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.

[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.

[Gunner C]

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.

Who is your region CISM coordinator?  I'll bet he's a chaplain.

Traditionally and by law (in the Real Military), chaplains are absolutely not allowed to lead units on the ground or in the air.  Chaplains are not peers.  That defeats the purpose of the chaplaincy.  That's why you are addressed as "Chaplain" and not "Captain".  I'm not trying to be a schnook, it's the way it's supposed to be.  I've seen military chaplains (two of them) resign their chaplaincy, revert to 2nd Lt and become line officers.  I've also seen two line officers resign as field grade officers and become chaplains (both became captains).

[DogCollar]

Sir, are you trained to be a CISM peer?  If you are thanks for your service.  If you aren't why not? 

The regional cism officer is NOT a chaplain, but there is nothing preventing a chaplain from being a CISO.  You are right.  Chaplains cannot be "peers."  But, they are still needed on the teams.   Again, trained peers are what drives a debriefing, which is only one part of CISM.  Please, become a peer if you are not already.

[Dragoon]

No.

Well, why not?  Nothing is keeping Chaplains (or any other CAP member) from also being GTMs.

This is the basic issue - we claim that unlike other support functions, we HAVE to do this ourselves because we HAVE to have peers.  And then we don't require the folks to be peers.

This just doesn't make sense to me.

[DogCollar]

No.

Well, why not?  Nothing is keeping Chaplains (or any other CAP member) from also being GTMs.

This is the basic issue - we claim that unlike other support functions, we HAVE to do this ourselves because we HAVE to have peers.  And then we don't require the folks to be peers.

This just doesn't make sense to me.

A CISM team performing a debriefing is made up intentionally of trained peer(s), mental health professional, and a team leader.  The chaplain should not be a leader.  A chaplain can be a mental health professional with the right credentials.  But the trained peer is someone from CAP, trained in basic group intervention, and if debriefing a GT, should have experience as a GTM, etc...  It is CRUCIAL for the CISM team members not to have served in any capacity on the traumatic situation they are trying to debrief.

But,,,AND I ASK EVERYONE TO REMEMBER, the debriefing is one part of CISM, and as the program evolves, it is becoming a secondary option to One to One interventions, demobilizations, and Critical Information Briefings.  In some of these other parts of the progam, chaplains can actually be very helpful!!  Imagine that...a helpful chaplain!!!!

[John Bryan]

Chaplains can be peers. I know Chaplains who are mission pilots, ground team leaders, ground team members, etc.

Indiana Wing CISM Team has a Chaplain who is a member. He is also a GTL, GBD-T, and has done some training for scanner.

I would encourage Chaplains to get out in the field we need you there as much as at the unit meetings and mission bases.

Thanks
John Bryan
Lt Col, CAP
INWG CISM Officer

[Dragoon]

Absolutely right.  In CAP ANYONE can be a GTM, barring physical disability. 

And our CISM teams, if we're gonna have 'em, need to be stocked with folks who truly be peers.

If we can't get those folks, it sounds like we shouldn't be doing this.  It needs to be a requirement.  Otherwise, we might as well let some other organization provide those services, and focus on the things we CAN find qualified folks for - like SAR.

[DogCollar]

Unfortunately, I think this conversation will continue to be circular.  I'm not going to convince you...you're not going to convince me.  I did join CAP a couple of years ago to do chaplaincy (I am a hospital chaplain by calling) and to be actively involved in CISM (I have taken multiple training offerings).  I have basic GES rating and I have a CAP radio operators card.  Yet, the people I am with don't look at me as being somehow "deficient" because I an not a GTM or a pilot.  Instead they look to me as someone who brings skills and experiences to the role of chaplain and CISM team member.
I'm glad that there are good dedicated, trained and experienced pilots and GTL's in CAP.  I'm glad that there those among us who have every ES rating and the experience to go with it.  I would never think to say that CAP shouldn't be involved in SAR unless all member are rated as at least GTL's!  I think that the requirement that ALL CISM members be GTL's is a wrong direction for CAP to consider, as it would be turning away people who are highly trained, skilled and passionate about the gifts they have to offer the organization.

[John Bryan]

I think a lot of folks miss the PEER lead part of CISM. Ground teams should be debriefed/defused by CISM trained peers so GTM or GTL who have CISM training. Pilots/aircrews should be debriefed/defused by aircrew members who are CISM trained.

I am CISM trained and part of a CAP team. I am a peer for CAP members. I could not debrief/defuse firefighters or police officers because I am not one.

The MHP is not always a peer ie someone with the background of the members being serviced. But chaplains are not MHP.

This is a basic principle of CISM.

[DogCollar]

So, let Chaplains be chaplains...I'm done!

[Dragoon]

I'm actually a big fan of chaplains and what they do.  I think a mission chaplain is a great asset, and wish we had more of them.

It's the circular reasoning behind CISM (which is specifically not a required chaplain function) that's, frankly driving me nuts.

On one hand, we say "WE HAVE TO DO THIS OURSELVES" because it requires peers.

Then we don't require peers to do the debriefings.  (Chaplain, I get your point about there being a place in CISM for non-peers.  But it's the lack of the requirement for debreifers to be peers that's eating me.)

It all hinges on the definition of "peer."  Some believe that just wearing a CAP uniform makes you a "peer" to the GTM with the stress issue.  I guess that's where we differ. 

If it's not gonna a guy who's walked a mile in my particular boots, it might as well be a guy from a external agency.  No need to waste CAP resources on a program that (it seems) we can't execute according to its guidelines.

This would all be cleared up if CAP would mandate that all CISM debriefers be required to hold ES ratings equal to the folks they debrief.  But I wonder if they could find enough folks willing to do this.

[DogCollar]

1.I'm actually a big fan of chaplains and what they do.  I think a mission chaplain is a great asset, and wish we had more of them.

I'm glad.  And I agree that mission chaplains should be a part of every live incident command structure.


2. On one hand, we say "WE HAVE TO DO THIS OURSELVES" because it requires peers.

Then we don't require peers to do the debriefings.  (Chaplain, I get your point about there being a place in CISM for non-peers.  But it's the lack of the requirement for debreifers to be peers that's eating me.)

What you are talking about is a CISM debriefing, which is only one of a multitude of CISM responses to crisis; including One-to-One Crisis Intervention, Pastoral Crisis Intervention, Suicide Prevention Intervention, Demobilizations, Managment Briefings, etc...and not all of these require a "peer."  I would argue that the Debriefing protocol should not be the first offered in a crisis, but rather, only when an assessment of need has been done, by the CISM trained personnel.  Most crises that are faced in CAP don't need debriefing, in my opinion.

3.  It all hinges on the definition of "peer."  Some believe that just wearing a CAP uniform makes you a "peer" to the GTM with the stress issue.  I guess that's where we differ.  I think there SHOULD be more of the kind of "peer" you speak of.

4. This would all be cleared up if CAP would mandate that all CISM debriefers be required to hold ES ratings equal to the folks they debrief.  But I wonder if they could find enough folks willing to do this.
Let me put another way...rather than having debriefers become GTM's, etc...why not have those trained AND experienced become debriefers?  Would you be willing to be trained as a CISM peer?

[Chaplaindon]

I'm actually a big fan of chaplains and what they do.  I think a mission chaplain is a great asset, and wish we had more of them.

It's the circular reasoning behind CISM (which is specifically not a required chaplain function) that's, frankly driving me nuts.

On one hand, we say "WE HAVE TO DO THIS OURSELVES" because it requires peers.

Then we don't require peers to do the debriefings.  (Chaplain, I get your point about there being a place in CISM for non-peers.  But it's the lack of the requirement for debriefs to be peers that's eating me.)

It all hinges on the definition of "peer."  Some believe that just wearing a CAP uniform makes you a "peer" to the GTM with the stress issue.  I guess that's where we differ. 

If it's not gonna a guy who's walked a mile in my particular boots, it might as well be a guy from a external agency.  No need to waste CAP resources on a program that (it seems) we can't execute according to its guidelines.

This would all be cleared up if CAP would mandate that all CISM debriefs be required to hold ES ratings equal to the folks they debrief.  But I wonder if they could find enough folks willing to do this.

A few specific clarifications are in order ...

1.  Much of this would-be "circular logic" is nothing more than people attempting to offer criticism about something most have not even bothered to read the relevant regulations about, much less complete the training.

2.  The concept of the "PEER" in CISM is an ideal/normative one. CISM works BEST with exact peers supervised and led by experienced MHPs (ideally MHPs with direct experience with the group being intervened with ... e.g. an MHP --like Dr. Jeff Mitchell, author of CISM originally who was a firefighter/paramedic while persuing his PhD).

Reality must rear its "ugly head" and state that idealism and normative goals are wonderful --and something to work toward-- but scarcely (based on my 30+ years of civilian emergency services and 23 years of CAP ES experience) experienced.

While the BEST peer for an affected GTM would be another GTM, likewise the BEST peer for a flightcrew member would be another green-bagger, and the BEST peer for a CUL/MRO would be an exact counterpart ... CISM can and is effective with less exacting CAP peers. A CAP member peer is still far better than a 3rd-party non-CAP CISM peer or MHP.

3.  To proffer that only GTM/GTLs are affected by CIS and thus only GTM/GTL qualified members should be peers is patently absurd.

Although, granted (if focused narrowly enough) it COULD be true that only GTM/GTLs are likely to actually walk up upon a grotesque crash site or get close enough to "appreciate" the smells and sights thereof, such scenarios are only a VERY SMALL part of the CAP operations and/or activities wherein CIS can occur.

A couple of examples:

a.  (This actually happened) A Squadron meeting is "invaded" by a shotgun wielding criminal who threatens everyone, takes a member hostage, walks he/she to his/her car and then forces them to turn away and walk away at gunpoint. No one in the meeting might even possess a CAPF101, but all could easily be poised for a CIS reaction and CISM could be a potential aid.

b.  (this JUST happened) a CAP aircraft crashes on a SAR/DR mission killing all aboard. Mission staff, to the 3 crewmember's squadron-mates, to the Wing and Region CC's may be affected by grief and CIS. I know CISM was used in NVWG, CAWG, and WYWG within the last month to deal with the aftermath of such events. Few, if any were actually exposed to the crash site but many were helped by CAP CISM personnel.

c.  (Another REAL event) a Cadet commits suicide ... CISM assisted the other cadets and squadron members deal with their CIS reactions.

CISM, thus, is NOT just for GTM/GTLs (and I say that as a GTM1/GTL/IC and former firefighter/paramedic) it potentially has a wide range of situations where one, or more, of its numerous interventions might be helpful.

We need peers from every specialty ... including WG/Region Commanders ... and chaplains.

4.  Chaplains CAN be peers ... in fact the only personnel on a CISM team (a "CIST" in CAP) are peers and MHPs ... chaplains who serve on CISTs are either serving as a peer or as a MHP (provided they have the requisite professional training and licensure). In an earlier permutation of CAPR 60-5, there were a variety of CIST positions listed (including a chaplain) but in the current 60-5 IAW ICISF standards there are only MHPs and peers.

Chaplains can be peers. I am a chaplain and I am a peer.

5.  About the nonsense that, ["Chaplains are for the chaplaincy.  In CAP, the chaplains have taken over the program" ... this is absurd too. The CAP CISM program rightly belongs where it is ... under OPERATIONS. The plan is to move it to health services. It has never been under the chaplaincy. To say that "chaplains have taken over the [CISM] program" is to demonstrate a fundamental misunderstanding of the CISM program.

CAP CISM, currently (and since its inception in CAP) has been led by an RN/paramedic. CISm works closely with the chaplaincy, but hasn't ever "taken over the program" or even tried.

I would suggest reading the relevant regulations (e.g. CAPR 60-5, 265-1) before proffering such an absurd allegation again.

6.  While on the subject of chaplains, the rhetoric excoriating CAP chaplains for doing things that USAF chaplains cannot do (e.g. "While USAF has chaplains on their teams, they are absolutely PROSCRIBED from being in charge") is to misidentify the CAP chaplaincy with the USAF chaplaincy. Although we share many things with our USAF HC counterparts ... and, we wear the USAF chaplain badges ... there are many
differences:

a.  We are not in the military. CAP members and their chaplains are civilians.
b.  We are not under or bound by the UCMJ.
c.  CAP chaplains can hold additional operational positions (e.g. pilots, observers, GTM/GTLs, ICs, etc.) USAF chaplains cannot.

Perhaps USAF chaplains are, in fact, proscribed from "being in charge" on a CISM team ... in CAP, IF the chaplain is a qualified/endorsed MHP she/he can be the MHP in charge of a CISD. Beyond that, if a chaplain can be in charge of a SAR/DR mission as IC (as I have done and continue to do), why could they not lead a defusing team, or lead a demobilization?

If they required chaplains to refrain from leading certain CISM interventions, they need to take the control yoke of CAP airplanes our of their hands as well. Allowing chaplains to be a PIC (pilot in command) of our aircraft and forbid them from leading a CISM intervention seems duplicitous.

I suggest that the only confusion or "circular logic" concerning the CISM program and/or the CAP chaplaincy (on this thread anyway) comes from folks who --based upon their own words-- ostensibly do not understand either program.

I would recommend studying the programs (and their Regs) and learning the FACTS before proffering commentary or criticism about either program.

[Horn229]

I would recommend studying the programs (and their Regs) and learning the FACTS before proffering commentary or criticism about either program.

It's very interesting you say that. Because, not only did I research CISM, I researched the effectiveness of it. Results? CISM does NOT work.

I spent many hours on multiple databases searching trying to find information on the effectiveness of CISM. Excluding articles written by Mitchell and Everly, all of the research articles and meta-analyses I located has the same results, Psychological Debriefings do not work.

A ten year old article on the ICISF website pertaining to CISM in the LAFD said that CISM works. Currently, however, the LAFD has switched to using Psychological First Aid and Cognitive-behavioral Therapy. In an interview I conducted with the current Director of Behavioral Health for the LAFD stated:

It doesn't meet the criteria of science for me to do it for eight years and say "well ya know, I did a lot of groups, I've done hundreds of debriefing groups" most people walk away and say "Thank you that was helpful", but I never had someone come up and say "that sucked, it upset me a lot". So my experience was it was pretty positive, but again that's not science. And just because someone said it was helpful doesn't mean that a year from now that it didn't... they still perceived it as helpful or that it didn't cause some other reaction that I never found out about.

According to the article on the ICISF's website, the LAFD had one of the oldest CISM programs, and they stopped using it.

Dr's McNally, Bryant and Ehlers conducted research into several meta-analyses, pertaining to the efficacy of CISD. They examined both research for and against CISD, and found the CISD does not work.

Dr Bledsoe conducted research using two reputable medical databases and found that CISD does not work.

The chief issue at hand in the psychological community around CISM is not only does CISD not work, it can lead to more adverse reactions. In Randomized Controlled Trials of CISD, control groups (groups that did NOT receive a psychological intervention) had better results than the debriefed groups. -- This is the chief issue that has caused many to cease using CISM. The USAF has even moved away from CISM and are now using the PFA method.

An organization known as the International Society of Traumatic Stress Studies (the world's largest group onthe subject) is in favor of PFA for the initial interaction with potentially traumatized personnel, and CBT and EMDR for treatment methods for PTSD.

All of the articles cited in research studies I located which were adduced in favor of CISD were only printed in the ICISF's journal. There is a very serious bias there, and an even stronger issue is that none (that I could find) were printed in non-biased peer-reviewed medical journals.


Some of you continue to say that CISD is just one part of CISM. Which is true, it is just one part of CISM. However, around here there is no formal training on the affects of stress, none of the other aspects of CISM take place in my wing, and the only time CISM is mentioned is during a SAR Eval, in which the evaluators ask the chaplain what he would do if a ground team was exhibiting severe signs of physical arousal.

Now the reason I say all this. Many very well education psychologists and psychiatrists have either found that CISM/CISD do not work, through scientific research; or have ceased using CISM. Psychologists from all over the country went to New Orleans after Katrina and used the PFA method.



Why, if so many people in the field of traumatic stress have said CISM and CISD do not work, does CAP continue to use this method?

I'd really prefer to not see a "I've been in a debriefing, and it works" or "I've worked in debriefings, and they work" type of response. I'd like to see something with actual scientific proof stating CISM/CISD does work.

I've provided links to articles I've mentioned in this post, in one of my previous posts in this thread, should you like to examine what I've mentioned here.

[Dragoon]

What you are talking about is a CISM debriefing, which is only one of a multitude of CISM responses to crisis; including One-to-One Crisis Intervention, Pastoral Crisis Intervention, Suicide Prevention Intervention, Demobilizations, Managment Briefings, etc...and not all of these require a "peer."  I would argue that the Debriefing protocol should not be the first offered in a crisis, but rather, only when an assessment of need has been done, by the CISM trained personnel.  Most crises that are faced in CAP don't need debriefing, in my opinion.

Again, what you're saying here is that the vast majority of CISM work doesn't need peers.  Which kind of negates the requirement for CAP to do it ourselves.

This is NOT an attack on the validity of the process - merely someone trying to figure out if we wouldn't be better off using external entities for this service, as we do for so many other CAP support services.  Because everything we do which is not a core mission is, to some extent a distraction.

We have to separate the two issues (1)  Does CAP need this service and (2) Is it worth doing it ourselves.

THIS IS IN NO WAY AN ATTACK ON THE COMPETENCY AND INTENTIONS OF THE CAP FOLKS CURRENTLY DOING IT.  Like everyone in CAP, you've got a passion for what you do. But there are equally passionate people interested in dog teams, helicopter SAR, cadet mountaineering, firearms training for cadets, etc etc.  We say no to a lot of these folks because of the corporate pain-to-pleasure ratio of what they want to do.  We don't have to do everything ourselves.

[Dragoon]

A CAP member peer is still far better than a 3rd-party non-CAP CISM peer or MHP.

Chaplain, do we have any data to back that assertion up?  I'm suspect - just because he's wearing the same suit as me doesn't mean I'm gonna think "hey, this guy is like me."  I think I'm looking for someone who's specifically been in my shoes in a similar crisis.  Otherwise, he ain't my peer. 

But mebbe I'm off base - are there any studies to support "members of the same organization who are otherwise unconnected to the patient are better than outsiders with similar credentials"?

Honest question below:

part of the CAP operations and/or activities wherein CIS can occur.

A couple of examples:

a.  (This actually happened) A Squadron meeting is "invaded" by a shotgun wielding criminal who threatens everyone, takes a member hostage, walks he/she to his/her car and then forces them to turn away and walk away at gunpoint. No one in the meeting might even possess a CAPF101, but all could easily be poised for a CIS reaction and CISM could be a potential aid.

b.  (this JUST happened) a CAP aircraft crashes on a SAR/DR mission killing all aboard. Mission staff, to the 3 crewmember's squadron-mates, to the Wing and Region CC's may be affected by grief and CIS. I know CISM was used in NVWG, CAWG, and WYWG within the last month to deal with the aftermath of such events. Few, if any were actually exposed to the crash site but many were helped by CAP CISM personnel.

c.  (Another REAL event) a Cadet commits suicide ... CISM assisted the other cadets and squadron members deal with their CIS reactions.

How do the Boy Scouts handle this stuff?   Your examples are likely to apply to them as well (except they're more likely to lose members in a car crash rather than a plane crash).  Have they stood up a CISM program equal to what CAP is shooting for?  Or do they use external resources.

[John Bryan]

If we only did cadet programs I might think you had a point. BUT we are an emergency services agency and thus are members are more likely to be exposed to CIS.

I think you should be asking things like do volunteer fire dept with as many members as my wing stand up their own teams? Do police dept with as many members as my wing stand up their own teams.

I think the regulations make it clear that the use of outside resources is ok but that does not mean wings and regions should not stand up their own programs.

Using the logic of someone else could do it and maybe better could be used to cross out all are programs and close down the CAP.....so be careful.

[Dragoon]

The reason I asked the question about the boy scouts was because the good chaplain's examples weren't related to ES.  In fact, he was arguing for the importance of CISM for non-ES purposes.  Hence the question.

The ES questions have already been covered under "how come you don't have to be a peer, when peers are the whole reason we do it ourselves" argument.

[DogCollar]

Using the logic of someone else could do it and maybe better could be used to cross out all are programs and close down the CAP.....so be careful.

This is most certainly true!  There is nothing that CAP does that outside groups aren't doing...including cadet-style youth programs.

AND, utilizing outside CISM resources is permitted in the regulations.

[Dragoon]

So why waste time and energy doing it ourselves?  (hint - the only good answer is "we can do it better than anyone else for less hassle.")

There's a big difference between support functions (like maintenance, accounting, CISM, etc) and mission functions (SAR, cadet programs, AE).  We have to do the latter ourselves.  We need to make smart choices about the former.

Now back to the Boy Scout question - they have same non-ES CISM need we do.  How do they handle it?

[DogCollar]

Why waste time doing SAR at all?  Do we do it any better than anyone else?  I doubt it.  We do it because it's our mission.  Why waste time doing cadet programs?  Certainly there are equal programs (albeit with differing starting points) to ours?  We do it because it's our mission.  Why teach and promote aerospace?  There are certainly flying clubs and rocket clubs galore.  We do it because it's our mission.
Now, I have training in multiple facets of critical stress management.  I utilize this training in my career in healthcare, but I also offer it voluntarily to Civil Air Patrol.  Now, I could offer it in countless other agencies and organizations that utilize a process for caring for those who experience traumatic stress, however, I believe in the multiple missions of Civil Air Patrol and I can best serve in this "support" capacity (along with being a unit chaplain).
Now, if CAP decides that it would be better to ONLY utilize outside resources for caring for those exposed to traumatic stress, I would find another agency to volunteer my CISM training and experience. 
You have said that the ONLY good answer is that "we can do it better than anyone else for less hassle."  I don't think that should EVER be the ONLY answer.  I think we do CISM as well as outside agencies can. 
Finally, it would be foolish for CAP to jettison it's support functions to "outside" sources (which would ultimately COST $$$$$), besides, outsourcing rarely works.  By your logic not only would CAP have to jettison CISM, but also the Chaplain Corp, Medical Services, DDR, etc...
Now maybe most members joined CAP to be on an aircrew or ground team...but not all.  You intimate, unless I completely misuncersand your logic, that support functions are not only "different" they are somehow less important.  That' s not the case in the "real military", Law Enforcement, Emergency Services, Government...and it certainly isn't true in CAP.

[Dragoon]

Why waste time doing SAR at all?  Do we do it any better than anyone else?  I doubt it.  We do it because it's our mission.  Why waste time doing cadet programs?  Certainly there are equal programs (albeit with differing starting points) to ours?  We do it because it's our mission.  Why teach and promote aerospace?  There are certainly flying clubs and rocket clubs galore.  We do it because it's our mission."

Right.  Those are our missions.  CISM isn't a CAP mission.  It's a support function.  Unless the intent is for CAP to provide CISM to non-CAP members as a new mission.

  By your logic not only would CAP have to jettison CISM, but also the Chaplain Corp, Medical Services, DDR, etc...
Now maybe most members joined CAP to be on an aircrew or ground team...but not all.  You intimate, unless I completely misuncersand your logic, that support functions are not only "different" they are somehow less important.  That' s not the case in the "real military", Law Enforcement, Emergency Services, Government...and it certainly isn't true in CAP.

Actually, it's true all over the rest of the government.

The USMC decided it was best to let the Navy handle it's medical assets, and the Army handle heavy logistics and maintenance.

USA and USMC outsource strategic air mobility to USAF.

Very few police departments have their own robust medical assets - they let the Fire Department/Ambulance folks handle most of that.

The Army decided to use civilians to guard gates at many installations, rather than soldiers.

USAF lets NASA carry many of its satellites into orbit.

CAP has chosen to use outside medical support for treating its own members, outside mechanics to repair its planes and it's vans, ,agencies like the Salvation Army and Red Cross to provide food and shelter support for extended missions, etc, etc.

There's a difference between core mission and support.  Support is critical - but you don't have to do it yourself.  You only do it yourself if you can do if it adds value without distracting from the core mission.  Otherwise, best to someone who specializes in that support function handle it.


Again, I'm not getting into the debate about whether CISM is useful or not - that's for guys more steeped in the details to debate. 

But  can someone make a cogent argument, with data,  on why we need to do this ourselves?  For example, does anyone have data about how screwed up things were before we started this, and how we're so much better now?  How about a study showing how other volunteer groups handle this (internal or external) and the results they've had?  What do the Boy Scouts do?

Or are we just doing it because we have some CAP members who want to do it?  Because I know members who want to use their search dogs, or parachute, or set up SCUBA teams - there's no end to how people wish to reshape CAP in their own image.

But we have core missions - ES, AE, CP.  We should consider support functions only as they relate to those core missions.  We can't do everything the best ourselves - sometimes best to let others take the lead in things they specialize in.

[whatevah]

I think this point may be getting lost from the original post...

the topic isn't about whether or not there should be any stress/ptsd/whatever support, but if CISM should be the method employed while many agencies and military branches have stopped using it in favor of other methods.

[John Bryan]

I think this point may be getting lost from the original post...

the topic isn't about whether or not there should be any stress/ptsd/whatever support, but if CISM should be the method employed while many agencies and military branches have stopped using it in favor of other methods.

Military is getting away from it??? 

The Air Force has been using it since the 90's....

http://findarticles.com/p/articles/mi_qa3912/is_200209/ai_n9094754/pg_1

AFI44-153 , which is now titled Traumatic Stress Response (but looks like CISM), the old title was CISM.

From March 06
http://www.e-publishing.af.mil/shared/media/epubs/AFI44-153.pdf

July 06
http://www.e-publishing.af.mil/shared/media/epubs/DOVERAFBI40-305.pdf

From July 1999
http://www.calguard.ca.gov/oc/csc/page%20info/afi44-153.pdf

July 05
http://www.af.mil/news/story_print.asp?id=123012627

========================================
US Coast Guard

http://www.uscg.mil/hq/cg3/cg3pcx/administration/fv157.asp
http://www.uscg.mil/hq/g-w/g-wk/wkw/EAP/pdf/CI_1754_3%5B1%5D.pdf
========================================

[Horn229]

Again, I'm not getting into the debate about whether CISM is useful or not - that's for guys more steeped in the details to debate. 

But  can someone make a cogent argument, with data,  on why we need to do this ourselves?  For example, does anyone have data about how screwed up things were before we started this, and how we're so much better now?  How about a study showing how other volunteer groups handle this (internal or external) and the results they've had?  What do the Boy Scouts do?

The most important aspect of CISD, when Jeff Mitchell created it, was the peer members of the debriefing team. That in and of itself is the only reason many EMS, Firefighter and Police personnel ever step foot into the debriefing room. If you replace the peers with just anyone who has gone through CISM training, then you've got a MHP and a few random people listening to professionals vent, or more likely you'll have the random people and the MHP trying to get the unwilling members to open up.

EMS and not the peers for Police, Firefighters are not the peers for radio dispatchers; EMS, Firefighters and Police all have different duties to perform at any given scene. They may all have scene the same thing, but due to their duties, were exposed to different aspect and stresses of the incident. Therefore none of the above groups should be debriefing together, nor debriefed by peers of a different profession.

Likewise, it would be ridiculous to have the someone trained in Admin/Finance debrief a Ground Team,  or Logistics to debrief an Aircrew. I hope I've answered your question.


Now then, in my previous post I stated CISD's do not work and have asked for a reason why CAP has chosen to continue on with CISM, while other organizations have switched to something more effective. I'd still like to see an argument as to why we continue on with this specific method when there are better options out there.

[John Bryan]

Could you name the other programs that "work better"?

[Horn229]

I've cut out the quote to just two specific links I'd like to talk about

Military is getting away from it??? 

The Air Force has been using it since the 90's....


AFI44-153 , which is now titled Traumatic Stress Response (but looks like CISM), the old title was CISM.

From March 06
http://www.e-publishing.af.mil/shared/media/epubs/AFI44-153.pdf

From July 1999
http://www.calguard.ca.gov/oc/csc/page%20info/afi44-153.pdf

If you actually read those two documents, you'll find the the July 1999 document was the old CISM base intervention guide for the USAF. The March 2006 document is a complete revision of their stress management program, they have completely done away with CISM and have switched to Psychological First Aid. In the "Summary of Changes" paragraph it states

This document is substantially revised and must be completely reviewed. This revision establishes
TSR teams at all active duty Air Force installations. TSR teams (1) serve as trauma response consultants
to unit leaders; (2) prepare personnel likely to be exposed to potentially traumatic events; and (3) provide
screening, education, psychological first aid, and referral for those exposed to potentially traumatic
events. This document also provides revised training guidance.

The other steps mentions in item number 3 are all aspects of Psychological First Aid. The references can be found in attachment 1 of the new version. If you go to the links in the references, you'll find most are about PFA, one link no longer works, and the other seems to discuss mass traumatic stress (irrelevant to us at this current time).

So it is clear, the USAF once used CISM, in the old version if you use the "Find" option and search "CISM" or "CISD" you'll get numerous responses, try again in the new version and you'll find none. In the new version, you will only find Psychological First Aid.

[Horn229]

Could you name the other programs that "work better"?

To save myself time in typing the same thing, I'll direct you to my previous post.

http://captalk.net/index.php?topic=3534.msg71170#msg71170

[John Bryan]

Yes but the Dover AFB pub is published after the latest AFI and it still says CISM. Why the difference?

The US Coast Guard still uses it. The Indianapolis police and fire depts still use it. Los Angeles County Fire Dept has a CISM team, City of Pittsburgh has a CISM team, Dallas Fire-Rescue has a CISM team......the list goes on and on.....

Not every department uses the ICISF CISM, so use other programs. Some fire departments train their firefighters with American Red Cross CPR , so use American Heart Assc, other use the National Safety Council......does this mean one is better then the other ?

[John Bryan]

I would recommend studying the programs (and their Regs) and learning the FACTS before proffering commentary or criticism about either program.

It's very interesting you say that. Because, not only did I research CISM, I researched the effectiveness of it. Results? CISM does NOT work.

I spent many hours on multiple databases searching trying to find information on the effectiveness of CISM. Excluding articles written by Mitchell and Everly, all of the research articles and meta-analyses I located has the same results, Psychological Debriefings do not work.

A ten year old article on the ICISF website pertaining to CISM in the LAFD said that CISM works. Currently, however, the LAFD has switched to using Psychological First Aid and Cognitive-behavioral Therapy. In an interview I conducted with the current Director of Behavioral Health for the LAFD stated:

It doesn't meet the criteria of science for me to do it for eight years and say "well ya know, I did a lot of groups, I've done hundreds of debriefing groups" most people walk away and say "Thank you that was helpful", but I never had someone come up and say "that sucked, it upset me a lot". So my experience was it was pretty positive, but again that's not science. And just because someone said it was helpful doesn't mean that a year from now that it didn't... they still perceived it as helpful or that it didn't cause some other reaction that I never found out about.

According to the article on the ICISF's website, the LAFD had one of the oldest CISM programs, and they stopped using it.

Dr's McNally, Bryant and Ehlers conducted research into several meta-analyses, pertaining to the efficacy of CISD. They examined both research for and against CISD, and found the CISD does not work.

Dr Bledsoe conducted research using two reputable medical databases and found that CISD does not work.

The chief issue at hand in the psychological community around CISM is not only does CISD not work, it can lead to more adverse reactions. In Randomized Controlled Trials of CISD, control groups (groups that did NOT receive a psychological intervention) had better results than the debriefed groups. -- This is the chief issue that has caused many to cease using CISM. The USAF has even moved away from CISM and are now using the PFA method.

An organization known as the International Society of Traumatic Stress Studies (the world's largest group onthe subject) is in favor of PFA for the initial interaction with potentially traumatized personnel, and CBT and EMDR for treatment methods for PTSD.

All of the articles cited in research studies I located which were adduced in favor of CISD were only printed in the ICISF's journal. There is a very serious bias there, and an even stronger issue is that none (that I could find) were printed in non-biased peer-reviewed medical journals.


Some of you continue to say that CISD is just one part of CISM. Which is true, it is just one part of CISM. However, around here there is no formal training on the affects of stress, none of the other aspects of CISM take place in my wing, and the only time CISM is mentioned is during a SAR Eval, in which the evaluators ask the chaplain what he would do if a ground team was exhibiting severe signs of physical arousal.

Now the reason I say all this. Many very well education psychologists and psychiatrists have either found that CISM/CISD do not work, through scientific research; or have ceased using CISM. Psychologists from all over the country went to New Orleans after Katrina and used the PFA method.



Why, if so many people in the field of traumatic stress have said CISM and CISD do not work, does CAP continue to use this method?

I'd really prefer to not see a "I've been in a debriefing, and it works" or "I've worked in debriefings, and they work" type of response. I'd like to see something with actual scientific proof stating CISM/CISD does work.

I've provided links to articles I've mentioned in this post, in one of my previous posts in this thread, should you like to examine what I've mentioned here.

It is interesting that the person you quote says most people said "it was helpful but....."

Is there any proof it hurts? Also just wondering It was my understanding that LA County still has a team.....did you interview the LA City Fire Dept or LA County Fire Dept?

[Horn229]

Yes but the Dover AFB pub is published after the latest AFI and it still says CISM. Why the difference?

The US Coast Guard still uses it. The Indianapolis police and fire depts still use it. Los Angeles County Fire Dept has a CISM team, City of Pittsburgh has a CISM team, Dallas Fire-Rescue has a CISM team......the list goes on and on.....

Not every department uses the ICISF CISM, so use other programs. Some fire departments train their firefighters with American Red Cross CPR , so use American Heart Assc, other use the National Safety Council......does this mean one is better then the other ?

I have no idea the reason why Dover AFB has their own thing going. From reading paragraph 3.2, they reference AFI 44-153 for the training CIST's must go through. I'm going to assume it's similar to a CAP wing, someone wrote up a supplement and forgot to make sure the regulation didn't get updated prior to approval.

In an interview I conducted with the current Director of Behavioral Health for the LAFD stated:

It doesn't meet the criteria of science for me to do it for eight years and say "well ya know, I did a lot of groups, I've done hundreds of debriefing groups" most people walk away and say "Thank you that was helpful", but I never had someone come up and say "that sucked, it upset me a lot". So my experience was it was pretty positive, but again that's not science. And just because someone said it was helpful doesn't mean that a year from now that it didn't... they still perceived it as helpful or that it didn't cause some other reaction that I never found out about.

According to the article on the ICISF's website, the LAFD had one of the oldest CISM programs, and they stopped using it.

It is interesting that the person you quote says most people said "it was helpful but....."

Is there any proof it hurts? Also just wondering It was my understanding that LA County still has a team.....did you interview the LA City Fire Dept or LA County Fire Dept?

Yep, people do walk away and say it was helpful, however that is not science, and the scientific studies say it doesn't work.

The interview I conducted was with the head of the behavioral health program for the LA City Fire Department.

And yes, there has been studies saying it hurts. Most studies find the control groups faired better, and a few say the debriefed groups had more adverse reactions. For reading material I'll quote myself again:

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.

The first link is a very interesting read, but on document page 58 (.pdf page 14 of 35 for me) starts the review of studies adduced in favor of CISD, then it moves on to studies showing null or adverse reactions, and some more good material continues on.