CAP Critical Incident Stress Management: Should it Exist?

[LittleIronPilot]

Our squadron had a psychological first aid course a few weeks ago that was instructed by Mental Health Professionals.  Their first slide said, "Never assume that everyone needs help and don't try to force it on people."

However, that doesn't mean don't offer the service.  There is a difference between the CISM guy asking if there is anything they can do for you and them forcing you to discuss what just happened or making you talk to them about it.

Agreed.....thank you for putting it better than I did.

[Slim]

Chaplain Don,

Don't get me wrong, I agree with what you're saying about making defusings mandatory.  The last company I worked at made them mandatory in a round about way.  You didn't have to attend, but you couldn't work again until you did.  Hmm, go sit through an hour with the team or go without a paycheck?  What choice did they leave us? 

The CISM team my company used (my FD used the same people) were great, and discouraged this practice.  They were always available to us, all we had to do was ask.  The team consisted of a psychologist, and there were several firefighters and medics available so the team was made up to fit the needs of the session.  The psychologist was great, she didn't even get involved in debriefings.  She just sat back and let the team of peers run everything.  I wouldn't have gone into my first defusing either, if I didn't think the team could relate to me, and know what I was saying.

I just don't think that someone else should be telling a person how they should be feeling.  Some people handle the stresses better than others.  If someone already has a healthy coping mechanism in place, why should one be forced upon them?

As I said, I agree with what you're saying, and I have seen people "Saved" by being forced to attend.  I just don't think that's the best way to go about getting the desired results.

[fyrfitrmedic]

Our squadron had a psychological first aid course a few weeks ago that was instructed by Mental Health Professionals.  Their first slide said, "Never assume that everyone needs help and don't try to force it on people."

However, that doesn't mean don't offer the service.  There is a difference between the CISM guy asking if there is anything they can do for you and them forcing you to discuss what just happened or making you talk to them about it.

I've seen some very good CISM personnel and some who tried hard to force their services on responders.

CISM should NEVER be mandatory, to do so is irresponsible.

[Chaplaindon]

"I've seen some very good CISM personnel and some who tried hard to force their services on responders ... CISM should NEVER be mandatory, to do so is irresponsible."

Maj. Rowley (and others) ...

I think we need to be a bit more specific in our use of vocabulary.

When one states categorically that "CISM should NEVER be mandatory, to do so is irresponsible" is to likely forget that "CISM" is not a single/monolithic type of mental health intervention but rather "a comprehensive, integrated, multi-component crisis intervention SYSTEM ... it consists of MULTIPLE crisis intervention components that functionally span then entire temporal spectrum of a crisis and can be applied to individuals, small functional groups, large groups, and even organizations."

CISM, thus, is comprised of a variety of activities and/or interventions. To deny that ANY of these activities/interventions EVER be mandatory is IMHO both over-reaching and perhaps even "irresponsible" itself.

I suspect many people (in and outside CAP) incorrectly equate CISM with one of its interventions the Critical Incident Stress Debriefing (or CISD). This is a seven-phase group intervention that should not be mandatory.

That having been said, participation even by the reluctant (the person who's coping well, for example) should be politely encouraged (per the Mitchell-model) even if all they do is state their name and their specific role in the event. Their presence, as Dr. Mitchell says, can help encourage others –often those with less developed coping mechanisms (but afraid of ridicule for admitting it)—to attend.

But a CISD is not the totality of CISM by a long shot (nor is it appropriate, or even POSSIBLE in every situation). That's where your (likely, well intentioned) statement calling mandatory participation "irresponsible" is IMHO misguided and over-reaching. That's different (VERY DIFFERENT) to my mind from "forc[ing] ... [CISM] servies" on another person. I'm not sure how we could FORCE a person in CAP, it's a volunteer organization EVERYONE is free to leave anytime they choose.

Let me explicate my point by examples ...

To give a "PEP-Talk" presentation at a SAREX (during downtime training) is to be doing CISM.

I fail to see how it would be irresponsible to require mission personnel to attend one. I see such as no different than a safety briefing. Attendance harms no one, insults no one, and COULD help someone deal with a serious event.

I know of PEP-Talks in Houston following Katrina before members were deployed to Ellington ANGB to unload critical ICU patients from MEDEVAC aircraft. They were mandatory (one-time attendance) for all before leaving CAP mission base for the flight-line. It was accompanied by briefings on avoiding propellers and jet intakes and FOD. I see this as RESPONSIBLE.

Pre-exposure training and preparation is CISM.

Requiring everyone who participates in a large-scale SAR/DR event (e.g. JTF-Katrina, or 9-11, or a search for downed CAP aircraft/crew) to attend a brief DEMOBILIZATION with a short (10 minutes) description of possible effects of the stress of the event followed by some refreshments and then send them home doesn't seem to be intrusive or irresponsible.

Spending a few minutes to learn HOW stress CAN or MIGHT affect a member and a fews effective ways to deal with it (and to OFFER further interventions) seems fairly harmless. It was the practice at both Ground-Zero and the Pentagon post 9-11. Again, this seems responsible to me, not the converse.

A "demob" is CISM.

For the NOC, WG/CC, or AFRCC, to REQUIRE a mission Incident Commander to participate in a CRISIS MANAGEMENT BRIEFING to the community –describing CAP operations-- during a DR mission seems sensible. She/He would know many necessary details about CAP operations and could determine what could/should be released.

To say that she/he should not be compelled by duty or higher authority to participate is (because "CISM [participation] should NEVER be mandatory") seems silly to me.

A "CMB" is CISM.

To see a member at a SAR/DR mission "slumped" alone in the corner with a "thousand mile stare" on her/his face after returning from a gory or tragic scene and going over and gently engaging that person in conversation (Individual/Peer Crisis Intervention) in other words and perhaps even being a little persistent is rebuffed initially seems neighborly to me. Members looking out for each other and ensuring that although many may cope very well with an event someone isn't needlessly –by assumption/presumption that "all's well"-- left behind coping less well.

No one is forcing him into therapy or a CISD, but a friendly, supportive chat may be all that's needded to help she/he re-engage their coping mechanisms.

That's CISM too.

So let's use the terminology properly so as not to misguide folks into seeing the totality CISM as one intervention (the CISD whic, I agree –as does Dr. Mitchell-- really shouldn't ever be mandatory) where other interventions may correctly, healthfully, and helpfully be SITUATIONALLY mandatory. Mind you, my first CISD (the 7-phase debriefing) WAS mandatory ... and although improperly so ... it got me into an intervention I would have never attended (due to prejudice). My involvement in CISM for nearly 20 years resulted from that improper act.

In that situation my paid job as a flight paramedic was in jeopardy if I didn't attend. CAP members are free to leave an event (or the organization) when they choose, so they really cannot be forced to do anything ... including notably, wearing the uniforms correctly.

CISM is far more than the CISD and participation in certain CISM roles in certain interventions (comprising CISM, as a whole) can be mandated in and out of CAP (insofar as volunteers can be mandated to do anything) depending upon the situation.

Recall too, that critical incident stress is a NORMAL reaction to an ABNORMAL or EXTRAORDINARY event or series thereof. As the precipitating even(s) are extraordinary and CAP operational response(s) likely will require operational flexibility, so too should IMHO our CISM responses as well.

[arajca]

When my fire chief (when I was a vol FF) came down and told everyone that there is a CISM session on x date at y time and everyon needs to attend, I equate CISM with CISD (or whatever acronym is being used this time). For those in the CISM field, there are siugnificant differences, but for most responders CISM, CISD, AID (After Incident Debrief), ad nauseum, are the same thing because our leadership has treated them as such! CISM, CISD, AID, are seen as buzzwords to make the agency appear to be on the leading edge of taking care of its people.

I have been to mandatory CISD after responding to a gory call that my involvement in was limited to driving the rig to the scene and making sure no one made 45,000 pound hood ornament of it, only to have the "professionals" sit there and pump everyone for all the gory details as a group at which no one was allowed to leave. Not a pleasent experience. I believe I can safely say that almost every emergency responder has had a very similar experience. I have also been to a well run AID on a similar call where the professionals gave us a brief description of typical sign and symptoms of Critical Incident stress responses nad told us they would be down the hall if anyone wanted to talk about the incident and left us with contact information. About half did then. Many of us contacted them later for a more private discussion.

So, keep in mind, that like most other jargon, CISM, CISD, etc, sound enough alike that those outside of the CISM field lump them all together.

[Horn229]

Wow, this thread picked up it's pace over the last few days.

I haven't read every post entirely, but have skimmed over all.

When I started the thread, I was beginning a research paper about PTSD in EMS personnel and actions that can be taken to help them. As I began writing the paper, it turned into discussing why CISM is not effective, why it should not be used, and two other routes than do work.

Throughout my research, which entailed reviewing meta-analyses, position papers, and an interview with the head of the behavioral health program for the LAFD, all of my research goes to say CISD does not work. Some studies pertaining to the efficacy of CISD have even gone to say CISD can cause more harm than had no intervention been initiated. The way these studies are done is through the use of randomized controlled trials (RCT). One of the position papers went so far as to mention all studies adduced in favor of CISD have only been published by a journal owned by Mitchell, with the editor being the chairman of the ICISF, Dr. Everly.

After studying numerous articles and going over the interview I conducted, I am of the opinion that a stress management program is a very good thing to have. However, that is not to say I support the Mitchell model. The active education of CAP members on common stress reactions, and proper stress management routines is something CAP should be doing.

Psychologically assessing members and recommending further help or not should NEVER be done by an every-day CAP member. From what I've been told, the MER CISM team does not have any mental health professionals (I could be wrong, but this is what I've been told). Based on my research, the original Mitchell model was to be mental health professionals conducting the debriefing, with a peer member to give the process some credibility and to let the traumatized individuals know it's okay to talk to these people.

This entire throught process has some issues. (1) with the non-mental health providers, there is no expectation of privacy in the room; (2) it seems that in CAP there are more peer members than MHP's, which is completely backwards; (3) some people were mentioning mandatory debriefings, this crosses way over the line in regards to medical ethics, look-up Autonomy, Beneficence, Fidelity -- ethically, we should always put forth what the member wants FIRST. Never, at any time does a CAP member have the right to say "well, here's what you NEED to do to".

We have a responsibility to watch our members, and mention they may want to keep an eye on their symptoms and for them to remember their pre-trauma stress training. Should symptoms last longer than 3-4 weeks, they really should seek professional help. But at no time should we be forcing a treatment method on anyone. Unless, of course, you are a licensed psychologist or psychiatrist.

Someone mentioned seeing a person slumped in a corner with a thousand mile stare. If someone is sitting in a corner with a thousand mile stare, there is some physiological arousal going on. Having this person go through a psychological debriefing and talk about the worst part of the incident is the exact opposite thing of what needs to be done. If someone is shutting down to the point they cannot function and are trying to get away from it all (ie. sitting in the corner in a daze), the arousal could be exacerbated and send them further into whatever they are experiencing. No CAP peer member has the capability to handle this situation. If a member is seen exhibiting medium to severe arousal symptoms, I would be calling an expert in the field of psychological trauma, not a CISM team.

Getting back on track, I think CAP should promote situational awareness with regards to pre-incident stress training, and seek psychologists to be available for interventions, should they be needed. I saw mentioned something along the lines of "the beauty of the Mitchell model, is that there isn't Suzy social worker coming in and talking to us." Well, by seeking psychologists to be available, and develop MOU's (or whatever the term would be), we could then educate the psychologist of what CAP is, what our missions are, and how our members are affected. That would be a proper program.

As I said before we should not be telling people "this is what you NEED", we should, however, have the psychologist come in and explain what his/her role is, symptoms to watch for (just like they were educated on prior to the incident) and if they would like to talk, there is a licensed professional available.

Now, there is more to helping a traumatized individual than just letting them vent. One technique I've looked into is called Cognitive-behavioral Therapy. It is conducted in three to six single person sessions, either within hours after the incident, or after 48 hours after exposure to the incident. CBT focuses on getting to the root of what is causing the person to be locked into the repetitive thought process. By identifying the negative thought pattern, the psychologist is able to recommend techniques to get out of the cycle.  --- I could go on for a while about CBT, but in essence, people are taught self-distracting techniques, assigned readings for homework, and learn how to identify and break the negative thought process.

Another method that is farely new, is called Psychological First Aid. It was used by psychologists who went to help at Hurricane Katrina with the IAFF (International Association of Fire Fighters). This method is similar to CISD in that there is a numerical process, there is an education part, and a referral process if so needed. However, one of the main differences is the victims do NOT talk about the worst part of the incident. The entire process is about taking care of the peoples basic needs first (food, water, bathroom), a question session (rationalizing the incident), and trying to make the person feel safe (is Maslow's Hierarchy of Needs ringing a bell to anyone?).

So once these first two steps on the Hierarchy are met, then it is more likely for individuals to seek additional help such listening to advice from the MHP, and take the referral information.


For some reading material, I would suggest looking at:
https://www.psychologicalscience.org/pdf/pspi/pspi421.pdf  -  A meta-analysis of studies for and against CISM, also discusses CBT.
http://www.bryanbledsoe.com/data/pdf/journals/CISM%20(Bledsoe).pdf  -   A review of information on CISM
http://www.bryanbledsoe.com/data/pdf/mags/CISM%20(CEN).pdf  -  Another article by the same person on CISM
http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_treatmentforptsd.html  -  Talks about some treatment methods for PTSD
http://www.thefreelibrary.com/Psychological+first+aid-a0158907275  -  An article on on Psychological First Aid, if you can find a .pdf from the journal it came from, it will be much easier to read.


A few other techniques to look up would be Eye Movement Desensitization & Respocessing (EMDR) and Thought Field Therapy (TFT). EMDR was just recently endorced by the International Society of Traumatic Stress Studies (ISTSS), TFT is still being reviewed, but is similar to EMDR.

[afgeo4]

Technically, Critical Incident Stress Management shouldn't exist because critical incidents shouldn't exist, but they do, so it does.

Take it from someone who lived through 9/11's WTC towers collapse and then worked at the site for several months... it's worthwhile.

[Cobra1597]

Technically, Critical Incident Stress Management shouldn't exist because critical incidents shouldn't exist, but they do, so it does.

So...Emergency Services shouldn't exist?

[fyrfitrmedic]

 It's interesting to note that in the majority of the texts currently in use to teach the Paramedic National Standard Curriculum, Mitchell's doctrine and methodology have been replaced by Psychological First Aid.

[RiverAux]

For example, we agree that First Aid instruction is critical to CAP, but we've decided to let other agencies like the Red Cross do the teaching. 

As a side note to this earlier comment, CAP does have several basic first aid items that are part of its ground team member program that are taught by CAP members without any relatinship to other national programs.

-natural hazards
-fatigue
-universal precautions
-hot weather injuries
-cold weather injuries

[SAR-EMT1]

Hmm, as someone who has been there done that and been forced to either sit through a CISM debrief or get fired, I can tell you that it doesnt always work out the way its supposed to...

We had a very guesome murder suicide. The couselor was from the hospital and not an EMT. (We be considered the unclean by the hospital staff) The Counselor was a Shrink with a superior attitude.

She ended up forcing us to spill the story, with the intent of talking us through it "to work out our frustrations in a non destructive manner " when we already had a perfectly acceptable method of dealing with it.

Well, suffice it to say, she was overwelmed, by the gore, the guys actions prior to the incident etc and ended up sobbing, had to be driven back to her office and was given paid time off by the hospital so that she could collect herself. ...  I have never seen an EMT or medic get paid time off for anything. lol

Since then the CISM debriefs have been formally ebolished at my former service. ( Which was ok for us, because other then that star case we hate them, and even when led by a co-worker we usually want to beat the
"MC" - for lack of a better term- over the head with a D Cylinder.

So in conclusion: CISM has its place with vollunteer members- like CAP folk,
but to professionals (EMS, Fire, Police) it tends to be a waste, a source of frustration and an invitation for physical harm to be brought upon the managment and the stress team.

[Dragoon]

Coming back in to this late.  If....


....the key to CISM is using peers.

....then shouldn't most CISM personnel have to be qualified functional GTMs/GTLs?

I'm making this leap for two reasons.

1.  It's the ground pounders who are most likely to be up close and personal with the stressful, icky stuff.  Sure, there's some effect on aircrews and staff, but my amateur guess is that the GTs are most likely to be in the middle of "critical incidents" that cause stress.

2.  Just because you're in CAP, you're not my peer.  You're only my peer if you do what I do.


Thoughts?

[Gunner C]

I've mentioned it here and other places, but it bears repeating.

If CISM was available on Aug 18, 1987 (through CAP), maybe I wouldn't have spent the last 20 years being affected by what I saw and did on Aug 16-17, 1987.  Those two days are still affecting me now, and will probably do so well into the future.  PTSD doesn't just go away, even with CISM, counseling and therapy.  What they do provide are tools to better equip people to deal with the symptoms.

. . .

As ChaplainDon mentioned, the key to CISM is peer intervention.  No offense to clergy, but most of them just don't know what it's like.  The average person can't fathom some of what I see on a normal Friday or Saturday night.  Sometimes I couldn't even fathom it, hence the need for intervention.  I'm of a mixed opinion about making them mandatory, though.  On the one hand, someone's not going to get much out of it if they have to be there.  On the other, if making them sit there and talk about it helps them, then it's served it's purpose.

I would have to agree.  While USAF has chaplains on their teams, they are absolutely PROSCRIBED from being in charge.  Chaplains are for the chaplaincy.  In CAP, the chaplains have taken over the program.

I, too, am a person who has suffered from PTSD.  If we would have had that program back then, I wouldn't have had some of the challenges that I've gone through.  Having said that, the last person I wanted to talk to was a chaplain.  Most folks don't want to hear their cutsey sayings and spiritual twinkies (if I ever hear another chaplain use the term "round tuit" I think I'll puke  ).  What a person needs is someone who has been there - a peer GTM/GTL who has seen what broken bodies look like and how you feel.

That doesn't call for someone who has a degree in reading ancient Greek and knows a cute and snappy comeback for every occasion.  Frankly, "pastoral counseling" isn't going to help much either.  What will help is someone who understands what you're feeling.

Chaplains:  give the operations stuff back to the operators.  We'll let you know if we need you.  :angel:

[Horn229]

Hmm, was just been doing some looking around and the capcism.com website has been closed. Anyone know what's going on? I can't even locate anything on the cap.gov about CISM besides the regulation.

A second item of interest I've found is the USAF seems to have switched from CISM to Psychological First Aid. The regulation governing their "Traumatic Stress Response" teams can be found at http://www.e-publishing.af.mil/shared/media/epubs/AFI44-153.pdf

[arajca]

Interestingly, in the National Commander's memo about the staff, the CISM Advisor falls under the Chief, CAP Health Services, not the Chief, CAP Chaplain Services. An indicator of chages to come?

[DogCollar]

I would have to agree.  While USAF has chaplains on their teams, they are absolutely PROSCRIBED from being in charge.  Chaplains are for the chaplaincy.  In CAP, the chaplains have taken over the program.

I, too, am a person who has suffered from PTSD.  If we would have had that program back then, I wouldn't have had some of the challenges that I've gone through.  Having said that, the last person I wanted to talk to was a chaplain.  Most folks don't want to hear their cutsey sayings and spiritual twinkies (if I ever hear another chaplain use the term "round tuit" I think I'll puke  ).  What a person needs is someone who has been there - a peer GTM/GTL who has seen what broken bodies look like and how you feel.

That doesn't call for someone who has a degree in reading ancient Greek and knows a cute and snappy comeback for every occasion.  Frankly, "pastoral counseling" isn't going to help much either.  What will help is someone who understands what you're feeling.

Chaplains:  give the operations stuff back to the operators.  We'll let you know if we need you.  :angel:

Sir, with all due respect, Chaplains are involved in CISM because NO ONE else seems to want to be trained and involved.  Chaplains aren't "controlling" the program, rather many are trying to keep it alive!

Your comments about chaplains seem to enforce a stereotype that is far from the norm (at least in my wing and region).  Chaplains are professionals, endorsed by our religious bodies for this ministry, and we have our own code of ethics.  If you see chaplains not abiding by that code you have a duty to report them up the chain of command.
Further, there are many of us in the chaplain corps that have "real" (whatever that means) experiences in traumatic situations.  Does that give us liscense to be "peers?" No.  But, it does give us an empathetic understanding of what others facing trauma are going through.

[Dragoon]

Yup, but any trained counselor (including non-CAP ones) can have the "empathic understanding of what others facing trauma are going through."


If the reason for CAP to do CISM itself (rather than use outside agencies) is that "we need peers to do it"....

....then I think a reasonable requirement for doing CISM is you need to be a true peer.  Which, I think, means a GTM/GTL at the very least.

Does that seem appropriate?

[DogCollar]

Very appropriate!  NO ONE has said anything different!  Please...go get trained to be a CISM peer!

[Dragoon]

Are all the current CISMs GTM/GTLs?

[DogCollar]

No.