Critical incident stress management

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Critical incident stress management
Other namesCISM
Specialty psychology

Critical incident stress management (CISM) has been misunderstood and unfairly criticized as a controversial, non-empirical, adaptive, short-term psychological helping-process that focused solely on an immediate and identifiable problem. Much of the "controversy" stems from confusion of terms.[ neutrality is disputed ] The overall ICISF Model of Critical Incident Stress Management includes several tactics to help mitigate the effects of a critical incident. It includes pre-incident preparedness to acute crisis management through post-crisis follow-up. Its purpose is to enable people to return to their daily routine more quickly and with less likelihood of experiencing post-traumatic stress disorder (PTSD). [1] The term CISM is frequently confused with one of the group intervention tactics under the model. That is the Critical Incident Stress Debriefing (CISD).

Contents

Further, many researchers[ who? ] appear to consider CISM to be some form of treatment when in fact it is a model of psychological first aid.

Although the creators of CISM have never proposed it as prevention of PTSD, researchers criticize it with evidence that debriefing techniques do not decrease rates of PTSD, [2] Whether that is the case or not, CISM is used by thousands of organizations around the world. Some organizations have adapted their practices of 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).

A 2002 workshop whose goal was to reach consensus on the mental health response to mass violence recommended ending use of the word "debriefing" in reference to critical incident interventions. [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] The International Critical Incident Stress Foundation refutes these analyses by citing Snelgrove [14] and others who argue that the critics have misapplied the established protocols.

Purpose

CISM is 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 is peer-driven by people who have completed one or more classes covering topics such as individual and group responses [15] [16] ) 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. The use of peers in the provision of Psychological First Aid and other interventions under the CISM model is a key to its continued success.

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 often seen as being 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 experiencing traumatic events.

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.[ citation needed ] However, the exact number of steps is not what is important for the intervention's success.[ citation needed ] The goal of the intervention is to address the trauma along the general progression: defusing, debriefing, and followup. [19]

Defusing

A defusing is 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 support, usually in the form of contact with a peer support person from their organization. Defusings are used to support groups, not individuals, who have shared the same traumatic experience. Never is a defusing done at the scene of an incident as this would violate the CISM principle of not interfering with operations. The purpose of a defusing is to assist groups in coping in the short term, address acute needs, facilitate a normalization of any symptoms that arise, and bring awareness of available resources if difficulties are encountered.

Debriefing

Debriefing is controversial and there is claimed to be empirical evidence that it may cause harm. [11] [10] [12] [13] The International Critical Incident Stress Foundation rejects these claims, writing that "There is no extant evidence to argue that the “Mitchell model” CISD, or the CISM system, has proven harmful! The investigations that are frequently cited to suggest such an adverse effect simply did not use the CISD or CISM system as prescribed, a fact that is too often ignored". [20]

ICISF specifies that defusings and debriefings are only intended for use with groups. [21] The individual intervention technique used in CISM is a version of psychological first aid. [22] A literature review concluded that a primary flaw in criticism of CISM 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]

For teams, group debriefings are suggested 48-72 hours after a critical incident giving the group an opportunity to support each other by 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. CISM protocols clearly state that no one should ever be pressured or coerced to speak, contrary to some of the criticisms offered (e.g., one firefighter's account of CISM properly offered [25] ).

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]) has 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]

Follow-up and referral

The important final step is follow-up and referral where indicated. This is generally done within a day and again the week following the debriefing by team members as a check-in. This step is important as symptoms may have developed or worsened during this time. One of the key components of the ICISF model is to ensure that anyone who is exposed to a critical incident and who continues to experience symptoms is referred to an appropriate mental health professional for treatment.

Research

Studies have shown that CISM protocols as described by the ICSIF have demonstrable benefits [26] [27] [28] and that the benefits exceed the costs. [29] Benefits include reduced alcohol consumption and increased quality of life. [30]

Some meta-analyses in the medical literature have found no benefit to CISM. A three-year five-state study on the relationships between critical incident stress debriefings, firefighters' disposition, and stress reactions. [31] [9] very low quality evidence of benefit or negative impact for those debriefed. [10] [11] [12] [13]

[32] [33] [34] [35] , although like many of the other studies cited here, the analysis focused on the CISM for preventing PTSD, a claim that ICISF and its founders have never made.

The ICISF's founders have argued that analyses raising questions about CISM, especially the idea that it could cause harm, are based in poor research quality or misapplications of CISM principles and protocols. [36]

See also

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences, with extreme examples being violence, rape, or a terrorist attack. The event must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se.

Acute stress reaction is a psychological response to a terrifying, traumatic or surprising experience. It may bring about delayed stress reactions if not correctly addressed. Acute stress may present in reactions which include but are not limited to: intrusive or dissociative symptoms, and reactivity symptoms such as avoidance or arousal. Reactions may be exhibited for days or weeks after the traumatic event.

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Peer support occurs when people provide knowledge, experience, emotional, social or practical help to each other. It commonly refers to an initiative consisting of trained supporters, and can take a number of forms such as peer mentoring, reflective listening, or counseling. Peer support is also used to refer to initiatives where colleagues, members of self-help organizations and others meet, in person or online, as equals to give each other connection and support on a reciprocal basis.

Debriefing is a report of a mission or project or the information so obtained. It is a structured process following an exercise or event that reviews the actions taken. As a technical term, it implies a specific and active intervention process that has developed with more formal meanings such as operational debriefing. It is classified into different types, which include military, experiential, and psychological debriefing, among others.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

Crisis intervention is a time-limited intervention with a specific psychotherapeutic approach to immediately stabilize those in crisis.

Incident stress is a condition caused by acute stress which overwhelms a staff person trained to deal with critical incidents such as within the line of duty for first responders, EMTs, and other similar personnel. If not recognized and treated at onset, incident stress can lead to more serious effects of posttraumatic stress disorder.

Vicarious trauma (VT) is a term invented by Irene Lisa McCann and Laurie Anne Pearlman that is used to describe how work with traumatized clients affects trauma therapists. The phenomenon had been known as secondary traumatic stress, a term coined by Charles Figley. In vicarious trauma, the therapist experiences a profound worldview change and is permanently altered by empathetic bonding with a client. This change is thought to have three requirements: empathic engagement and exposure to graphic, traumatizing material; exposure to human cruelty; and the reenactment of trauma in therapy. This can produce changes in a therapist's spirituality, worldview, and self-identity.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Childbirth-related post-traumatic stress disorder is a psychological disorder that can develop in women who have recently given birth. This disorder can also affect men or partners who have observed a difficult birth. Its symptoms are not distinct from post-traumatic stress disorder (PTSD). It may also be called post-traumatic stress disorder following childbirth (PTSD-FC).

Psychological first aid (PFA) is a technique designed to reduce the occurrence of post-traumatic stress disorder. It was developed by the National Center for Post Traumatic Stress Disorder (NC-PTSD), a section of the United States Department of Veterans Affairs, in 2006. It has been endorsed and used by the International Federation of Red Cross and Red Crescent Societies, Community Emergency Response Team (CERT), the American Psychological Association (APA) and many others. It was developed in a two-day intensive collaboration, involving more than 25 disaster mental health researchers, an online survey of the first cohort that used PFA and repeated reviews of the draft.

Trauma risk management (TRiM) is a method of secondary PTSD prevention. The TRiM process enables non-healthcare staff to monitor and manage colleagues. TRiM training provides practitioners with a background understanding of psychological trauma and its effects.

Secondary trauma can be incurred when an individual is exposed to people who have been traumatized themselves, disturbing descriptions of traumatic events by a survivor, or others inflicting cruelty on one another. Symptoms of secondary trauma are similar to those of PTSD. Secondary trauma has been researched in first responders, nurses and physicians, mental health care workers, and children of traumatized parents.

Trauma-sensitive yoga is yoga as exercise, adapted from 2002 onwards for work with individuals affected by psychological trauma. Its goal is to help trauma survivors to develop a greater sense of mind-body connection, to ease their physiological experiences of trauma, to gain a greater sense of ownership over their bodies, and to augment their overall well-being. However, a 2019 systematic review found that the studies to date were not sufficiently robustly designed to provide strong evidence of yoga's effectiveness as a therapy; it called for further research.

<span class="mw-page-title-main">Post-traumatic stress disorder and substance use disorders</span> Association of PTSD and substance dependencies

Post-traumatic stress disorder (PTSD) can affect about 3.6% of the U.S. population each year, and 6.8% of the U.S. population over a lifetime. 8.4% of people in the U.S. are diagnosed with substance use disorders (SUD). Of those with a diagnosis of PTSD, a co-occurring, or comorbid diagnosis of a SUD is present in 20–35% of that clinical population.

<span class="mw-page-title-main">Trauma and first responders</span> Trauma experienced by first responders

Trauma in first responders refers to the psychological trauma experienced by first responders, such as police officers, firefighters, and paramedics, often as a result of events experienced in their line of work. The nature of a first responder's occupation continuously puts them in harm's way and regularly exposes them to traumatic situations, such as people who have been harmed, injured, or killed.

Disaster psychiatry is a field of psychiatry which focuses on responding to natural disasters, climate change, school shootings, large accidents, public health emergencies, and their associated community-wide disruptions and mental health implications. All disasters, regardless of exact type, are characterized by disruption: disruption of family and community support structures, threats to personal safety, and an overwhelming of available support resources. Disaster psychiatry is a crucial component of disaster preparedness, aiming to mitigate both immediate and prolonged psychiatric challenges. Its primary objective is to diminish acute symptoms and long-term psychiatric morbidity by minimizing exposure to stressors, offering education to normalize responses to trauma, and identifying individuals vulnerable to future psychiatric illness.

Being exposed to traumatic events such as war, violence, disasters, loss, injury or illness can cause trauma. Additionally, the most common diagnostic instruments such as the ICD-11 and the DSM-5 expand on this definition of trauma to include perceived threat to death, injury, or sexual violence to self or a loved one. Even after the situation has passed, the experience can bring up a sense of vulnerability, hopelessness, anger and fear.

References

  1. ↑ "Critical Incident Stress Management: Purpose" (PDF). Virginia Beach Department of Emergency Medical Services. Retrieved July 16, 2009.
  2. 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. ISSN   1469-493X. PMC   7032695 . PMID   12076399.
  3. ↑ "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 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. ↑ 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.
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  8. ↑ 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.
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  14. ↑ Dass-Brailsford, Priscilla (2007). A Practical Approach to Trauma: Empowering Interventions. doi:10.4135/9781452204123. ISBN   978-1-4129-1638-7.
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  20. ↑ "A Primer on Critical Incident Stress Management (Cism) - Icisf".
  21. ↑ "A Primer on Critical Incident Stress Management".
  22. ↑ "Assisting Individuals in Crisis - ICISF".
  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. ↑ "CISM and Peer Support: My Thoughts - ICISF".
  26. ↑ Adler, Amy B.; Litz, Brett T.; Castro, Carl Andrew; Suvak, Michael; Thomas, Jeffrey L.; Burrell, Lolita; McGurk, Dennis; Wright, Kathleen M.; Bliese, Paul D. (2008). "A group randomized trial of critical incident stress debriefing provided to U.S. Peacekeepers". Journal of Traumatic Stress. 21 (3): 253–263. doi:10.1002/jts.20342. PMID   18553407.
  27. ↑ Caponnetto, Pasquale; Magro, Rosanna; Inguscio, Lucio; Cannella, Maria Concetta (2018). "Quality of life, work motivation, burn-out and stress perceptions benefits of a stress management program by autogenic training for emergency room staff: A pilot study". Mental Illness. 10 (2): 67–70. doi:10.1108/mi.2018.7913. hdl: 11573/1326359 .
  28. ↑ Vogt, Joachim; Leonhardt, Jörg; Pennig, Stefan (2007). "Critical Incident Stress Management in Air Traffic Control and Its Benefits". Air Traffic Control Quarterly. 15 (2): 127–156. doi:10.2514/atcq.15.2.127.
  29. ↑ Vogt, Joachim; Pennig, Stefan (2016). "Cost Benefit Analysis of a Critical Incident Stress Management Program". Critical Incident Stress Management in Aviation. pp. 153–170. doi:10.4324/9781315575001-12. ISBN   978-1-315-57500-1.
  30. ↑ Tuckey, Michelle R.; Scott, Jill E. (2014). "Group critical incident stress debriefing with emergency services personnel: A randomized controlled trial". Anxiety, Stress, & Coping. 27 (1): 38–54. doi:10.1080/10615806.2013.809421. PMID   23799773. S2CID   27769659.
  31. ↑ USFA-FEMA CISM Research Project. Commerce, TX: Texas A&M University, 1998.
  32. ↑ 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.
  33. ↑ 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.
  34. ↑ 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.
  35. ↑ 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.
  36. ↑ Everly, George S.; Flannery, Raymond B.; Mitchell, Jeffrey T. (2000). "Critical incident stress management (Cism)". Aggression and Violent Behavior. 5: 23–40. doi:10.1016/S1359-1789(98)00026-3.
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