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} A THREE YEAR FIVE STATE STUDY ON THE RELATIONSHIPS BETWEEN

CRITICAL INCIDENT STRESS DEBRIEFINGS, FIREFIGHTERS'
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DISPOSITION, AND STRESS REACTIONS

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USFA-FEMA CISM Research Project

Texas A&M University-Commerce
RFA #EMT-96-RP-009

#EMT-95-G-0304

#EMT-94-G-0288

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Final Report

Principal Investigator: Morag B. Harris, Ph.D.

Data Analyst: James Stacks, M.S.
 2

t
CONTENTS

Foreword

Contributing Fire Departments

Executive Summary

1. Background and Objectives

2. Design and Method
3. Major Findings and Conclusions
4. Discussion
5. Oklahoma City Study
6. Firefighters' Family Study
7. Summary
Technical Report
I
List of Figures
} List of Tables

, 1. Research Questions
2. Method
3. Results
I
Assessments
Data Analyses
Post Hoc Analyses
I 4. Discussion and Recommendations
5. Appendices
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Appendix A: Research Survey
Appendix B: Figures and Tables
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Foreword

United States Fire Administration

Federal Emergency Management Agency

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The United States Fire Administration(USFA) provided

) funding to Region VI of the United States Federal Emergency
Management Agency(FEMA) for research into firefighter
stress on September 1, 1996. Subsequently, a cooperative
j agreement was reached between FEMA Region VI and Texas A&M
University-Commerce to meet this funding objective by
continuing an existing FEMA funded evaluation of the
effectiveness of critical incident stress management
debriefings for emergency responders (1994-1996). As a
result the USFA project extended the 1994-1996 evaluation
research, utilizing the same research questions and
I hypotheses on the premise that crisis intervention theory
had appropriately grounded the rationale for the previous

,
) inquiry, and an increase in the size of the population
sample (n=1053) would provide a stronger representation of
the firefighter population in the Region VI area. Given
the general absence of pre-incidence data, there also
appeared to be an opportunity to make pre-post-bombing
comparisons on firefighters in Oklahoma City. Comparisons
in this report have been based on fifty Oklahoma
firefighters outside of Oklahoma City who engaged in search
and rescue activities after the Alfred P. Murrah Federal
Building was bombed.

In terms of the Cooperative Agreement dated November 13,

1996, Texas A&M University-Commerce appointed me to
continue as Principal Investigator for the purposes of this
research and its terms of reference as,

1. An expanded data collection to enhance the

representative nature of the existing sample by including
urban, suburban, and rural emergency responders as well as
those responders who have been exposed to debriefing
i procedures, and
 4

2. A post incident study of the effects of the

Oklahoma City Bombing on the Oklahoma City firefighters.

I have carried out this research and now respectfully

submit my report. A list of the names of the fire
departments who contributed surveys for the research
follows,
/ / ,,j/ ~- ,,,_~ / ;'fit ~-,_
Morag B. Harris, Ph.D.
Associate Professor
January 20, 1998

)
 5

Contributing Fire Departments

ARKANSAS TEXAS
188 th Ft. Smith Amarillo
Conway Austin
Fort Smith Beaumont
Little Rock Brownwood
North Little Rock Campbell
Texarkana Cedar Hill
Commerce
LOUISIANA Cooper
Baton Rouge Dallas
Bogalusa DeSoto
Hammond Duncanville
Monsanto El Paso
Ouachita County Garland
Plaquemine Groves
Slidell Lancaster
Liberty/Eylau
NEW MEXICO Nederland
Albuquerque Orange
Hobbs Port Arthur
Kirtland AFB Port Neches
Las Cruces Redwater
Las Vegas Seagoville
Roswell Sulphur Springs
Santa Fe Texarkana
 6

'
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EXECUTIVE SUMMARY

OF A

THREE YEAR FIVE STATE STUDY ON THE RELATIONSHIPS BETWEEN

CRITICAL INCIDENT STRESS DEBRIEFINGS, FIREFIGHTERS'

DISPOSITION AND STRESS REACTIONS

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1. BACKGROUND AND OBJECTIVES

Review of Critical Incident Stress Debriefing Research

A "Critical Incident" is defined as one in which the

l firefighter has been exposed to personal loss or injury,

traumatic stimuli, mission failure or human error. Other

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descriptions include responding to several difficult

situations in a short space of time, calls which attract

1
excessive media attention, and contact with dead or

severely injured children. The suggestion has been made

that these kinds of experiences may overwhelm the

firefighter's normal ability to cope (Mitchell, 1983;

Mitchell, 1988; Mitchell & Bray, 1990).

A Critical Incident Stress Debriefing (CISD) is a peer

counseling group procedure with psychoeducational

components that provides information on various stress

reactions following exposure to a Critical Incident. This

model was designed by Jeffrey Mitchell and George Everly

(1992, 1994) and appears to be the one most widely used in

Region VI. Other models include the Conservation of

Resources Model (COR) (Hobfoll, 1988, 1989, 1991) which

focuses instead on the consequences of diminished resources

during a post-disaster phase. The premise here is that the

more rapidly resources are lost, and the greater the number

lost, the greater the possible harm to individuals and

communities. Both the American Red Cross (ARC) and the

 8

National Organization for Victims Assistance (NOVA) also

provide post disaster interventions. Nevertheless the

"Mitchell Model" was the only approach identified by the

fire departments in this study.

A review of the literature on the stress reactions of

l professional emergency responders suggests that those who

respond to disasters/critical incidents may be at risk for

developing a variety of psychological, social and physical

reactions (Duckworth, 1986; Fullerton, Mccarroll, Ursano, &

Wright, 1992; McFarlane, 1988; Raphael, 1986). While

alcohol and drug abuse, depression, and anxiety are the

most common mental health sequelae associated with trauma,

both trade journals (Becknell, 1995; Dernocoeur, 1995;

Gray, 1981; Mitchell, 1983; Powell, 1995; Stout & Smith,

1981; Wagner, 1979), and professional publications (Bryant

& Harvey, 1996; DeAngelis, 1995; Duckworth, 1986;

Fullerton, Mccarroll, Ursano & Wright, 1992) have published

a number of articles suggesting that critical incidents

also have the potential to produce stress reactions with

post traumatic stress disorder (PTSD) features of arousal,

intrusion and avoidance. As a result, psychological or

Critical Incident Stress Debriefing has been adopted by

many fire, emergency medical, and police departments in the

belief that this approach will inoculate their employees

against the more distressing of these stress reactions.

Conflicting summaries of the research evidence on

debriefings have appeared during the period of this

 9

research project - 1994-1997 (Gist, Lohr, Kenardy, Bergman,

Meldrum, Redburn, Paton, Bisson, Woodall, & Rosen, 1997;

Mitchell, 1997; Ostrow, 1996; Robinson & Mitchell, 1995).

The majority of the findings have been neutral or negative

when conducted by independent researchers following

accepted research protocols. The following major points

have been outlined by Gist (1996, 1997). First, there is

no reliable evidence that debriefing prevents adverse

psychological reactions (Bisson & Deahl, 1994; Foa &

Meadows, 1997; Gist 1996a & b, Kenardy & Carr, 1996;

Raphael, Meldrum, & McFarlane, 1995; Stephens, 1997).

Second, while there is evidence that emergency responders

for the most part appreciate and are pleased with

debriefings, the same effect can be achieved by both

informal and formal measures such as pre-incident and post-

incident review and social support (Alexander & Wells,

1991; Hytten & Hasle, 1989; Stephens, 1997). Further the

Alexander and Wells study (1991) suggested that positive

organizational structures along with discreet professional

support may be more useful in protecting emergency

personnel against the possible traumatic effects of

critical incidents. Third, there is a very limited

empirical basis for CISD and no apparent evidence that any

particular model of debriefing is superior (Meichenbaum,

1994). Since debriefing is essentially a group phenomenon

it is essentially group leadership and the resultant group

dynamics that may determine the outcome in therapeutic

 10

terms. Fourth, immediate post-incident debriefings are now

being questioned by researchers both in the USA and

overseas (Orner, 1997; Bisson, Jenkins, Alexander, &

Bannister, 1997; earlier, 1996). The suggestion has been

made that firefighters may need a period of time without

any emphasis on emotional reactions. Rather, they may

need, during the immediate aftermath of a difficult

incident, to develop coping skills such as cognitive

reframing and distancing.

earlier (1996) conducted an extensive review of the

empirical evidence for the effectiveness of debriefing for

her presentation to the Annual Meeting of the International

Society for Traumatic Stress. She reported two classes of

studies. First, controlled studies in general were unable

to find significant differences between debriefed and non-

debriefed groups. However, in six studies where

differences were found these were not in the expected

direction; the debriefed participants were adversely

affected by higher levels of PTSD symptoms, depression,

agoraphobic complaints, anger, and anxiety than the non-

debriefed.

The second group of studies, exploratory or non-

controlled studies, did not fare any better. Significant

symptomatology was reported despite the debriefings. In

studies using satisfaction as a measure of debriefing

effectiveness, she found relatively low rates (from 50% to

68%) being reported. earlier pointed out that in research

 11

a more conservative satisfaction rating of 80% or higher is

more generally accepted because of the "social

desirability" nature of such questions. Another curious

and disturbing finding was that there appeared to be no

relationship between such measures of satisfaction and

positive outcome.

earlier concluded that there is no evidence from

controlled studies for positive effect, but some evidence

from uncontrolled studies and considerable evidence from

controlled studies for adverse effects from debriefings.

These adverse effects included elevated levels of PTSD

symptoms, anxiety, and depression.

Clearly there are several conditions that require

careful control before coming to the conclusion that the

research in this area is complete. Researchers need to be

able to describe the exact nature, the length of the

debriefing, the qualifications, training, experience and

quality of the debriefers, and the timing of the debriefing

(Robinson & Mitchell, 1993). Also there is a need to

conduct clearly defined longitudinal studies which would

document long term outcome (Paton & Violanti, 1996). When

pre-incident assessments are unavailable researchers may

instead be measuring the effects of pre-morbid personality.

In sum, although proponents of CISD protest that

several studies have demonstrated the effectiveness of

debriefing and provide many testimonials and anecdotal

reports claiming highly positive outcomes, no such studies

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(that is studies which use randomized assignment to

treatment condition and provide a clear, scientific and

empirical test for the efficacy of debriefing) appear in

the refereed professional journals. Indeed, those articles

and studies which do appear (Alexander & Wells, 1991;

Bisson & Deahl, 1994; Deahl, Gillham, Thomas, Searle, &

Strinivasan; Gist & Woodall, 1995; Raphael, Meldrum, &

McFarlane, 1995; Kenardy & Carr, 1996; Kenardy, Webster,

Lewin, Carr, Hazell, & Carter, 1996) suggest that there is

no substantive effect from CISD. Further, they report that

there may even appear to be negative outcomes indicating

that CISD may be iatrogenic for some and having no

demonstrable outcomes for others.

In order to investigate the effectiveness of critical

incident stress debriefings being employed by fire

) departments in the FEMA Region VI area this study was based

on crisis theory and post traumatic stress disorder models.

Crisis theory proposes that whenever a stressful event

takes place, certain recognized balancing factors can help

any individual regain his/her sense of balance or

'equilibrium' (Aguilera, 1994). These factors are the

individual's beliefs about the world, available situational

supports, and coping mechanisms. In addition, while some

events may cause a strong emotional reaction in one person,

these same events may leave others apparently unaffected.

A good deal of this difference may be determined by the

presence, absence or inadequate supply of the three

 13

balancing factors. Post traumatic stress disorder studies,

especially on emergency responders, have typically measured

intrusion, avoidance, and arousal as the three effects of

exposure to severe trauma (Horowitz, Wilner, & Alvarez,

1979).

Objectives for the Research

In order to examine the conflicting findings about the

effects of debriefings this study was developed from the

following assumptions.

1. By examining the relationships between

firefighters' disposition, or characteristic attitudes and

behaviors, and the emotional after-effects of critical

incidents, we would find that the key features of social

support, an ability to integrate critical incidents into

their experiences, a positive sense of self, and coping

strategies provide an effective buffer against stress.

2. If debriefing reduces the stress created by

critical incidents then there would be clear differences in

stress levels between those who had, and those who had not

been debriefed.

3. If satisfaction with debriefings was evidence

that debriefings were effective then those firefighters

 14

reporting high levels of satisfaction would also report

lower levels of emotional distress.

4. It is firefighters' beliefs that a critical

incident is highly distressing that is the key to the

degree of their post-incident stress.

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2. DESIGN AND METHOD

At an early stage in the 1994-1996 survey, multiway

frequency analyses were conducted to limit the number of

hypotheses tested in future samples when assessing the

general relationships among protective factors (social

support, coping, and belief systems), anxiety, depression,

intrusion, avoidance, and debriefing scales. In addition,

these earlier analyses were used to rule out hypotheses

that would reduce power if all possible relationships were

tested in the final sample. As larger samples were

collected, several of the initial effects diminished or

disappeared. The relationships ultimately demonstrated in

this final sample of firefighters were present, however, in

the earlier smaller samples.

Distributional and other assumptions surrounding

parametric techniques were not met for much of the data.

For this reason, the nonparametric techniques of Mann

Whitney U-Wilcoxon Rank Sum W, Wilcoxon Matched Pairs Rank

Sum and Kruskal Wallis one-way Analysis of Variance, were

chosen. More sensitive multivariate parametric techniques

were used in an exploratory examination of the data, but no

additional results were found beyond the reliable effects

first suggested in the earlier samples and demonstrated

with the nonparametric tests reported here. A more

 16

detailed description of these statistical procedures and

their results can be found in the Technical Report.

Participants

A total of 1890 emergency responders from the FEMA

Region VI five state area responded to this study between

December 1994 and June 1997; 1745 of this sample were

firefighters and firefighters with paramedic duties. An

initial contact for data collection was done by

distributing the research packets (Appendix A) to training

officers and debriefing teams with a request for them to

administer and return the packets by mail. Despite

considerable interest in the project this approach resulted

II in a poor response rate and the method was altered so that

the Principal Investigator could administer the research

packets personally. This approach was continued through

the Cooperative Agreement year. In addition to the

firefighter population, 33 police, 97 emergency medical

personnel and 15 Red Cross volunteers participated in the

research.

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Assessments

Firefighters were administered a series of self report

questionnaires by the Principal Investigator during a

single session of approximately one hour. Following a 2 0-

item demographic questionnaire, seven standardized

instruments were administered to assess the three

'balancing factors' of social support, beliefs, and coping,

the post traumatic stress disorder symptoms of intrusion

and avoidance, and symptoms of anxiety and depression.

First, three versions of the Perceived Social Support

l Scale (PSSS) (Procidano & Heller, 1983) measured perceived

social support from friends, coworkers, and family.

Second, the 34-item World Assumptions Scale (WAS) (Janof-

!I Bulman, 1989) provided three subscale scores measuring

Benevolence, Meaningfulness, and Self Worth. Third, the

66-item Ways of Coping Questionnaire (WOC) (Folkman &

Lazarus, 1985) provided eight subscale scores measuring

Confrontive Coping, Distancing, Self-Controlling, Seeking

Social Support, Accepting Responsibility, Escape-Avoidance,

Planful Problem Solving, and Positive Reappraisal. The 14-

item Hospital Anxiety and Depression Scale (HAD) (Zygmond &

Snaith, 1983) was used to assess levels of mood disorder.

This attempt to capture differences was also carried

out by comparing the firefighters' reactions based on their

opinions about whether or not an incident was critical.

Firefighters were therefore asked to complete 3 versions of

a critical incident response package. The first version

 18

l concerned those incidents identified by all responders as

critical (Type A) , the second those incidents that the

t responder alone considered critical (Type B), and third

} those incidents that the responder did not view as critical

but were being identified as such by coworkers (Type C).

I Given an absence of pre-incident data and the inevitable

} and unavoidable condition of retrospective recall,

firefighters were asked to limit their descriptions of

critical incidents and debriefings to exposures which had

taken place within three years of the survey.

For each version of a critical incident, firefighters

completed the Impact of Event Scale (IES) (Horowitz, 1979),

)
and in the event of a debriefing, an Evaluation of

Debriefing (EOD). The 15-item IES scale produces two

subscale scores measuring Intrusion and Avoidance. (It

should be noted here that a recent revision of this scale

permits the assessment of hyperarousal, the third factor in

the post traumatic stress disorder triad. All data

l collection from August 1996 used the Revised Impact of

' Event Scale). The 14-item Evaluation of Debriefing (EOD)

Scale was designed by the investigators to measure

emergency responders' evaluation of the efficacy of the

1 various components of the critical incident debriefing.

Items on this scale were derived from the literature

J-
describing the aims and goals of psychological debriefing

i (Lewis, 1994; Mitchell, 1983; Raphael, 1986; Marshall,

1944). Reliability and validity for the EOD was established

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in a separate study through internal consistency evaluation

and expert content review (Harris and Stacks, submitted).

(
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3. MAJOR FINDINGS AND CONCLUSIONS

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Demographics of the Firefighter Sample

Although no record was kept of the number of non-

participants, it is suggested that of those asked to

participate a high participation rate was reached when data

collection took place in the fire stations. Only one

department produced incomplete surveys. In this case,

there were clear organizational issues which made data

collection problematic. In sum, the predominant response

to our requests for participation was positive and

encouraging, and the researcher was welcomed into

approximately 50 fire departments in the Region VI area.

As a result, professional firefighters made up 86% of the

firefighter sample.

Most firefighters in the study were male (97.0%), and

30-49 years old (70.1%). As indicated in Table 1, the

1 median length of service was 11.0 years, and the median

annual salary was 30-39 thousand dollars. Most were

t Caucasian (77.7%), or Hispanic (11.8%), with another 7.1%

indicating African American ethnicity. The majority of the

firefighters were married or cohabiting (77.6%), or single,

j. divorced, separated or widowed (22%). With regards to the

number of minor children (less than 18 years of age) living

l at home, 601 (34.4%) reported none, 1089 (62.4%) reported

one to three, and 44 (2.5%) reported four or more. A

 21

minority, 15.3%, reported adult children (older than 18

years of age) living at home. Some indication of the

degree of social interaction and support for the group was

found in the responses to the questions about the number of

friends met on a weekly, monthly and annual basis. The

majority of the firefighters (62.0%) reported contact with

1-6 friends on a weekly basis, with 7 or more friends on a

monthly basis (60.2%), and 79.4% reported meeting with 7 or

more friends on an annual basis. In addition, 27.6%

reported that they considered 7 or more coworkers as close

friends. These figures suggest a fairly sociable group.

When the firefighters were asked to specify

professional sources of emotional support, 40.9% identified

their clergy, whereas only 7.4% sought professional

counseling. Approximately one third reported other,

unidentified sources.

Firefighters' Dispositions

The method of data collection used in this study

I}
provided an unusual opportunity to collect very detailed

information on a large and representative sample of

firefighters in Region VI (n=1745). The assessments were

chosen specifically to examine the relationships between

positive personal dispositional factors and traumatic

exposure. The following portrait of the firefighters

emerges from the assessments.

When given the opportunity to respond to measures of

social support from family, friends and coworkers,

 22

firefighters rated their families as their principle source

of support, information, and feedback. Friends and

coworkers were rated next in importance. This finding may

reflect firefighters' levels of social competence so

essential in a job where team-work is a key component for

successful emergency response.

Their responses to the World Assumptions Scale

provided information on the kinds of theories that

firefighters have developed about themselves and their

jobs. Have their contacts with people who may be badly

injured or burned, may be victims of natural or man-made

disasters, and who may even be without resources for their

basic needs, affected their sense of the benevolence and

meaningfulness of the world and their own selfworth?

Firefighters appear to have retained positive views

despite continued exposure to traumatic events in their

communities. It may be that they have, through their

exposures, developed strength rather that weakness from

developing competence during difficult rescues. They may

t
believe that they have developed a special kind of insight

1 into trauma and as a result are better able to accept that

outcomes are not always controllable, nor success always

possible.

j. How firefighters in this study coped with exposure to

stressful events was measured by the Ways of Coping

l Questionnaire. When they could choose to allocate their

preferences across eight possible coping strategies, they

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preferred Planned Problem Solving. This strategy involves

"deliberate problem focused efforts t o alter a situation,

c o upled with an analytic approach t o s o lving problems".

Very few chose Escape-avoidance which involves "wishful

thinking and behavioral efforts to escape or avoid the

problem". The choice of Planned Problem Solving appears to

be congruent with the nature of the firefighters'

occupation.

Summary of results

The findings from this study suggest the following;

1. The subscales on the two clinical assessments commonly

used in trauma research, the IES and the HAD, are all

significantly related. This finding suggests that post

trauma affect management reflects an association with mood

disorder.

2. A protective factor derived from positive social

support and attitudinal views may provide a shield against

anxiety and depression but is unable to protect against

critical incident stress discomfort associated with

intrusion and avoidance.

3. While evaluations of debriefings reflect firefighters

satisfaction with debriefings, the levels of satisfaction

are more closely linked to intrusion and depressive

symptoms than previously realized. Those with higher

intrusion found the debriefing helpful while those with

depressive symptoms reported low satisfaction.

 24

4. The essential hypothesis in this research that

firefighters' beliefs that an incident was critical

influenced both their evaluations of debriefings and their

post trauma exposure affect management, was supported.

This finding is also supported by more current findings in

I stress management theories and practices which recognize

the important interaction between individual disposition

J and experiences and stressors.

5. Although this was an uncontrolled study the

comparisons between debriefed and non-debriefed found that

debriefing was associated with higher levels of intrusion

and lower levels of depressive symptoms.

6. The preferred method of coping among firefighters was

Planned Problem Solving. This method of coping with a

specific stressful encounter entails deliberate problem

focused efforts to alter the situation coupled with an

analytic approach to solving a Problem. However, when the

relationships between methods and post trauma symptoms were

analyzed, it became clear that Confrontive Coping,

t
Distancing and Social Support may be coping strategies
j which could more positively contribute to critical incident

stress management practices.

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4. Discussion

The survey a l so provided the firefighters with an

opportunity to describe verbally and in writing their

debriefings and the scenes of critical incidents they had

responded to within the previous three years. These

descriptions when classified provided a rich backdrop for

the quantitative results (page 24-25).

Firefighters suggested that debriefings tended to

bring back feelings about past calls and experiences that

they wanted to forget. Some even suggested that when this

happened it did more harm than good. They knew that they

had always carried out their own informal debriefings and

were able to go to their coworkers for support when needed.

They suggested that mixing debriefings with strangers did

not work well, and they were particularly uncomfortable

with the idea that somehow they could not cope, that stress

had 'built up' during the years without their awareness.

In particular, they wanted to know whether they were

'normal' while at the same time they would acknowledge that

their vocation took a special

kind of person. If debriefings needed a mental health

practitioner did that mean that they were not 'normal'?

 26

MAJOR CATEGORIES OF CRITICAL INCIDENT DESCRIPTIONS

CATEGORY SUB-GROUP A 8 C

1 Personal loss or injury 1.1 Coworker A B C

1.2 Friend A B
I 1.3
1.4
Self
Family
A
A B C

J 2 Traumatic stimulation 2.1 with children A B C

2.2 dead/severely injured
children A B C
2.3 descriptive
not graphic A B C
2.4 descriptive
& graphic A B C
2.5 not descriptive A

3. Several situations in a 3.1 without children A B C

short period of time
3.2 with children A B C
3.3 with children &others C

4. Difficult situations 4.1 with elaboration A B C

4.2 w /out elaborationA B C

5 Personalization 5.1 family or self A C

5.2 situation C
5.3 past situation A C

6 Media A B C

7 Positive outcome A B C

8. Mission failure A B C

9 Ambiguous response A B C

10. Uncertain A B

11 Realization of meaning of life A

 27

FEEDBACK CATEGORIES FROM RESEARCH SURVEY

1. Positive about or love of job

2. Negative about job

3. Calls that affect firefighters

4. Organizational stress problems with administration

(work in general) stress with coworkers
income
long hours
years of service

5. Feelings expressions of & detached

6. Oklahoma City

7. Ambiguous

8. Stress management minimized

outside activities
family & coworkers
using humour

9. Religious issues

10. Children

11. Stress description of different stressors

unexpected
large amounts

12. Survey suggestions about

comments about

13. Debriefings these were moved to debriefing

comments from EOD on survey
 28

A second area for comment re l ated to the quality of

service delivery. Fire fighters tended to blame themselves

for poor service delivery. They needed respect from the

public; so.criticism from their communities was hurtfu l and

many wondered if the public were aware of the ways in which

their jobs had changed. Today they are exposed much more

closely to "intimate personal emergencies" (Gist, 1997),

and the risks associated with unsecured scenes, hepatitis,

tuberculosis, and HIV. Such exposures may not even be fire

related but obviously reveal an increasing number of

responses to medical emergencies described by a firefighter

as 'probably needing a social worker on the ladder truck'.

Yet, the most positive classification of comments

revealed a population whose motivation and satisfaction

related to serving the public, helping others, enjoyment of

the challenge, and being a member of a close knit team.

They believed that they learned how to cope with their

exposures and became acclimated with time. Many suggested

to the researcher that those for whom the survey was

intended had in all probability left the fire service

already because they could not manage to adapt to the job.

The suggestion was made that the more critical the scene,

the less affected the firefighter because he was 'doing his

job'. Such a view suggesting that an 'instrumentality' or

sense of agency may play a large part in the firefighters'

responses to critical incidents.

 29

Firefighters thrived on the challenge presented by

difficult scenes. In helping the researcher to understand

why they really did not need this survey, they spoke of how

satisfying it was to them to meet a challenge and

successfully complete rescues and fire suppressions. They

view themselves as ordinary people, with some expressing a

dislike for being labeled 'heroes'. 'What we want' they

said, 'is respect' .

A central issue for a majority of this sample was the

unnecessary carnage involving children. Children seriously

hurt through neglect or stupidity by their families or

their communities was acutely stressful. Firefighter

families were reported in the survey to be their strongest

source of social support. As a result, they were also

aware that their families and their children could

inadvertently be badly hurt. They worried about their

families because, more than most parents, they know how

quickly emergencies can happen and how seriously these can

hurt, maim or kill children.

An interesting finding from the qualitative reports

and comments reveals the times at which firefighters'

families are in specific stages of development, referred to

in family research as 'life cycles'. Firefighters with

young children are clearly sensitive to the risks and

vulnerabilities of young children, but when they have

teenagers at home then the risks associated with

adolescence become more salient. However, there is another

 30

stage of the family life cycle when grandchildren remind

the older firefighter of those earlier risks all over

again. One described going home to 'hold his granddaughter

very close' after a critical incident involving children

her age. They reported that children rescued from or

surviving severe injury were a source of immense

satisfaction.

Thus both the quantitative results and this

qualitative information suggest that occupational stress in

the fire service is far more complex and systemic than has

been previously recognized. Taylor (1997) quotes Brunicini

(1996) that organizational contexts paired with

firefighters natural desire to deliver good service

"produces a stress-inducing bind that, over time,

makes us personally and occupationally nuts."

As mentioned in the Rationale section of this report,

several summaries of the research evidence on debriefings

have appeared during the period of this research project

(1994-1997) and the majority of these findings have not

endorsed CISD as an proactive intervention to protect

emergency responders against adverse psychological

reactions resulting from exposure to critical incidents.

However, debriefing is essentially a group phenomenon. It

is essentially group leadership and the resultant group

dynamics that determine the outcome in therapeutic terms.

Further research with the Evaluation of Debriefing Scale

developed for this study might shed some light on this

 31

contribution of group process rather than satisfaction to

positive outcome. In addition, debriefers need to be

mindful of the professional standards for the education and

practice of group leaders and counselors (Association for

Specialists in Group Work, American Counseling

Association). Professional counselors are required to have

graduate course work in the theory and practice of group

counseling and group therapy, and are required by their

professional ethical code to screen members for admission

to group treatments. Clearly, workshops which train

debriefers should recognize that their primary focus would

be more productively centered on the advantages of informal

peer support. This support should remain informal and

closely connected to traditional fire service practices

including strong mentoring programs for new recruits.

A number of firefighters in this study questioned the

idea of mandatory debriefings specifically within the group

context. They reported that they had indeed reviewed the

incident with peers, understood what had happened,

certainly felt distressed for a period of time but did not

r believe there was any need to do more than 'talk to their

shift' about what had happened. Indeed, those who did

appear to have ruminated about the incident and were unable

I- to let go intrusive memories appeared to be resentful of

debriefing practices as well as assumptions by debriefers

l of an expertise gained through one or two day workshops.

Many were puzzled by the insistence of debriefers that

I
 32

their reactions were normal in the face of abnormal events,

yet, these 'normal' reactions needed a special treatment or

else they could somehow get out of hand and become

abnormal. Our finding on significantly elevated levels of

intrusion among the 'debriefed' suggests a relationship

between distress and debriefing that should give fire

departments cause to carefully re-think their stress

management programs. Recently Roderick Orner of the

Lincolnshire Joint Emergency Services (UK) arranged for a

systematic evaluation of the impact of their debriefing

programs and found unsettling evidence about therapeutic

effect. A close examination of their evaluation data

suggested that there were distinct limitations to this

intervention. Specifically, the finding that the rated

"helpfulness of psychological debriefing is inversely

proportional to the reported impact of a critical incident

on emergency responders." In other words, the greater the

impact the less helpful the debriefing! As a result, the

Lincolnshire service has decided to review and reconsider

the advisability of continuing psychological debriefings

using the Mitchell model. Rather, Orner suggests an

assessment process that identifies responders most at risk

following exposure to a critical incident. As a result,

the Lincolnshire group believe that their services can now

be specifically tailored to their responders needs.

 33

5. Oklahoma City Study

Prior to the Murrah Federal Building bombing on April

19, 1995, forty two firefighters in Oklahoma City and the

Oklahoma area had completed the survey. This pre-incident

data could have provided a basis for pre-post-bombing

comparisons as well as an opportunity to conduct a

longitudinal follow-up investigation into the effects of

search and rescue activities on emergency personnel. In

addition, a matched control group could have been

established from the Region VI data base providing a rare

opportunity to examine the effects of a large urban

disaster in an urban fire department. The mitigation value

of defusing and debriefing procedures carried out both

during the search and rescue phase and the summer of 1995

could have been evaluated using the same Evaluation of

Debriefing scale used in the rest of this survey.

In 1995-1996 the Department of Psychiatry and

Behavioral Sciences at the University of Oklahoma and the

Oklahoma Department of Health established the parameters

and procedures for conducting the evaluations necessary to

establish the need for funding the long-term mental health

care necessary for Oklahoma City. These evaluations

included the possible vulnerability of the city's emergency

responders. The delay in the Cooperative Agreement funding

made it impossible to conduct a collaborative study as

 34

suggested by the University of Oklahoma's Principal

Investigators. By March 1997 the Oklahoma City Fire

Department were unable to agree to the requests for survey

participation made by Region VI Hazmat Project Manager.

As a result an examination was carried out on all data

collected in Oklahoma and three contrasting groups appeared

to have a sufficient nwnber firefighters in order to make

some comparisons. The surveys from Oklahoma during the

summer of 1995 had produced forty five firefighters who

were able to report that they had participated in search

and rescue efforts at the Murrah Building. Some forty

eight of their peers, who had not participated, had also

completed the survey at this time. The third group was

possible from the forty two firefighters who had

participated in the research prior to the bombing of the

Murrah building. Thus, these three groups became the basis

for the comparisons;

Group 1: Post-bombing search and rescue firefighters

(SAA)

Group 2: Post-bombing peers of Group 1 who did not

participate in search and rescue, and

Group 3: Pre-bombing incident firefighters

 35

Comparison of Exposure Findings Between Firefighters

Responding to Oklahoma City Search and Rescue Activities
and their Non-responding Peers.

Group 1 Group 2 Group 3

SAR Peer Pre-Incident
n=45 n=48 n=42

Measure Mean (SD) Mean (SD) Mean (SD)

HAD-Anxiety 6.39 (3.00) 7.08 ( 2.89) 7.81 ( 3.54)

HAD-Depression 2.91 (2.17) 3.3 1 ( 2.43) 4.10 (3.38)

!ES-Intrusion 13.98 (8.89) 11.38 ( 7.33) 11.47 (8.92)

IES-Avoidance 10.00 (8.71) 11.40 ( 8.18) 10.73 (7.20)

EOD 36.37 (7.67) 35.50 (10.10) 41 .60 (6.87)

Examination of these results finds that the mean

scores for anxiety, depression and avoidance were higher

for firefighters who did not participate in the search and

rescue activities at the Murrah building (Group 2) than for

the SAR group (Group 1). By contrast, the mean score for

intrusion for the SAR group was higher than for their

peers. Evaluation of Debriefing Scale scores obtained prior

to the bombing (Group 3) are higher than those obtained in

both the SAR group and their non-responding peers.

It should be noted that while these results have not

been tested for statistical significance, they do suggest

 36

that the relationship between exposure to a large-scale

critical incident and possible stress reaction is more

complex that previously thought. Also the results point to

the need for an alternative approach to measuring and

interpreting the experiences of firefighters before,

during, and after large-scale critical incidents.

Despite the intense aftermath from the Murrah Building

bombing in which pressure from television, radio and

newspaper reporters was focused on the telling and

retelling of stories from survivors and rescue personnel,

there was evidence of the strength of this community.

Numerous stories were told in which helpers made

considerable sacrifices in terms of donations of time,

money, expertise and material goods. Viewed against this

background one can begin to understand the inspiration that

comes with disaster response, especially for emergency

responders. Firefighters are uniquely trained and prepared

to work in this atmosphere on a daily basis, albeit on a

far smaller scale. Although their typical incidents do not

measure up in terms of magnitude to the Murrah Building

bombing, they are the experts under these conditions.

Their shared experiences created an atmosphere of common

purpose. Those firefighters unable to assist were not

participants in this important search and rescue. They

were not 'there'. This may have resulted in their scores

being marginally higher on the Depression and Anxiety

Subscale. Those who were able to contribute may well have

 37

been able to find profound meaning in their contributions,

to come to terms with their exposure, to rebuild their

'shattered assumptions' and to develop a healing story that

has served them well, bringing with it a sense of

satisfaction from their unique ability to contribute to the

Oklahoma city community. Lower evaluations of the post-

bombing debriefings may be accounted for by several

factors. The post-bombing period was extended over a

l period of several weeks whereas typical critical incidents

may take place during a 24 hour shift. With few details

j about the debriefers or the debriefings one can only

speculate on their similarity to, or differences from, the

l typical debriefings provided in the Region at that time.

Without careful longitudinal studies, however, these

conclusions can only be speculation and we may have to

accept that this population of firefighters should not be

made to participate in further research studies. The

lesson learned here for both researchers and fire

departments could be that fire department administrations

might consider careful long-term human resource/personnel

1I contributions by maintaining contacts with community,

clinical, and research psychologists. Cooperative projects

need to be developed to design and implement regular

evaluations of firefighters. Such projects could provide a

structure to be used during and after a local

natural/technological disaster of the magnitude of the

 38

Murrah bombing. As a result the answers sought to the

following questions would be easier to obtain.

1. What effect has this event had on our employees?

\ 2. What can we expect in terms of needed assistance?

3. Do we have employees who are particularly vulnerable

I to an acute stress reaction?

4. What is the most beneficial and professionally

responsible treatment that can be offered?

} 5. What funding should be budgeted for these services?

I This approach would eliminate the trap described by

Alexander wherein trauma specialists end up as "peddlers of

l doom and miserable statistics about the presence of post

traumatic stress symptoms". Fire departments will be able

to recognize that their employees do cope and that

organizational culture and leadership accompanied by

preparation and training can significantly enhance that

coping ability (Taylor, 1997).

 39

6. Firefighters' Family Study

The possible reciprocal relationship between family

strengths and firefighters' resistance to the negative

impact of critical incidents was examined briefly during

the 1996-1997 Cooperative Agreement period. Preliminary

impressions of unique strengths in these families, the

stresses they face, and their ways of coping, were

formed when visits were made informally with

firefighters and their wives (Roswell, N.M.; Baton

Rouge, LA; Bogalusa, LA; New Orleans, LA; Little Rock,

AR; North Little Rock, AR; Conway, AR; and Tulsa, OK).

The closed and protective nature of the firefighter

community made it unlikely that firefighters' families

would respond to data collection unless it was carried

out during face-to-face meetings between the families

and the researchers. An offer was made to provide a

free marriage workshop in any department that would

allow us to collect both qualitative and quantitative

I
information from firefighter families regarding their

l strengths, stresses, and ways of coping. Meetings were

arranged with two New Mexico fire departments and had

) been scheduled with the families of two other

departments before funding for this part of the project

was cut. Although there is insufficient data available

from this small sample of firefighter families for valid

analysis, impressions formed during these contacts

 40

contribute to the overall finding of the nature of

family s oc ial support in firefighter families.

1. It appeared that firefighters' wives expressed more

stress and frustration that did their spouses. They

agreed that being at home and not knowing what was

! happening to their spouses during a critical incident

was more stressful than being at the scene itself. This

l is congruent with the finding study that firefighters in

the Oklahoma City Region who did not respond to the

t
bombing of the Federal Building experience appeared to

be more anxious than their peers who had been able to

participate in the search and rescue efforts at the

Murrah building.

2. In addition the wives express frustration over the

( lack of services designed specifically for their needs

in these situations. One example that was often

mentioned was that during a major incident there was no

one they could call to find out if their husbands were

at the scene. Most often, they reported, there were no

I procedures for communication with the department during

major incidents or when their husbands had been injured.

3. Firefighters' wives reported that they often felt that

there was no one available for them to talk to about

 41

their frustrations. They wanted to be able to

understand their spouses' stress, but they sensed a lack

of departmental assistance unless there were severe

psychiatric difficulties involved. They reported that

there was no safe place to address marital and family

l stresses. Wives reported that in the 'old days' there

was more of a sense of a 'larger extended family' among

the fire station families, but with most wives now

working outside the home, this kind of larger family

support system had disappeared.

4. Firefighters' wives reported that they did not have

the kinds of community and systemic supports that their

spouse's received for service to the community. Instead

they experience being a single parent and homemaker much

of the time because of their spouse's unusual work

schedule and rotations

5. Firefighters' wives recognized their husbands' deep

needs for their support, but when husbands did not

communicate these needs directly, wives were left

feeling confused and frustrated.

In summary, it may be that firefighters' marriages are

at greater risk than those in the larger population.

The risk may be greater for younger couples who have not
 42

experienced the support of the firefighter community

experienced by some of the older couples. However, even

though this was a small sample of families, the finding

from the Perceived Social Support Scales (Figure 1) of

the value placed by firefighters on support from their

families suggests that support programs could be

designed to meet the kinds of needs being expressed.

Clearly these findings, though tentative, should be

researched further with a much larger number of

families, including families of dual career emergency

responders, and female firefighters. In the meantime

fire departments might explore the possibilities of

including the following policies and procedures in their

l organizations:

1. All departments could establish procedures for spouses

and families to use when they need information during

critical incidents.

2. All departments should explore the possibilities for

programs of supportive services for firefighters'

families.

3. Appropriate and professional referrals for group,

individual, marital, and family counseling should be

made available, normalized, and encouraged where needed.

 43

4. Systemic supports should be built into the activities

of departments--such as family picnics and parties,

information and social meetings for families,

orientation meetings for families of new recruits,

communication skill training workshops for couples, and

self-help groups aimed at education.

In general these discussions with a limited number of

firefighter families suggested that their levels of stress

and general welfare was more closely tied to fire

department organizational policies and procedures rather

than critical incident scenes.

l
 44

7. Summary
l Although the general public may subscribe to the view

that exposure to horrific images creates substantial stress

for emergency responders, a closer examination of the

experience suggests that distress is created by the

interaction of responder with circumstance, and by the

quantity and quality of social resources, prior

experiences, and a sense of hope.

This quantity and quality of social contacts, prior

training, a sense of competence, and an absence of

psychopathology produces a resilient firefighter

population, the majority of whom find their job the 'best

that there is' because they want primarily to serve their

communities. The fire service provides an ideal vocation

in which to do just that.

The success of debriefing more probably reflects the

camaraderie of the fire service with its informal 'kitchen

table' reviews of the runs during the shift - an approach

probably as productive as a formal, structured debriefing

and certainly less likely to do harm. Recent studies have

questioned the desirability of early debriefings shortly

after a critical incident. One outcome being the

unfortunate consequence of firefighters own resources going

j
unrecognized, or even being viewed as not good enough or

1J insufficient.
 45

Those who are prepared for adversity are surely more

capable in its circumstance and more able to cope with its

I
I
difficulties. They manage to survive and move on with

their lives. This is certainly true of fire service

personnel. Their preparation should include personal,

I professional, organizational, and psychological components.

Thus, an emphasis on physical health, preparation and

~ training in effective response techniques, routine incident

review, and incident command within the context of a

J
healthy organization can produce the requisite resiliency.
) Effective communication and interpersonal skills could be

the glue that is needed to hold all of this in place.

Thus, regardless of the size and type of incident the

structural framework of management, operations and human

resource development programs will play key roles in the

depth and breadth of firefighters' psychological response

to difficult scenes. Established employee assistance

programs should be known to fire service employees, from

rookie school class through fire chief's office. These

services must be properly prepared to assist fire

departments in developing programs which support this

developmental and proactive approach. Recruitment and

annual physical screening can include psychological

assessments and as a result identify those employees in

need of professional assistance before exposure to

) stressful incidents. The emphasis here must be on

competent professionals who are also willing to study the

)
 46

unique job demands and environment of the fire service.

For example, a firefighter described a counselor as "not

knowing anything about my job - it took the whole hour to

explain it to her. I didn't go back there." "There" was a

fancy office in a high rise building utterly divorced from

the other world of the firehouse.

Both psychologists and debriefers need to be strongly

f
cautioned that firefighters need a belief that solutions

are possible. If they quantify the responder's sense of

\
helplessness by teaching the inevitability of post
} traumatic stress symptoms they may be reinforcing the

firefighters' sense of helplessness over solutions that

were not possible and over which they had no control.

Learning to succeed takes training, and training

should be able to tap the motivation and resiliency in the

fire service. By recognizing the increasingly closer

proximity of firefighter to acutely distressed adults and

children, the responsibility of the fire service is to

maximize on their opportunities to train their men and

women to meet this challenge.

The World Assumptions Scale used in this study

revealed a population of fire fighters which, for the most

part, believed that their worlds were benevolent, that

justice prevailed, and that they themselves were worthy

people. Critical incidents can represent strong

disconfirming experiences of firefighters' views and as

such may temporarily shatter these positive assumptions.

 47

The challenge will be to restore these assumptions in a way

that does not victimize the very men and women who are

proud of their job, and competent in the implementation of

rescue and fire suppression measures so essential to the

health and safety of all communities.

 48

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l
t 57

TECHNICAL REPORT

OF THE

THREE YEAR FIVE STATE STUDY ON THE RELATIONSHIPS BEWTEEN

CRITICAL INCIDENT STRESS DEBRIEFINGS, FIREFIGHTERS'

DISPOSITION AND STRESS REACTIONS

l
j

!
 58

l List of Figures
Figure 1 PSSS: Perceived Social Support Scale Score Distributions
l
Figure 2 WAS: World Assumption Scale Score Distributions

l Figure 3 WOC: Ways of Coping Relative Percent Score Distributions

Figure 4 HAD: Anxiety and depression Scale Score Distributions

Figure 5 IES: Intrusion Scale Score Distribution

Figure 6 IES: Avoidance Scale Score Distribution

Figure 7 IES: Hyperarousal Scale Score Distribution

Figure 8 EOD: Evaluation of Debriefing Scale Score Distribution

Figure 9 HAD Scales (Anxiety & Depression) Scores of Extreme Intrusion Groups

l Figure 10 HAD Scales (Anxiety & Depression) Scores of Extreme Avoidance Groups

Figure 11 HAD Scales (Anxiety & Depression) Scores of Extreme Hyperarousal

1·
Groups

Figure 12 HAD Scales (Anxiety & Depression) Score Ranks of Low and High

Protective Factors Groups

Figure 13 EOD: Evaluation of Debriefing Scores Across Intrusion Groups

Figure 14 EOD: Evaluation of Debriefing Scores Across Avoidance Groups

Figure 15 IES: Intrusion/Avoidance and Beliefs about Incident

Figure 16 EOD: Evaluation of Debriefing and Beliefs about Incident

Figure 17 HAD: Depression Scores in Debriefed and Non-debriefed Groups

'.
I Figure 18 HAD: Intrusion Scores in Debriefed and Non-debriefed Groups

Figure 19 HAD: Depression Scores Across Coping Categories

1 Figure 20 HAD: Anxiety Scores Across Coping Categories

Figure 21 IES: Intrusion Scores Across Coping Categories

Figure 22 IES: Avoidance Scores Across Coping Categories

Figure 23 IES-R: Intrusion Scores Across Coping Categories

 59

List of Tables

Table 1. Demographic Characteristics of the Sample

Table 2. Mann-Whitney U - Wilcoxon Rank Sum W results for HAD Depression and
Anxiety Across Extreme IES Intrusion and Avoidance Groups

Table 3. Mann-Whitney U - Wilcoxon Rank Sum W results for HAD Depression and
Anxiety Across Extreme Protective Factors Groups

Table 4. Mann-Whitney U - Wilcoxon Rank Sum W results for EOD Evaluation of

Debriefing Scores Across Extreme Intrusion and Depression Groups

Table 5. Wilcoxon Matched Pairs Signed Ranks Test results for comparisons of IES
Intrusion and Avoidance Scores Across Type A and Type C Incidents

Table 6. Mann-Whitney U - Wilcoxon Rank Sum W results for comparison of

EODEvaluation of Debriefing Scores across Beliefs about the Critical
Incident

Table 7. Mann-Whitney U - Wilcoxon Rank Sum W results for Depression and

Intrusion Scores Across Debriefed and Non-Debriefed Groups

Table 8. Kruskal-Wallis One-way Analysis of Variance results for IES Intrusion Scores
Across Highest Relative Percent woe Coping Categories
I
I
Table 9. Kruskal Wallis One-way Analysis of Variance results for IES Avoidance
Scores Across Highest Relative Percent WOC Coping Categories

Table 10. Kruskal Wallis One-way Analysis of Variance results for IES-R Intrusion
Scores Across Highest Relative Percent woe Coping Categories

Table 11. Kruskal Wallis One-way Analysis of Variance results for HAD Depression
Scores Across Highest Relative Percent WOC Coping Categories

Table 12. Kruskal Wallis One-way Analysis of Variance results for HAD Anxiety
Scores Across Highest relative Percent WOC Coping Categories

Table 13. Matrix of Post Hoc Comparisons for HAD Depression Scores Among
WOC Coping Categories

Table 14. Matrix of Post Hoc Comparisons for HAD Anxiety Scores Among
woe Coping Categories
 60

1. Research Questions

The following research questions were addressed by this

study:

1. Is there a direct relationship between clinical measures

of anxiety and depression and the impact of event measures
of intrusion, avoidance and hyperarousal which are the
characteristics of post-traumatic stress disorder?

2. Is there an inverse relationship between dispositional

protective factors such as social support, world
assumptions and coping and clinical outcome measures such
as anxiety, depression, intrusion, avoidance, and
hyperarousal.

3. Is there a relationship between firefighters' evaluation

of debriefing experiences and clinical outcome measures?

4. Is there a relationship between firefighters' beliefs

about a critical incident and clinical outcome measures?

5. Is there a relationship between firefighters' beliefs

about a critical incident and their evaluations of
debriefing experiences.

6. Is critical incident stress debriefing associated with

different clinical outcomes for firefighters?

7. Are different coping styles or strategies associated

with different clinical outcomes?

l Note: It should be noted that while correlational relationships do not

imply causation, the data reported here establish basic lines of

J inquiry for further investigations into these types of occupational

studies.
i 61

2. METHOD

At an early stage in the 1994-1996 survey (Appendix

A), multiway frequency analyses were conducted to limit the

number of hypotheses tested in future samples when

assessing the general relationships among protective

factors (social support, coping, and belief systems),

anxiety, depression, intrusion, avoidance, and debriefing

scales. In addition, these earlier analyses were used to

rule out hypotheses that would reduce power if all possible

relationships were tested in the final sample. As larger

samples were collected, several of the initial effects

diminished or disappeared. The relationships ultimately

demonstrated in this final sample of firefighters were

present, however, in the earlier smaller samples.

Distributional and other assumptions surrounding

parametric techniques were not met for much of the data.

For this reason, the nonparametric techniques of Mann

Whitney U-Wilcoxon Rank Sum W, Wilcoxon Matched Pairs Rank

Sum and Kruskal Wallis one-way Analysis of Variance, were

chosen. More sensitive multivariate parametric techniques

were used in an exploratory examination of the data, but no

additional results were found beyond the reliable effects

first suggested in the earlier samples and demonstrated

with the nonparametric tests reported here.

 62

Assessments

Descriptive statistics of firefighters' scores on

the assessments used in this study are illustrated by

the histograms in Figures 1-8 (Appendix B).

Perceived Social Support (PSS)

Raw scores on the Perceived Social Support Scale,

measuring perceived social support from friends,

coworkers, and family, can range from Oto 20. The

negatively skewed family distribution (Figure 1)

suggests that family, rather than coworkers or

friends, provides stronger social support for

firefighters.

World Assumptions Scale (WAS)

Figure 2 illustrates the distribution of scores

on the three World Assumptions Scale (WAS) subscales

measuring Benevolence, Meaningfulness, and Self Worth.

Raw scores from these scales range from Oto 48 for

Benevolence, and Oto 72 for both Meaningfulness and

Self Worth. Although the distributions appear to be

/.
fairly similar, these are not comparable with each

J other because of scale differences.

 63

From the distribution of firefighters scores on

the World Assumptions Scale, it could be speculated

that, despite continued exposure to traumatic events,

firefighters retain their assumptions about the world

as being benevolent and meaningful in general while

accepting the instances that may disconfirm these

assumptions. They realize that the world is not

always good, people not always supportive, outcomes

not always controllable, and success not always

possible. In addition, firefighters appear to have

highly positive views about themselves as decent,

worthy, and competent individuals. Without

established normative data on the scale, however,

these can only be tentative conclusions.

Ways of Coping Questionnaire (WOC)

Figure 3 illustrates the distribution of scores

( on the eight Ways of Coping Questionnaire (WOC)

l subscales; Confrontive Coping, Distancing, Self-

Controlling, Seeking Social Support, Accepting

Responsibility, Escape-Avoidance, Planful Problem

Solving, and Positive Reappraisal. It should be noted

J that these profiles are comparable because they are

expressed as relative percentages. Planned Problem

Solving has a higher mean and wider distribution

suggesting that a higher relative percentage is

allocated by firefighters to this type of coping.

 64

Planned Problem Solving is described as "deliberate

problem focused efforts to alter a situation, coupled

with an analytic approach to solving problems".

In contrast to the positively focused Planned

Problem Solving approach to coping, very few

firefighters chose Escape/Avoidance as their preferred

means of dealing with distress. This strategy involves

wishful thinking and behavioral efforts to escape or

avoid problems. Worth noting are two other coping

approaches, Positive Reappraisal and Self Controlling,

which rank close to Planned Problem Solving and appear

to reflect the firefighters positive approach to

coping with anxiety and distress. Positive

Reappraisal describes their efforts to create positive

meanings from the situation, and Self Controlling

efforts to regulate their feelings and actions.

The Hospital Anxiety and Depression Scale

(HAD)

The Hospital Anxiety and Depression Scale (HAD)

consists of two subscales measuring Anxiety and

Depression (Figure 4). Raw scale scores range from O

to 21 for each scale. It should be noted that the

authors describe their instrument as a valid measure

of the severity of these mood disorders, with the

upper end of the borderline score of 10 to 11 being

used in research to reduce the number of false

 65

positives. Although few firefighters in this

population suffered from significant levels of mood

disorder, there were 2.4% with clinical levels of

Depression and a slight overrepresentation, 14.2%, for

clinical levels of Anxiety.

Impact of Event Scale (IES)

There were 549 valid scores for IES Intrusion and

548 valid scores for IES Avoidance. After the IES-

Revised (IES-R) was implemented, additional scores

were obtained for Hyperarousal. For the revised

scale, 346 valid IES-R intrusion, 346 IES-R avoidance

and 356 IES-R hyperarousal scores were obtained.

Figures 5 through 7 illustrate the distribution of

scores on the IES and the IES-R. For the IES, raw

scale scores for the two subscales Intrusion and

Avoidance range from Oto 35 and Oto 40 respectively.

For the IES-R, all three subscales range from 0-40.

The most striking finding here was that approximately

120 (20%) responders indicated no effect of Intrusion

or Avoidance, and 47% no effect from Hyperarousal from

their exposures to critical incidents.

Figures 5, 6, and 7 also show that for a few

firefighters there appeared to be clinical levels of

Intrusion (13.6%), Avoidance (11.1%), and Hyperarousal

( 9%) •
 66

The Evaluation of Debriefing Scale (EOD)

The Evaluation of Debriefing Scale (EOD) was

designed with only four responses for each question

thus preventing participants from opting for a middle

or neutral choice. Figure 8 shows that firefighters

who had experienced a debriefing held a fairly

positive view about the experience. Since the EOD

scale is constructed so that higher likert ratings

reflect more positive evaluation, the mean score of 40

out of a possible 52 points suggests a fairly positive

perception of the debriefing procedures to which

participants had been exposed.

Data Analyses

Research Question 1

Firefighters were selected for extreme scores on

the IES scales by taking those scoring above 66%ile

and below 33%ile. The extreme groups for each of the

three IES scales were compared on the two HAD scales.

Since there is reason to believe that the IES and the

IES-Revised differ in what they are measuring, the

sample was split according to form when computing the

rank cut-points for the extreme groups. The two

samples were then combined again for comparison with

 67

the HAD scales. There were thus six comparisons, two

for each IES scale. The Mann-Whitney U - Wilcoxon

Rank Sum W Test was used to evaluate the differences.

The hypotheses were one-tailed because all of the

scales are expected to be directly related. There was

some overlap in the extreme groups between the

intrusion, avoidance, and hyperarousal groups. A

conservative alpha level was therefore chosen by

straight Bonferroni correction based on six

comparisons between two groups (~.= .0083). All

results were significant at this level. All

directionalities were positive as hypothesized. The

results are shown in Figures 9-11. Statistical

results are given in Table 2.

Research Question 2

I To test the hypothesis that clinical measures are

inversely related to protective factors, a composite

J
protective factors score was derived from the PSS

scales and the WAS scales. This was done by

transforming each of the PSS and WAS scales to

standard scores and summing the standard scores for

each participant. Each protective factors scale was

therefore given equal weight in the composite score.

Extreme (below 33%ile and above 66%ile) groups were

formed based on the composite score. These two groups

 68

were compared on HAD and IES. The sample was split

for the IES and I ES-Revised forms f o r the IES

comparisons. The entire sample was used for the HAD

comparisons (N=l097). There were therefore six

comparisons, but the two IES forms constitute samples.

There are effectively four comparisons for each

sample. Each one-tailed hypothesis was therefore

evaluated at an alpha level of p = .0125. Both of the

HAD scales were significantly different between the

protective factors groups in the predicted inverse

direction. There were no significant differences

between groups for IES or IES-Revised scores.

However, trends were in the predicted direction for

four of the five IES and IES-Revised comparisons.

Results are shown in Figure 12. Statistical results

are given in Table 3.

Research Question 3

Extreme groups were formed for IES, IES-Revised

and the HAD scales. These were again the scores below

33%ile and above 66%ile. In this analysis, each pair

of extreme groups were compared on EOD scores. These

comparisons were evaluated at the p=0.05 alpha level,

two-tailed, using the Mann-Whitney U - Wilcoxon Rank

Sum W test. This time there were differences for the

extreme intrusion groups and for the extreme

 69

depression groups. High intrusion participants had a

significantly higher mean rank EOD score than low

intrusion participants (N=188, ~ < 0.05). In contrast,

participants in the high depression group had a

significantly lower mean rank EOD score than

participants in the low depression group (N=l67,

~=0.05). Results are shown in Figures 13 and 14.

Statistical results are given in Table 4

Research Question 4

To test the hypothesis that beliefs about the incident

are related to IES scores, comparisons were made

between those who reported only an "A" type incident,

where the firefighter and others agreed the incident

I was critical, and those who reported only a "C" type

incident, where the firefighter did not believe the

l incident was critical (although his/her coworkers

did). The Wilcoxon Matched Pairs Signed-Ranks test

was used. Significantly more subjects had higher IES

scores in the A category than in the C category for

all three IES subscales (~<.05). Results are shown in

Figure 15. Statistics are given in Table 5.

 70

Research Question 5

To test the hypothesis that beliefs about the

incident will also affect the firefighters' evaluation

of debriefing, the 37 participants who were debriefed

following a "C" type incident were selected. Another

37 were randomly selected from those who were

debriefed after an "A" type incident. The EOD scores

for the two groups were compared using the Mann-

Whitney U - Wilcoxon Rank-Sum W test. The "A" type

incident group had a significantly higher mean rank

EOD score than the "C" group (~<.05). Therefore those

who believed the incident was critical rated the

debriefing more positively. Results are given in

Figure 16. Statistical results are given in Table 6.

Resaerch Question 6

Debriefed and non-debriefed groups were compared

on IES and HAD to determine if any possible causal

relationship could exist between intervention and

outcome. Of the five scores compared, differences

were found for depression and intrusion. The

debriefed group had significantly lower mean rank HAD

depression score than the non-debriefed group (~<.05).

The debriefed group had a significantly higher mean

rank IES intrusion score than the non-debriefed group

 71

(~< .05). Results are given in Figures 17 and 18.

Statistical results are given in Table 7.

Research Question 7

The highest relative percent coping category was

determined for each participant. This was the woe

subscale on which the firefighters had their highest

relative percent score. Eight groups were formed for

the eight coping categories. Kruskal-Wallis One-Way

Anova was used to compare Anxiety, Depression, IES

Intrusion, IES Avoidance, IES-R Intrusion, and IES-R

Avoidance scores between the eight coping groups.

Using an alpha criterion based on Bonferroni

correction for six comparisons, the groups differed

significantly on all the scores except IES-R

Avoidance. Results are shown in Figures 19-23, and

Kruskal-Wallis statistics are given in Table 8-12.

The intervals shown in Figures 19-23 are the 95%

confidence intervals for each mean rank value. Tables

8-12 contain post-hoc comparison data for the five

significant Anova results.

There were eight coping categories; so, 28

pairwise comparisons were possible for each analysis.

All possible pairwise post hoc comparisons were made

for each analysis with Bonferroni correction, so the

post hoc tests are necessarily low in power. Even

 72

with this conservative approach to control for type I

error, several significant differences were found.
For JES-Intrusion, there were two post hoc
comparisons which were significant. The Positive
Reappraisal group had significantly higher mean rank
Intrusion score than both the Confrontive Coping and
the Distancing groups. For IES-R Intrusion, the mean
rank Intrusion score for the Positive Reappraisal
group was significantly higher than the mean rank
Intrusion score for the Seek Social Support group.
For JES-Avoidance, only one post hoc comparison was
significant. The Self-Controlling group had a
significantly higher mean rank Avoidance score than
the Confrontive Coping group.
There were nine of the post hoc coping category
comparisons which were significant for HAD-Depression
scores, and five for HAD-Anxiety scores. These
differences are shown in matrix form in Tables 13 and
14.
 73

4. Discussion and Recommendations

The findings from this study suggest the following;

1. The subscales on the two clinical assessments

commonly used in trauma research, the IES and the HAD,

are all significantly related. This finding suggests

that post trauma affect management reflects an

association with mood disorder.

2. A protective factor derived from positive social

support and attitudinal views may provide a shield

against anxiety and depression but is unable to

protect against critical incident stress discomfort

associated with intrusion and avoidance.

3. While evaluations of debriefings reflect

firefighters satisfaction with debriefings, the levels

of satisfaction are more closely linked to intrusion

and depressive symptoms than previously realized.

Those with higher intrusion finding the debriefing

helpful while those with depressive symptoms reporting

low satisfaction.

l 4. The essential hypothesis in this research that

firefighters' beliefs that an incident was critical

I influenced both their evaluations of debriefings and

j. their post trauma exposure affect management, was

supported. This finding is also supported by more

current findings in stress management theories and

practices which recognize the important interaction

 74

between individual disposition, experiences, and

stressors.

5. Evaluations of debriefing experience were more

positive among those firefighters who believed the

incident referred to was critical than among those who

did not believe the incident was critical although

their peers did designated it as critical. This is

consistent with contemporary stress theory in that the

firefighter's beliefs and perceptions about the

incident are possibly more important in the etiology

of stress reaction than the objective quality of the

incident.
l 6. Although this was an uncontrolled study the

comparisons between debriefed and non-debriefed found

that debriefing was associated with higher levels of

intrusion and lower levels of depressive symptoms.

7. The preferred method of coping among firefighters

was Planned Problem Solving. This method of coping

with a specific stressful encounter entails deliberate

problem focused efforts to alter the situation coupled

with an analytic approach to solving a problem.

However, when the relationships between methods and

{ post trauma symptoms were analyzed, it became clear

l that Confrontive Coping, Distancing and Social Support

may be coping strategies which could more positively

contribute to critical incident stress management

practices.
 75

The results of the present study demonstrate a need

for more controlled studies in the area of critical

incident stress management among firefighters. Although

PTSD symptoms have been the primary focus of research in

this area, this study demonstrates that classical

psychological symptoms of depression and anxiety need to be

included as outcome measures. The present study

demonstrates that there may be reactions to components of

the job which are better described in ways other than the

PTSD rubric. There may also be differences in the

effectiveness of interventions for these different

reactions.

This study clearly demonstrates an association between

outcome and coping strategies. These relationships need to

be researched further. One plausible component of

effective stress interventions would be training in coping

strategies and education of firefighters as to the outcomes

associated with different coping strategies.

~
I-
 76

APPENDIX A

RESEARCH PACKET
 77

RESEARCH PACKET CONTENTS

Informed Consent

Demographics

Friends & Family Survey

(9 items)

Perceived Social Support

Friends (20 items)-Co-Workers (20 items)-Family (20 items)

World Assumptions Scale

(32 items)
Benevolence of the World
Meaningfulness of the World
Self Worth

Ways of Coping Scale

(66 items)
Confrontive Coping-Accepting Responsibility-Distancing-
Escape/Avoidance-Self Controlling-Planful Problem Solving-Seeking
Social Support-Positive Reappraisal

Hospital Anxiety & Depression Scale

(14 items)
Anxiety & Depression

Critical Incident Descriptions

Impact of Event Scale

(15 items)
Intrusion & Avoidance

Evaluation of CISD
(14 items)
 78

Critical incidents have been described as events which

appear to have the potent ial for creating emot ional
distress in fire-fighters and other emergency responders.
These events may include personal loss or injury, traumatic
stimuli, mission failure or human error. They may also
include responding to several difficult situations in a
short period of time, calls which attract excessive media
attention, or contact with dead or severely injured
children. Critical incidents are therefore described as
powerful experiences which may overwhelm the emergency
responder's normal ability to cope.

CRITICAL INCIDENT
CATEGORIES

1. During the past 3 years

have you responded to a
call that was IDENTIFIED BY
OTHERS, AND YOURSELF, as
a critical incident?

2. During the past 3 years

have you responded to a
call that YOU would describe
as a critical incident
but was NOT identified as
such by OTHERS?

3. During the past 3 years

have you responded to a
call that OTHERS identified
as a critical incident
but was NOT particularly
stressful to YOU?
 79

APPENDIX B

FIGURES AND TABLES

1-

l
 80

Table 1 Demographic Characteristics of the Sample

Age % Secondary Occueation %

20-29y 18.2 Yes 45.1
30-39y 41.9 No 12.4
40-49y 28.2 No Reseonse 42.5
50-59y 7.4
60+ 1.1 EAP %
No Reseonse 3.2 Yes 70.0
No 21.3
Gender % No Reseonse 8.8
Male 97.0
Female 2.6 Volunteers %
No Reseonse 0.4 Yes 10.3
No 86.0
Marital Status % No Reseonse 3.7
Married 77.1
Single 11.5
Life Partner 0.5 Education Level %
Widowed 0.3 High School 69.6
Divorced 9.3 Associates 18.3
Separated 0.9 Undergraduate 10.1
No Response 0.4 Masters 0.9
Doctorate 0.0
Ethnicity % No Response 1.1
Caucasian 77.7
African Americar 7.1 Children %
Hispanic 11.8 Children < 18 yrs. 65.3
I Asian
American Indian
0.3
1.4
Adult Children at Home 15.3

Other 0.4 Friendships %

l No Response 1.2 (Meets with Weekly
more than Monthly
32.9
60.2
Rank % 7 friends) Annually 79.4
l Entry Level
Mid Level
55.4
35.8 Friendships with Coworkers %
Upper 6.9 (Considers more than 6 27.6
j No Response 1.9 coworkers to be friends)

Income Support %
!- Median Income 30-39K Minister/Priest/Rabbi 45.0
Professional Counselor 9.4

l
 81

Figure 1

Perceived Social Support Scale Distributions

al
19
18
17
(1) 16
s... 15
0 14
0 13
Cl) 12
(1) 11
- 10
~ 9
Cl) 8
3 ~ 0
0
&. 5
4
0
0
Cl) 3 0
Cl) 2 0

a.. 6 0

N= 1737 1728 *
1719
Friends Cooorkers Family

Note. Boxes represent the second and third quartiles .

Whiskers represent range excluding outliers and
extreme scores.
o Outliers are scores greater than 1.5 box lengths
from the median.
* Extreme scores are greater than 3 box lengths
from the median.
 82

Figure 2

Wo rld Assumption Scale Distributions

Benevolence
600 ~ - - - - - - -- - - -- - - - - - ,

>-
(.)
500

Z 400
w
J 300 Std. Dev. = 6.66
a
W 200
Mean= 36
N = 1730
a::
LL 100

Meaningfulness

>-
(.)
z
w
::> Std. Dev.= 7.47
aw Mean= 43
N = 1718
a::
LL

15 20 25 30 35 40 45 50 55 60 65 70

Self Worth

>-
(.)
z
w
::> Std. Dev.= 7.97
aw Mean= 55
N = 1703
a::
LL

20 25 30 35 40 45 50 55 60 65 70
 83

Figure 3

Ways of Coping Questionnaire Relative Percent

Score Distr ibutions

60
* * *

0
Q)
L... 50
*
*
** **
*
* I *
~
0
t
Cl)
I t
I t
*
I
40 *
'cf!-

~
Q)
>
ro
Q)
30
t
0 I **
0
0

et: 20
t)
0
s 10

0
N = 1667 1 666 1657 1665 1 671 1 6 63 1 660 1 67 1
cc DS SC ss AR EA pp PR

Note:CC = Confrontive Coping DS = Distancing

SC = Self Controlling ss = Seek Social Support
AR = Accept Responsibility EA = Escape Avoidance
pp = Pl anful Problem Solving PR = Positive Reappraisal

Boxes represent the second and third quartiles.

Whiskers represent range excluding outliers and extreme
scores.
o Outliers are scores greater than 1.5 box lengths from
the median.
* Extreme scores are greater than 3 box len gths from the
median .
 84

Figure 4

Anxiety and Depression Score Distributions (HAD).

Anxiety

>-
(.)
z 2 00

w
::::>
a
w 100

0::: S td . D e v = 3 . 7 7
LL M e an=7 .4
0 l.-l....-l....-l.,...l....-1,...1.,...1,...1,...l.,...l....-l....-l....-L.-L.-l....-t:;:r::;::J::;::c;:i....-J N = 1 7 1 5 .0 0
0 .0 2 .0 4 .0 6 .0 8 .0 10 .0 12.0 14 .0 16 .0 18 .0 20 .0
1 .0 3 .0 5 .0 7 .0 9 .0 11 .0 13.0 15 .0 17 .0 19 .0

Depression
400 ~ - - - - - - - - - - - - - - - - - - - ~

300

>-
(.) 200
z
w
::::>
aw 100
Std . Dev= 3 .11
0::: Mean= 3 .8
LL ....,._,..........,,.....,r-r~---y-l N = 1 71 5 .0 0
0
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0
1.0 3.0 5.0 7.0 9.0 11 .0 13.0 15.0 17.0 19.0
 85

Figure 5

I ntrusio n Sc ore Distributi ons ( IES & !ES - Re vi s ed)

IES

>-
u
z
w
:::>
aw
et:: Std . Dev = 9 . 1 7
Mean=11 .2
LL N = 549 .00
0 .0 4 .0 8 .0 12 .0 16 .0 20 .0 24 .0 28 .0 32.0 3 6. 0

IES-Re v i s ed

>-
u
80

z
w 60

:::>
aw 40

et::
LL 20
Std. D e v= 8 .95
M e an= 10 .2
0 N = 346.00
0 .0 4 .0 8 .0 12.0 16 .0 2 0 .0 24 .0 28 .0 32.0 36 .0 40 .0
 86

Figure 6

Avoidance Score Distributions (IES & ! ES-Revised)

IES

>-
0
120

z 100

w 80
:J
aw 60

~
40

LL 20 Std. Dev = 6 .6 1
Mean=10 . 1
0 1111111•-,,--~.JN = 548 . 00
0.0 4.0 8 .0 12 .0 16 .0 2 0.0 24 . 0 28 .0 3 2.0 36 .0 40 . 0

IES-Revised

>-
0 60

z
w 40
:J
a
w
er: 20

Std . 0 e v = 8 . 3 6
LJ..
Mean= 9 .2
0
..._ __.. . . . N = 346.00
0 .0 4 .0
 87

Figure 7

Hyperarousal Score Distribution for !ES-Revised

>-
()
z
w
::J 100

aw
c::
LL Std . Dev= 8 .04
Mean=5 .6
0 L..--L-L..-..L...--...L...--...C:::;:::::k_..,=<==.==:::;::::::i..-.-_c:::.::;:=::1 N = 342 . oo
0 .0 4.0 8.0 12 . 0 16 .0 20 . 0 24 . 0 28 .0 32 . 0 36 . 0 40 .0
 88

Figure 8

Evaluation of Critical Incident Stress Debriefing

0 5 10 15 20 25 30 35 40 45 50

Mean= 38
SD= 8.24
N = 276
 89

Figure 9

HAD Scores of Extreme Intrusion (IES) Groups (N = 587)

445
M 425
E 405
A 385
N 365
345
R 325
A 305
N 285
K 265
245
H 225
A 205
D 185
165
145
LOW INTRUSION HIGH INTRUSION

- DEPRESSION Ill ANXIETY

 90

Figure 10

HAD Scores of Extreme Avoidance (IES) Groups (N = 583)

445
M 425
E 405
A 385
N 365
345
R 325
A 305
N 285
K 265
245
H 225
A 205
D 185
165
145
LOW AVOIDANCE HIGH AVOIDANCE

• DEPRESSION Ill ANXIETY

 91

Figure 11
\
=
I HAD Scores of Extreme Hyperarousal (IES) Groups (N

175
227)

M 165
l E
A 155
N 145
135
R
A 125
N 115
K 105
I
I H
95
A 85
D 75
65
55

- -
LOW AROUSAL HIGH AROUSAL

DEPRESSION ANXIETY
 92

\ Table 2

Mann-Whitney U - Wilcoxon Rank Sum W results for

i
HAD Depression and Anxiety Across Extreme IES Groups

l
Mean Mean

Rank Rank

Depression Anxiety

LOW INTRUSION 262. 7 241. 8

HIGH INTRUSION 324.7 345.3

N 587 587

z -4.45 -7.42

p_ <.05 <.05

LOW AVOIDANCE 248.4 235.7

HIGH AVOIDANCE 335.8 348.5

N 583 583

z -6.30 -8.11

p_ <.05 <.05

LOW HYPERAROUSAL 90.8 86.1

HIGH HYPERAROUSAL 134.7 138.9

N 227 227

z -5.07 -6.07

p_ <.05 <.05
 93

~ Figure 12

I HAD Score Ranks of Low and High Protective Factors Groups

N = 1097

l M
830
790
E 750
I A
N
710
670
630
R 590
A 550
N 510
K 470
430
390
H 350
A 310
270-1-----
LOW PROTECTIVE FACTORS HIGH PROTECTIVE FACTORS

- DEPRESSION D ANXIETY

I Table 3

! Mann-Whitney U - Wilcoxon Rank Sum W results for

HAD Depression and Anxiety Across Extreme Protective
Factors Groups
I Mean Mean
Rank Rank
Depression Anxiety

f LOW PROTECTIVE FACTORS 685.9 640.4

HIGH PROTECTIVE FACTORS 414 . 3 459.1
N 1097 1097
l z
~
-14.30
<.05
-9.31
< . 05

l
I
 94

Figure 13

Evaluation of Debriefing Scores across IES Intrusion Groups

N = 188

120
M
E 110
A 100
N ---- -- ----- ------
90 - · -··· - - -----•-·· ·-

R 80 ·
A
70
N
K 60
50 -
E
40
LOW INTRUSION HIGH INTRUSION

Figure 14

Evaluation of Debriefing Scores across HAD Depression

Groups
N = 167

120 · - -- ··-· ---------- -· ---·-----· ·

~ 110 ·· ------· --··· ------- -·· ··- ·-----··-· · ···----·-··---·-····-- · · · ······ ··- ··-·-
A 1 00 -·---···· · -
N 90 ,___ ___, -· •· · · ··· - ---· -····
80
R 70 -·· ---· ·· · ---- - -- . ----1 - - - - - - - - - - i

A
N 60 ···-··--
K 50 .. ··· ··• ········--·-··
40
· -i.ow DEPRESSION HIGH DEPRESSION
 95

} Table 4

Mann-Whitney U - Wilcoxon Rank Sum W results for

i Evaluation of Debriefing Scores across Extreme

l Intrusion and Depression Groups

I Mean

Rank
i
EOD

J LOW INTRUSION 85.7

HIGH INTRUSION 102.1

l N 188

! z -2.06

p < . 05

LOW DEPRESSION 92.7

HIGH DEPRESSION 75.5

N 167

z -2.30

l p <.05

l
)
 96

Figure 15

INTRUSION/ AVOIDANCE (IES) AND

BELIEFS ABOUT THE INCIDENT

WILCOXON MATCHED- PAIRS SIGNED- RANKS TEST

130
120
110
100
F
90
R
E 80
Q 70
u
E 60
N 50
C
y 40 -
30
20 ·
10
0

- C<A

Hyperarousal (N=46
- A<C

Intrusion (N=131)

EVENT TYPE "A" PERCEIVED AS CR ITICAL

• Avoidance (N=131)

EVENT TYPE "C" NQX. PERCEIVE D AS CRITICAL

 97

Table 5

Wilcoxon Matched PairsSigned Ranks Test results

for comparison of IES scores across Type A and Type C

incidents.

Intrusion

Mean Rank Cases

57.4 89 Type C < Type A

33.2 17 Type C > Type A

25 Ties

N=131 Z=-7 .16, p<.05

Avoidance

Mean Rank Cases

56.0 82 Type C < Type A

36.5 21 Type C > Type A

25 Ties

N=128 Z=-6.29, p<. 05

Hyperarousal

Mean Rank Cases

14.5 25 Type C < Type A

I 20.4 5 Type C > Type A

16 Ties
l
N=46 Z=-2. 68, 12<.05

i
 98

Figure 16

Evaluation of Debriefing
and Beliefs About the Incident (N=74)

I M
55
E 50 -····-·-- ---- .•. . -•· ·-·--·-···- - -- --·--------- -- ------- --··--····- ·
A
I
N 45 - •--··--·-- ---- - - - -· -- - - ---------- .. - - - - -- ----------~------------- - - --- -·

40 ·-•- - - - --- ------ -1 - - - ···----• ----·------ -----·· --- - -

R
A
35 -
N
K
30
E 25 I•

0
D 20
15 ---- -' - - - - - - - - - - - ' --- ----- -- - ---- --- - --- -- --~ - - - - - - - '
EVENT TYPE A EVENT TYPE C
EVENT TYPE "A" PERCEIVED AS CRITICAL
EVENT TYPE "C" Nm PERCEIVED AS CRITICAL

Table 6

Mann-Whitney results for comparison of EOD

scores across beliefs about the incident.

Mean
Rank
EOD

Incident Type A 32.1

Incident Type C 42.9
74
I N
z
p_
-2.15
<.05

t
 99

Figure 17

Depression Sc ores in Debriefed

and Non-debriefed Groups (N=517)
385 ...
M 365 -
E 345 ·-
A 325 ··-- --·---- - ·
N 305 - --- -
285 --
R 265
A
N
245
K 225
205
E 185 -
0 165
D 145 - -- -
125 ~--------' --- .. · • ·- - - --

Debriefed Not debriefed

Figure 18

Intrusion (IES) Scores in Debriefed

and Non-debriefed Groups (N=337)
275 · -- ·
M 255 ---····-- - - -·- ·-·--·-·-····-··· - - -

E 235
A
N 215 ·-
R 195 ---- ---- ------· ---- -·-- -- ---·· - ----·· ···-- - -- -- . ... --- -- -

A 175 ---· -----

N 155 - -
K
135 - -·-- --
~ 115 --·- ·--
D 95 -- -···
75 ·----- - ' - - - - - - - - - --"--·- ··--·-'--- - - - - - ' -
Debriefed Not debriefed
 100

Table 7

Mann-Whitney U - Wilcoxon Rank Sum W results for

Depression and Intrusion scores across debriefed

and non-debriefed groups.

Mean Mean

Rank Rank

Depression Intrusion

DEBRIEFED 244.0 181. 0

NOT DEBRIEFED 275.0 154.6

N 517 337

z -2.34 -2.48

I2- <.05 <.05

 101

Figure 19

Intrusion (IES) Scores across Coping Categories

(N=543)
570~-------------------------
530+--------------------------
490+--------------------------
450+---------------------------
410+---------+-------------------
370-i----------+------------------
M
e '
330-i-----------t-------''f-- - - - - - - - - - ' t - - - - , - - - -
a • ~
n 2 9 0 + - - - - - - - - - + - - - + - - -w
'f----t-------'f - - - -,l - - - - -
•

!
250t---;t,-- -!l!--- - - - - - - - - - - - '·~ - -;••+•-----'----+--
~- - -
R 210t-----,l; t-----<e--- - - - - - - - - - - - - - - - - - - -
a
n 170+---+-----..--- - - - - - - - - - - - - - - - - - - -
k 130+---------------------------
90+-----------------------------
50+---------------------------
10+---+---+---+----+----+----t----t----1------i
cc OS EA PR pp SC ss AR
Note: Asterisks indicate 95% confidence intervals for the
mean rank.
Table 8
Kruskal-Wallis One-way Anova results for IES Intrusion
scores across highest relative percent coping
categories.

Coping Mean
Category Rank N

Confrontive Coping 203.1 43

Distancing 209.1 53
Escape/Avoidance 347.9 15
Positive Reappraisal 304.7 82
Planful Problem Solving 274.6 174
Self Controlling 270.4 66
Seek Social Support 301. 0 55
Accept Responsibility 281.7 55

x2=26.13, .ct.t=7, ~<.os N = 543

 102

Figure 20

Avoidance (IES) Scores across Coping Categories

(N=542)
570.----------------------------
530t---------------------------
490t---------------------------
450t---------------------------
4 1 0 t - - - - - - - - -____..,._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

370+---------t------------------
M 3 3 0 + - - - - - - - ----"IL-- -)!,- - - - - -·+
,"----,-----i'f-'- - -
e
a 290+------c;:-
. ---t----+-------t---------,,!------,1----
n ' •• '

1I - - - - - - - :,t-~- - - - - -
250+--~r---clt-------"'-------..--
R 210+--~ t----- - - , 1 - - - - - - - - - - - - - - - - - - - - -
a
n 170t-----,.....-------------------------
k 130+--------------------------
90+--------------------------
50+--------------------------
10+---i-----1---+----+---+-----+----+----+------<
cc DS EA PR PP SC ss AR
Note: Asterisks indicate 95% confidence intervals for the
mean rank.
Table 9

Kruskal-Wallis One-way Anova results for IES Avoidance

scores across highest relative percent coping
categories.

Coping Mean
Category Rank N

Confrontive Coping 211.2 43

Distancing 239.6 52
Escape/Avoidance 334.8 15
Positive Reappraisal 298.6 82
Planful Problem Solving 252.6 174
Self Controlling 304.9 66
Seek Social Support 281.5 55
Accept Responsibility 301.0 55

x2 =21.31, .df=7, ~<.o5 N = 542

 103

Figure 21

Intrusion (IES-R) Scores across Coping Categories

(N=340)
350
330
310
290
270
250
230 ·• '
M 210
"

e '
a 190 ' ; ..
n 170 ,: ,~
. .
·*
150
,~ +
-,1;
R 130 ••
tl
a
n 110 ,.
k 90
70
50
30
10
cc OS EA PR PP SC ss AR
Note: Asterisks indicate 95% confidence intervals for the
mean rank.
Table 10

Kruskal-Wallis One-way Anova results for IES-R

Intrusion scores across highest relative percent woe
coping categories.

Coping Mean
Category Rank N

Confrontive Coping 196.2 30

Distancing 189.8 40
Escape/Avoidance 235.2 6
Positive Reappraisal 203.3 52
Planful Problem Solving 160.6 110
Self Controlling 152.3 37
Seek Social Support 142.2 42
Accept Responsibility 140.7 23

x2 =20.05, .df.=7, ~<.o5 N = 340

 104

Figure 22

Depression Scores (HAD) across Coping Categories

(N=1663)
1725
1625
1525
1425
1325
1225 ,.
1125
M 1025
...
e
a
n
925
825
l
j
,,.
f
J f
!
1 ,.,_ •
ii:·

725
l * •
R 625 * *
a
n 525
k 425
325
225
125
25
cc OS EA PR pp SC ss AR
Note: Asterisks indicate 95% confidence intervals for the
mean rank.
Table 11

Kruskal-Wallis One-way Anova results for HAD

Depression scores across highest relative percent WOC
coping categories.

Coping Mean
Category Rank N

Confrontive Coping 903.5 133

Distancing 914.1 162
Escape/Avoidance 1032.3 47
Positive Reappraisal 811. 3 257
Planful Problem Solving 721.2 521
Self Controlling 928.6 207
Seek Social Support 765.7 176
Accept Responsibility 972.5 160

x2=7o.s8, .d.f.=7, ~< . o5 N 1663

 105

Figure 23

Anxiety Scores (HAD) across Coping Categories

(N=1663)
1725
1625
1525
1425
1325
1225

M
1125 ,. 1'-
1025
e ,., f.,,
a 925
' l t • 1
n 825
1
* I i *
725 ·¥
R 625
a
n 525
k 425
325
225
125
25
cc OS EA PR pp SC ss AR
Note: Asterisks indicate 95% confidence intervals for the
mean rank.
Table 12

Kruskal-Wallis One-way Anova results for HAD Anxiety

scores across highest relative percent woe coping
categories.

Coping Mean
Category Rank N

Confrontive Coping 823.9 133

Distancing 851. 8 162
Escape/Avoidance 1078.7 47
Positive Reappraisal 830.9 257
Planful Problem Solving 737.5 521
Self Controlling 871. 0 207
Seek Social Support 843.7 176
Accept Responsibility 992.5 160

x2 =52.s9, df.=7, ~<.os N 1663

 106

Table 13

Matrix of post hoc comparisons for HAD-Depression

scores among woe coping categories.

cc DS EA PR pp SC ss

DS NS

EA NS NS

PR NS NS NS

pp * * * NS

SC NS NS NS NS *
ss NS NS * NS NS *

AR NS NS NS * * NS *

*p<.05

Note: CC= Confrontive Coping, DS = Distancing, SC=

Self Controlling, SS = Seek Social Support, AR=

Accept Responsibility, EA= Escape Avoidance, PP

Planful Problem Solving, PR= Positive Reappraisal.

 107

Table 14

Matrix of post hoc comparisons for HAD-Anxiety scores

among woe coping categories.

cc DS EA PR pp SC ss

DS NS

EA NS NS

PR NS NS *

pp NS NS * NS

SC NS NS NS NS *

ss NS NS NS NS NS NS

AR NS NS NS * * NS NS

* p < .05

Note: CC= Confrontive Coping, DS = Distancing, SC

Self Controlling, SS = Seek Social Support, AR=

Accept Responsibility, EA= Escape Avoidance, PP

Planful Problem Solving, PR= Positive Reappraisal.