Critical incident stress management
Other namesCISM
Specialtypsychology

Critical incident stress management (CISM) was a controversial, non-empirical, adaptive, short-term psychological helping-process that focused solely on an immediate and identifiable problem. It included pre-incident preparedness to acute crisis management through post-crisis follow-up. Its purpose was to enable people to return to their daily routine more quickly and with less likelihood of experiencing post-traumatic stress disorder (PTSD).[1] However, after researchers showed that debriefing techniques did not decrease rates of PTSD,[2] CISM is now seldom used and has largely been replaced with immediate psychological care techniques that do not use debriefing such as those endorsed by the CDC, Red Cross, WHO, American Psychological Association and National Center for Post Traumatic Stress Disorder (NC-PTSD). Responsible practitioners who still use CISM must eliminate debriefing steps in order to remain compliant with best practices and clinical guidelines.

CISM was widely discredited, has not been practiced by licensed mental health professionals, and was expressly rejected by the US Government in 2002.[3] Recent evidence-based reviews have concluded that CISM is ineffective and sometimes harmful for both primary and secondary victims,[4] such as responding emergency services personnel. CISM was never intended to treat primary victims of trauma.[5][6][7][8][9][10][11][12][13] One analysis of the psychological debriefing method used in CISM linked it to increased rates of PTSD one year after an event.[2] As of 2022, peer-reviewed meta-analysis specifically warn against the clinical use of CISM for all patients, primary or secondary, stating, "clinical guidelines for managing post-traumatic stress recommend not to practice psychological debriefing".[4]

Purpose

CISM was designed to help people deal with their trauma one incident at a time, by allowing them to talk about the incident when it happens without judgment or criticism. The program was peer-driven (often by people with less than a week of training, and no formal mental health or counseling training or credentials[14][15]) and the people conducting the interventions may have come from all walks of life, but most were first responders (Police, Fire, emergency medical services) or worked in the mental health field. A major CISM training source appears to deliberately legally distance themselves from the training they provide by issuing a "certificate of attendance" and specifically stating: "We do not offer a certificate that specifically states you are CISD/CISM trained."[15] Another training source that does offer certificates also legally distances themselves from their own training, stating that they do "not represent, warrant or guaranty that the certificant is properly prepared or equipped to perform CISM or any of its components".[16] All interventions are strictly confidential, the only caveat to this is if the person doing the intervention determines that the person being helped is a danger to themselves or to others. The emphasis was always on keeping people safe and returning them quickly to more normal levels of functioning.

Normal is different for everyone, and it is not easy to quantify. Critical incidents raise stress levels dramatically in a short period of time and after treatment a new normal is established, however, it is always higher than the old level. The purpose of the intervention process is to establish or set the new normal stress levels as low as possible.

Recipients

Critical incidents are traumatic events that cause powerful emotional reactions in people who are exposed to those events. The most stressful of these are line of duty deaths, co-worker suicide, multiple event incidents, delayed intervention and multi-casualty incidents.[17] Every profession can list their own worst-case scenarios that can be categorized as critical incidents. Emergency services organizations, for example, usually list the Terrible Ten.[18] They are:

  1. Line of duty deaths
  2. Suicide of a colleague
  3. Serious work related injury
  4. Multi-casualty / disaster / terrorism incidents
  5. Events with a high degree of threat to the personnel
  6. Significant events involving children
  7. Events in which the victim is known to the personnel
  8. Events with excessive media interest
  9. Events that are prolonged and end with a negative outcome
  10. Any significantly powerful, overwhelming distressing event

While any person may experience a critical incident, conventional wisdom says that members of law enforcement, fire fighting units, and emergency medical services are at great risk for post-traumatic stress disorder (PTSD). However, less than 5% of emergency services personnel will develop long-term PTSD symptomatology.[19] That percentage increases when responders endure the death of a co-worker in the line of duty. This rate is only slightly higher than the general population average of 3–4%,[20] which indicates that despite the remarkably high levels of exposure to trauma, emergency workers are resilient, and people who join the field may self-select for emotional resilience. Emergency responders tend to portray themselves as "tough”, professional, and unemotional about their work. They often find comfort with other responders, and believe that their families and friends in other professions are unable to completely understand their experiences.[19] Humor is used as a defense mechanism. Alcohol or possibly other drugs/medications may be used to self-medicate in "worst case" situations.

Types of intervention

The type of intervention used depended on the situation, the number of people involved, and their proximity to the event. One form of intervention was a three-step approach, whereas different approaches include as many as five stages. However, the exact number of steps is not what is important for the intervention's success. The goal of the intervention is to address the trauma along the general progression: defusing, debriefing, and followup.[21]

Defusing

A defusing was done the day of the incident before the person(s) had a chance to sleep. The defusing was designed to assure the person or people involved that their feelings are normal, to tell them what symptoms to watch for over the short term, and to offer them a lifeline in the form of a telephone number where they can reach someone whom they can talk to. Defusings were limited only to individuals directly involved in the incident and were often done informally, sometimes at the scene. They were designed to assist individuals in coping in the short term and address immediate needs.

Debriefing

Debriefing is controversial and there is empirical evidence that it may cause harm.[11][10][12][13] Those considering adopting a psychological intervention strategy should strongly consider allowing only licensed medical or mental health counselors to engage in any debriefing-like intervention vs. "certified" counselors who are not licensed medical professionals. Individuals trained by CISM businesses/programs often have less than a week of training[15] and are not mental health professionals, are not subject to oversight, are not subject to licensing and are not required to abide by ethics programs. CISM training providers often go out of their way to legally distance themselves from the consequences of their own training.[16]

Contrary to ICISF protocols, the research papers show potential harm applied debriefing to individuals. ICISF specifies that defusings and debriefings are only intended for use with groups.[22] A literature review concluded that a primary flaw in the criticism is "the lack of consistent terminology," which has led investigators to evaluate distinct interventions as if they were identical, and to use variable outcome measures, making it difficult to compare outcomes across different studies. The review authors concluded that CISM "should continue to be offered to secondary victims of trauma."[23]

Debriefings were usually the second level of intervention for those directly affected by the incident and often the first for those not directly involved.

A debriefing was normally done within 72 hours of the incident and gives the individual or group the opportunity to talk about their experience, how it has affected them, brainstorm coping mechanisms, identify individuals at risk, and inform the individual or group about services available to them in their community.[24] The final step was to follow up with them the day after the debriefing to ensure that they are safe and coping well or to refer the individual for professional counselling.

Although many co-opted the debriefing process for use with other groups, the primary focus in the field of CISM was to support staff members of organizations or members of communities which have experienced a traumatic event. The debriefing process (defined by the International Critical Incident Stress Foundation [ICISF]) had seven steps: introduction of intervenor and establishment of guidelines and invites participants to introduce themselves (while attendance at a debriefing may be mandatory, participation is not); details of the event given from individual perspectives; emotional responses given subjectively; personal reaction and actions; followed again by a discussion of symptoms exhibited since the event; instruction phase where the team discusses the symptoms and assures participants that any symptoms (if they have any at all) are a normal reaction to an abnormal event and "generally" these symptoms will diminish with time and self-care; following a brief period of shared informal discussion (generally over a beverage and treat) resumption of duty where individuals are returned to their normal tasks. The intervenor is always watching for individuals who are not coping well and additional assistance is offered at the conclusion of the process.[17]

There is peer-reviewed evidence that CISM-like recounting of the "details of the event given from individual perspectives" can cause psychological harm through re-telling/re-exposure to the traumatic event with additional details,[25][26] and the potential creation of consequential false memories.[27][28][29] Through this step it is possible for a CISM counselor to re-traumatize and potentially provide a basis for ASD or PTSD that may not have otherwise occurred.[30][29] Studies have shown that debriefing increases the rate of PTSD one year after an event.[2] This discussion of "details of the event given from individual perspectives" is the single most controversial and potentially dangerous aspect of CISM and should not be undertaken by anyone but a licensed medical professional. Due to the real potential for harm, this should not be attempted by non-licensed "counselors" who have attended a commercial CISM course.

Follow-up

The important final step is follow-up. This was generally done within the week following the debriefing by team members as a check-in.

Research

The overwhelming preponderance of peer reviewed, published research found that CISM was ineffective or harmful.[4][31] Several meta-analyses in the medical literature either found no preventative benefit of CISM,[6][8][9] very low quality evidence of benefit,[7] or negative impact for those debriefed.[10][11][12][13][26][32][25][33] Research evidence linking debriefing to harm had been identified as early as 2002 where Rose et al. identified increased rates of PTSD one year after a psychological debriefing like those used in CISM[2] leading to a rejection of the practice of debriefing by many US Government Agencies that year[3] under the medical ethical principle of "do no harm".[34] Twenty years later, the evidence against CISM/debriefing had strengthened with a January 2022 peer-reviewed evidence synthesis stating, "current evidence is consistent in not endorsing it as a form of treatment or prevention of post-traumatic symptomatology", "clinical guidelines for managing post-traumatic stress recommend not to practice psychological debriefing" and "psychological debriefing and associated interventions should be avoided in the management of acute trauma".[4]

See also

References

  1. ↑ "Critical Incident Stress Management: Purpose" (PDF). Virginia Beach Department of Emergency Medical Services. Retrieved July 16, 2009.
  2. 1 2 3 4 Rose, S.; Bisson, J.; Churchill, R.; Wessely, S. (2002). "Psychological debriefing for preventing post traumatic stress disorder (PTSD)". The Cochrane Database of Systematic Reviews (2): CD000560. doi:10.1002/14651858.CD000560. ISSN 1469-493X. PMC 7032695. PMID 12076399.
  3. 1 2 "Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence: A Workshop to Reach Consensus on Best Practices" (PDF). PsycEXTRA Dataset. 2002. Retrieved 2023-01-10.
  4. 1 2 3 4 Arancibia M, Leyton F, Morán J, Muga A, Ríos U, Sepúlveda E, Vallejo-Correa V (January 2022). "Debriefing psicológico en eventos traumáticos agudos: síntesis de la evidencia secundaria". Medwave (in Spanish). 22 (1): e8517. doi:10.5867/medwave.2022.01.002538. PMID 35100248. S2CID 246443705. Las principales guías clínicas para el manejo del estrés postraumático recomiendan no practicar debriefing psicológico.
  5. ↑ Mitchell JT (February 10, 2003). "CRISIS INTERVENTION & CISM: A Research Summary" (PDF). International Critical Incident Stress Foundation. Retrieved January 29, 2016.
  6. 1 2 Rose S, Bisson J, Churchill R, Wessely S (2002). "Psychological debriefing for preventing post traumatic stress disorder (PTSD)". The Cochrane Database of Systematic Reviews (2): CD000560. doi:10.1002/14651858.CD000560. PMC 7032695. PMID 12076399.
  7. 1 2 Roberts NP, Kitchiner NJ, Kenardy J, Robertson L, Lewis C, Bisson JI (August 2019). "Multiple session early psychological interventions for the prevention of post-traumatic stress disorder". The Cochrane Database of Systematic Reviews. 8 (8): CD006869. doi:10.1002/14651858.CD006869.pub3. PMC 6699654. PMID 31425615.
  8. 1 2 Harris MB, Stacks JS. A three-year five-state study on the relationships between critical incident stress debriefings, firefighters' disposition, and stress reactions. USFA-FEMA CISM Research Project. Commerce, TX: Texas A&M University, 1998.
  9. 1 2 Harris MB, Balolu M, Stacks JR (2002). "Mental health of trauma-exposed firefighters and critical incident stress debriefing". J Loss Trauma. 7 (3): 223–238. doi:10.1080/10811440290057639. S2CID 144946218.
  10. 1 2 3 van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM (September 2002). "Single session debriefing after psychological trauma: a meta-analysis". Lancet. 360 (9335): 766–771. doi:10.1016/S0140-6736(02)09897-5. PMID 12241834. S2CID 8177617.
  11. 1 2 3 Carlier IV, Voerman AE, Gersons BP (March 2000). "The influence of occupational debriefing on post-traumatic stress symptomatology in traumatized police officers". The British Journal of Medical Psychology. 73 (Pt 1): 87–98. doi:10.1348/000711200160327. PMID 10759053.
  12. 1 2 3 Carlier IVE, Lamberts RD, van Ulchelen AJ, Gersons BPR (1998). "Disaster-related post-traumatic stress in police officers: A field study of the impact of debriefing". Stress Medicine. 14 (3): 143–148. doi:10.1002/(sici)1099-1700(199807)14:3<143::aid-smi770>3.3.co;2-j.
  13. 1 2 3 Rose S, Brewin CR, Andrews B, Kirk M (July 1999). "A randomized controlled trial of individual psychological debriefing for victims of violent crime". Psychological Medicine. 29 (4): 793–799. doi:10.1017/s0033291799008624. PMID 10473306. S2CID 35346492.
  14. ↑ "Training – Critical Concepts". criticalconcepts.org. Retrieved 2023-01-10.
  15. 1 2 3 "Education & Training - ICISF". icisf.org. Retrieved 2023-01-10.
  16. 1 2 "Disclaimer". Retrieved 2023-01-10.
  17. 1 2 Pulley SA (March 21, 2005). "Critical Incident Stress Management". eMedicine. Archived from the original on August 11, 2006. Retrieved July 16, 2009.
  18. ↑ Mitchell JT. "Stress Management" (PDF). Szkoła Główna Służby Pożarniczej. Archived from the original (PDF) on June 25, 2008. Retrieved July 16, 2009.
  19. 1 2 Mitchell JT, Bray GP (1990). Emergency service stress: Guidelines for preserving the health and careers of emergency services personnel. Englewood Cliffs, N.J.: Prentice-Hall.
  20. ↑ Brandon SE, Silke AP (2007). "Near- and long-term psychological effects of exposure to terrorist attacks". In Bongar B, Brown LM, Beutler LE, Breckenridge JN, Zimbardo PG (eds.). Psychology of terrorism. New York: Oxford University Press. pp. 175–193.
  21. ↑ Mitchell JT, Everly GS (2000). "Critical incident stress management and critical incident stress debriefings: Evolutions, effects and outcomes.". In Raphael B, Wilson J (eds.). Psychological debriefing: Theory, practice and evidence. New York, NY.: Cambridge University Press. pp. 71–90. doi:10.1017/CBO9780511570148.006. ISBN 9780521647007.
  22. ↑ "A Primer on Critical Incident Stress Management".
  23. ↑ "Is Critical Incident Stress Management Effective?" (PDF).
  24. ↑ "Critical Incident Stress Management". Corrective Service of Canada. Archived from the original on September 27, 2009. Retrieved July 16, 2009.
  25. 1 2 Brainerd, C.J.; Stein, L.M.; Silveira, R.A.; Rohenkohl, G.; Reyna, V.F. (September 2008). "How Does Negative Emotion Cause False Memories?". Psychological Science. 19 (9): 919–925. doi:10.1111/j.1467-9280.2008.02177.x. ISSN 0956-7976. PMID 18947358. S2CID 37001782.
  26. 1 2 Strange, Deryn; Takarangi, Melanie K. T. (2015-02-23). "Memory Distortion for Traumatic Events: The Role of Mental Imagery". Frontiers in Psychiatry. 6: 27. doi:10.3389/fpsyt.2015.00027. ISSN 1664-0640. PMC 4337233. PMID 25755646.
  27. ↑ Nourkova, Veronika; Bernstein, Daniel; Loftus, Elizabeth (June 2004). "Altering traumatic memory". Cognition & Emotion. 18 (4): 575–585. doi:10.1080/02699930341000455. ISSN 0269-9931. S2CID 144467440.
  28. ↑ Paterson HM, Whittle K, Kemp RI (March 2015). "Detrimental Effects of Post-Incident Debriefing on Memory and Psychological Responses". Journal of Police and Criminal Psychology. 30 (1): 27–37. doi:10.1007/s11896-014-9141-6. ISSN 0882-0783. S2CID 145132669.
  29. 1 2 Clark A, Nash RA, Fincham G, Mazzoni G (2012-03-09). Andersson G (ed.). "Creating non-believed memories for recent autobiographical events". PLOS ONE. 7 (3): e32998. Bibcode:2012PLoSO...732998C. doi:10.1371/journal.pone.0032998. PMC 3302900. PMID 22427927.
  30. ↑ Bolton, Elisa E.; Gray, Matthew J.; Litz, Brett T. (January 2006). "A cross-lagged analysis of the relationship between symptoms of PTSD and retrospective reports of exposure". Journal of Anxiety Disorders. 20 (7): 877–895. doi:10.1016/j.janxdis.2006.01.009. PMID 16530379.
  31. ↑ Jacobs J, Horne-Moyer HL, Jones R (2004). "The effectiveness of critical incident stress debriefing with primary and secondary trauma victims". International Journal of Emergency Mental Health. 6 (1): 5–14. PMID 15131998.
  32. ↑ Kagee A (February 2002). "Concerns about the effectiveness of critical incident stress debriefing in ameliorating stress reactions". Critical Care. 6 (1): 88. doi:10.1186/cc1459. PMC 137400. PMID 11940272.
  33. ↑ Blaney LS (2009). "Beyond 'knee jerk' reaction: CISM as a health promotion construct". The Irish Journal of Psychology. 30 (1–2): 37–57. doi:10.1080/03033910.2009.10446297. hdl:10613/2581. ISSN 0303-3910.
  34. ↑ Varkey, Basil (2021). "Principles of Clinical Ethics and Their Application to Practice". Medical Principles and Practice. 30 (1): 17–28. doi:10.1159/000509119. ISSN 1011-7571. PMC 7923912. PMID 32498071.
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