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CISM is not enough to help responders deal with difficult calls

There should be a more formal system in place to make sure responders get the support they need

Updated June 2015

A few days after Christmas last year, medics at Wake County EMS in Raleigh, N.C., got called to a tragic scene. A 12-year-old boy had been fatally shot by his uncle when the man’s shotgun accidentally went off at close range during a hunting trip.

“It was a young child, killed by a family member,” recalls Jon Olson, operations chief for Wake County EMS. “There was lots of family at the scene, lots of emotion and significant physical injury to the boy.”

Supervisors knew the responders would be shaken. “Their supervisors recognized that these folks had dealt with a very out-of-the-ordinary, traumatic, psychologically taxing situation and had the forethought to take these folks back and talk to them a little bit before they returned to service for the next call,” Olson says.

But the tragedy got Olson and his team wondering: Was talking to the crew enough? Should there be a more formal system to make sure responders got the support they needed after difficult calls? How would they determine who needed help and who should provide it?

From movie theaters in Aurora to schools in Sandy Hook, horrifying events happen—and paramedics, EMTs, firefighters and police are called on to respond to them. Mass killings such as these are, thankfully, relatively rare, yet every day around the nation, responders witness smaller tragedies that are no less painful: the drowned toddler, the gruesome car crash, the teen suicide.

In the not-so-recent past, responders were expected to basically suck it up: Death and mayhem were part of the job, and real men (or women) should answer the call, then get right back to work. In reality, long-time EMS practitioners say, responders were suffering, albeit in silence.

Today, there are few in EMS who don’t recognize that psychological turmoil after tragic events is a normal response, and that the fallout can vary from a few nights of sleeplessness to more chronic stress that can interfere with responders’ lives, both on the job and off. For some, the turmoil can cause them to leave the field altogether. “Psychological injuries to responders are real. It’s the same as a back injury,” Olson says. “It’s something that happens, and we have to do what we can to fix it.”

But questions remain. Starting in the early ’80s, the go-to strategy for many fire and EMS agencies was Critical Incident Stress Management (CISM), in which teams of professional responders and mental health experts are dispatched to support responders after unusually difficult events. Closely associated with CISM is Critical Incident Stress Debriefings (CISD), in which responders meet with crisis management teams to recount what they saw and how it made them feel, and are given educational information about typical responses and where they can go for additional support.

While many agencies continue to use debriefings, the technique fell out of favor in some agencies after a series of research papers in the late ’90s questioned the validity of debriefings and new techniques, such as “psychological first aid,” emerged. While the International Critical Incident Stress Foundation, which trains CISM teams, stands by debriefings, it, too, has evolved.

Debriefings are but one alternative in a continuum of support that starts before a critical incident has even occurred, says Donald Howell, the Foundation’s executive director and a retired battalion chief in charge of public information and EMS for the Howard County Department of Fire and Rescue Services in Maryland. “Critical Incident Stress Debriefings nowadays are 5 percent or less of what critical incident stress management teams do,” he says.

But if not debriefings, then what?

Small tragedies take their toll

As a paramedic, Mark Rector responded to one of the nation’s worst mass shootings. He asks that the specific event not be mentioned—it took a long time to get over what he saw, and he doesn’t want people who didn’t know he was there to bring it up. But as awful as that day was, the call that shook him to his core happened a few years before.

When he arrived on scene for that call, he says, “Two cops were exiting the apartment, throwing up. I walked in and had to deal with the situation. I was the caregiver.” Inside, he found a child who had been killed by a psychotic father.

After the incident, Rector didn’t miss a beat. He declined an offer of a debriefing and went back to work. But images of what he’d seen haunted him.

“I would visualize it and replay the call over and over again,” he says. “I knew there was nothing I could do, and I never questioned my care or my decisions. But the horror of the call, I would replay it. I even do it now, but not as frequently.”

Over the years, there were other calls he never forgot. The teenager who hung himself. The kid who shot himself in the head because he’d had an argument with his mother over homework. The infant who died of SIDS while Rector’s wife was pregnant with their first baby. “The mass casualty event sucked in its own ways, but that one patient, you look into their eyes, and the look they have in their eyes is just as bad, it affects you just as intensely,” he says.

The way he coped wasn’t entirely good for him, he says. He would isolate himself from family, act recklessly on the ski slopes, work seven days a week to avoid having too much time to dwell. “For me, the cumulative effect from all the years I was in the field resulted in a self-destructive approach to things, trying to find ways to escape some of those memories you wish would go away,” he says.

After 18 years in the field, Rector moved into management and currently is consulting director for Priority Dispatch Corp., a switch he made more for career reasons than as a reaction to what he’d experienced. But a few years ago, he finally confided what he’d seen and how it had impacted him to a professional: Jim Marshall, a therapist with the 911 Wellness Foundation. It was the first time he had really told anyone what he’d experienced in that apartment so many years ago, and he felt immediately unburdened. “Should I have done it a long time ago? Definitely. But I will not share it with anybody else ever again,” he says.

Rector also found a healthier way of dealing with the stress. He stopped working so much, spent more time with his family, ate right and exercised, and in the process he slowly began to feel better.

Over the years, he’s seen long-time responders whose response to their experiences is a jaded, callous attitude. Others, it seems, manage to avoid taking the job home with them. “There are guys out there, rock solid, running calls for 25 or 30 years, and they have it all together,” Rector says. “That’s great, but we are all built differently. Some people can take it—and some take things differently.”

Even today, the memories have never faded entirely. “If there is one thing I do miss about being in the field, it’s taking care of people,” he says. “I don’t miss lights and sirens whatsoever; I don’t even like hearing them. They bother me. It takes me back. In one fell swoop, it takes me back,” he says.

Openness took root in the ’80s

Many trace the sea change that led to a greater openness about emotional and psychological stress in EMS, fire and police to the work of Jeffrey Mitchell, an EMT in the early 1970s who happened to be on the road when he witnessed a gruesome accident: A bride, still in her white dress, was impaled when the car she was riding in—driven by her intoxicated husband—slammed into the rear of a truck carrying pipes.

“It left a strong impression,” Mitchell recalls. “The husband was very intoxicated, and I remember a lot of cursing and threats coming out of him when I tried to feel her carotid artery for a pulse. I was shoved and punched a few times before the police arrived.” Later, he told his brother, a New York City firefighter, about the disturbing scene. “He just listened and let me tell my story,” Mitchell says. Talking about it was a relief.

Mitchell went on to get a master’s degree in psychology and a Ph.D. in human development. He also began to develop a model for helping responders cope with traumatic events. In the early ’70s, he received a federal grant to hold four conferences on the topic. He sent out 10,000 invitations to responders in six states; four people showed up to the first conference. “The growth of Critical Incident Stress Management services in the earliest days in the early 1970s was horribly slow,” he says.

But that gradually began to change. By the fourth conference, about 150 people attended. And in 1983, he published an influential paper in the Journal of Emergency Medical Services about his multi-step debriefing process for responders after traumatic events: Critical Incident Stress Debriefing.

During debriefings, individuals or groups of responders were brought together by a trained facilitator typically 24 to 72 hours after an event to learn about common stress reactions such as irritability and insomnia. Participation was to be voluntary, and responders were to be grouped according to how close they were to the event: Those who were on scene were not to be in a group with responders who may have been impacted by the event but were not there.

“A couple of times, we’ve had to ask the chief to step out,” says Russ Meyers, chaplain for Allina EMS in Minneapolis and a long-time CISM team member. “They want to be there to support their people, but a lot of times people don’t want to talk about it except with people who were there. They don’t want people being voyeuristic.”

Participants were asked to reconstruct what they saw and what they were thinking. Afterward, counselors offered tips for coping and services for additional help.

In the late ’80s and ’90s, many EMS, fire and police agencies adopted the method, including King County (Wash.) EMS. Launched in 1987, King County’s program initially had its CISM teams focus on debriefings, says Linda Culley, manager of community programs for King County EMS, part of the Seattle-King County Public Health Department. Over time, the program evolved to include a system of stress management, including educating responders before events occur about normal stress reactions; focusing on overall mental and physical wellness; and developing peer support teams within the department.

Culley says responders have found the debriefings to be very helpful. “Overwhelmingly we’ve received positive feedback over the years,” she says. “It wasn’t definitive research, but we rarely had anyone say they felt worse after they came out of a debriefing than when they went in.”

Debriefings questioned

In 2010, Jon Olson wrote a research paper about crisis management programs while participating in the Executive Fire Officer Program. In it, he details what can be viewed as the debunking of debriefing.

In the 1980s, Bryan Bledsoe, M.D., a physician, former paramedic and well-known contrarian, implemented a mandatory CISD program in the EMS system where he was medical director. “Intuitively, it seemed like a good idea,” he wrote years ago.

But after several firefighters threatened to get the union involved if sessions continued to be mandatory, Bledsoe decided to look into what was known about the effectiveness of debriefings. In a 2003 article published in EMS Magazine (now EMS World), Bledsoe cited two meta-analyses (studies that group together previous randomized controlled trials and re-analyze the results), which concluded that CISD is at best ineffective and may even make people worse. The studies also found “no evidence” that the process is a preventive measure for post-traumatic stress disorder (PTSD).

Debriefings came to the general public’s attention after the 9/11 terrorist attacks, when swarms of grief and mental health counselors descended on New York, some from charitable or religious organizations, others self-styled. A scathing 2004 article in The New Yorker quoted one expert who said debriefings could plant disturbing memories that people wouldn’t otherwise have had, and included interviews with New Yorkers who felt coerced into participating in debriefings.

Despite the bad press, Howell believes CISM has been unfairly maligned, with a reminder that debriefing sessions should never be mandatory and that groups should be homogenous—those who were on scene should only do debriefings with other people who were there.

Nor should there be a one-size-fits-all approach. “You can have 10 people witness the same event,” Howell says. “Some are going to say, ‘I feel bad’ but they are truly OK. Some will say, ‘That’s the worst thing I’ve ever seen. I’m going to leave the profession,’ and some are in between.”

And though some articles have brought up a lack of evidence that CISM can prevent PTSD, that’s never been the goal, Howell says. “CISD and CISM have no impact on PTSD,” he says. “CISM is to reduce responder psychological distress after difficult incidents; it’s not cognitive behavioral therapy. It’s just an educational process and a method of offering support to the individuals who wish to participate.”

Support for CISD wanes

In the early 2000s, multiple organizations, including the World Health Organization, the Department of Defense, the Department of Veterans Affairs and the American Red Cross, stopped using single-session debriefings, according to The New Yorker and Bledsoe’s article. In January of this year, King County EMS joined them, though not because they no longer believe in CISM methods, Culley says.

Instead, many CISM principles have become woven into other King County services, such as peer support teams, wellness programs and employee assistance programs, which may offer mental health counseling in times of crisis. As a result, in the past three to five years, demand for debriefings dwindled from about 20 to 30 a year in CISM’s heyday to about five a year—and most of those were officer-involved shootings, not EMS-related incidents, Culley says.

“Back when CISM started, there really wasn’t anything,” she adds. “Nobody was talking about wellness for emergency responders, or peer support, or resilience, or psychological first aid.”

While it’s true that much of what CISM pioneered and what teams offer may be available in other formats, Howell says his organization still has a role. Hundreds of CISM teams are still doing good work nationwide, including assessing the stress level of responders after events; assisting with “demobilization,” or making sure responders have had something to eat and drink and are safe to drive home after a trying event; and organizing crisis management briefings, or pulling together multiple agency representatives to supply information to the public after a disaster.

Allina EMS is among the EMS organizations still using debriefings. “I’ve seen it work,” says Meyers. “It provides a safe place for people to talk. There is nobody included who wasn’t at the scene, there are clear ground rules, and what’s said here stays here. People feel more settled: Somebody hears me, I’m not crazy. Other people were impacted similarly to me.”

When responders decline formal debriefings, reaching out informally can help. “Sometimes it’s an expression of concern, compassion, acknowledging it was a stressful event,” Meyers says. “Sometimes people don’t want debriefings. They say, ‘Thank you for calling. We are very appreciative knowing we work for an organization that’s concerned about us, but we’re ok.’”

Seeking crisis management best practices

Olson began giving serious thought to how best to deal with post-incident stress in March 2010, when a 3-year-old was struck and killed after wandering into the street at a soccer game. The child had obvious, severe head injuries and family members on scene were distraught. A few days later, a 5-year-old was killed in similar circumstances. Responders, who had small children of their own, were overcome with emotion. One skipped the next several shifts.

Olson, the supervisor at the scene, provided what he thought was appropriate peer counseling, but he was “making it up as I went along,” he wrote in his research paper.

“They were good medics and could handle most anything—or so you thought,” he wrote. “It wasn’t until after the call at the hospital when you realized how truly unprepared they were for what they had to encounter, and worse, how unprepared you were as their supervisor to assist them in managing this crisis of emotion.”

In researching how he could do better, Olson scoured medical journals and looked around the country for what other agencies were doing. He found that many still use CISM or something similar. Others have turned to psychological first aid, a technique developed in the 1990s by the Center for the Study of Traumatic Stress to meet the emotional and psychological needs of survivors of disasters, aspects of which have been adapted for use with responders.

His experiences, along with his research, led him to believe his agency needed more than the informal approach they were using.

Among the recommendations he outlines in his paper:

  • Adopt a standardized process to ensure the consistent application of a crisis management system
  • Educate all personnel about which types of incidents tend to be the most stressful
  • Educate all personnel about the signs and symptoms of stress reactions
  • Educate supervisors about how to spot those signs and symptoms and refer individuals to supportive services

They’d planned to have a program up and running by now, but as the months passed after the incidents in 2010, their attention turned to more pressing matters. The Christmas shooting brought the issue to the fore again. As a result, Olson and his team hope to have supervisors trained in recognizing symptoms by the end of the year and are working to identify mental health professionals who could be called on to assist responders. He has not decided if he will include group debriefings, but individual responders will be triaged by supervisors to determine who might be in need of additional help.

Based on his research, Olson believes this is as close to an evidence-based solution as he can find.

“We all want to be able to as much as possible reset these employees psychologically. But everybody is different. Some things we do will work very well on some folks and not on others,” he says. “The fact that as a profession, we have acknowledged the fact that a psychological injury from an experience in the workplace is real and valid, and is not something as administrators we should just accept, has led to more folks openly admitting, I did have a problem with this, and I think that’s a very positive thing for EMS.”

Jenifer Goodwin is Best Practices’ associate editor

Produced in partnership with NEMSMA, Paramedic Chief: Best Practices for the Progressive EMS Leader provides the latest research and most relevant leadership advice to EMS managers and executives. From emerging trends to analysis and insight, practical case studies to leadership development advice, Paramedic Chief is packed with useful, valuable ideas you simply can’t get anywhere else.
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