The provision of mental health services after major crime victimization has become just as expected as the media frenzy that surrounds these incidents. Until quite recently, the intervention techniques used after these events have also been accepted without much examination. The typical response has been to gather together all those who have been impacted and provide group meetings or debriefings. However, during the past few years, there have been growing concerns about this type of intervention and its usefulness. The purpose of this article is to outline some of the problems with traditional trauma response interventions after crime victimization and suggest an alternative approach that may have promise.

Researchers and practitioners have noted a number of difficulties with traditional trauma response efforts which focus on group sessions and debriefings. Gist and Woodall (1998) have reviewed the debriefing literature and noted that there is no significant difference between those who receive and do not receive this intervention. In addition, they argues that there is a stable 5% casualty rate among debriefing participants. Chris Dunning (1988) has argued that most debriefing and intervention models focus on the potential development of serious symptoms or pathology during the debriefing process. While observing that only a few survivors develop stress reactions and other symptoms, she agues that intervention should focus on survivor strengths, coping skills and the use of social support.

These criticisms and our experience in responding to over 150 potentially traumatic incidents each year have convinced us that it is critical to look beyond debriefing focused interventions. In fact, given the complexity of traumatic stress and the potential for its life altering impact on individuals and groups, it is unlikely that a single intervention can adequately meet the needs of crime victims.

Our approach has been to use a "menu" of interventions and activities to promote recovery among individuals and organizations or communities. In the past, debriefings and other counseling interventions have focused on the impact on the individual. Thus, support was provided to the individual survivor and skills for managing stress responses focused on that person as well. These intervention options assume that traumatic events impact organizations and individuals and that some of the most effective interventions for individual recovery occur at the level of the organization.

Options for interventions include those that occur before going to the site of an event, interventions occurring on site and those that occur after the initial on-site response. One other note: The description of these interventions assumes no previous planning or efforts to create a trauma response. Of course, organizations that have plans and ongoing programs tend to respond more quickly and effectively.


Initial Contact and Planning

Initial Telephone Consultation (TelC) Trauma response begins when the initial call occurs and this contact sets the stage and expectations for the entire response process. During the initial contact, information is collected about the incident, organization, key personnel, levels of impact and expectations for trauma response and fees, if applicable. A tentative schedule of on-site services may also be negotiated.

Telephone Availability (TelA) Between the time of the initial contact and first on-site services, 24 hour crisis availability is provided to all members of the organization.

Telephone Check-In (TelCI) Based on recommendations made by the initial contact, trauma responders may make individual calls to those who are most impacted, have a history of exposure to trauma or are currently experiencing psychological symptoms. These calls are just check-ins to insure safety, provide basic information about initial stress reactions and offer further availability.

On Site Interventions

There has been much discussion about the timing of trauma response interventions. We haven't found anything magical about when the response should begin. One consideration is the scheduling of funerals and other memorials for those who die during the incident.

Humanitarian Assistance (Hum) This includes all the practical assistance provided by an employer, community or organization to support the recovery of survivors. Examples of humanitarian assistance might include assistance with travel costs, direct financial assistance, benefits coordination and building materials. Such assistance is just as important as any psychological intervention offered to survivors and should not be ignored.

Immediate On-Site Response (Imm) In general, survivors have related their need and desire to leave the site of the traumatic exposure, reconnect with their family and rest. Additionally, we have not noted any particular therapeutic value in such intervention and as a general rule have found it to be intrusive. The exception is the need of hostages to psychologically reorient after their release.

Initial On-Site Meeting (InMeet) Immediately after arrival on the scene of the incident, there should be a meeting between managers and/or community leaders and trauma responders. During this time, details of the response are reviewed, a clearer understanding of organizational or political issues is obtained and expectations for the condition of survivors after response is provided.

Crisis Intervention (CI) During the course of on-site services, some of the most impacted survivors will benefit from individual time with trauma responders. Typically, a room is set aside and staffed for those identified as needing crisis intervention or those who select individual time as their preferred choice of support.

Psychological Debriefing (PsyD) These are the group meetings that have been the mainstay of trauma response. Our debriefing model has changed and now includes the opportunity for each survivor to briefly describe the incident, report the development of any psychological symptoms and learn basic support skills. The purpose of the psychological debriefing is not to prevent the development of stress disorders but to build cohesion, teach management skills and allow for the assessment of all participants. Some of our trauma response efforts may include no psychological debriefings.

Educational Debriefing (EdD) This intervention is more like a seminar and workshop than a psychological debriefing. It allows those with less exposure to be included in the provision of trauma response services and teaches basic information and support skills that are helpful after such an incident. These sessions normally last about one hour. Educational debriefings do not provide the opportunity for individual assessment so care is necessary in selecting participants for this intervention.

Final On-Site Meeting (FiMeet) Before trauma responders leave the site of the incident, a team leader or representative of the group meets with those with administrative responsibility. Expectations for immediate recovery and organization functioning are reviewed and plans are made for follow-up services and other interventions.

Follow-up Interventions

Trauma response does not end with the initial on-site services. Those who have been identified as in need of further services must begin treatment in a timely way, debriefings should be followed up and efforts for returning the organization to functioning formalized.

Post Trauma Counseling (PTCo) Mental health services provided to survivors should be focused on developing the skills necessary to facilitate recovery and perception of control over the event and symptoms. About 10-20% of those impacted may require such services depending on exposure and vulnerability.

Follow-up Debriefings (FUD) This intervention is really just another check-in. About ten days to three weeks after the initial debriefings, participants are gathered together to check in with responders. It is usually immediately obvious who is experiencing continuing difficulties. These survivors are referred to posttrauma counseling if this has not already been accomplished.

Telephone Follow-Up (TelFU) Telephone follow-up is a good way to check-in with survivors and show continued concern for those struggling with recovery.

Return to Work Strategies (RTW) For incidents that occur in the workplace, a critical component of trauma response is assisting the organization return to productivity. The "get back on the horse philosophy" has proved quite unsuccessful and resulted in increased symptoms, resignations, retirements and very negative feelings about support received. The likelihood of success is greatly increased by slowly increasing survivors' exposure to the site and tasks associated with the traumatic incident and monitoring them carefully.

Memorial/Anniversary Assistance (Mem) Public recognition of traumatic events and their anniversaries is an important part of the recovery process. Poorly planned and implemented memorials can indicate a lack of concern and sensitivity about the incident. Similarly, anniversaries that go unrecognized can also send a negative message.

Evaluation (Eval) Trauma response services can be evaluated in several ways. Among the most common methods we have used include immediate verbal and written perceptions of participants and managers, satisfaction questionnaires and an analysis of sick leave and job absence over an extended period of time.

Figure I
Trauma Response Activities

Bank Robbery with Bank (Trauma response program in place)
TelC, TelA, PsyD, TelFU


Current Employee Kills Three
TelC, TelA,InMeet, CI, PsyD, EdD, FiMeet, PTCo, FUD, FiMeet, RTW, Eval, Mem


Corrections Hostage Incident, 3 Held/Released, 3 Physically Injured Imm, TelA, InMeet, PsyD, EdD, FiMeet, PTCo, PTCo, RTW, Eval

Figure I illustrates the use of intervention options in three different types of traumatic events. Factors used in making decisions for options include the magnitude and severity of the victimization, immediate needs of survivors, number of survivors that develop stress-related symptoms and need and prior preparation of organization to manage such incidents.

There are no "quick fixes" after exposure to crime victimization and the management of these incidents requires flexibility and a comprehensive approach. While moving away from a debriefing centered intervention strategy appears more "complicated" and time consuming, the opportunity to completely respond to these tragic incidents and insure the support, assessment and treatment of survivors make these extra efforts well worth the effort.

References

Gist, R. and Woodall, S.J. "Social science versus social movements: The origins and natural history of debriefing." The Autraliasian Journal of Disaster and Trauma Studies, 1998-1.

Dunning, C. Salutogenesis Presented at the International Society for Trauma Stress Studies, November, 1998.

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