Dr Manda Holmshaw examines why critical incident debriefing may be the wrong approach to meet the needs of emotionally distressed people after a major disaster.
Claims managers can be shy, retiring creatures. Their job may be considered unglamorous and they tend to stay out of the limelight. But when a disaster strikes, claims managers often find themselves the focus of attention — especially if they are thought not to have responded appropriately to customers' needs. This is particularly so in the case of disasters, from a flood in a previously little-known Cumbrian town; to a crane falling onto a block of flats; or a road traffic accident involving bystanders, drivers, passengers and their families.
Whatever the circumstances, disasters are undoubtedly telegenic and, as such, these images generate an almost instant wave of public emotion, requiring insurance company action. While the emergency services are initially seen rushing around in high-visibility jackets, the insurance company's presence is less obvious. Yet soon there are cries for the insurance company — and the technical claims manager — to 'do something'.
Sending out loss adjusters or bridge builders to deal with the physical consequences of a disaster is one aspect of the situation. Dealing with the emotional needs of distressed people is another matter. Recently, it has become accepted that the victims need 'counselling' or critical incident debriefing.
To meet this perceived need, there are a multitude of CID providers. CID forms a staple of the products that nearly every employee assistance programme offers. Some emergency services and NHS trusts provide CID almost as a matter of course and some insurance companies offer it to their clients. It would seem that providing this form of counselling after a traumatic event is a habitual response, similar to providing first aid for a physical injury. So, should the well-intentioned claims manager provide CID as a matter of course? Actually, no.
CID has been around for almost 30 years. It has an academic origin in the 1974 work of Jeffery Mitchell after working with paramedics and fire-fighters. Terms changed from critical incident stress debriefing (Mitchell, 1983) to psychological debriefing (Dyregrov, 1989) and anecdotal evidence of its usefulness led to widespread adoption.
The efficacy of CID was called into question by both Bisson in 1994 and in a British Medical Journal editorial the following year. The latter called for randomised controlled trials. This need was answered by Professor Richard Mayou, the indefatigable investigator of post-traumatic psychological conditions. His study showed "no evidence that debriefing had helped and, indeed, indications that it might have been disadvantageous". More recently, McNally concluded in a 2004 review of CID/CISD that it should not be used — it being at the very least ineffective and, quite possibly, harmful.
These answers seemed to satisfy the academic community who by and large lost interest in the benefits or otherwise of CID. But this attitude has not been matched by some commercial organisations that continue to promote its use.
In 2005, the National Institute for Health and Clinical Excellence wrote a report on the management of post-traumatic stress disorder, a common long-term psychological consequence of traumatic events. NICE's studies examined seven randomised controlled trials in which psychological debriefing was used after psychological traumas — and it concluded that "there is unlikely to be a clinically important effect on subsequent PTSD [from CID]".
In March 2005, these findings were summarised in the NICE Clinical Guideline 26, which clearly states, with reference to treatment for PTSD for individuals: "You should not normally be offered a single session of psychological therapy (often called 'debriefing') immediately after a traumatic event such as a major disaster. It is not very helpful and may make you worse. Instead, you should be offered practical support and information about how to cope over the following weeks."
This seems to be the best current informed opinion on debriefing after major traumatic events, as CID has no evidence-based support for preventing long-term mental health issues. Yet despite these very firm recommendations, CID seems as widely used as ever. The attraction of doing something — rather than just sitting there — can apparently be overwhelming.
So, what might a beleaguered claims manager offer, either directly or indirectly, to recently traumatised clients? Psychologists recommend a graded response with several components, rather than the short, potentially re-traumatising CID. Reliving the trauma by talking in detail in a group setting is now regarded as either unhelpful at best, actually counter-productive or possibly toxic.
The first stage can be categorised as a watch and wait, or 'psychological first aid'. The mind naturally heals in about a month. Before then, there may be symptoms of an acute stress disorder — examples of which include distress, low mood, agitation, anxiety and numbness. The patient's GP is often best placed to help with any sleep problems and possibly minor tranquilisers for a few days. Psycho-education should be provided to normalise and reassure. And getting support from family, friends and colleagues helps. In addition, access to a trauma helpline will allow people to voice their fears and anxieties, while information about the normal psychological response to traumatic events are also useful.
If symptoms have not settled after one month, it becomes appropriate to offer a face-to-face appointment with a qualified mental-health professional. Unresolved symptoms may suggest the possibility of PTSD or anxiety. In such cases, two evidence-based therapies are recommended — trauma-focused cognitive behaviour therapy or eye-movement desensitisation and reprocessing — but not non-focused general counselling, which NICE recommends against. Only approximately 14% of individuals are likely to need this kind of help.
Although this may seem like a rather low-key approach in the face of disaster, it is likely to be the most effective and least expensive route. So maybe the next time a disaster lands on the claims manager's crowded desk, a modern psychological response is the answer — rather than CID from one of its enthusiasts.
Dr Manda Holmshaw is clinical director at Moving Minds
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