Rethinking critical-incident debriefings
Not every emergency responder reacts the same way to a bad call and a cookie-cutter debriefing may do more harm than good
By Sara Jahnke
Every EMS provider can tell you even the smallest details of their worst call — and most have more than one that comes back to haunt them. There has been increasing understanding and awareness about the impact not just of one or two bad calls, but of regularly responding to everyone's worst days.
Given this repeated exposure to trauma, it's not surprising that research is finding elevated rates of mental health concerns like depression, anxiety, and substance abuse among fire and EMS personnel. Suicide is receiving increasing attention as well.
With the awareness that there is a problem comes the question about how to handle it. In the 1980s, the idea of Critical Incident Stress Debriefing was introduced as a way to manage the psychological toll of the critical incidents first responders face.
A cottage industry was formed that trained CISD teams around the country to conduct debriefings after identified events. The original process was designed to bring in a debriefing team (often from the outside) who met with the group or crew that had been exposed and then went through a step-by-step process of reviewing the incident and each individual's reactions to it.
Research that occurred after the implementation of the CISD model found confusing results. While many indicated they found the process useful in early evaluations, more rigorous studies found that outcomes related to mental health were not always consistently improved and, at times, the debriefing process actually made people feel worse and increased negative symptoms.
To debrief or not to debrief?
In a recent study we published in the Journal of Workplace Behavioral Health, we conducted focus groups and interviews with firefighters around the country and asked about perceptions of behavioral health among firefighters and paramedics. Some had participated in a CISD process.
While a few who found the process helpful, others found that they left the debriefings feeling worse. For instance, hearing how bothered their colleagues were could make them feel even worse that they didn't feel bad about the particular call.
The challenge is that not every bad call bothers everyone the same. What is particularly disturbing for any given firefighter often depends on who they are and what is going on with their own lives at the time.
Someone who doesn't have children may not struggle with responding to a pediatric code as much as someone who has a child the same age.
What our participants did say is that there were several ways interacting with other firefighters could be extremely helpful. For instance, many crews debrief on their own around the kitchen table after extremely bad calls.
Company officers, in particular, were identified as people who should be trained on intervening and who should be able to effectively identify personnel who are struggling or at risk.
In practice, several departments have already moved forward with what has been found to be most helpful about the CISD process. Many have developed teams within their departments and trained personnel to identify and intervene on peers or crew members who are struggling. Most also understand that not every person needs the same intervention at the same time — even after extremely stressful calls.
Current efforts in the fire service and in fire service research are being made to bring about and test the next evolution of behavioral health interventions.
Groups are working toward understanding what was most effective about CISD when it was effective such as group and peer support, education on identifying warning signs, training of employee assistance programs on how to work with first responders, and shifting department dynamics to open the conversations about behavioral health.
While the new innovations have, at times, been presented as an alternative to or opposite of the CISD model, several of the key components that have been found to be effective have been used in developing the new models.
Newer versions of behavioral health training are focused on enhancing education and awareness with organizations as a whole and reducing the broad stigma associated seeking help. Revised versions of behavioral health interventions that are in the works tend to focus on keeping people aware and helping them to learn when to intervene.
So the question remains — to debrief or not to debrief? The answer, as it almost always is when interpreting the science, is it depends. In this case, it depends on how you want to do the debriefing and with who and why.
If a department already has a program that is working, particularly if it capitalizes on the strengths of the organization's personnel and is based on crew level or internal processes of debriefing, keep doing what is working. But keep in mind that forcing people into a session and insisting they process the experience based on a prescribed list of questions may not be the best approach.
It is important to remember that what works for one person might not work for everyone. It also is important to realize when symptoms are severe enough that they need to be handled by someone outside of the department.
There are limits to what peers can provide in terms of support. And when that limit is reached, the most supportive thing a firefighter can do is be willing to help their brother or sister find the right help.
About the author
Sara A. Jahnke, Ph.D. is the director of the Center for Fire, Rescue and EMS Health Research at the National Development and Research Institutes Inc. Dr. Jahnke has served as the principal investigator of two large-scale studies of the health and readiness of the U.S. fire service funded by the Department of Homeland Security and a qualitative study of health and wellness with a national sample of fire service representatives from the American Heart Association. She serves as the principal investigator of a study on the health of women firefighters. She also serves as a co-investigator of several studies focused on fitness, nutrition and health behaviors in both firefighters and military populations. She completed her doctorate in psychology with a health emphasis at the University of Missouri – Kansas City and the American Heart Associations' Fellowship on the Epidemiology and Prevention of Cardiovascular Disease. You can reach her at Sara.Jahnke@firerescue1.com.