 |
 |
|
|
By Lynda McCullough
When members of the search and urban rescue team from Fairfax County, Va., returned from Nairobi, Africa, recently, they were greeted as heroes in their community and the nation's capitol. After a week off, they were back at work. But the problems of some rescue workers upon returning from the Oklahoma City bombing (including a suicide) raise the question of how the recent team will fare in coping with the aftermath of their rescue and recovery efforts.
Fairfax County mental health professionals from the Woodburn Center for Community Mental Health provide a debriefing for their rescue workers to address any emotional difficulties or adjustment problems that they might have. The critical incident stress debriefing (CISD) is part of a larger effort at Critical Incident Stress Management (CISM) in which officers and peer firefighters are trained to recognize the signs of psychological distress and to intervene when necessary.
This particular rescue team was prebriefed about what its members might experience or feel while working in Africa, how to take care of themselves physically and mentally, and how to seek help if they needed it.
"Information will help anyone deal with the stress level," said Patrick Morrison, chair of the Fairfax County CISM Team and a lieutenant in the Health and Safety Division of the Fairfax County Fire Department. "Without it, there is more damage."
"They need to be aware that when they are tired, they need to back off," said Morrison. "What they encounter is not right," he said, referring to the carnage of bombings. While doing body recovery work like the firefighters did in Africa, said Morrison, they need to be aware of their emotional reactions and stress levels and to get the rest and support that they need.
When the firefighters returned to Virginia, they were given information about a voluntary debriefing that took place about a week after they returned. On the same day, a debriefing was provided for spouses and significant others.
Clinicians from Woodburn conducted the debriefing after the workers spent a couple of days resting and reuniting with their families but before they "sealed over" emotionally, said Gary Axelson, Psy.D., a clinical psychologist who is on the CISM team. The Africa team was in "pretty good shape" after their work, said Axelson, but the CISM team was on the alert for symptoms such as changes in sleep patterns and appetite as well as for irritability, intrusive thoughts and images, and somatic complaints.
At the debriefing, "we get them talking, then get out of the way," said Axelson. "When they talk and work together, they grow closer and can call and support each other."
He added, "While we use a therapeutic modality, it's not psychotherapy." Clinicians ask the firefighters to talk first about facts-where people were, what they did, what happened, and then about what they were thinking. Then they ask the firefighters about their feelings. "If you bring up emotions right away," noted Axelson, "people clam up." But once they are ready to talk about their responses to pulling body parts out of the bombed ruins, they find that others have similar feelings, and that those feelings are normal and natural, said Axelson.
The leader wrapped up the debriefing by providing information. He provided handouts on what to watch for in the coming weeks, stress management, and how to get more help. Firefighters were told to contact peers to talk or to get referrals for individual counseling if they needed it.
After the debriefing, the CISM team met to discuss it and to make decisions about follow-up. They focused on individuals who needed help and ways to follow up with them such as having peers meet them for a casual discussion over coffee or clinicians schedule appointments with them.
While noting that peer involvement in CISM gives the clinicians credibility and connection with firefighters, the judgement and experience of clinicians is necessary for successful debriefings, said Axelson. "Credibility is almost nil for mental health folks" without that connection with the fire service, he said, but clinicians can spot troubled or vulnerable people and make sure a person is hooked up with right resources and care.
In addition, said Axelson, clinicians can "make sure as people bring their feelings out onto the table that they are not damaged in the process." Of primary concern, he said, is the possibility of scapegoating. Sometimes the discussion centers on operational procedures and who may have made mistakes, said Axelson, and the clinician has to steer the conversation back to feelings and individual experience.
Decompensation is another danger that clinicians have to monitor, said Axelson. "Firefighters have to deal with people in agony, and they have to have enough distance to help. They need to feel intact. You can't take away what allows them to do that." Clinicians, he said, should be careful not to tear down defenses.
The impetus for developing critical incident stress teams came from World War I and II. At that time it was discovered that soldiers given immediate psychological support after combat were more likely to be able to return to battle than those not given such support. In more recent years the Israeli Defense Forces found that providing group and individual psychological support after bombings in the Middle East decreased the incidence of psychiatric disturbance by as much as 60 percent. In the early 1980s, Jeffrey Mitchell, Ph.D., instigated the idea of creating formal CISM teams in fire and emergency medical services units. There are now more than 400 CISM teams in place across the country.
According to Arshad Husain, M.D., who is a professor of psychiatry in the department of psychiatry at the University of Missouri and works in CISM, very few psychiatrists participate in CISM work. (Most mental health professionals involved in CISM are psychologists or social workers). Husain said psychiatrists are needed to lead teams and to deal with rescue workers who have acute reactions to an incident, he said.
"The severity of response varies from person to person. Some may respond to the standard debriefing approach while others may require more than a simple intervention." Those with acute symptoms may need treatment by a psychiatrist, he noted.
Husain, who has worked with trauma victims in Bosnia with the University of Missouri's International Center for Psychosocial Trauma, said that there are two reasons for the lack of psychiatrist involvement in CISM. One is that psychiatrists are busy with their practices and don't volunteer for CISM work, he said. The other is that psychiatry residents are not trained in state-of-the-art interventions in treating trauma patients. Other mental health professionals are learning a variety of techniques for helping victims of trauma, said Husain, and psychiatrists need to do so as well.
Another issue for the field of CISM is a controversy regarding its effectiveness. "There is a battle going on right now about how much people are actually getting out of CISD," said Morrison. Some psychologists have said there is not enough scientific proof that CISD is effective, while others say that it is and point to a decrease in the numbers of fire fighters out on medical disability.
Fairfax County CISM is changing as it learns from its experiences. "We're looking at doing fewer debriefings and providing more information in an up-front way," Morrison said. The fire department would like to include stress management courses in fire service training and more education for officers to increase awareness of stressful situations and their effects on firefighters. For example, said Morrison, if someone has just come back from a sudden infant death call, it is important not to send that person out on a similarly stressful call right away. He added that it is important to build a support network at the shift level, where there are strong bonds among people who continually work together, and CISD members can recognize those who need help from outside mental health professionals.
"It is important for the wellness of the department to look out for people," said Morrison. "The human resource liabilities are great. Stress is a risk factor-if it's not taken seriously, we're going to lose good people." Two Fairfax County firefighters have left the department in the last 10 years because of posttraumatic stress disorder, he noted.
Morrison, who has worked in the fire service for 16 years, said he has seen a lot of change in the department in terms of dealing with emotion. "Fifteen years ago, if you cried, you were seen as a baby and sent home. We've come a long way. Crying is such a release, a natural, normal process. Over the years we have allowed ourselves to become more human."