Harvard University

Crisis Intervention – A Critique

Crisis events are not only associated with adverse mental health conditions for our students, but also with significant learning difficulties. As educators, it is important for us to know what we can do immediately following a crisis involving our students in order to prevent the traumatization that contributes to these negative outcomes.

Crisis intervention in schools today is still in its infancy. No single model has been adopted because of the lack of scientific research indicating a reason to do so. We simply do not yet know what works best with students in schools. We grapple with what will work most effectively, as we continue to rely on cognitive approaches or so-called “talking cures” that ignore the physiology of trauma. Recent scientific research has not supported the use of what is still a widely adopted crisis intervention model: Jeffrey T. Mitchell’s model of critical-incident stress debriefing (CISD). Several studies have found Mitchell’s model to be no more effective than no intervention at all, and in some cases, found it actually increased posttraumatic stress symptoms in a number of the recipients.

Within approximately forty-five minutes, with up to thirty individuals at a time, CISD involves a “fact phase” during which basic information is provided to inform those involved of what to expect. Facts disseminated include common stress reactions and other more debilitating symptoms. This is followed by a “feeling phase” during which, the up to thirty participants are encouraged to answer such questions as “What was the worst part of the incident for you personally?” This phase is followed by suggestions for coping with stress and then “reentry” into the world.

At a presentation Mitchell made of his model that I attended with school district personnel and state department mental health workers, I was most struck by how uncomfortable the audience was as they listened to his proposal. The body language of the audience members indicated that their own stress levels were increased when only watching the video shown of a debriefing session. Many audience members actually rose and left the presentation visibly shaking their heads. During the video, we watched several people delve into the worst part of the trauma for them, clearly becoming aroused physiologically and emotionally, yet within moments, the time was up and the group was left with one last caution. “Be careful driving home,” they were warned, “as you may still be upset” after leaving the intervention.

Individuals have spoken out about their experiences participating in debriefing sessions. After 9-11, for example, many participants indicated that the intervention was not helpful. One participant said that he was “numb” throughout the session and that, weeks later, he was still having nightmares and often felt as though he was choking (Groopman, 2004). Another participant said that hearing other victims describe what they saw and what they suffered was too much. He had to flee the session when another participant described seeing a body part roll down a sidewalk (Begley, 2003). After an earthquake in Turkey, a recipient said, “It was as if the debriefers opened me up as in surgery and didn’t stitch me back up (Begley, 2003, p. 1).”

Cognitive approaches, such as Mitchell’s, that ignore the body’s physiology have the potential to create hysteria because of how readily the body experiences overwhelm. When the body goes through a flooding of stress and emotion, which often happens as one recalls the worst part of the trauma, it protects itself by creating another reality or dissociated state. Hysteria is a form of dissociation. Participants who become hysterical during debriefing sessions are removed from the group so they do not distract other group members (Mitchell & Everly, 1996a). Rather than accept this as an expected outcome of crisis intervention, however, we can bring our new knowledge of the brain and body to the work we do to prevent such responses.

Adaptations of Mitchell’s model are what many educators in the field of crisis intervention rely upon. Some hesitate to make broad conclusions that the model is not helpful (Brock & Jimerson, 2002) despite the growing number of studies that support abandoning debriefing approaches (Gist & Devilly, 2002). Practitioners “remain committed to the principle of debriefing” because “clinical experience” suggests value in the “opportunity to express feelings (Deahl, Gillham, Thomas, Searle, & Srinivasan, 1994, p. 64).” Others consider economic reasons for the continued use of the approach (Arendt & Elklit, 2001). We need something, and it seems we lack any other efficient model to work from. Why else would we continue to use debriefing techniques when calls for caution and restraint have been heard from so many responsible scientists and practitioners (Gist & Devilly, 2002)?

Instead of heeding the many warnings to abandon, debriefers continue their work by creating adaptations of their model. The concern with that response, however, is that without careful consideration of how crises impact the brain and body’s physiology, intervention models continue to be developed and implemented that have the potential to cause the harm described by too many recipients.

In a review of recent developments in the field of crisis intervention, I was alarmed to find how little discussion there was of how the brain and body are impacted by trauma. Crises are repeatedly referred to as psychological events that have to be intervened with psychologically, as though trauma happens to the mind alone. We seem to be determined that our cognitive mind is the most powerful tool we have for healing, when in fact, it is the body, mediated by the ancient reptilian brain, that has the wisdom to know how to naturally recover from trauma and heal itself.

Most people recover from catastrophic events naturally and spontaneously over time. In fact, any “abnormal” behavior witnessed in the aftermath of trauma is actually part of a healthy process of recovery (Groopman, 2004) during which the body does what it knows how to do to process stress to its natural completion. Recall the impala that takes moments to shake off the stress from its attack and then carries on (see chapter four). Whether we are aware of it or not, in most cases, our body naturally finds a way to do the same. It is only a small percentage of people who experience a catastrophic event that will require formal intervention. This small percentage is comprised mostly of individuals with previous histories of trauma, with “fragile emotional profiles and few available resources (Torem & DePalma, 2003, p. 12).” For example, we know that students with previous exposure to traumatic events are more at risk due to the accumulation effect of stress on the nervous system. “The new [traumatic] energy necessitates the formation of more symptoms…[so that the traumatic] response not only becomes chronic, it intensifies” (Levine, 1997, p. 105).

More vulnerable students will likely need formal assistance in recovering from a crisis at school. For the majority, however, we know that the body has the capacity to heal itself, and that healing from stress and trauma is possible simply by being in community with others. These are important points to keep in mind when creating an effective crisis intervention model for schools. Dr. Steven Hyman, the provost of Harvard University, reminds us that the rituals we have adopted through our various cultures can be supportive in our healing and recovery from crisis events. He makes note of shivahs in Jewish cultures and wakes among Catholics. Dr. Hyman stated that, “No one should have to tell anyone anything! Particularly not in the scripted way of a debriefing.” Dr. Hyman has argued that when facing crises it is the power of our social networks that helps us create a sense of meaning and safety in our lives (Groopman, 2004).

Dr. Hyman is not the only responsible academic making statements that “no one should have to tell anyone anything.” A panel of eminent researchers assembled by the American Psychological Society – Richard McNally of Harvard University, Richard Bryant of the University of New South Wales, and Anke Ehlers of King’s College London – has reached a clear conclusion: “Pushing people to talk about their feelings and thoughts very soon after a trauma may not be beneficial…For scientific and ethical reasons, professionals should cease compulsory debriefing of trauma-exposed people (Begley, 2003, p. 2).

With a growing number of studies cautioning us to abandon debriefing approaches, why is telling the story and verbally going over the details of a crisis still considered helpful? Why are cognitive and narrative approaches to crisis intervention gaining support in some professional circles? This trend may be part of a prevailing cultural bias that we can talk our way out of anything. Talking is, for most counselors, the best-known and most comfortable mode of operation. However, no explanation seems to warrant that, as ethical professionals, we ignore a striking body of evidence. Exposure techniques used in cognitive approaches to trauma are “not good for people with brains and not good for people with bodies;” telling the “story will re-traumatize and make things worse (van der Kolk, 2002).”

Dr. van der Kolk, when recently speaking at a professional conference, was open about the fact that like most counselors, he did not know how to pace the work he did with trauma survivors. Like most counselors today, he said he “wasn’t mindful about the effect of having people talk about these very scary things.” Learning about trauma’s impact on the brain is what prompted him to speak around the world educating professionals about the dangers of re-telling the story and the so-called “talking cure.” Crisis intervention specialists working in schools are beginning to acknowledge the dangers. School crisis management research summaries provided in the official newspaper of the National Association of School Psychologists (NASP) stated that early crisis interventions involving detailed verbal recollections of events may not be helpful and may place those with high arousal at greater risk (Brock & Jimerson, 2002).

What seems to be most helpful about current approaches in managing crises is meeting in a group and disseminating information. Litz and colleagues published a study comparing the CISD model with cognitive-behavioral therapy (CBT) (Litz, Gray, Bryant, & Adler, 2002). Common between the approaches was education on typical reactions and instruction in coping skills for stress and anxiety. Results indicated that meeting in a group is what helped to maintain morale and cohesion. Group interventions seemed to serve as an opportunity for those in the group to feel less stigmatized, more validated, and empowered. Psycho-education or dissemination of information regarding what to expect was also cited as a helpful part of these crisis approaches. Even single sessions when they were supportive rather than therapeutic were helpful when they (a) assessed for the need for sustained treatment, (b) provided psychological first aid, and (c) offered education about trauma and treatment resources.

Some group interventions have been found to reduce anxiety, improve self-efficacy, and enhance group cohesion (Shalev, Peri, Rogel-Fuchs, Ursano, & Marlowe, 1998). They have also been found to play a role in reducing alcohol misuse (Deahl, Srinivsan, Jones, Thomas, Neblett, & Jolly, 2000). However, it has also been found that single-session group crisis interventions are insufficient for high-risk trauma survivors, those with poor pre-trauma mental health (Larsson, Michel, & Lundin, 2000). Individuals with previous traumas, such as burns, accidents or violent crime, may actually be harmed by single-session group crisis intervention (Bisson, Jenkins, Alexander, & Bannister, 1997; Mayou, Ehlers, & Hobbs, 2000). This information is invaluable as we continue to work together as educators to develop an effective crisis intervention model.

Common Myths About Crises

It is important to address some of the myths that persist today regarding the impact of trauma on our students. These myths are pervasive and stem from outdated beliefs about children that we now have the brain research to refute.

Some Events are More Traumatic than Others

I have witnessed professionals in the field of crisis intervention delve into lengthy presentations about certain events being more traumatic than others. For the most part, these discussions are not helpful. I listened to one presenter talk extensively about a broken arm from a physical assault being more traumatic than a broken arm from a car accident, and about war being more traumatic than an earthquake. It is not a matter of some events being more traumatic than others. Trauma is not in the event; it is in the nervous system (Levine, 1997). Depending on the condition of the individual’s nervous system and available resources before, during, and after the event, what may seem benign to some can be very debilitating to another. Believing that some events can be objectively judged for everyone as more or less traumatic leads to very dangerous assumptions about individual students. We cannot expect that some students will be less traumatized by what we have judged as a less frightening event. This is how we misunderstand students and fail to see their trauma-related symptoms after an event that was terrifying to them.

Trauma Causes Psychological Injury

While it is true that trauma has the potential to induce psychological injury, such a statement does not reflect the whole truth concerning the damage caused by traumatization. When people who are traumatized learn that crises are not simply psychological events but physiological ones, they experience relief. What they are going through is not “in their head;” it is the natural response of the body. People suffer years of anguish following a car accident, for example, or a surgery, believing that they must be going crazy. Their medical doctors tell them that there is nothing physically wrong with them, that there is no reason for their suffering. No one talks to them about what their brain and body have gone through so they conclude that the problem must be in their head. With that conclusion comes the belief that they must be in need of some form of talk therapy. I have seen firsthand how this conclusion leads to hopelessness, as traumatized people make numerous attempts at various forms of therapy with little or no success. They know they do not feel the same inside. They know they have applied all the cognitive techniques they were taught by their well-meaning therapists. They simply do not get better.

Medical tests cannot detect the problem and psychological approaches that do not intervene with the body’s response to trauma leave traumatized people feeling like they are going crazy. When we look at physiology, however, we find answers. We learn that, among other physiological changes, traumatization increases resting heart rates and decreases cortisol levels. Hormones and neurotransmitters are altered in the short term or long term depending upon previous history and resources. Physiological symptoms require a physiological approach. This is what is missing from the crisis intervention programs used today.

Children Look to Adults to Determine How Threatening an Event Is

No matter how young children are, pre-verbal or verbal, they have their own nervous system, their own brain, their own body and mind, and they experience life and its events as much as anyone else. They may not have words for their experiences, and they may look to adults for comfort and understanding in the face of a frightening event, but they do not need to be guided when to feel fear. We cannot tell a student that they are fine and what happened is “no big deal” if, in fact, it was a big deal to them. We stand the risk of shutting down their body’s natural healing mechanism when we do so. There are ways to support the natural process of healing and there are ways to undermine it. Telling students how to feel is an example of how our cognitive mind can interfere with the body’s capacity to heal.

A colleague of mine once shared that when she was a young girl she fell from her bicycle and badly hurt her knee. She was so stunned from the fall that she could not cry. She realized as an adult looking back on the event that she must have been in a state of shock because all she felt was numb. When she arrived at the door of her home and her mother saw that she had been injured but was not crying she was praised for being such a brave girl. “Look at what a good girl you are,” her mother said, “You are not even crying.” After that incident, my colleague said that she made sure she did not cry no matter what else came her way. She used her words, the power of her cognitive mind, to shut down her body’s natural responses so that she would be regarded as brave and strong.

Adults have no way of knowing how threatening or frightening an event is to a child. If we think we can decide objectively what a student’s subjective experience will be, we have no chance of understanding or intervening with students in crisis.

Developmental Immaturity Can be Protective

Some believe that the younger a student is, the less the student will experience fear and terror. This is not supported by scientific evidence. One Nationally Certificated School Psychologist (NCSP) made a presentation at my school district encouraging us to utilize his crisis intervention model. As part of the introduction to his work, he said that both developmentally mature and gifted students are more vulnerable and impacted by crises than their less well-developed peers. Smarter students can be more traumatized than less intelligent students because they realize the event was threatening, he said. They realize the event was traumatic because they are cognitively sophisticated enough to judge the event as threatening. According to this presenter, “Developmentally immature students don’t understand the event, so it is not traumatic for them.”

Trauma is a physiological event that impacts everyone in its wake (to varying degrees) regardless of level of intellect. The school psychologist’s statements demonstrate a dangerous ignorance of science and what the brain and body experience in the face of threat.

Current Attempts at Crisis Intervention in Schools

Several educational professionals from various areas of expertise have attempted to develop crisis intervention models that will meet the needs of schools. Three different men who each developed their own approach presented to my school district on three separate occasions. I will review each of their proposals: (1) Bill Saltzman from the National Center for Child Traumatic Stress, (2) Michael Hass from Chapman University in Orange County, California, and (3) Stephen Brock, a nationally credited school psychologist and coordinator of the Crisis Management in the Schools Interest Group.

Saltzman

Dr. Bill Saltzman’s approach emphasizes the need to tailor crisis intervention to the developmental level of the students being served (Saltzman, 2003). He reminds us that students’ responses may be specific to their age and stage of development. For instance, preschoolers may display cognitive confusion. They may not know that the danger is over when a crisis event ends and may need to be given repeated concrete clarifications for anticipated confusions. Older, school-age students may display specific fears triggered by traumatic reminders. They may require help in identifying and articulating those reminders as well as associated anxieties. They may benefit from being encouraged not to generalize, according to Saltzman. Adolescents, on the other hand, may begin to exhibit posttraumatic acting out behavior such as drug use, delinquency, or sexual activity. Saltzman postulates that helping adolescents understand the acting out behavior as an effort to numb their response to, or to voice their anger over, the event may be of benefit.

Importance is placed on family and friendship. Maintaining and nurturing relationships is critical after a crisis event for students at every stage of development. Saltzman points out that sometimes crisis events cause physical relocations that can abruptly interrupt usual daily contact with loved ones. When this happens, it is helpful to make the effort to keep relational ties regardless of physical separation in order to be comforted by them.

Saltzman makes clear that it is always important to reintegrate students back into the school and classroom environment as soon as possible. Somatic complaints and specific fears related to school or loss of a loved one may make it difficult for a student to want to enter back into school. The family and the school need to work together to make sure students’ fears are resolved and attendance in school is maintained.

Saltzman’s model includes an initial interview protocol that asks crisis survivors questions in seven stages. The first step is to gather factual information about where the student was during the event, what they were exposed to and how they knew the people involved. One important question to ask at this stage is whether or not the student has ever experienced any other kind of crisis or trauma, including subjection to violence, serious illness or sudden, unexpected loss. The next four stages of questions have to do with the students’ responses to the crisis. What was their subjective response to the event? Are they exhibiting new behaviors or new concerns since the event? What type of grief responses are they displaying? Finally, in the sixth stage of the interview, students are asked about their coping mechanisms before the final stage of closing the interview is done.

Saltzman’s approach is useful. Awareness and consideration of the different expressions and needs of students at varying developmental levels is helpful. Caution should be made, however, that during times of crises, students may easily and quickly regress back to earlier stages of development so that even adolescents display the behaviors of pre-school children. Saltzman highlighted “anxious attachment” as a possible pre-school response that may involve clinging and not wanting to be away from the parent or worrying about when the parent is coming back. This can happen with teenagers. Like pre-school students, adolescents may also greatly benefit from being reassured about “consistent caretaking” of being picked up after school and always knowing where their caretakers are.

In a review of all of Saltzman’s hypothesized responses of students at different ages, it was easy to see that any one of these responses could come from a student at any developmental level. We do not want to make assumptions about how a student will act given their age. If we have expectations we may not see what we need to. Nonetheless, it is useful to be aware of the possibility of age and stage differences. Especially in teenagers should we expect to see such age-specific behaviors as “premature entrance into adulthood.” Certainly that is something specific to adolescence. However, behaviors attributed to adolescence in Saltzman’s approach, such as “life threatening re-enactment, self-destructive or accident-prone behavior, abrupt shifts in interpersonal relationships, and desires and plans to take revenge,” are readily seen in some younger school age children after a crisis event.

Saltzman’s approach, like most, is cognitive and emphasizes the use of verbal language and asking questions. It is unclear how soon after a crisis event all of the questions from the initial interview protocol are to be asked. Like other cognitive approaches, including the debriefing model, Saltzman asks crisis survivors to talk about their “most disturbing moment” and “worst fear.” We need to learn from the examples we now have available to us that this kind of questioning may increase suffering.

Hass

Dr. Michael Hass has attempted to help schools develop a crisis intervention model utilizing the principles of Solution Focused Brief Counseling (Hass, 2002). His emphasis, like most others, is on interviewing the crisis survivor. The stages of crisis interviewing in his approach include role clarification, a description of the problem, an exploration of current coping efforts, “scaling” of coping progress, formulation of the “next step,” and closure. The focus of this approach is on the establishment of helpful coping skills. Questions during the interview are intended to facilitate coping in order to empower students to take action on their own behalf.

Examples of coping questions include: What are you doing to take care of yourself in this situation? Who do you think would be most helpful to you at this time? What about that person would be most helpful? Have you been through a frightening situation before? How did you get through it then? Developing resources for the student to draw upon during difficult times is key. “Scaling” questions are also related to coping. They help students rate how much better or worse they think they are doing and give a gauge to crisis counselors of how much progress has been made. Together, the counselors and students problem-solve to arrive at solutions for moving the scale in the desired direction.

During Hass’ presentation, he highlighted the importance of telling the story of what happened during the crisis. He stated that researchers have found that putting a traumatic incident into language is a critical feature of the healing process. The idea being that language helps the images and feelings we have about a frightening event become more organized, understood and resolved.

The studies that Hass was referring to were led by Dr. Edna Foa, a professor of psychology at the University of Pennsylvania who, twenty years ago, began studying rape victims. She found that most rape victims spontaneously recovered without the need for formal intervention, but that fifteen per cent developed symptoms of posttraumatic stress (Groopman, 2004). Foa devised a technique of storytelling to restore resilience in those who continued to suffer. The women were asked to tell their story into a tape recorder and listen to it, then re-tell it and listen to it, and so on. Within approximately twenty sessions, Foa found that twenty-nine of the thirty participants experienced a marked improvement in their symptoms and ability to function. She attributed their improvement to the changing of the story over time. It became more organized, with a beginning, a middle, and an end. It was hypothesized that because they were able to give such a well-developed account of the incident, they were more likely to develop perspective on the event, create a sense of distance from it, feel a sense of closure about it, and feel more hopeful about the future.

Hass’ overall focus on strengthening and empowering students to cope after a traumatic event is very helpful. It is important to create a balance in the nervous system between the alarm response triggered by the event and whatever will be soothing to that sense of alarm. However, it is dangerous to recommend a technique to professionals who work with school-aged children, when the few studies that support such an approach have been done with adult women who experienced sexual assault. The appropriateness of using such an approach with students may be suspect, especially when other eminent professionals in the field have seen that telling the story can re-traumatize the victim (van der Kolk, 2002). It is true that when trauma survivors can tell their story in an organized, fluid way without becoming overwhelmed by it, this can be a sign that they are recovering from the experience. Telling the story at some point in a trauma survivors’ treatment may be relevant. However, we are not talking about adults receiving therapy. We are talking about crisis intervention for school-aged students. Now that so many responsible scientists and practitioners are warning us that telling the story can cause hysteria and re-traumatization, it is best not to endorse such an approach to schools.

Brock

Dr. Stephen Brock developed a model of crisis intervention for schools that takes into account the different stages of the event (Brock & Jimerson, 2002). The first stage is the impact, or when the crisis occurs. The next stage is the first phase of the school’s response to the event, which he calls “recoil.” Immediately after the event, the students involved receive “psychological first aid” and, in some cases, medical intervention. Support systems need to be enlisted during this phase, ensuring that loved ones are located and reunited. Psycho-education groups, caregiver training, and informational flyers are also important at this time, as is risk screening and referral for students who may require more intense intervention.

The “postimpact” phase occurs in the days and weeks after the event. This is the time that Brock suggests that group crisis debriefings occur, as well as ongoing psychological first aid, psychotherapy, and crisis prevention/preparedness for the future. Rituals and memorials may be helpful at this time, as well as in the next phase of “recovery/reconstruction.”

Recovery/reconstruction, the final stage of the approach, involves anniversary preparedness. Anniversary reactions have been found to be as intense as initial ones (Gabriel, 1992).

Brock recommends that, before the school responds in the recoil phase, all pertinent staff members meet as a team, clarify their roles, and decide who will do what. There will be a different part to play for school psychologists, nurses, counselors, and administrators.

The psychological first aid approach developed by Brock specifically for schools is called Group Crisis Intervention (GCI). It is designed to work with large groups of students who experienced a common crisis. Such large groups are typically classrooms. The approach is not intended for use with severely traumatized students, whose crisis reactions are thought to interfere with GCI (Brock, 2002). Like in Mitchell’s model, these students are removed from the group and referred to mental health professionals. It is suggested that GCI occur at the start of the first full school day following resolution of the event to ensure that participants are psychologically ready to talk about the crisis (Brock, 2002).

The six-step model includes an introduction, provision of facts and dispelling of rumors, sharing stories, sharing reactions, empowerment, and closing. GCI is ideally completed in one session lasting one to three hours, depending on the developmental level of the classroom of students. Similar to other approaches, group facilitators introduce themselves and define their roles. Opportunities are provided for students to share their stories, their reactions, and become “empowered” through a focus on coping and stress management.

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