Australia: rethinking the strict CISM model.

In earlier days, the way to deal with trauma in Australia was to go to the pub and have a beer with your mates. This, combined with a talk with your local chaplain, was seen as sufficient treatment for post-trauma stress. It wasn't until 1977, after a train disaster in the Sydney suburb of Granville killed 83 people and left hundreds traumatized, that it became clear Australia's traditional approach to disaster response needed reworking.

It was around this time that external EAP firms in Australia (as in the United States) began pushing the proactive model of trauma management known as critical incident stress management (CISM). This seven-phase model was embraced by Australia's emergency services, defense forces, manufacturing and mining companies, and most other industries concerned with employee welfare and protection, for CISM was said to not only help ward off the onset of post-traumatic stress disorder (PTSD) but also demonstrate the employer's fulfillment of post-crisis psychological care.

Employers were encouraged to use CISM after a string of cases in which employees sued because they were not offered appropriate assistance following traumatic incidents. In one instance, a railway worker successfully sued his employer for AUS $750,000 because he developed chronic PTSD after seeing a suicide victim's body parts scattered on the tracks. Had the employer ensured CISM was used, it was claimed, the likelihood of developing PTSD would have been reduced.

Then, in a dramatic turn of events, evidence (mostly from the United Kingdom) began cropping up in the 1990s suggesting that the critical incident stress debriefing--a crucial step in the CISM model--could be ineffective or even counterproductive to recovery from a traumatic incident. While such evidence has yet to be empirically confirmed, employers increasingly are dropping stress debriefings from their trauma management programs. These employers include emergency services teams such as the New South Wales Department of Health and the Australian Defence Force--the very types of workers for whom the CISD process was designed.

Another factor sparking changes in Australia's view on psychological debriefing was the Port Arthur massacre in 1996, where trauma management reportedly was handled inappropriately. When Martin Bryant opened fire in this historic tourist town off the coast of Tasmania, killing 35 people, emergency services teams were debriefed before the site had been secured and eyewitness accounts taken. Police expressed concern the debriefing sessions would contaminate these accounts and that the process would generate undue trauma in those who felt relatively unaffected.

It is this point that has generated the most contention among health professionals in Australia--that individuals exposed to trauma, regardless of their level of involvement, are forced to "relive" the event through mandatory debriefings. Some health experts contend that grief and stress can become contagious among groups of debriefed workers, increasing rather than reducing the possibility of post-traumatic stress and undermining their natural trauma response strategies.

OUTLOOK FOR TRAUMA MANAGEMENT

One of the most prominent and influential figures in Australia in the area of trauma management is Beverly Raphael, director of mental health in New South Wales (NSW). Raphael was once an advocate of CISM and CISD, but has changed her position. She and the NSW Department of Mental Health do not support the provision of CISD until further empirical research on its effectiveness has been completed. Her reluctance to support CISD has influenced the views of many others.

Attitudes in Australia are certainly turning away from using strict CISM models with mandatory debriefings and toward individual post-trauma counseling. Bruce Parry, global trauma manager for IPS Worldwide, says this approach is more suitable in addressing an individual's needs.

"Different individuals respond to trauma in different ways and therefore need to be treated differently in accordance with their response," says Parry "A one-size-fits-all model will not be right for each person or group."

In IPS' view, an individual should never be required to undergo debriefing; rather, the employer and the worker, in consultation with the psychologist, should determine the appropriate way forward in accordance with the extent of trauma and preferences of the individual. Using this triad of decision-makers, the best possible combination of treatments can be prescribed to achieve the most desirable results.

Robin Smith, CEAP 

Robin Smith is chief executive officer and managing director of IPS Worldwide, an international provider of EAPs and work-life balance solutions. She is president of the Australia Chapter of EAPA.