had significantly less post-
trauma morbidity at follow-up (312 months post raid) compared to CISD alone supplying evidence
for the superior efficacy of postdisaster interventions when these are delivered in an integrated CISM
format. Calls to cease debriefing are premature and integrated CISM systems should now be the
subject of randomised controlled studies.

Introduction (OBrian & Hughes, 1991) to 30.6% (Kulka,

et al., 1990); in survivors of natural disasters,
The effect of traumatic events on psycho- 28% in flood victims (Green et al., 1990) to
logical wellbeing is well established. Epide- 59% of tornado survivors (Madakasira &
miological studies have suggested that the OBrien, 1987) and after terrorist attacks,
prevalence of Post-Traumatic Stress Disor- where 50% of survivors had PTSD 6 months
der (PTSD) in the general population is be- after the event (Curran et al., 1990).
tween 1% and 3% (Davidson et al., 1991; Crime victims are also vulnerable, with the
Helzer et al., 1987). Disaster survivor studies prevalence of post crime PTSD estimated as
estimate that 22% to 50% of victims suffer 5.5% for American men and 11.5% for women
from PTSD (Curran et al., 1990; Raphael, (Norris, 1992). Sexual crime consistently
1986). In one study 46% of motor vehicle produces high psychological morbidity of up
accident victims suffered from PTSD plus a to 47% PTSD in those assaulted (Rothbaum
further 20% with sub-syndro mal PTSD et al., 1992). In a study of 4,008 American
(Blanchard et al., 1995). Other studies have women (Resnick et al., 1993), 69% had expe-
shown high levels of PTSD after traumatic rienced at least one traumatic event during
events, for example: in war veterans, 22% their lives and of these 17.9% met lifetime
Address for Correspondence: Dr David Richards, Senior Lecturer, School of Nursing Midwifery and Health
Visiting, University of Manchester, Coupland III, Oxford Road, Manchester M13 9PL, UK. Tel: 0161 275 7589;
Fax: 0161 275 7566; E-mail: David.A.Richards@man.ac.uk

ISSN 0963-8237print/ISSN 1360-0567online/2001/030351-12 Shadowfax Publishing and Taylor & Francis Ltd
DOI: 10.1080/09638230020023868
352 David Richards
and 6.7% met current PTSD criteria, giving a
total population PTSD prevalence of 12.3%
lifetime and 4.6% current. European studies
of crime victims on this scale are absent but
smaller scale studies tend to concur with
those from the US. For example, Fisher &
Jacoby (1992) found that 23% of bus crews
subject to violent assault developed PTSD
compared to no cases in a control group of
non-assaulted crews. Brewin et al. (1998)
found that 20% of crime victims met criteria
for PTSD 6 months after their trauma.
The last 15 years have seen significant
advances in the development of treatments
for PTSD. Major controlled studies have
demonstrated the efficacy of a range of treat-
ments, particularly those based on cognitive
behavioural approaches (Foa et al., 1991;
Keane et al., 1989; Marks et al., 1998). The
main techniques studied have been (a) pro-
longed exposure, where the patients re-expe-
rience their traumatic memories until habitu-
ation and emotional processing are complete;
(b) stress inoculation training, where patients
are instructed in symptom management tech-
niques; and (c) cognitive restructuring, where
patients are helped to consider alternative
interpretations of the incident itself, the world
and their own self image.
Early intervention or crisis intervention
services (Raphael, 1986) have been devel-
oped with the explicit aim of reducing the
initial psychological impact of trauma and to
prevent the development of long-term mor-
bidity. A common organisational response to
traumatic stress has been the development of
Critical Incident Stress services including, as
a major component, Critical Incident Stress
Debriefing (CISD) based on Mitchells work
(Mitchell, 1983) with emergency service per-
sonnel. CISD is defined as a meeting of those
involved in a traumatic event which aims to
diminish the impact of the event by promot-
ing support and encouraging processing of
traumatic experiences in a group setting. It
attempts to accelerate recovery before harm-
ful stress reactions have a chance to damage
the performance, careers, health and families
of victims (Busutill & Busutill, 1997). It is
recommended that CISD be incorporated into
an integrated system of pre-incident training,
initial post-incident defusing, group debrief-
ing and further counselling, referred to by
Mitchell & Everley (1997) as Critical Inci-
dent Stress Management (CISM).
Unfortunately, the evidence base is gener-
ally characterised by a lack of robust control-
led evidence for the efficacy of early inter-
ventions in traumatic stress CISD or CISM.
The efficacy of CISD in particular is a matter
of debate. Recently, several randomised con-
trolled trials have demonstrated that, when
CISD was carried out with individual trauma
victims rather than in groups it produced
either no improvement compared to controls
(Brewin et al., 1998; Hobbs & Adshead,
1996) or, had the potential to cause signifi-
cant harm to those debriefed (Bisson et al.,
1997). These studies have led to claims that
CISD is an ineffective crisis intervention
technique which should be discontinue d
(Avery & Orner, 1998; Wessley et al., 1998).
Mitchell and others (Mitchell & Everley,
1997) have criticised these studies on the
grounds that they sacrifice internal validity
for experimental control, participants are self-
selected, CISD timing is outside that recom-
mended and debriefers appear inadequately
trained.
However, there are also methodologica l
objections to those studies which purport to
show CISD delivered in a CISM framework
in a positive light (e.g. Bohl, 1991; Chemtob
et al., 1997; Robinson & Mitchell, 1993)
including participant self-selection, variable
intervention timings and a lack of control
comparison groups. Essentially, the debate
hinges on the degree to which trade-offs

between experimental purity and realistic
field trial methodologies are acceptable and
valid and which research approaches pro-
duce the most reliable, generalisable find-
ings. As noted by Chemtob et al. (1997),
despite the desirability of randomised con-
trolled trials, post-event environments re-
quire special sensitivity which may preclude
randomly withholding treatment from a con-
trol group.
Despite the debate, there are no published
studies where the single-shot CISD used by
the negative effect studies is compared di-
rectly with an integrated CISM system cited
by the positive effect studies. This paper
reports the results of a field trial of CISD
delivered as a stand alone intervention com-
pared to an integrated CISM system with
victims of armed robbery.
Method
A prospective field trial of CISD alone
compared to CISD integrated within a CISM
system was conducted with victims of armed
robberies working in a major financial serv-
ices company in the UK. Concerned by
increasing levels of crime in the early 1990s
the company had rapidly introduced a single
intervention CISD response, which operated
for 16 months before a more comprehensive
CISM system could be developed. Thereaf-
ter, a CISM system of pre-raid training, CISD
and additional individual repeat assessment
and advice sessions one month post-raid was
introduced. This developmental change in
service delivery, therefore, afforded an op-
portunity for a pragmatic, field trial where the
constraints of providing a routine service to a
sensitive post-event environment allowed
neither randomisation nor a no-treatment
control condition to be introduced. However,
routine outcome measures and protocol based
interventions facilitated comparative outcome
evaluation of the two interventions .
Field trial of CISM v. CISD 353
Sample
Intervention 1: CISD alone, 225 people;
intervention 2: integrated CISM, 299 people.
There were no differences between the groups
on age, gender or employee grade. The mean
age per group was 31.40 years (SD 8.33) for
CISD alone v. 32.50 years (SD 9.60) for
CISM. The sample was overwhelmingly
female (91.80% v. 88.00%) with 80.5% in
lower paid clerical grades (82.3% v. 79.1%)
and less than 20% overall in supervisory or
management grades (17.7% v. 20.9%). The
raid experiences were remarkably similar.
While all the employees had been directly
confronted by the raider or raiders, no fire-
arms had been discharged, there were no
physical injuries and none of the incidents
involved hostage taking.
Interventions
Intervention 1: CISD alone
This was a structured group meeting of all
employees working in a raided branch and
closely followed the Mitchell model of de-
briefing a seven stage process where par-
ticipants are encouraged to talk about the
incidents facts, their thoughts, their emo-
tions and stress reactions, followed by symp-
tom education and re-entry or session clo-
sure. CISD took place in the branch environ-
ment a mean of three days after the robbery,
was conducted by DR or one other trained
debriefer and lasted 1.5 2 hours.
Intervention 2: CISM
CISM was an integrated programme of (a)
pre-trauma training, (b) CISD and (c) indi-
vidual follow-up.
(a) All employees working in customer fac-
ing environments were given a pre-raid
training programme based on stress in-
oculation training (SIT) principles
(Meichembaum, 1985). Staff were trained
in groups, facilitated by the branch man-
ager, and shown videos of real and en-
354 David Richards
acted robberies together with instruction
on procedural and anxiety management
coping strategies. Each employee was
given an individual workbook, which con-
tained information and exercises on cop-
ing with robberies. The training took
place in four monthly parts with home-
work exercises between each training ses-
sion.
(b) CISD was identical to that delivered in the
CISD alone group.
(c) Each raided employee received an indi-
vidual counselling session, lasting between
0.5 and 1 hours, 1 month after the robbery.
In this session the same debriefer assessed
the employees recovery and identified
any ongoing difficulties. Individually tai-
lored advice and guidance was given,
structured around a cognitive-behavioural /
problem focused model of intervention .
For example, employees with sleep diffi-
culties were advised on sleep hygiene;
those experiencing nightmares instructed
on nightmare relief; avoidant employees
given advice on prolonged exposure.
Note: All interventions were delivered as
part of the companys standard support pro-
cedure. The company had a history of pro-
viding employee care and counselling after
raids. As raids increased in frequency, em-
ployees expected to be given support and
almost no one refused to take part in either
CISD or CISM. Employees worked in close
knit teams where supporting ones colleagues
was seen as a key element of the occupational
culture which typified the day to day working
environment. While refusal to participate
was always an option, only five people de-
clined to take part in CISD and two people in
the initial CISD element of CISM. Of the 299
people in the CISM condition offered indi-
vidual counselling one month after the raid,
50 declined stating that they did not feel they
needed to be seen by the debriefer again as
they were in no need of further assistance. In
the CISM condition, pre-raid training was
timetabled as part of the overall training
structures used to deliver other training such
as financial product training. No employees
raided in the CISM condition had previously
refused to take part in the training.
Measures
All raided employees completed standard
health questionnaires at day 3 post-raid, im-
mediately before the start of the CISD. Ques-
tionnaires were also collected 1 month after
the raid and at 3, 6 and 12 months post raid.
The Impact of Events Scale
The impact of events scale IES (Horowitz
et al., 1979) is a 15-item scale measuring both
intrusive and avoidant symptoms of post-
traumatic stress. Respondents were asked to
rate on a 0, 1, 3, 5 scale how often 15 state-
ments such as I had waves of strong feeling
about it or I tried not to talk about it were
true for them. Scores above 26 are regarded
as indicating significant clinical psychopa-
thology (Corneil et al., 1994).
The Post-traumatic Stress Scale
The post-traumatic stress scale PSS (Foa
et al., 1993) is based on the DSM (III) R
diagnostic criteria for PTSD (APA, 1987). It
asks respondents to score on a 0, 1, 2, 3 scale
how troubled they are by symptoms such as
distressing dreams or avoiding activities
and situations which remind you of the event.
The General Health Questionnaire - 28
(GHQ-28)
The GHQ-28 (Goldberg & Hillier, 1979) is
a 28 item measure of psychological distur-
bance consisting of four, seven-item sections
which relate to psychosomatic symptoms,
anxiety symptoms, social functioning and
depression. Scoring is 0, 0, 1, 1 for each item.
A score of four or above is regarded as
indicating a significant level of psychiatric
caseness
 Field trial of CISM v. CISD 355

Results t=0.38, NS). Therefore, the following tables

Calculation of follow-up scores
Because of declining response rates to ques-
tionnaires at 3, 6 and 12 months a composite
measure of follow-up was computed. Re-
peat measures t-tests determined the point
where there was no significant difference
between measures over time. In all meas-
ures, this point was reached 3 months post-
raid, when scores remained stable at subse-
quent time points (IES: 3 month x 6 month,
t=1.30, NS; 3 month x 12 month t=0.14, NS;
PSS: 3 month x 6 month, t=1.04, NS; 3 month
x 12 month t=0.09, NS; GHQ: 3 month x 6
month, t=0.95, NS; 3 month x 12 month
present data from day three, 1 month post-
raid and a composite follow-up score where
each individua ls follow-up score was com-
puted by taking the mean score from those
they returned at one or more of the 3, 6 or 12
month points.
Outcome at CISD, 1 month and follow-
up
Table 1 details the mean scores, standard
deviations and responder numbers to all three
questionnaire measures at day three, 1 month
and follow up points. Data is presented for
the complete sample (n=524) and the smaller
sample (n=217) for whom data is available
from all three time points.

Table 1: Outcome measures post raid for both intervention groups at day 3, 1 month and follow-
up, total sample and sample of respondents who returned data at all three time points.

Measure Subscale Total sample Sample with complete data set

CISD alone CISM CISD alone CISM
Day 3 Immediately post-raid
n=225 n=299 n=75 n=142
IES Intrusion 17.44 (9.17) 18.25 (9.05) 18.79 (8.29) 18.60 (8.89)
Avoidance 14.17 (9.14) 15.26 (9.66) 14.16 (8.59) 15.46 (9.58)
Total 31.61 (16.45) 33.52 (16.52) 32.95 (15.10) 34.06 (16.34)
PSS 13.87 (9.57) 15.38 (10.71) 14.39 (8.35) 15.52 (10.85)
GHQ 7.33 (6.53) 7.92 (6.57) 8.24 (6.14) 7.71 (6.59)
1 month post raid
n=114 n=249 n=75 n=142
IES Intrusion 4.77 (6.52) 6.05 (7.00) 4.48 (6.44) 5.31 (6.22)
Avoidance 3.68 (6.66) 5.08 (7.72) 3.60 (6.25) 4.17 (6.55)
Total 8.46 (12.00) 11.13 (13.83) 8.08 (11.43) 9.48 (11.72)
PSS 4.40 (6.11) 5.42 (7.00) 4.63 (6.17) 4.85 (6.00)
GHQ 1.86 (4.00) 2.07 (4.36) 1.99 (4.19) 1.68 (3.88)
Follow-up
n=106 n=152 n=75 n=142
IES Intrusion 5.02 (6.81) 2.50 (4.55) 4.04 (6.24) 2.40 (4.22)
Avoidance 3.90 (6.79) 2.67 (5.66) 3.08 (5.60) 1.77 (4.57)
Total 8.92 (12.97) 4.31 (8.57) 7.12 (11.17) 4.17 (8.49)
PSS 4.40 (6.11) 2.75 (5.01) 3.85 (6.40) 2.52 (4.69)
GHQ 1.47 (3.77) 1.26 (3.14) 1.48 (3.93) 1.02 (2.73)
356 David Richards
Initial symptom severity was high with
mean scores on both the IES and GHQ above
the cut off points, which would indicate clini-
cal concern. However, by 1 month post-raid,
symptoms had reduced considerably and re-
mained low in both intervention groups at
follow up. At day three and 1 month, scores
in the CISD alone group were marginally
lower than the CISM group. However, at
follow up the CISM group scored lower on all
measures.
In the sample of employees for whom data
is available at all three time points (n=217),
scores for 1 month and follow up measures
were entered into repeat measures analyses
of covariance ( ANCOVA) with day three scores
entered as covariates to control for initial
post-robbery symptom severity, yielding the
following results. IES: group F=0.76, ns;
time F=22.43, p<0.001; group x time F=10.76,
p<0.01. PSS: group F=1.68, ns; time F=20.57,
p<0.001; group x time F=5.14, p<0.05. GHQ:
group F=0.57, ns; time F=3.89, p<0.05; group
80
67.2
64.5
60
Percentage cases
40
20
12.3
0
Day 3
Figure 1: Percentage of employees with significant clinical symptoms on the IES
x time F=0.06, ns. On two out of the three
outcome measures, therefore, the main ef-
fects of time and group x time demonstrate
the superior outcomes for employees receiv-
ing CISM over CISD alone when initial symp-
tom severity is controlled for. Furthermore,
independent sample t-tests at each time point
reveal that the mean differences between the
groups were only significant at follow up
(IES: t=3.43 p<0.01; PSS: t=2.55, p<0.05,
GHQ: t=0.49, ns) and in favour of the CISM
group. This was true only for specific post-
trauma symptoms. GHQ scores were not
significantly different between groups at any
time.
Clinical cases
The mean symptom scores for the sample
as a whole (reported above) are well below
those considered clinically significant. How-
ever, a proportion of employees continued to
experience raised levels of symptoms above
a clinical threshold. Figure 1 illustrates the
CISD alone
CISM
15.7
11.3
5.3
1 month Follow up

percentage of employees with significant
clinical symptoms over time, as defined by a
score of 26 or more on the IES (Corneil et al.,
1994). At day three post raid more than two
thirds of employees were in this category.
However, by 1 month these rates fell to
15.7% (CISM group) and 12.3% (CISD alone
group). The numbers of employees with
clinically significant post-trauma symptoms
at the follow up point reduced by two thirds
to 5.3% in the CISM group but remained
almost unchanged in the CISD alone group at
11.3%. At the follow-up point there was a
trend for this difference to approach signifi-
cance (Fishers exact one tailed significanc e
test - 0.061).
Treatment of missing data
Despite the size of the data set, the declin-
ing response rate at the 1-month and follow-
up assessment points is of concern. Although
there were no differences between the groups
on gender, age, employment grade or raid
experience, the subset of employees who
returned 1-month and follow-up question-
naires may be unrepresentative of the origi-
nal sample because they suffered either more
or less initial post-traumatic stress symp-
toms. This problem was addressed as fol-
lows.
Imputing the missing data by the usual
methods such as the last value carried for-
ward method would add no value to the
analysis given that, there are too few data
points post-intervention. That is, for most
non-respondents, this would require carrying
forward the baseline score 3 days post rob-
bery to the 1- month and follow-up points.
However, in order to test the proposition that
the difference at follow-up between CISD
and CISM was due to non-responder bias, an
analysis of the immediate post-raid morbid-
ity of responders and non-responders was
undertaken by comparing the mean scores on
Field trial of CISM v. CISD 357
day 3 of employees who returned 1-month or
follow-up questionnaires with those who did
not. Using independent samples t-tests, two
comparisons were made comparing initial
scores for employees who returned measures
at 1-month compared to those who did not
return measures and a similar comparison for
those employees who returned questionnaire s
at follow-up compared to those that did not.
In each case the dependent variable was the
initial symptom score at day 3.
Table 2 shows that CISD and CISM re-
sponder and non-responder groups suffered
similar levels of initial post raid morbidity.
Of the two traumatic stress measures that
show a significant advantage of CISM over
CISD at follow up, there is a tendency in the
PSS - though not the IES - for the CISD non-
responders to be less symptomatic than those
that did return questionnaires. It is conceiv-
able, therefore, that the advantage of CISM
over CISD may be accounted for in part by
questionnaire responder bias in favour of
more symptomatic CISD responders. In con-
trast, however, as can be seen from Table 1,
the mean differences between the CISD and
CISM groups at follow-up are actually less in
the sample of respondents with data from all
three time points compared to the total sam-
ple at follow up. The significant group mul-
tiplied by time ANCOVA result at follow up is,
therefore, based on a conservative reading of
the data.
Discussion
CISD v. CISM
This pragmatic comparative field trial of
two interventions designed to support and
ameliorate symptoms of post-traumatic stress
after armed robbery demonstrates that supe-
rior outcomes may be achieved with a struc-
tured CISM package of care compared to a
stand alone CISD intervention. The incorpo-
358 David Richards

Table 2: Comparison of initial symptom scores at day 3 for employees returning subsequent
questionnaires compared to those that failed to return questionnaires at 1 month and
follow-up

Measure Initial scores at day 3 - ns, means (SD) t -value p

n Returned n Not returned
IES 1 month CISD 111 32.32 (15.90) 114 30.91 (17.00) 0.64 0.52
Measures CISM 247 34.12 (15.93) 52 30.64 (18.97) 1.24 0.22
Follow-up CISD 101 33.45 (15.26) 124 30.11 (17.27) 1.54 0.13
Measures CISM 152 33.78 (16.26) 147 33.24 (16.82) 0.29 0.78

PSS 1 month CISD 111 13.83 (8.67) 113 13.90 (10.41) 0.06 0.95
Measures CISM 247 15.53 (10.50) 52 14.64 (11.73) 0.55 0.58
Follow-up CISD 101 15.14 (9.44) 123 12.82 (9.58) 1.81 0.07
Measures CISM 152 15.45 (10.68) 147 15.31 (10.77) 0.11 0.91

GHQ 1 month CISD 111 7.50 (6.32) 114 7.18 (6.76) 0.37 0.71
Measures CISM 247 7.96 (6.48) 52 7.75 (7.07) 0.21 0.84
Follow-up CISD 101 8.25 (6.48) 124 6.59 (6.50) 1.91 0.06
measures CISM 152 7.65 (6.46) 147 8.21 (6.70) 0.74 0.46

ration of the initial CISD alone procedure
into an integrated CISM system of pre-raid
training and a short, focused mental health
advice session one month after a raid to
robbery victims produced significantly im-
proved recovery rates in terms of mean symp-
tomatology. There was also a trend to signifi-
cance for clinical caseness. Employees in the
CISM group were less traumatised at later
follow-up and the proportion of clinically
significant cases was less than half the number
in the CISD alone group.
The timing of the extra individual session
in CISM deserves comment. A number of
studies have suggested that at 1-month post
trauma it is possible to identify victims who
will go on to develop chronic disorders and
therefore, it is at this time that one should
offer effective interventions. Rothbaum et
al. (1992) found that 1 month after a rape
trauma it was possible to distinguish between
women who would recover and those who
were likely to develop chronic PTSD, a feat
impossible closer to the time of the trauma.
Brewin et al. (1998) also suggested that inter-
ventions of 48 hours in length might be
delivered to the 20% of trauma victims who
are in danger of developing chronic PTSD.
The results from the current study indicate
that in the context of an integrated CISM
system, significant improvement may be
gained with even smaller investments of thera-
pist time and that these can indeed be achieved
by intervening 1 month after a trauma.
Limitations
The results of this study are limited by its
non-randomised field trial methodology. A
more robust trial would have involved ran-
dom allocation to the two groups with a no
intervention control. This trade-off between
experimental rigour and pragmatic investi-
gation is familiar to those working in post-
event situations where the nature of the serv-
ice delivery contract and employees expec-
tations for post-incident care render no-treat-
ment controls unethical and impractical
(Chemtob et al., 1997). Indeed, given that the
 Field trial of CISM v. CISD 359

two interventions being compared were de- Efficacy of CISD alone

livered during consecutive periods of opera-
The specific impact of CISD as a stand
tion of the Societys trauma support service,
alone intervention is difficult to determine
other differences over time may have been
from this study. The levels of spontaneous
responsible for the results reported. While recovery are impossible to assess directly, as
this is impossible to rule out it is, however, the current study did not include a control
somewhat unlikely as the two groups were group. However, levels of long-term mor-
very similar in demographic profile and sta- bidity are considerably lower than expected
tistically indistinguishable in their symptom from other recent studies of crime victims.
profiles at the initial CISD point. Further- Such normative data allows benchmark com-
more, the author knows of no significant parisons to be drawn. For example, Brewins
organisational or other factors existing dur- recent study (Brewin et al., 1998) showed
ing the time when CISM was being delivered that crime victims debriefed individually had
compared to the CISD alone period which mean scores which were twice as high on the
may have accounted for the observed differ- IES 6 months post-event compared to the
ence in effect. follow up morbidity levels in this study, even
A further caution is that this study does not in the CISD alone group. Furthermore, fol-
purport to investigate the individual impact low up caseness in Brewins study was also
of the interventions included in CISM pre- double that of the CISD alone group in this
raid stress inoculation training (SIT), CISD study. This suggests that group CISD alone
and individual follow-up counselling. These may indeed have reduced morbidity below
were developed from the authors extensive that expected following traumatic criminal
experience in the cognitive behavioural treat- events with even greater improvements from
ment of PTSD and anxiety disorders (Richards the CISM intervention .
& Rose, 1991; Richards et al., 1994). It is However, caution should be exercised when
certainly possible that the effect of some of undertaking such comparisons. As suggested
these elements (in particular SIT and indi- by recent controlled studies (Bisson et al.,
vidual follow-up sessions) may have been 1997; Brewin et al., 1998; Hobbs & Adshead,
due to attention from the traumatic stress 1996) it may be that the interventions in
counselling service per se rather than as a either condition had no effect whatsoever.
result of their specific content. Several other factors may account for the low
A final limitation is the loss of data at one long-term morbidity in this study. First,
month and follow-up points. Although non- although the implied threat in an armed rob-
significant, there was a trend for the CISD bery is very severe the actual nature of the
questionnaire non-responders at follow-up to assault is predominantly psychological with
have lower morbidity immediately after the little actual physical injury. Physical injury
raid. Had these people returned follow-up has been found to be associated with greater
measures it is conceivable that the difference long-term psychological morbidity (Brewin
found between CISD and CISM may have et al., 1998; Resnick et al., 1993) so the lack
been less marked. However, in contrast, the of physical injury in raids may lead to low
significant ANCOVA result was found in the long-term morbidity in this specific popula-
more conservative follow-up results obtained tion. Secondly, Building Society branches
from the smaller sample of respondents who are small, close knit workplaces where em-
returned data at all three time points. ployees work regularly together with a small
360 David Richards
number of other people, supporting each other
and often socialising together. Social sup-
port has been identified as a major protective
factor post-trauma, enhancing the opportuni-
ties for recovery (Joseph et al., 1992, 1997).
Experiencing and recovering from traumatic
incidents together with ones colleagues in a
pre-existing supportive environment may lead
to better outcomes.
It is certainly possible, however, that the
design of CISD as implemented in this study
1.52 hours long, in groups and as such
much closer to the model proposed by Mitchell
(1983) may have had more of a therapeutic
effect than the short, individually focused
intervention procedures used in the published
negative effect randomised controlled stud-
ies (Bisson et al., 1997; Brewin et al., 1998;
Hobbs & Adshead, 1996). Certainly, the
level of clinically significant cases in this
study even at 1-month post-trauma was
considerably lower than that found in similar
victim populations in the UK.
Is CISD an appropriate early interven-
tion?
Whereas many studies have concentrated
on long-term psychiatric morbidity, research-
ers, policy makers and service managers
should remember that the potential beneficial
effects of CISD can also be measured in
many other outcome domains. First, CISD is
a highly valued people management tool in
organisations, which suffer repeatedly from
traumatic incidents. Studies have shown that
it is appreciated by both the traumatised and
their managers (e.g. Flannery et al., 1991;
Shapiro & Kunkler, 1990; Turner et al., 1993).
Secondly, doing nothing in response to a
traumatic event is not an option for managers
where expectations of appropriate post-
trauma care are part of the implicit bargain
between employers and employees which
facilitates employees repeatedly and volun-
tarily entering into potentially traumatic situ-
ations. Thirdly, while both Bisson et al.
(1997) and Brewin et al. (1998) argue against
the provision of immediate services for all
victims suggesting instead a symptom moni-
toring system to pick up cases at one month
post-trauma such a strategy is unlikely to
engage victims in therapy unless initial con-
tact has been made with victims earlier.
Evidence for the last point is unexpectedly
provided in Brewin et al.s own study (Brewin
et al., 1998), where less than 10% of those
crime victims initially approached came for-
ward into the study, despite being offered an
intervention not normally available to the
general public. Given the choice, the trauma-
tised do not readily volunteer for assistance.
CISD might work best as part of the inte-
grated CISM approach proposed by Mitchell
(Mitchell, 1983, Mitchell & Everley, 1997)
by allowing the therapist or counsellor to
build a rapport and establish competence.
When coupled with the positive experience
reported by the majority of those debriefed,
CISD (and/or the SIT pre-trauma training)
may lead to enhanced compliance with sub-
sequent interventions at one month post-
trauma or later. Indeed, in this study, even
when CISD alone was offered as a standard
intervention, the response rate to postal moni-
toring questionnaires (51% of those origi-
nally debriefed) was five times that of Brewin
et al. (1998). The effect of CISM was to
increase this engagement rate to 83% when
employees were offered a visit from the
debriefer one month post raid.
Conclusion
Despite its necessary methodological com-
promises, this study has shown that embed-
ding CISD within an integrated CISM sys-
tem can significantly reduce the levels of
long-term morbidity in crime victims com-

pared to both a stand alone CISD intervention
and morbidity levels reported elsewhere. The
debate on the effectiveness of CISD itself is
unresolved but it would be unwise to heed the
calls to cease CISD on the basis of studies,
which apply CISD alone in an inappropriate,
individualised manner. Even if CISD alone
is clinically ineffective, it may serve to in-
crease the acceptability of and compliance
with subsequent interventions. This study,
therefore, provides important evidence, which
should be used in the development of CISM
systems. Rather than the watered down,
internally invalid procedures currently being
cited as evidence against debriefing, CISM
must now be studied in empirically rigorous
randomised controlled trials. Such studies
are sorely needed before policy makers should
heed the premature cries to cease debriefing.
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