|Year : 2020 | Volume
| Issue : 3 | Page : 128-133
Critical incident stress debriefing for frontline military rescuers in a helicopter crash disaster in Taiwan: A preliminary report
Ming-Wei Lin M.D 1, Chu-Wei Tsai M.D 2, Chung-Chih Hsu M.D 3, Lien-Cheng Kao M.D 3, Yueh-Ming Tai4, Szu-Nian Yang M.D 5
1 Department of Psychiatry, Beitou Branch, Tri Service General Hospital, National Defense Medical Center; Department of Research and Development, Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
2 Department of Psychiatry, Beitou Branch, Tri Service General Hospital, National Defense Medical Center, Taipei, Taiwan
3 Military Suicide Prevention Center; Disaster Mental Health Center, Beitou Branch, Tri Service General Hospital, National Defense Medical Center, Taipei, Taiwan
4 Department of Psychiatry; Military Suicide Prevention Center, Beitou Branch, Tri Service General Hospital, National Defense Medical Center, Taipei, Taiwan
5 Department of Psychiatry; Military Suicide Prevention Center; Disaster Mental Health Center, Beitou Branch, Tri Service General Hospital, National Defense Medical Center, Taipei, Taiwan
|Date of Submission||06-Apr-2020|
|Date of Decision||04-May-2020|
|Date of Acceptance||05-May-2020|
|Date of Web Publication||28-Sep-2020|
No. 60, Shin-Ming Road, Taipei 112
Source of Support: None, Conflict of Interest: None
Objective: With the goal of optimizing the outcome of frontline rescuers from psychiatric morbidities, especially posttraumatic stress disorder, preventive interventions is necessary. But the effectiveness and timing of the group debriefing programs remain controversial. In this study, we intended to share the process of a debriefing group, consisting of several therapeutic elements and showing the benefits and effectiveness of each therapeutic element. Methods: A helicopter crash tragedy took place on January 2, 2020, in Taiwan. We recruited 71 frontline military rescuers for providing a group debriefing program, a semi-structured critical incident stressing debriefing (CISD). After the program was finished, all participants filled out their demographic data and a copy of an anonymous questionnaire, the Sharing Support Group for Crisis Intervention Questionnaire for the attendant's self-perceived benefits with 11 elements. Comparing to their perceived therapeutic elements and demographic information, we later discussed the factors associated with the therapeutic effectiveness of this program. Results: The male dominant participants perceived the benefits of all therapeutic elements with no significant differences between gender. Those with service-year < 4 years showed significantly higher self-perceived benefits from this program (p < 0.05). The sergeant rank showed significantly lesser self-perceived benefits from the program, for example, emotion catharsis (Q4, p < 0.05), reviewing of what the group members experienced (Q5, p < 0.01), and coping skills extension (Q8, p < 0.05). Conclusion: This study revealed that the sociodemographic factors, rescuers' ranks and years of service but no gender, play rôles in the effectiveness of the group debriefing programs for the frontline military rescuers. We hope that further understanding can improve the therapeutic effectiveness of debriefing management in the future.
Keywords: group debriefing, posttraumatic stress disorder, sociodemographic factors, the Sharing Support Group for Crisis Intervention Questionnaire
|How to cite this article:|
Lin MW, Tsai CW, Hsu CC, Kao LC, Tai YM, Yang SN. Critical incident stress debriefing for frontline military rescuers in a helicopter crash disaster in Taiwan: A preliminary report. Taiwan J Psychiatry 2020;34:128-33
|How to cite this URL:|
Lin MW, Tsai CW, Hsu CC, Kao LC, Tai YM, Yang SN. Critical incident stress debriefing for frontline military rescuers in a helicopter crash disaster in Taiwan: A preliminary report. Taiwan J Psychiatry [serial online] 2020 [cited 2020 Oct 26];34:128-33. Available from: http://www.e-tjp.org/text.asp?2020/34/3/128/296457
| Introduction|| |
A military helicopter crash disaster occurred on January 2, 2020, with 8 dead and 5 survivors. Rescuers were asked to be involved in the rescue mission for searching the possible survivors and unfortunately, human remains. The negative impacts of the disaster on both the victims and the frontline rescuers are considered serious to rescuers' both physical and mental health. Rescuers are under great risk of developing psychological morbidities, such as acute stress disorder, posttraumatic stress disorder (PTSD), and symptoms of depression or anxiety ,,. Previous studies revealed that the disaster rescuers are under greater risks of psychiatric morbidities, and that the incidence varies between different studies ,... Despite limited information, several studies indicated that nonprofessional disaster rescuers are under higher risk of psychiatric morbidities than professional ones when both of them have involved in disaster rescue missions ,. The negative consequences on these nonprofessional rescuers can have PTSD and anxiety or depression symptoms; those rescuers can experience a poorer quality of life ,. To understand the risks of nonprofessional rescuers and to provide appropriate intervention to lower their risks are important.
The military in Taiwan has been involved in disaster rescue tasks for decades. In fact, those tasks have been one of their major missions. Although many studies have explored the association between PTSD and veterans ,,,, adequate information of the frontline military rescuers, as well as the effective psychological intervention for PTSD prevention, has been largely missing.
Psychological debriefing, especially for critical incident stress debriefing (CISD), has been considered as one of the interventions of PTSD or other psychiatric morbidities' posttraumatic exposure for decades. The process of debriefing has been reported to have the process of switching the traumatic memory from a nonverbal sensory expression to a verbal or semantic one. Some research explored that psychological debriefing has positive therapeutic effects for people with traumatic events exposure [13,, and for military personnel. Moreover, psychological debriefing can bring out other important treatment factors, such as cohesion, to provide better therapeutic effectiveness for those after traumatic events.
Some other single-session individual early psychological interventions, such as trauma-focused cognitive-behavioral therapy, cognitive therapy without exposure, eye movement desensitization and reprocessing, structured writing therapy, and internet-based guided self-help, have positive therapeutic effects for people with traumatic exposure. Contrariwise, the early intervention of psychological debriefing may be harmful . “Many studies discovered that the ineffective and harmful consequences can be due to the haste of psychological debriefing intervenes in repetitive traumatic re-experience during the therapeutic processes ,,. The therapeutic effectiveness of CISD, which is most often used in the military, is also controversial in previous studies. With those inconsistent effects of early psychological intervention, further understanding of therapeutic elements within this psychological intervention warrants the optimizing outcome of posttraumatic psychological managements.
Previous research has revealed the benefits of stress debriefing interventions among military population. But the social factors have effects on both of the PTSD development and CISD benefits. Those findings suggest that the frontline military rescuers can benefit from CISD and the benefits may be influenced by their personal sociodemographic factors, such as gender, rank, and years of service. With a predesigned semi-structured psychological debriefing for the military rescuers, we intended in this study to explore the association between personal characteristics of the frontline military rescuers of a helicopter crash disaster and the self-rated received benefits of CISD in those rescuers after their rescue mission and traumatic exposures.
| Methods|| |
This is a cross-sectional survey study. The experimental protocol was approved by the institutional review board at the Tri Service General Hospital, National Defense Medical Center in Taipei, Taiwan, with the stipulation of obtaining informed consent from the study participants (IRB protocol number = 1-108-05-147, and date of approval = September 18, 2019).
The study participants were recruited from the frontline military rescuers of the helicopter crash disaster, who were involved in the tasks of searching the survivors and collecting human remains of the deceased. Those frontline military rescuers were offered to join the debriefing group, and we included only those who were willing to attend and complete the two-hour debriefing group courses (N = 71). Eventually, every attendant agreed to sign the consent form and finished the copy of the questionnaire after the debriefing group.
Following the recommendations of previous research, we provided a two-hour debriefing group for the frontline rescuers 1 day after their rescue task, while they were having break time. The two-hour debriefing group courses were provided by professionals, such as psychiatrists, psychologists, and social workers, from our hospital. All the professionals were all experienced in providing clinical psychosocial support. They did the group psychological debriefing programs following a predesigned semi-structured process based on CISD protocol, so all the group psychological debriefing programs were similar in the processes. There were 2 therapists and 7–9 rescuers in each CISD program. The processes of the group psychological debriefing programs, which were predesigned and based on CISD protocol, were divided into seven phases including introduction phase, introducing members and explaining process, fact phase, describing traumatic event from each attendant's perspective, thought phase, describing cognitive reactions, reaction phase, describing emotional reactions, symptom phase, identifying personal symptoms of distress, education phase, educating adaptive coping skills, and re-entry phase, as well as preparing for termination ,. Besides, cohesion, which has been considered as an important and effective therapeutic factor, was put in the process of our group debriefing program.
All attendants were invited to finish the copy of the questionnaire about their own experiences and self-rated perceived benefits of the group psychological debriefing.
We used the Sharing Support Group for Crisis Intervention Questionnaire (SSGCIQ) to focus on self-perceived benefits of 11 different therapeutic elements during the process of the two-hour group debriefing programs we provided. Excepting the second item of the questionnaire which is an open-question, those other 11 therapeutic elements include impression of progression (Q1), benefit from groups (Q3), catharsis (Q4), benefit from reviewing (Q5), organization of conflicts (Q6), facing what avoided (Q7), extension of coping skills (Q8), relief from PTSD classes (Q9), self-enhancement (Q10), cohesiveness (Q11), and sharing support (Q12). All the questions about the perceived benefit of each therapeutic element were evaluated with a five-point Likert scale from 1 as totally disagree to 5 as totally agree. As the second item (Q2) is an open-end response about participant's impression for this program, we decided not to include this item in the quantitative statistical analysis model in this study.
The descriptive analyses were used to present demographic characteristics of the total sample and different sex. Then, we compared variables between sex, military rank, and military service year with independent t-test for continuous variables, and with Chi-square test for categorical ones. The difference of perceived benefit and each item of SSGCIQ between gender, military rank, and military service year was tested by using independent t- test. We also compared the difference of age and military service year between military rank as well as the difference of age and military rank between junior and senior group with Chi-square. Those data were to explore if those sociodemographic characteristics have potential effects on the therapeutic effectiveness of CISD.
The correlation and linear regression were all done using the Statistical Package for Social Science version 22 (SPSS Inc., Chicago, Illinois, USA). The differences between groups as well as the indirect effects and moderation effects were considered significant if p < 0.05.
| Results|| |
The sociodemographic data and psychology well-being after our two-hour debriefing group courses of 71 rescue personnel samples are represented in comparison with different sex [Table 1] and different military ranks [Table 2]. No significant differences existed in Q1, impression of progression, and in the self-perceive benefit from each phase of CISD between gender. Although Q1, impression of progression, did not have significant difference between military ranks, Q3 (p < 0.05), Q4 (p < 0.05), Q5 (p < 0.01), and Q8 (p < 0.05) had significant difference.
|Table 1: The sociodemographic data and the selfperceived benefit of the group debriefing and each therapeutic element of 71 rescue personnel samples|
Click here to view
|Table 2: The sociodemographic data and the self-perceived benefit of the group debriefing and each therapeutic element between different military ranks|
Click here to view
[Table 3] shows the intercorrelations between age, seniority in year, impression of progression, and ten therapeutic element items. [Table 4] compares junior and senior groups of those rescuers using the year-service medium (4 years) of samples, and the senior group had less self-perceived benefit in Q5, Q7, and Q8.
|Table 3: Correlation coefficients between variables and self-perceived benefit scales|
Click here to view
|Table 4: The comparison of variables between samples with years of military service below and above the median (4 years)|
Click here to view
| Discussion|| |
The result of our study showed that our two-hour postdisaster debriefing program for the frontline military rescuers enhanced the psychological well-being of frontline military rescue personnel who experienced similar stress event. Especially, more salient effects [Table 4] existed among officer group and the junior participants significantly (p < 0.05). No difference existed between gender in our study results [Table 1] although the gender difference of sex in the psychopathology of depression and suicidality among Taiwan soldiers has been reported. On the other hand, the sergeant level showed significantly less self-perceived benefits from the items of benefits from the group (Q3, p < 0.05), emotion catharsis (Q4, p < 0.05), reviewing of what the group members experienced (Q5, p < 0.01), and coping skills extension (Q8, p < 0.05). Those findings can be associated with that the sense of stigma, shame, or sense of failure can be promoted during CISD.
To clarify the effect of seniority in military to the well-being of rescue personnel, we divided our samples into two groups by the medium age (4 years old, [Table 4]. The senior group showed significantly lower mean magnitudes in Q5 (p < 0.05), benefit from reviewing; Q7 (p < 0.05), facing what avoided; and Q8 (p < 0.05), extension of coping skills. Previous studies suggested that hierarchical organizational structure can impede the effectiveness of debriefing. The reason why senior group benefits less during our debriefing, in our observation, is probably due to the embracement and humbleness of senior group by expressing their feeling in front of colleagues, especially the junior ones.
As a matter of fact, the strong inter-correlations existed among the impression of progression and those ten debriefing program therapeutic element items (p < 0.05, [Table 3]. Using logistic regression model for adjusting effects between variables, the Q5 item, benefit from groups, remained to have significant associated factor (p < 0.05).
Without previous articles supporting or contradicting our findings to our knowledge, we suggest that our two-hour CISD program can generally benefit frontline disaster military rescue personnel, especially for those who are new in experience or junior in military service. The reason why this program benefited less among the sergeant group is, in our opinion, that most sergeants in our sample were senior in military service at that time. Although there was no significant difference of Q1, impression of progression, between gender, military rank, or military service year, several items of SSGICQ differed between groups. The perceived benefit of different phases in CISD can possibly modified by sociodemographic factors. Future studies with large sample size, randomized controlled trial, qualitative study, and follow-up of PTSD development are required for further understanding. CISD programs which have been designed based on the attendants' military seniority, can provide better self-perceived benefit and furthermore, PTSD prevention.
The readers are cautioned not to overinterpret the study finding because this study has the following three limitations:
- The limited sample size and the nature of a cross-section study prohibit our results from generalization to other populations and long-term effects without further examination. According to the reports of government, more than 200 civilian and military frontline rescuers were involved all over the island not to mention the chronological changes of mental conditions and various tasks participants were involving
- The arbitrary stratification of the seniority of participants was roughly dependent on the statistical medium age of samples. Further regression models or clustering methods are warranted for further study with a larger sample size
- According to the statement of the author of the questionnaire, the validity and reliability of SSGCIQ are still on the working stage, and not ready for publication. The lacking of further information of this instrument suggests the need of future investigations to fill the knowledge gap.
From a survey of 71 military personnel in the frontline rescue action for the Taiwanese helicopter crash on January 02, 2020, this study reveals the sociodemographic factors, rescuers' ranks and years of service but gender, play rôles in the effectiveness of the group debriefing programs.
To summarize, we suggest that in this study, the sociodemographic factors, rescuers' ranks, and years of service but gender, play rôles in the effectiveness of the group debriefing programs for the frontline military rescuers. We hope that further understanding can improve the therapeutic effectiveness of debriefing management in future.
| Acknowledgment|| |
The authors sincerely appreciate all the participants and the author of SSGCIQ. Without their generous contribution, this work is impossible to be accomplished.
| Financial Support and Sponsorship|| |
The authors report no financial support in writing this report.
| Conflicts of Interest|| |
The authors declare no conflicts of interest in writing this report.
| References|| |
Ursano RJ, Fullerton CS, Kao TC, et al.
: Longitudinal assessment of posttraumatic stress disorder and depression after exposure to traumatic death. J Nerv Ment Dis
1995; 183: 36-42.
Bills CB, Levy NA, Sharma V, et al.
: Mental health of workers and volunteers responding to events of 9/11: review of the literature. Mt Sinai J Med
2008; 75: 115-27.
Khatri KJ, Fitzgerald G, Poudyal Chhetri MB: Health risks and challenges in earthquake responders in Nepal: A qualitative research. Prehosp Disaster Med
2019; 34: 274-81.
Guo YJ, Chen CH, Lu ML, et al.
: Posttraumatic stress disorder among professional and nonprofessional rescuers involved in an earthquake in Taiwan. Psychiat Res
2004; 127: 35-41.
Fullerton CS, Ursano RJ, Wang L: Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers. Am J Psychiatry
2004; 161: 1370-6.
Berninger A, Webber MP, Niles JK, et al.
: Longitudinal study of probable post-traumatic stress disorder in firefighters exposed to the World Trade Center disaster. Am J Ind Med
2010; 53: 1177-85.
Hagh-Shenas H, Goodarzi MA, Dehbozorgi G, et al.
: Psychological consequences of the Bam earthquake on professional and nonprofessional helpers. J Trauma Stress
2005; 18: 477-83.
Horesh D, Solomon Z, Zerach G, et al.
: Delayed-onset PTSD among war veterans: the role of life events throughout the life cycle. Soc Psychiatry Psychiatr Epidemiol
2011; 46: 863-70.
Britton PC, Bossarte RM, Lu N, et al.
: Prevalence, correlates, and symptom profiles of depression among men with a history of military service. Soc Psychiatry Psychiatr Epidemiol
2011; 46: 607-14.
Woodhead C, Rona RJ, Iversen AC, et al.
: Health of national service veterans: an analysis of a community-based sample using data from the 2007 Adult Psychiatric Morbidity Survey of England. Soc Psychiatry Psychiatr Epidemiol
2011; 46: 559-66.
McKenzie DP, Creamer M, Kelsall HL, et al.
: Temporal relationships between Gulf War deployment and subsequent psychological disorders in Royal Australian Navy Gulf War veterans. Soc Psychiatry Psychiatr Epidemiol
2010; 45: 843-52.
Katz CL, Pellegrino L, Pandya A, et al.
: Research on psychiatric outcomes and interventions subsequent to disasters: a review of the literature. Psychiatry Res
2002; 110: 201-17.
Auxéméry Y: Treatment of post-traumatic psychiatric disorders: a continuum of immediate, post-immediate and follow-up care mediated by specific psychotherapeutic principles - clinical experience in French-speaking countries. Encephale
2018; 44: 403-8.
Dolan N, Tedeschi C: A qualitative study of psychological outcomes in avalanche first responders. High Alt Med Biol
2018; 19: 344-55.
Campfield KM, Hills AM: Effect of timing of critical incident stress debriefing (CISD) on posttraumatic symptoms. J Trauma Stress
2001; 14: 327-40.
MacDonald CM: Evaluation of stress debriefing interventions with military populations. Mil Med
2003; 168: 961-8.
Wu S, Zhu X, Zhang Y, et al.
: A new psychological intervention: “512 Psychological Intervention Model” used for military rescuers in Wenchuan Earthquake in China. Soc Psychiatry Psychiatr Epidemiol
2012; 47: 1111-9.
Roberts NP, Kitchiner NJ, Kenardy J, et al.
: Early psychological intervention following recent trauma: a systematic review and meta-analysis. Eur J Psychotraumatol
2019; 10: 1695486.
Rose S, Bisson J, Wessely S: A systematic review of single-session psychological interventions ('debriefing') following trauma. Psychother Psychosom
2003; 72: 176-84.
Carlier IV, Lamberts RD, Van Uchelen AJ, et al.
: Disaster-related post-traumatic stress in police officers: a field study of the impact of debriefing. Stress Med
1998; 14: 143-8.
Arendt M, Elklit A: Effectiveness of psychological debriefing. Acta Psychiatr Scand
2001; 104: 423-37.
Wei YF, Szumilas M, Kutcher S: Effectiveness on mental health of psychological debriefing for crisis intervention in schools. Educ Psychol Rev
2010; 22: 339-47.
Elhart MA, Dotson J, Smart D: Psychological debriefing of hospital emergency personnel: review of critical incident stress debriefing. Int J Nurs Student Scholarship
2019; 6: 1-9.
Adler AB, Litz BT, Castro CA, et al.
: A group randomized trial of critical incident stress debriefing provided to U.S. peacekeepers. J Trauma Stress
2008; 21: 253-63.
Yuan C, Wang Z, Inslicht SS, et al.
: Protective factors for posttraumatic stress disorder symptoms in a prospective study of police officers. Psychiatry Res
2011; 188: 45-50.
Halpern J, Gurevich M, Schwartz B, et al.
: Interventions for critical incident stress in emergency medical services: a qualitative study. Stress Health
2009; 25: 139-49.
Mitchell AM, Sakraida TJ, Kameg K: Critical incident stress debriefing: Implications for best practice. Disaster Manag Response
2003; 1: 46-51.
Mitchell JT: When disaster strikes...the critical incident stress debriefing process. J Emerg Med Serv
1983; 8: 36-9.
Norman G: Likert scales, levels of measurement and the “laws” of statistics. Adv Health Sci Educ Theory Pract
2010; 15: 625-32.
Smith MH, Brady PJ: Changing the face of Abu Ghraib through mental health intervention: U.S. army mental health team conducts debriefing with military policemen and Iraqi detainees. Milit Med
2006; 171: 1163-6.
Huang JH, Tai YM, Yang SN: The moderator rôle of family support between depression and suicidal ideation: discrepancy between male and female military population in Taiwan. Taiwan J Psychiatry
(Taipei) 2019; 33: 164-9.
Litz BT: Research on the impact of military trauma: current status and future directions. Milit Psychol
2007; 19: 217-38.
[Table 1], [Table 2], [Table 3], [Table 4]