CAP Critical Incident Stress Management: Should it Exist?

[Horn229]

So there I was, sitting in my college library doing research for a paper I'm writing on PTSD in EMS personnel. The intent of my paper was to be the usefulness of CISM, and have a few miscellaneous topics to fill the remaining portion of the paper such as gallows humor, substance abuse and suicide.

I had learned of CISM through CAP several years ago, and heard it is used to help people work through traumatic stress. Little did I know, I was sorely mistaken. All of the results of my search queries were describing how CISM is not efficient and that it can actually cause more harm than had no intervention been initiated.

I could go on for a while about this topic (about 20 pages worth, actually ), but I won't, at least not yet.

For now, I'd like to hear what you may know of CISM, and what your thoughts are on the topic. And of course an answer to the topic question. Should it exist?

[Kojack]

The answer is yes, it should.  It's always possible to not get anything out of it.  But had it been around some number of years ago, PTSD may not have impacted me as hard as it did.

I've since been trained in CISM and have been used several times.  The people I've followed up with have all been positive about it's use.

[Horn229]

Wow, I just scrolled down the page and noticed there was a thread on CISM that seems to have ended already. I didn't expect CISM to have been discussed on here and therefore didn't bother to search, let alone scroll down the page.

Seeing as the topic has already been beaten to death, I suppose it wouldn't be a bad idea if this thread just disappeared into the archives... Unless some people would like to discuss it further?

[SarDragon]

I think it has an important place in CAP, and elsewhere. Our National Commander thought it was important enough to bring some CISM folks out with her to the CAWG Conference in the aftermath of the Lewis-DeCamp crash last Thursday night. Quite a number of folks went to talk to the team.

[RNPilot]

For those interested in what was already covered:

http://captalk.net/index.php?topic=3301.0;all

[Dragoon]

This is actually a two part question

1.  Is CISM important and useful to CAP?


2.  Is CISM something CAP should do, or something we could rely on outside agencies to do?


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.  We agree that Search Dogs are critical to missing persons search, but we've decided to let other agencies provide that resource, rather than mandating CAP dog teams in every wing.

[John Bryan]

Well first I would say YES...CISM is important to CAP and YES we should be doing it.

As for the First Aid.....many CAP officers teach First Aid to their units using the American Red Cross , National Safety Council , or other groups material. Many CAP use First Aid skills....we don't call 911 for a cadet with a blister(well I hope not )

Like First Aid uses ARC, NSC, etc.....CISM uses the International Critical Incident Stress Foundation's (ICISF) materials.  CAP is not making it up as we go along. We are using a proven international standard.

[Dragoon]

But should we be doing it?  There are lots of things CAP needs that we don't do internally (for example flight physicals, aircaft maintenance, search dogs).  We let others specialize in those things, and use them instead of doing it ourselves.

I believe the CAP officers teaching first aid do it because they are Red Cross or NSC instructors.  CAP does not train or certify our own instructors, even with outside materials. 

[Chaplaindon]

"But should we be doing it?  There are lots of things CAP needs that we don't do internally (for example flight physicals, aircraft maintenance, search dogs).  We let others specialize in those things, and use them instead of doing it ourselves."

Dragoon,

As an active participant in/with CAP CISM and an outspoken supporter of CISM, in general, I would answer in two separate ways:

1.  CAP is actively conducting CISM interventions, are you suggesting that we SHOULD shut it all down?

2.  If CAP did shut its CISM program down and elected to ONLY use external CISM teams in support of CAP personnel needs, the efficacy of those third-party teams' interventions would be diminished for want of legitimate CAP-member PEERS.

Simply put, CISM wouldn't work as well and we'd be intentionally short-changing (even, perhaps HARMING) our members, needlessly.

The same is not true of third-party providence of "(for example flight physicals, aircraft maintenance, search dogs)." CISM works differently.

You see, the beauty of the Mitchell-model (Dr. Jeff Mitchell being the creator of the program and the one who coined the term "CISM") is its reliance on peers working along side mental health professionals. As Lt Col Sherry Jones, CAP (the NHQ Director for CISM) is fond of saying, it isn't "Suzy Social Worker" that helps CISM interventions reach those in need, it's the peer. It's the firefighter speaking to firefighter; police officer speaking to police officer; and (in CAP) the GTM/GTL --or pilot-- speaking to GTM/GTL/pilot, etc.

As a former flight paramedic and firefighter, I can speak (first hand) to the essential function of the peer in such interventions.

If you brought in a third-party team absent a CAP peer/peers, the CISM intervention MIGHT still work but you've "tied one hand behind your back" needlessly.

So we need --IMHO (IAW the Mitchell-model)-- CAP peers. If we have peers (and we also already have the personnel to train them ... and Col Jones, alone, has trained hundreds of CAPers thus far --including me) ... why not recruit some CAP MHPs? With CAP peers and MHPs ... why not have a real CISM program?

In short, we need at least a limited CISM program (e.g. peers, at the very least) in CAP just like many other emergency services organizations. But we have the WHOLE PROGRAM already ... I see no rational reason to try and end it.

CISM in CAP is here; it's regulation; it's reality; and I doubt seriously that it's ever going away.

That's a good thing.

[Pylon]

Outside of CAP, who are people are generally are accepted to provide counseling?  Clergy and professionals with appropriate certifications/degrees/accreditations, right?

[isuhawkeye]

chaplain don, that was the best argument I have ever heard for cap's use of CISM.  I may just reconsider my views on the program

[DogCollar]

CISM works well when the CIST has strong peer membership.  CISM fails, in my experience, when it relies on the "professionals."  Professionals are needed on the team for their "expertise" in helping disciplines...but, it is the peer that brings credibility to the process.  The only way to provide peers for CAP members affected by critical incident stress is to have CAP CISM teams. 

My friend, Chaplain Don has said it ever so more eloquently than I can!!

[Chaplaindon]

"Outside of CAP, who are people are generally are accepted to provide counseling?  Clergy and professionals with appropriate certifications/degrees/accreditations, right?"

Capt Kieloch,

Inside and outside of CAP the practice of COUNSELING is commonly reserved for those appropriately trained and licensed in its practice. Frankly, I am unsure if there is an official billet for MH Counseling IN CAP.

Nevertheless, those so licensed may vary from state to state as do the prerequisite qualifications to become licensed.

The same is true of the practice of MEDICINE or NURSING or (in those states that license EMS personnel; e.g. Texas for paramedics) EMS.

I sense, in your question (quoted above) an equation of CISM interventions with counseling. That is a mistake.

It would be similarly improper to equate the adminsitration of first aid and/or CPR with the practice of medicine. CPR doesn't require a CV Surgeon or a board-certified Cardiologist to perform. Stopping external hemorrhage by direct pressure at home usually doesn't await the arrival of a General Surgeon.

Two levels of intervention are being confused here. One is a immediate action to "stop the bleeding" or maintain absolute basic life support until the patient can be referred to DEFINITIVE CARE as needed.

Those practicing definitive care are practicing medicine/nursing.

Likewise, CISM is an immediate, proximal intervention to help a person cope with an event (or a series of events) that supercede her/his usual coping mechanisms. It is "emotional first aid."

It is GUIDED by a mental health professional (like an EMT being directed/ordered by an on-line medical director ... likely you are too young to remember "Rampart, this is Squad-51 ...") and seeks to provide basic emotional support, an attempt to "stop the [emotional] bleeding" and afford the opportunity for referral --as needed-- to definitive care (perhaps counseling, EMDR, or even psychotherapy) ... all outside of the realm of CISM and CAP and into the exclusive realm of the mental health practitioner.

It is often the case that CISM --more than anything else-- NORMALIZES the experience of the participant. It reinforces the fact that they are not alone in their discomfort about an event and that the common symptoms (e.g. nightmares, nausea, vomiting, loss of apetite, a desire to be alone, etc.) are also normal. Many people I've had the opportunity to help through CISM interventions commented that they, "thought they were going crazy" or that they "were the only one feeling those feelings." CISM helped detoxify the affects of stress by normalizing them and by reinforcing helthful and helpful coping strategies.

Occassionally we'll see someone who still has problems and those are the folks who the CISM model will endeavor to refer for definitive care.

Even the CAP CISM MHPs DO NOT provide "counseling" as a part of their CISM duties. Rather they help assess and refer those in need of such definitive care to practitioners in their area who can provide it.

Similarly a Trauma Surgeon in CAP (e.g. SWR/CC) would be constrained from performing an open thorachotomy at a crash site. CAPRs permit and encourage first aid, not definitive care.

As to clergypersons providing "counseling," this too is likely subject to local laws. While I can "counsel with" someone on a religious matter, in my state I cannot provide mental health counseling. I have not received sufficient academic and clinical training nor possess a license as a Licensed Professional Counselor (LPC), psychologist, psychiatrist, school counselor, etc.

There's a difference between the empathic listening and clergy-parishioner ADVICE and actual COUNSELING in its medical-legal meaning.

With all that as preface, just know that CISM is not, and presumes not, nor is it allowed to under the Mitchell-model of CAPR 60-5, perform MH counseling. It is merely emotional first aid.

[Flying Pig]

With law enforcement, at least in the agencies I have worked with, CISM debriefings, talking to counselors after traumatic events, is ordered by the Chief or Sheriff and is a punishable violation if you do not attend at least one session.  I never used to agree with that tactic, but now I do and here is why.  Cops, like other EMS poeple are usually "tough guys" with nerves of steel, yada yada....

"It isnt cool to to need counseling."  So now, many departments have now taken the peer pressure/perception side of it out by mandating counseling for officers who are involved in incidents.   Its going to wear on you.  Sometimes, it may only take one incident to put you over the edge. 
Often just having someone tell you what to expect in the future, related to PTSD helps, because you know your not a freak when it happens.  As far as CAP, they are in the same boat and it is something that should be offered by qualified personell.  The only hurdle I can see is the potential cost should a member start having problems.

[Cobra1597]

I was 16 during 9/11, and spent most of the week in the FEMA bunker running the response efforts. I seriously wish that I had received CISM back then. In that bunker, I heard things (I'm not sure what level of detail I can give here, so I will be sparse) like numbers of body bags being requested, confusion over some of what had happened, etc. I was among the early people to see the pictures taken by the CAP aircraft of Ground Zero. I had a Lt Col next to me telling me I was seeing the start of World War III.

You can bet that the things I heard, saw, and felt effected me greatly. I physically cannot watch movies like Flight 93 or World Trade Center, I get a physical response on seeing the standard pictures of the towers smoking, etc. Some of the confusing things that I heard I only received closure on in the last year by being able to talk to some of those people that I was in the bunker with again.

It would not be an overstatement to say that I was at least mildly traumatized by those events. I never questioned the value that CISM could have after that, and wish it had been around and available to me then.

[SarDragon]

I only watched the events of 9/11 on TV (for far too long as it turns out) and I have the same feelings as Captain Ingraham. I also have similar feelings about the 1989 SF earthquake, which I experienced first hand (and watched way too much news about after the power came back on). I don't watch much of anything about either event, particularly reenactments or newsy analyses.

Yes, CISM would have been a good thing for me at the time, but it wasn't something I even knew about in 1989 (did it even exist?), and was only vaguely familiar with in 2001. I did discuss my feelings with a friend who does CISM in VA, and got a better handle on my feelings about 9/11.

[Slim]

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.

I've worked in Fire and EMS for 17 years, and there were times where CISM probably meant the difference between me showing up for my next shift, or bagging it up and going to teach typewriter repair or something.  It also helped to know what was going on, and to know that what I was going through was normal.

I too was/am very deeply affected by 9/11, as were a lot of people in my line of work.  I'm to the point now where  I can watch the end of "United 93" without shaking like a leaf, and remembering to breathe.  OTOH, I bought a DVD of "World Trade Center" almost a year ago, when it first came out.  It still sits on a shelf, unopened, waiting for the day I can bring myself to watch it.

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.

[Chaplaindon]

"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."

Maj. Freytag,

I understand your "mixed opinion" regarding mandatory CISM interventions, and fundamentally believe that they SHOULD BE voluntary ... in most cases.

That having been said, I know that I would have never ventured into my first CIS Debriefing in April of 1989 had it not been mandatory. I was a flight paramedic and we'd just had one of our helo's crash causing devastating injuries to the 3 crewmembers.

I had never heard of CISM or a CISD. I expected "Suzy Social Worker" to tell me what at to feel and to do about it. What did she know about what I did for a living: the risks, stresses, emotional strain, and whatnot?

I sure didn't need some white-coated "do-gooder" pshrinking my head. I wasn't about to go ... until the boss made me. Thank God that she did too.

In that closed room, along side the "head pshrinker" (as I saw her, then) were several flight paramedics and flight nurses who really did know my job. That CISD was a true blessing.

My affiliation with CISM began then and continues to this day.

I think that mandatory CISM can be SITUATIONALLY beneficial, especially overcoming misconceptions about the program and about stress. Likewise, so can Pre-Exposure Preparation (a USAF term) for briefing people about stress and its normal reactions BEFORE a stressful event (e.g. before deploying to JTF-Katrina).

In CAP we call these prep's "PEP-Talks" and they are available as "turnkey" PowerPoint presentations that can be given by any CISM qualified CAP member to any CAP member/group/event. They are ideal for safety briefings and for downtime training at a SAREX. You can find them on the www.capcism.com website or the SWR CISM page at http://cap.defined.net/protected/cism/peptalk.htm.

One last reminder about making CISM mandatory ... although NOT a normative approach in all situations, there may be times when the affected individual's judgement is so clouded by their stress reaction that their refusal should not be considered appropriate. It's a lot like seeing heat exhaustion (borderline heat stroke) symptoms in a person working flightline on a SAREX. You suggest that they go inside and cool down and rehydrate but they refuse. I wouldn't take a refusal from someone exhibiting obvious heat exhaustion symptoms (or worse) as "gospel." I'd send them inside anyway. Their judgement might just be affected by their shock.

The same could be true with a CIS reaction. Sometimes we need to be more persuasive. As a paramedic, I know I've used similarly "persuasive means" to get a symptomatic chest pain patient to go to the ER in spite of her/his refusals.

[LittleIronPilot]

I still have issues with mandatory CISM attendance.

I am a combat vet and former law enforcement officer. I have seen, and done, things that many would have a hard time dealing with. For me...I just roll on, life is life and you cannot get all hung up on the "bad stuff".

Again...this is ME speaking, so yeah I would attend a meeting, and then never go back.

[jimmydeanno]

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.