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Modifying CISD So As Not to Re-traumatize Survivors

26 Oct


Dear Belleruth,

I am a professional counselor (LMFT) who has been involved with Trauma and Critical Incidents of all types since 1987.  Early on I was trained in the Mitchell model of CISD [Ed. Note: This is Critical Incident Stress Debriefing].  I currently respond to these types of incidents on behalf of EAP providers who continue to value the CISD model.  

My observation of this model is that it has some effectiveness in the short-term.  Many people have commented on the improvement they have felt after completing the debriefing process.

However, I am now faced with evidence--most recently re-discovered on your Not Alone page - that talking about the incident, particularly immediately following the event may not only not be helpful but could re-traumatize the participants.

I am certainly not in the business of making things worse.  Consequently, I am in a quandary about the CISD model.  It is "standard practice" for many of the EAP companies with whom I contract.  In fact, many will not allow any other type of intervention as part of the response following a traumatic event at a client site.  

I am not sure how to reconcile this disparity in my own mind.  I am wondering what ideas or directions you might have for making these interventions helpful to the participants and operating within the bounds of contractual obligations.  Given that, I would certainly understand if you declined any response to this inquiry.

I have found your imagery scripts extremely helpful in managing my own "vicarious" trauma -especially the ones on depression and anger …so much so that I recently sent my sister-in-law your series on healthy pregnancy.  She loves it.

James C. Clingan, LMFT
Blue Mound, Texas


Thanks for the comment/question, James.  This comes up a lot, and I welcome the chance to clarify this.

At least three separate reviews of CISD in the past few years concluded that CISD can be helpful, but doesn't fulfill its initial promise of preventing the later acquisition of PTSD.  The problem isn't with the whole protocol, by any means - just the part about, "Tell me what happened". Asking people to identify how they're feeling; what their symptoms are; how they're managing, eating, sleeping, relating; what social supports they have to depend on; coping tricks; how they handle work and home; etc etc - all that's supportive and helpful.  

But asking the person to talk about the traumatic event itself, if they've been truly traumatized, will generally get you one of three responses:  

  1. They'll talk about it in a numbed out, dissociated, rote way, which doesn't do them any good, because they're not "home".

  2. They'll stare into space and go blank, because they can't access with words the part of the brain where the traumatic memory is stored.

  3. They'll have a flashback and re-experience the trauma.  

So what a lot of CISD people have been intuitively doing is tweaking the protocol - they insert some preliminary, calming, "oasis" imagery first - Favorite Place Imagery, or the Protective Cushion of Energy Imagery, or something along those lines - so that, similarly to the EMDR or Somatic Experiencing protocols, if they become distressed or flooded, they can immediately move back into that calming imagery and self-regulate; and they either avoid or save for last the "Tell me what happened" part.  This fits in the allotted time and it's much easier on everyone.  

So I’d suggest you give 'em some self-regulation tools up front; and either avoid or save for last the question about what happened (if it looks to you by then that they can respond without tripping loose a flashback).  

I also recommend doing this when debriefing rape survivors, which for legal reasons, usually has to be done immediately afterward; or when preparing them for a deposition or a court appearance.

And if, by the way, you have somebody who can speak coherently in an embodied, feelingful way about the traumatic event, without dissociating, there's a good chance they're not going to get PTSD – in fact, this is very revealing and useful diagnostic information.  

I hope this helps! Thanks again for the question.
All best,

Belleruth Naparstek

Psychotherapist, author and guided imagery pioneer Belleruth Naparstek is the creator of the popular Health Journeys guided imagery audio series. Her latest book on imagery and posttraumatic stress, Invisible Heroes: Survivors of Trauma and How They Heal (Bantam Dell), won the Spirituality & Health Top 50 Books Award