Incident Stress Debriefing After A Line Of Duty Death
Fizer worked with rescue workers at the World Trade Center following the September
11th attacks. She is an Independent Clinical Social Worker in the greater Boston
area. Carol trained with the International Critical Incident Stress Foundation
and Smith College School for Social Work.
A debriefing is essentially a highly structured conversation, which moves from
the cognitive to the affective and back to the cognitive level, from person to
person around the group. This is done in a series of seven steps:
1. Introduction this is when the leader tells the group its focus and
set the group boundaries. We are here to talk about Seans death in
the fire on Monday.
2. Fact Stage the leader asks
each participant his or her recollection of the trauma. How did you know
something wasnt right, that Sean was missing?
Stage the leader focuses on the cognitive reaction. What was
the first thought that came into your mind when you realized that he had not come
out of the building?
4. Reaction Stage - there is more
sharing of feeling about the trauma and is usually the most extended in time.
Whats it like to lose a member of your Engine? How is the firehouse
5. Symptom Stage - the leader asks directly whether
group members have had any unusual thoughts or feelings since the event. What
has been going on internally since Monday? Has anything been unusual for you?
6. Teaching Stage - in this stage the leader tries to normalize
symptoms and offer self-help steps. What you all are feeling, the anger,
the sadness, is what happens when someone close to you dies. I want to make suggestions
about how you can help yourself feel better. Specific steps to reduce stress
are offered at this point. They include using less alcohol and caffeine, emphasizing
the need for exercise and a balanced diet, encouraging communication with friends,
and doing activities which feel good or whatever is stress reducing.
7. Reentry Stage - the leader wraps up the group, but leaves open the door
for future contact. Thank you all for being here when you would rather be
at home. I know this has been a tough thing to talk about, but it helps. Please
feel free to contact us if there is anyway we can be of help in the next days
or weeks. At this point, the group leader may ask to talk privately to targeted
group members, for example, someone who is drinking more than usual, or has stopped
taking his or her medication and is showing signs of decomposition, or has been
reluctant to participate in the group. The remainder of this article contains
a narrative as to how I applied the Seven Steps to a group of firefighters.
It had been five days since the trauma took the lives of two firefighters, Sean
and Michael, experienced veterans of the department whom all the rest looked up
to. There had been two funerals and life had gone on as normal in
the firehouse, but the chief, James, had heard more than the usual complaints
of not sleeping, arguing with family members, meetings at the local bar, and a
general sense of tension among the men. James attempts to talk about Michael
and Seans death had been met with a wall of silence. At that point James
decided to call the local County Critical Incident Stress Team. As its Mental
Health Coordinator, I discussed various options with him and set a time for the
next morning to debrief the group of ten firefighters from the house who were
all at the fire. We did not include firefighters from other houses since this
group had a unique relationship with the two dead men. It was best not to meet
in the firehouse, so we met at the Community Center. James arranged for transportation.
I contacted Randy, a County Critical Incident team member and a firefighter, who
has been trained in Critical Incident Stress Debriefing. Randy works in another
town, and we ran through the plan for the debriefing.
Meeting: I walked into the meeting room to see nine tired-looking men and
one woman. They ranged in experience from young newcomers of the department to
seasoned veterans of thirty years. The mix was about half and half. There was
minimal conversation, but a lot of cigarette smoking and coffee drinking. Randy,
the peer leader, and I worked out who should take the lead. I leapt in with a
brief introduction that we were here because of Sean and Michaels death.
I briefly explained that everything that was said was confidential, that we were
here for them, and what was happening to them. There was some grumbling from an
older man about psychological crap, which I just chose to ignore.
Something was Wrong: We initiated a round-robin style group discussion by
giving each person the opportunity to speak about when they first realized something
was wrong. Each person gave his or her perspective. The general consensus in the
group was that during the fire quite a bit of time elapsed before fellow firemen
realized Michael and Sean were missing. In fact, it had been at least fifteen
minutes after the building evacuation was called since there was so much confusion
between the four different companies.
First Thoughts: A second
round focused on the first thoughts which popped into their minds after realizing
that the two were missing. The responses ranged from who was going to tell their
wives to what they would do without them. Several men said nothing.
Guilt and Anger: Feelings started to emerge and the conversation focused on how
hard it was to go to the funeral and go to work without Sean and Michael. There
were feelings of guilt when no one realized that Sean and Michael had been caught
in a quick burn. Sadness for their families surfaced, and Julia cried as she talked
about seeing the kids at the funeral. The guilt emerged and the focus switched
to what could have been done differently. I gently reminded the group that this
was not an operational critique, and again talked about how sad it was to lose
someone in this way. Ralph turned away, hiding his tears. There was an immediate
group response in terms of several people talking about their sadness. The group
stopped. I asked what was going on that had stopped everyone in their tracks.
A younger firefighter said he really thought their deaths were stupid, they had
been doing something risky and left them with this mess. The group tentatively
talked about their anger for the guys who left us. The group went
back and forth between sadness, guilt, and anger, until they all seemed somewhat
Behavioral Changes: I summarized the feelings they had
talked about and moved on to ask them about changes in their behavior and feelings
during the past week. I heard complaints of sleeplessness, preoccupation with
how we could have done it differently, and fears about the next
time the bell rings. Another person kept wondering whether it could be himself
the next time. A joke about nightly trips to the bar made me concerned about Jons
increased drinking as a response to the situation. Randy addressed the feelings
and behavior as a normal reaction to a major loss in their lives that not only
affected their work lives, but also their personal lives. Its like
losing a family member, so you are going to feel this way. I interjected
specific, concrete ways of handling these types of uncomfortable feelings
example, talking to buddies and family members, as well as doing the activities
that help them feel good. These were stressed as ways to get through the next
week. The group then spontaneously planned a memorial for Sean and Michael. The
group decided to hang Sean and Michaels pictures in the kitchen, a place
where they both liked being. As we ended, I thanked them all for being there and
left the door wide open by giving them each our cards for further assistance if
they or their families needed it. We said goodbye. As the group lingered to talk,
I approached Jon, the person who joked about drinking. He quickly told me that
he had not been to an AA meeting, but promised to go at the end of his shift.
I told him I would check in with him the next day.
The Seven Stage Critical
Incident Stress Debriefing, described by Mitchell in his 1983 article, has been
shown to help individuals, like this group of firefighters, move from a traumatic
situation back to work life. The debriefing is a group crisis intervention, a
healing conversation, not psychotherapy and, when used correctly, shows the potential
for reduced symptomatic behavior.
This is a brief overview of debriefing (CISD) which used with other interventions
(CISM) can be potentially powerful in helping a wide variety of populations through
traumatic situations with a reduced potential for long range symptoms.
Association of Social Workers
Code of Ethics
1.01 Commitment to Clients
Social workers' primary
responsibility is to promote the well-being of clients. In general, client's interests
are primary. However, social workers responsibility to the larger society
or specific legal obligations may, on limited occasions, supersede the loyalty
owed clients, and clients should be so advised. (Examples include when a social
worker is required by law to report that a client has abused a child or has threatened
to harm self or others.)
respect and promote the right of clients to self-determination and assist clients
in their efforts to identify and clarify their goals. Social workers may limit
a client's right to self-determination when, in the social worker's professional
judgment, client's actions or potential actions pose a serious, foreseeable, and
imminent risk to themselves or others.
1.05 Cultural Competence and
(a) Social workers should understand culture and its
function in human behavior and society, recognizing the strengths that exist in
(b) Social workers should have a knowledge base of their clients
cultures and be able to demonstrate competence in the provision of services that
are sensitive to clients cultures and to differences among people and cultural
(c) Social workers should obtain education about and seek to understand
the nature of social diversity and oppression with respect to race, ethnicity,
national origin, color, sex, sexual orientation, age, marital status, political
belief, religion, and mental or physical disability.
(b) Social workers should not take unfair advantage of any
professional relationship or exploit others to further their personal, religious,
political, or business interests.
1.07 Privacy and Confidentiality
(a) Social workers should respect client's right to privacy. Social workers should
not solicit private information from clients unless it is essential to providing
services or conducting social work evaluation or research. Once private information
is shared, standards of confidentiality apply.
(c) Social workers should protect
the confidentiality of all information obtained in the course of professional
service, except for compelling professional reasons. The general expectation that
social workers will keep information confidential does not apply when disclosure
is necessary to prevent serious, foreseeable, and imminent harm to a client or
other identifiable person. In all instances, social workers should disclose
the least amount of confidential information necessary to achieve the desired
purpose; only information that is directly relevant to the purpose for which the
disclosure is made should be revealed.
(e) Social workers should discuss
with clients and other interested parties the nature of confidentiality and limitations
of client's right to confidentiality. Social workers should review with clients
circumstances where confidential information may be requested and where disclosure
of confidential information may be legally required. This discussion should occur
as soon as possible in the social worker-client relationship and as needed throughout
the course of the relationship.
(k) Social workers should protect the confidentiality
of clients when responding to requests from members of the media.
(a) Social workers should seek the advice and counsel of
colleagues whenever such consultation is in the best interests of clients.
(b) Social workers should keep themselves informed about colleagues areas
of expertise and competencies. Social workers should seek consultation only from
colleagues who have demonstrated knowledge, expertise, and competence related
to the subject of the consultation.
(c) When consulting with colleagues about
clients, social workers should disclose the least amount of information necessary
to achieve the purposes of the consultation.
Social workers should not practice, condone, facilitate, or collaborate with any
form of discrimination on the basis of race, ethnicity, national origin, color,
sex, sexual orientation, age, marital status, political belief, religion, or mental
or physical disability.
Association of Marriage and Family Therapists
Code of Ethics
1. Responsibility to Clients
1.1. Marriage and family therapists provide
professional assistance to persons without discrimination on the basis of race,
age, ethnicity, socio-economic status, disability, gender, health status, religion,
national origin, or sexual orientation.
1.6 Marriage and family therapists
comply with applicable laws regarding the reporting of alleged unethical conduct.
1.7 Marriage and family therapists do not use their professional relationships
with clients to further their own interests.
2.1 Marriage and family therapists disclose to clients and other interested parties,
as early as feasible in their professional contacts, the nature of confidentiality
and possible limitations of the client's right to confidentiality. Therapists
review with clients the circumstances where confidential information may be requested
and where disclosure of confidential information may be legally required. Circumstances
may necessitate repeated disclosures.
2.2 Marriage and family therapists do
not disclose client confidences except by written authorization or waiver, or
where mandated or permitted by law. Verbal authorization will not be sufficient
except in emergency situations, unless prohibited by law. When providing couple,
family or group treatment, the therapist does not disclose information outside
the treatment context without a written authorization from each individual competent
to execute a waiver. In the context of couple, family or group treatment, the
therapist may not reveal any individuals confidences to others in the client
unit without the prior written permission of that individual.
Competence and Integrity
3.12 Marriage and family therapists make efforts
to prevent the distortion or misuse of their clinical and research findings.
3.13 Marriage and family therapists, because of their ability to influence and
alter the lives of others, exercise special care when making public their professional
recommendations and opinions through testimony or other public statements.
Ethical Principles of Psychologists and
Code of Conduct
1.02 Relationship of Ethics and Law.
If psychologists' ethical responsibilities
conflict with law, psychologists make known their commitment to the Ethics Code
and take steps to resolve the conflict in a responsible manner.
In their work-related activities, psychologists respect
the rights of others to hold values, attitudes, and opinions that differ from
In their work-related
activities, psychologists do not engage in unfair discrimination based on age,
gender, race, ethnicity, national origin, religion, sexual orientation, disability,
socio-economic status, or any basis proscribed by law.
Psychologists do not knowingly engage in behavior that is
harassing or demeaning to persons with whom they interact in their work based
on factors such as those persons age, gender, race, ethnicity, national
origin, religion, sexual orientation, disability, language, or socio-economic
1.13 Personal Problems and Conflicts.
recognize that their personal problems and conflicts may interfere with their
effectiveness. Accordingly, they refrain from undertaking an activity when they
know or should know that their personal problems are likely to lead to harm to
a patient, client, colleague, student, research participant, or other person to
whom they may owe a professional or scientific obligation.
of Psychologist's Influence.
Because psychologist's scientific and professional
judgments and actions may affect the lives of others, they are alert to and guard
against personal, financial, social, organizational, or political factors that
might lead to misuse of their influence.
Psychologists have a primary obligation
and take reasonable precautions to respect the confidentiality rights of those
with whom they work or consult, recognizing that confidentiality may be established
by law, institutional rules, or professional or scientific relationships.
(a) Psychologists disclose confidential information
without the consent of the individual only as mandated by law, or where permitted
by law for a valid purpose, such as (1) to provide needed professional services
to the patient or the individual or organizational client, (2) to obtain appropriate
professional consultations, (3) to protect the patient or client or others
from harm, or (4) to obtain payment for services, in which instance disclosure
is limited to the minimum that is necessary to achieve the purpose.
Board for Certified Counselors Code of Ethics
Section A: General
9. Certified counselors must insure that they do not
engage in personal, social, organizational, financial, or political activities
which might lead to a misuse of their influence.
12. Through an awareness
of the impact of stereotyping and unwarranted discrimination (e.g., biases based
on age, disability, ethnicity, gender, race, religion, or sexual orientation),
certified counselors guard the individual rights and personal dignity of the client
in the counseling relationship.
Section B: Counseling Relationship
The primary obligation of certified counselors is to respect the integrity and
promote the welfare of clients, whether they are assisted individually, in family
units, or in group counseling. In a group setting, the certified counselor is
also responsible for taking reasonable precautions to protect individuals from
physical and/or psychological trauma resulting from interaction within the group.
4. When a clients condition indicates that there is a clear and
imminent danger to the client or others, the certified counselor must take reasonable
action to inform potential victims and/or inform responsible authorities. Consultation with other professionals must be used when possible. The assumption
of responsibility for the clients behavior must be taken only after careful
deliberation, and the client must be involved in the resumption of responsibility
as quickly as possible.
COUNSELING ASSOCIATION CODE OF ETHICS
A: The Counseling Relationship
Standard of Practice One:
Counselors respect diversity and must not discriminate against clients because
of age, color, culture, disability, ethnic group, gender, race, religion, sexual
orientation, marital status, or socioeconomic status.
Section H: Resolving
Standard of Practice Forty-Nine:
Ethical Behavior Expected.
Counselors must take appropriate action when they possess reasonable cause that
raises doubts as to whether counselors or other mental health professionals are
acting in an ethical manner.
Standard of Practice Fifty:
Complaints. Counselors must not initiate, participate in, or encourage the filing
of ethics complaints that are unwarranted or intended to harm a mental health
professional rather than to protect clients or the public.
Cooperation With Ethics Committees. Counselors must
cooperate with investigations, proceedings, and requirements of the ACA Ethics
Committee or ethics committees of other duly constituted associations or boards
having jurisdiction over those charged with a violation.
Evolution of Social Work Ethics by Mary Rankin, J.D.
The change in a social worker’s approach to ethical concerns is one of the most significant advances in our profession. Early in the 20th century, a social worker’s concern for ethics centered on the morality of the client, not the ethics of the profession or its practitioners. Over the next couple of decades, the emphasis on the client’s ethics began to weaken as social workers began developing new perspectives and methods that eventually would be fundamental to the profession, all in an effort to distinguish social work’s approach from other allied health professions.
The first attempt at creating a code of ethics was made in 1919, and by the 1940s and 1950s, social workers began to focus on the morality, values, and ethics of the profession, rather than the ethics and morality of the patient. As a result of the turbulent social times of the 1960s and 1970s, social workers began directing significant efforts towards the issues of social justice, social reform, and civil rights.
In the 1980s and 1990s, the focus shifted from abstract debates about ethical terms and conceptually complex moral arguments to more practical and immediate ethical problems. For example, a significant portion of the literature from the time period focuses on decision-making strategies for complex or difficult ethical dilemmas. More recently, the profession has worked to develop a new and comprehensive Code of Ethics to outline the profession’s core values, provide guidance on dealing with ethical issues and dilemmas, and also to describe and define ethical misconduct. Today, ethics in social work is focused primarily on helping social workers identify and analyze ethical dilemmas, apply appropriate decision-making strategies, manage ethics related risks, and confront ethical misconduct within the profession.
The following contains thee key Legal issues for mental health professionals: Tarasoff - Duty to Warn, Duty to Protect; and Mandatory Reporting of Child Abuse
Tarasoff - Duty to Warn, Duty to Protect
Most states have laws that either require or permit mental health professionals to disclose information about patients who may become violent often referred to as the duty to warn and/or duty to protect. These laws stem from two decisions in Tarasoff v. The Regents of the University of California. Together, the Tarasoff decisions impose liability on all mental health professionals to protect victims from violent acts. Specifically, the first Tarasoff case imposed a duty to verbally warn an intended victim victim of foreseeable danger, and the second Tarasoff case implies a duty to protect the intended victim against possible danger (e.g., alert police, warn the victim, etc.).
Domestic Violence – Confidentiality and the Duty to Warn
Stemming from the decisions in Tarasoff v. The Regents of the University of California, many states have imposed liability on mental health professionals to protect victims from violent acts, often referred to as the duty to warn and duty to protect. This liability extends to potential victims of domestic violence. When working with a client who has a history of domestic violence, a social worker should conduct a risk assessment to determine if whether there is a potential for harm, and take all necessary steps to diffuse a potentially violent situation.
Mandatory Reporting of Child Abuse
All states have laws that identify individuals who are obligated to report suspected child abuse, including social workers these individuals are often referred to as “mandatory reporters.” The requirements vary from state to state, but typically, a report must be made when the reporter (in his or her official capacity) suspects or has reason to believe that a child has been abused or neglected. Most states operate a toll-free hotline to receive reports of abuse and typically the reporter may choose to remain anonymous (there are limitations and exceptions that vary by state so please review your state’s laws).
Reflection Exercise Explanation
Goal of this Home Study Course is to create a learning experience that enhances
your clinical skills. We encourage you to discuss the Personal Reflection
Journaling Activities, found at the end of each Section, with your colleagues.
Thus, you are provided with an opportunity for a Group Discussion experience.
Case Study examples might include: family background, socio-economic status, education,
occupation, social/emotional issues, legal/financial issues, death/dying/health,
home management, parenting, etc. as you deem appropriate. A Case Study is to be
approximately 50 words in length. However, since the content of these Personal
Reflection Journaling Exercises is intended for your future reference, they
may contain confidential information and are to be applied as a work in
progress. You will not
be required to provide us with these Journaling Activities.
Reflection Exercise #1
The preceding section contained Codes of Ethics
for mental health professionals. Write two case study examples regarding applications
of Ethical Principles you feel might be in conflict with national terrorist activities
such as the September 11, 2001, attack on the New York World Trade Center. Much
fear was generated by these attacks; thus, patient symptoms in many cases were
amplified. An anxiety disordered client may have experienced heightened feelings
of anxiety and a mood disordered client may have experienced increased depression.
These may include Major Depressive Episode, Manic Episode, Mixed Episode, Hypomanic
Episode, Major Depressive Disorder, etc. Conflicts with your professions
code of ethics may arise regarding the therapists personal feelings concerning
a certain religion or cultural ethnicity related to clients viewpoints.
Ethical principles of self-determination, cultural competence, conflict of interest,
and perhaps personal problems may present some ethical questions in your mind.
Record the letter of the correct answer on the .
sentences and phrases are in bold type, in each Section of this Manual, for the
purpose of highlighting key ideas for easy reference.
7: When a clients condition indicates that there is a clear and imminent
danger to the client or others, the certified counselor must do what? To select
and enter your answer go to .
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