BY MIKE McEVOY
Critical Incident Stress Debriefing (CISD) is familiar to most emergency responders as a tool for lessening the effects of major stressors or what some refer to as “critical incidents.” Recently, mental health organizations have suggested Psychological First Aid (PFA) is more beneficial than CISD for reducing symptoms and avoiding long-term psychological consequences of major stressful events. While a battle of opinions rages in fire and EMS publications, scientific research holds fascinating CISD insights. Using these data, this article charts a course for futuristic minded emergency services.
Fire and EMS responders hold front-row seats at some of the happiest moments of life, but our job is not all delivering babies and rescuing people from deadly situations. Darker moments tend to outweigh happy endings and, in many situations, comfort and reassurance are all an emergency responder has to offer. There is tremendous value in a front-row seat at the darkest moments of people’s lives: We gain knowledge and strength against future adversities. Yet, these experiences can come at an emotional cost to emergency responders. That thought is relatively new.
For many years, the prevailing belief was that people whose jobs took them to the front lines of horrible, grotesque, and disgusting events were somehow unaffected by their experiences. Soldiers returning from war suggested otherwise; in 1980, the psychological problems exhibited in Vietnam veterans led the American Psychiatric Association to include Post Traumatic Stress Disorder (PTSD) in its list of official mental health diagnoses. Exit the “John Wayne Syndrome,” which implied that troops, medical personnel, firefighters, and police officers weren’t hurt unless they had a “bone stickin’ out.”
SYMPTOMS OF PTSD AND ASD
PTSD and ASD (Acute Stress Disorder-a precursor to PTSD added in 1994) remain on the listing of psychological disorders today. Either can occur to any person exposed to an incredibly traumatic event. Although the symptom list of ASD and PTSD is lengthy, the symptoms boil down into three categories: reliving the event, emotional anesthesia, and persistent anxiety.
Reliving an event can include dreams, nightmares, flashbacks, instant replays of an event in the mind, and other intrusive images with a general inability to erase a traumatic event from the mind.
Emotional anesthesia implies a numb feeling, detachment, a dazed-like state in which a person is not particularly sad or happy but is essentially devoid of feelings.
Persistent anxiety refers to a heightened state of emotional arousal that can involve difficulty sleeping, trouble concentrating, restlessness, and significant feelings of anxiousness. This constellation of symptoms combines under the ASD and PTSD label differentiated by when they occur. ASD applies to symptoms happening within four weeks of a traumatic event; PTSD applies after four weeks.
Mental health professionals have come to expect ASD and PTSD in people exposed to extremely traumatic events. Emergency responders should be familiar with the symptoms and know that their jobs increase the likelihood that they will develop one of the stress disorders themselves. Numerous studies have shown increased incidences of both ASD and PTSD in emergency responders in comparison with the general public. To some degree, the pendulum has swung from the era of the “John Wayne Syndrome” to an age where fire, EMS, and law enforcement personnel are considered vulnerable, overly sensitive, and in need of emotional assistance with every major incident to which they respond. Nothing could be further from the truth, and it’s time to recognize the strengths within the emergency services. Emergency responders deal with stress every day; their job is to help others deal with stress as well. We are well prepared for any incident and, when compared with the general public, handle the effects of major events much more effectively. Although all of us are susceptible to the effects of extraordinary stress at times, developing symptoms that require professional help is the exception, not the rule. The reason emergency responders have an increased incidence of stress disorders is that they see more traumatic events. If ordinary citizens were exposed to the same levels of stress, it is quite likely they would have significantly greater incidences of stress disorders than emergency workers.
CRITICAL INCIDENT STRESS DEBRIEFING
CISD was born in response to a perception by Jeff Mitchell, a training coordinator for the State of Maryland, that high attrition rates in fire and EMS services were related to critical incidents. Mitchell conducted his first CISD in 1974 after a drunk driver killed five of six family members. In 1982, Mitchell (then a graduate student in education at the University of Maryland at Baltimore) published an article in RESPONSE! Magazine, formally introducing CISD to the fire/EMS community. The CISD process consists of a two- to three-hour, seven-step group session facilitated by a trained team of peer support staff and mental health professionals. The session is composed of various phases: an introductory phase during which ground rules and objectives are explained; a facts phase during which participants review the event factually; a thoughts and experience phase in which individual experiences during and after the incident are explored; a reactions phase for participants to vent feelings; and a phase to review symptoms experienced. A teaching phase allows the CISD team the opportunity to provide information about stress management strategies, ASD, and mental health services. The final (re-entry) phase includes a summary and wrap-up.
Mitchell’s introduction of CISD, along with other similar stress debriefing designs, could not have been timelier. National tragedies such as the 1980 MGM Grand Hotel fire in Las Vegas, the 1981 Hyatt Regency skywalk collapse in Kansas City, and a series of jetliner crashes in 1982 focused national and international attention on the needs of emergency responders. Quality-of-life issues became increasingly important to fire and EMS leaders. CISD gradually became available to all segments of the emergency services community.
Controversy over CISD began in a 1996 issue of the Journal of Emergency Medical Services (JEMS) magazine1 when Senior Editor Lauren Ostrow contended CISD had become a business venture and studies failed to find positive outcomes. She suggested: “In the end, EMS may want to examine the all-American notion that we should always feel good, that stress is bad, and that we have to take corrective action to resolve every negative reaction to stress, even if it is normal.” Ostrow concluded: “Perhaps CISD has its place … but at least EMS should know what it is buying.”
Few JEMS features generated the resulting volumes of correspondence. With a battle line clearly drawn in the sand, proponents and opponents of CISD continue arguing today on the effectiveness of CISD. Confounding CISD opponents, the International Critical Incident Stress Foundation (ICISF), an organization founded by Mitchell, now refers to Critical Incident Stress Management (CISM) as an overall model, instead of CISD.
One of CISD’s most extreme critics is Bryan Bledsoe, a Texas-based emergency physician and paramedic and a well-published author. In a December 2003 article2 Bledsoe cited a systematic review of CISD (also published in 2003) as grounds to cease using CISD or psychological debriefing of any form in emergency services. He suggested an immediate switch to PFA, which he believes requires “no special training and no certification and provides no psychological intervention, just meeting basic human needs.” Unfortunately, the review cited by Bledsoe did not separately examine CISD outcomes in emergency responders in comparison with those of the public, and his interpretation of PFA ran largely contradictory to the latest published recommendations3 by the National Institutes of Mental Health and the World Health Organization.
An excellent source of an unbiased review of scientific literature is the Cochrane Library Database, compiled by a highly regarded independent organization that conducts systematic reviews of the effects of health-care (including mental-health) interventions. Its collection is exhaustive and subject to rigorous scientific and statistical scrutiny. Thousands of individual papers and publications are placed in context with one another and allow you to clearly outline a comprehensive, scientifically defensible approach. Cochrane repeatedly has culled the CISD literature. Its latest revision was published in 2004, and a brief update became available in Summer 2005. Using the Cochrane Library database, it is possible to separate the effects of CISD for emergency services from those for the general population and to draw some important conclusions about the continued use of CISD.
Cochrane reveals CISD is unsafe for the general population and should not be used. Evidence shows that CISD adds to the trauma and complicates recovery for the general population. The U.S. Institutes of Mental Health and the World Health Organization have strongly recommended against the use of CISD for the public. Britain’s National Public Health Service lists CISD as “contraindicated.”
The value of CISD for emergency service personnel, unlike the public, is neutral to negative, according to Cochrane. No form of debriefing (CISD included) is effective when compared with no debriefing at all for emergency responders. Many studies show that rescuers perceive CISD as helpful; however, rescuer satisfaction has no relationship to CISD’s effectiveness in promoting recovery or preventing psychological complications. Some evidence of harm to certain individuals exists; this harm is often iatrogenic (meaning it is caused by the incorrect use of CISD). Overall, Cochrane research indicates that CISD is not appropriate for 60 percent of police, fire, and EMS personnel.
Since CISD involves talking with relative strangers about a traumatic event, it is interesting to note that 85 percent of emergency responders talk afterward about critical incidents and prefer to talk with colleagues and peers. Fifteen percent prefer not to talk at all about an event.
Harm from debriefing implies that participants experienced worsened anxiety, depression, or developed PTSD as a result of CISD. Three factors are known to result in CISD harm to emergency responders: mandatory attendance, reliving emotional trauma, and “mixing” groups. All of these are mental health errors but can (and do) happen. No one should be required or coerced to attend CISD. Discussion of a traumatic event in ways that cause participants to relive the experience is wrong and has bad results. Mixing personnel peripheral to an event with those directly involved confuses participants and can lead to harm. Mixing those who lost a colleague or loved one with others whose loved one survived can also have harmful results.
Certain emergency responders are at increased risk for harm from participating in CISD. Cochrane reveals who these people are. They include responders with repeated or accumulated unresolved stressors in their lives; preexisting psychological problems, and unresolved previous losses of loved ones; those who lack social supports; responders injured during an incident; and folks with strong negative beliefs about the meaning of normal stress reactions (those who believe it a grave sign of personal weakness to cry, for example). Finally, rescuers who most anxiously seek out CISD show poorer long-term psychological outcomes.
Cochrane poignantly illustrates some important CISD issues. First, if offered, CISD must be completely and 100-percent voluntary. Second, we must keep an eye out for badly run CISD and for personnel at risk for harm. Finally, if we eliminate the harm that can result from making CISD mandatory, poorly run programs, or allowing at-risk personnel to attend, we’re left with an intervention with relatively neutral value.
PSYCHOLOGICAL FIRST AID
Enter Psychological First Aid (PFA), a set of interventions proven to improve outcomes, lessen complications, and shorten recovery times for both the general public and emergency service personnel. There are three objectives of PFA that correlate with the building blocks of mental and emotional strength: (1) recreate a sense of safety, (2) establish meaningful social connections, and (3) reestablish a sense of efficacy.
For rescuers, recreating a sense of safety starts during the course of any incident and continues immediately thereafter in three ways: meeting immediate physical needs including bathrooms, food, fluids, breaks, clothing changes, sleep, and time off; protecting emergency personnel from onlookers and the media; and determining if formal or informal help is required. This last element mandates the involvement of a competent mental health professional to train department leaders in assessing and developing assessment tools or in conducting assessments during and after an incident.
Establishing meaningful social connections, which occurs after an incident, also has three action items:
1. To help rescuers connect with family, friends, children, and significant others. Keep in mind that emergency responders prefer to talk in homogenous groups (i.e., firefighters with fellow firefighters).
2. To provide information on normal signs and symptoms experienced after a traumatic event, including suggestions on what to do about them.
3. To educate significant others on signs and symptoms they might observe in their loved ones and how they can help.
Again, a mental health professional or local CISD team can prepare a brochure for distribution to emergency responders and a separate flyer for their significant others. These same folks can conduct educational programs before, during, and after an event.
Reestablishing a sense of efficacy or worthfulness is the third PFA objective. This objective has seven action items, including recognizing a job well done; encouraging resumption of normal routines and roles; discussing self-care strategies that reduce anxiety; encouraging rescuers to support and assist others; identifying resources that promote effective coping; giving accurate and simple information about department plans, schedules, and events; and performing a follow-up assessment for mental health needs three months after the incident.
Many fire and EMS departments already practice parts of PFA. Every department should have a plan in place for personnel exposed to psychologically traumatic events. Preparation can be protective as well-education and past experiences have been plainly linked to reduced incidence of psychological complications following traumatic events, which is probably one reason emergency responders fare better than the public.
If your department plan for members exposed to traumatic events is to call the CISD team, don’t abandon your personnel by doing nothing at all. Consider instead what more you could offer your colleagues. The National Institutes of Mental Health and the World Health Organization recommend PFA as a set of interventions that have proved to improve psychological outcomes in rescuers and the public. CISD harms the public and certain rescuers; for the 40 percent of rescuers for whom CISD is appropriate, the outcomes are neutral (comparable to no debriefing at all). It’s time to expand what we offer our members using what scientific evidence shows is our most powerful and effective mental health tool: helping each other. ■
References
1. Ostrow, L. S., “Critical incident stress management: Is it worth it?” Journal of Emergency Medical Services; 1996, 8, 28-36.
2. Bledsoe, B. E. & D. Barnes, ”Beyond the debriefing debate: What should we be doing?” Emergency Medical Services Magazine; 2003, 32(12), 60-68.
3. McEvoy, M. Straight Talk About Stress: A Guide for Emergency Responders. Quincy, Mass.: National Fire Protection Association, 2004.
■ MIKE McEVOY, Ph.D., REMT-P, RN, CCRN, is the EMS coordinator for Saratoga County, NY; chief medical officer for the West Crescent Fire Department; and EMS director for the New York State Association of Fire Chiefs. Formerly a forensic psychologist, he is a clinical coordinator and an instructor in cardiothoracic surgery at Albany Medical College in New York and a member of the editorial advisory boards for Fire Engineering and fireEMS magazines. His book, Straight Talk About Stress: A Guide for Emergency Responders, was published by the NFPA in 2004.
