CISD: CRITICAL TO HEALTH AND SAFTY
Firefighters respond to a wide variety of calls involving building fires, motor vehicle accidents, hazardousmaterials incidents, searches for fire and drowning victims, and other catastrophes. Specific incidents can present firefighters with situations that emotionally overwhelm them, becoming emotionally overwhelmed by a response is an occupational hazard of firefighting, and it can happen to any firefighter. This stress reaction never should be confused with a firefighter’s being weak or “losing his/her mind.”
WHAT IS CRITICAL INCIDENT STRESS?
Critical incidents are markedly distressing situations outside the usual experience of the emergency service worker. Examples include incidents that involve multiple fatalities, the death of a coworker, a child fatality, or prolonged rescue attempts that prove unsuccessful. Large-scale catastrophes such as earthquakes and plane crashes during which responding firefighters are working with mass casualties who have suffered multiple serious injuries and where there may be multiple fatalities also are critical incidents, but calls that involve only one individual or a few people can be critical events as well.
Critical incident stress (CIS) is the reaction experienced by emergency service workers who cannot cope with what they experienced at a response. Firefighters responding to a critical incident can develop posttraumatic stress disorder, which has among its manifestations repeated and intrusive memories of the event, recurrent dreams of the event, or sudden feelings that the trauma is happening again (see “Post-Traumatic Stress Disorder and the Firefighter,” Fire Engineering, November 1985). Psychological reactions to critical incidents, however, also can include a wide variety of other psychological conditions including but not limited to anxiety, depressive, or adjustment disorders.
Supervisors and coworkers should be on the alert for a combination of any of the following symptoms: excessive sick calls, isolation from the firehouse and coworkers, irritability, decreased attention/concentration, increased use of alcohol, anxiety, recurrent images/thoughts of the incident, or any significant change in behavior.
BARRIERS TO CISD PROGRAMS
I nfortunately, many firelighters develop critical incident stress but never are treated for it.
One reason for this is that firefighters typically have a personality that includes being action-oriented, self-confident, and assured that they can cope with whatever they may experience. Admitting that they are experiencing emotional difficulty as the result of an incident may be embarrassing or cause them to perceive themselves as being weak. Many firefighters would rather suffer in silence than seek help.
I also perceive myself as a strong, self-confident, and in-charge individual. Nevertheless, 1 was emotionally overwhelmed as a result of my role as clinical coordinator of a critical incident stress debriefing (CISD) team called to the Coldenham (NY) elementary school catastrophe in which a cafeteria wall collapsed and killed nine young children. While on the way home, I began to experience emotional symptoms that lasted for days; 1 underwent debriefing by a team of mental health coworkers, being a board-certified neuropsychologist with an appointment to a medical school and having significant experience in responding to critical incidents did not make me immune to the critical-stress reaction.
Firefighters must understand that critical incident stress is a normal reaction by normal individuals to a devastating scene. Firefighters’ reluctance to undergo CIS debriefing can be overcome in several ways. Most important is that the firefighters be told that they are having a normal reaction to a critical event. This approach decreases the chance of their reacting with, “He must think I’m crazy” or “I can’t handle it.” The firefighter should be informed that all I MS personnel involved at the scene have been asked to attend; doing this decreases the chance that the firefighter will feel that he or she “is being singled out.” Firefighters who respond with “1 don’t need it” can be approached by being asked to attend to provide support for their coworkers who do need it.
Overcoming the prevalent “conditioning” that emotional reactions are weaknesses is a difficulty facing CIS!) teams when responding to overwhelmed firefighters. A long-term approach to solving this problem is to make CISD training mandatory’ for recruits. A more immediate solution is to use veteran firefighters as role models —they can validate the mental health worker’s debriefing statements that CIS is a normal reaction.
Firefighters experiencing the anxiety. irritability, sleep disturbances, and other depressive features of critical incident stress rarely recognize the source of their suffering. They typically perceive themselves as “going crazy” and are afraid to let their coworkers or family members know what they are going through. They often are afraid that admitting emotional problems may become a part of their jacket and affect their potential for promotion. Firefighters typically look at mental health in black-orwhite terms: You are either crazy or normal —if you are experiencing these symptoms, then you must be crazy. Psychological symptoms vary, and many of them have nothing to do with being psychotic (the technical term for being “crazy’”).
THE HACKENSACK ROOF COLLAPSE AFTERMATH
In July 1988, a roof collapsed during a fire that involved a car dealership in Hackensack, New Jersey, killing five firefighters. Many of the individuals responding to this fire experienced critical incident stress. As with many firefighters experiencing stress, a number of these firefighters initially were reluctant to acknowledge their stress or have it addressed. Today, however, some of those Hackensack firefighters are active members of the GEMINI critical incident stress debriefing team. As peer members of this team, they perform debriefings and teach CISD to firefighters at the local fire academy.
“There is no doubt in my mind that CISD and follow-up were responsible in whole or part for the retention of eight to 10 fire personnel following the roof collapse,” asserts I.t. Thomas Canzanella of the Hackensack Fire Department, an official of the Fire Fighters Association of New Jersey and of the International Association of Fire Fighters, who was president of the Hackensack Professional Fire Fighters Union, IAFF Local 2081, at the time of the fire.
He indicates that CIS debriefing was very helpful to the Hackensack firefighters. “I further believe that much of the success of that venture was the direct result of a joint labor-management approach. Just as we are conditioned with certain opinions regarding mental health and the ‘He-Man’ firefighter, there is a fear or distrust of management,” Canzanella adds. “The union’s involvement gave the program more credibility [with the firefighters].”
DEBRIEFINGS
Critical incident stress debriefings are one-time group interventions for firefighters, designed to reduce their emotional difficulty following a critical incident. The debriefing is run by a CISD team that includes a mental health professional and fire department peers. The team performs all debriefings in confidence and at no cost to the emergency service workers or their departments.
Debriefings never include critiques of an individual’s response at a call or the department’s strategy for dealing with the technical aspects of the incident. The CISD intervention always is supportive, and no technical record of the debriefing is kept. The debriefing focuses on having participating firefighters become aware that their feelings and thoughts regarding the incident are normal. Individuals taking part in the process never are required, or pushed, to talk.
Mental health professionals on teams are trained in CISD techniques as well as in the psychology of emergency service workers. Individuals experiencing CIS who become involved in a debriefing never are viewed as patients by team members. Team members have a deep appreciation of and respect for the difficulty and demanding work required of emergency service workers. Using trained peers from the fire service, police department, and emergency medical groups significantly improves the debriefing process. For example, the GEMINI team recently performed a debriefing for a fire department that lost a firefighter. Department members taking part in the debriefing immediately developed a rapport with and respect for the team when they realized that the team included two of the firefighters who had been involved in the fatal Hackensack Ford fire.
While debriefings are effective in helping individuals deal with critical incident stress, CISD teams also provide other services, such as demobilization: Team members respond to the actual scene of an incident to provide support and recommendations for the emergency service workers involved. Another service, defusing, provides that team members’ interaction with EMS personnel emphasize education over intervention. CISD teams also provide one-on-one interventions, if needed. A major role of many teams is to educate specific departments or recruits receiving basic training at a fire academy about critical incident stress debriefing.
Recently, many CISD teams have begun to address the needs of the firefighters’ families, including providing support groups for the spouses of firefighters experiencing CIS. This service, however, is not yet a national one and currently is available only from some CISD teams.
STRESS TRAINING FOR FIREFIGHTERS
Making CISD training part of all firefighter training has several advantages. It assists officers and coworkers in recognizing the emotional effects firefighters may develop as a result of responding to an extremely traumatic event. It also helps ensure that firefighters needing intervention will obtain it relatively quickly, which could potentially decrease problems at work and at home. CISD training also can help firefighters who develop critical incident stress to become somewhat desensitized to their reactions and to working with a CISD team.
Debriefing can be very supportive and effective for firefighters experiencing the natural and normal psychological effects of a traumatic incident, but it is not a cure-all. Sometimes a firefighter may continue to find it difficult to cope with the emotional effects of an incident. In such cases, it is helpful to refer the firefighter to a trained mental health professional.
CISD teams are part of a national network that provides training for establishing CISD teams in your area. The training typically takes two days; books and videotapes on CISD also are available through the network. Information on how to find the team nearest your area is available from the International CISD Team, 1TO. Box 204, Ellicott City, MD 21404, (410) 750-0856.
