CISM:

Does It Help or Not?

Rev. KC Schuler, MDiv, BCC
Supervising Chaplain
ThedaCare
(and ICISF Trained Trainer)

kc.schuler@thedacare.org

Most slides borrowed from ICISF: Group Crisis Response Training

At the heart of any field of study or practice

resides a basic vocabulary. Unfortunately, the
field of crisis and disaster mental health
intervention has been plagued by the lack of a
standardized nomenclature.
So, we will begin with a review of several key
terms and concepts that will help clarifiy some of
the issues and the materials later presented.

Critical Incident Stress (CIS)

is also known as
Post Traumatic Stress (PTS),
which is not the same as
Post Traumatic Stress Disorder (PTSD).

CIS/PTS is a normal response

of normal people to an abnormal event.
CIS/PTS reactions may look similar to some
symptoms of PTSD.
If the CIS/PTS does not get resolved,
it may turn into the disorder (PTSD).
Only a trained, Mental Health professional
can diagnose PTSD.

Definitions

CRITICAL INCIDENTS are unusually

challenging events that have the potential to
create significant human DISTRESS and can
overwhelm ones usual coping mechanisms.
In other words, and abnormal event that
evokes a normal response (CIS/PTS) to that
abnormal event

Definitions

The psychological DISTRESS in response to

critical incidents such as emergencies,
disasters, traumatic events, terrorism, or
catastrophes is called a
PSYCHOLOGICAL CRISIS
(Everly & Mitchell, 1999)

Psychological Crisis
An acute RESPONSE to a trauma, disaster,
or other critical incident wherein:
1.
Psychological homeostasis (balance) is
disrupted (increased stress)
2.
Ones usual coping mechanisms have failed
3.
There is evidence of significant distress,
impairment, dysfunction (PTS/CIS)
(adapted from Caplan, 1964, Preventive Psychiatry)

IMPORTANT!
Crisis intervention targets
the RESPONSE,
not the EVENT, per se.
Thus, crisis intervention and disaster
mental health interventions must be
predicated upon assessment of need.

Crisis Intervention (CI)

An active, short-term, supportive, helping

process.

Acute intervention designed to mitigate the

crisis response (CIS/PTS).

NOT psychotherapy or a substitute for

psychotherapy.

Crisis Intervention (CI)

Goals:
1. Stabilization
2. Symptom reduction
3. Return to adaptive functioning, or
4. Facilitation of access to continued care
(adapted from Caplan, 1964, Preventive Psychiatry)

Crisis Intervention (CI):

Lessons Learned From The Military

Salmon (1919, NY Med J) Nothing could be

more striking than the comparison between the cases
treated near the front and those treated far behind the
linesAs soon as treatment near the front became
possible, symptoms disappearedwith the result that
sixty percent with a diagnosis of psychoneurosis were
returned to duty from the field hospital (p. 994).

Principles of Crisis Intervention (CI):

(Most Were Developed By The Military)

Proximity
Immediacy
Expectancy
Innovation
Brevity
Simplicity
Pragmatism

Crisis Intervention:
Leadership Communication

Intentional or unintentional communication:

1.
Compassion: Deep awareness of the suffering of
another coupled with the wish to relieve it
2.
Disdain: To regard or treat with contempt;
despise
3.
Indifference: Having no particular interest or
concern; apathetic
The American Heritage Dictionary of the English
Language, Fourth Edition
Copyright 2006 by Houghton Mifflin Company.

The Need in EMS?

Incidence of Posttraumatic Stress with EMS in urban

setting (NYC)
(9.3%) met the strict DSM-III-R criteria for PTSD
Another (10%) had the required number and combination
of symptoms for PTSD, but these symptoms had not
persisted for the 1 month required by the DSM-III-R
criteria.
Thus, a total of 19.3% of subjects who completed the
survey were shown to be suffering from PTSD
symptoms.
Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers ,
Medscape Psychiatry & Mental Health eJournal 2(5), 1997. 1997 Medscape

The Need in EMS? (cont.)

The interaction between age and several other factors,

however, was significant, including:
Study participants between the ages of 18 and 24 who
graduated from a rural high school were nearly 3
times as likely to have PTSD as those from urban or
suburban high schools
The prevalence of PTSD increased significantly with
the total number of previous medical emergency work
jobs
Development of Posttraumatic Stress Disorder in Urban Emergency Medical Service Workers ,
Medscape Psychiatry & Mental Health eJournal 2(5), 1997. 1997 Medscape

Review for Canadian Armed Forces

Ritchie, P. (2002)

Literature suggests value in debriefing

CISD (debriefing) should only use group format
CISD should be offered as part of a larger integrated
intervention system (CISM)

Participation is Voluntary and involves informed consent

CISD contraindicated if basic physiological, shelter, &
safety needs not met
Positive outcome may be other than prevention of PTSD
(provides information, support, may increase cohesion,
positively viewed)

Lessons Learned From

Community Mental Health

Early Psychological Intervention may reduce the need

for more intensive psych services.
(Langsley, Machotka, & Flomenhaft, 1971, Am J Psyc;
Decker, & Stubblebine, 1972, Am J Psyc)

Early Psychological Intervention may mitigate acute

distress .
(Bordow & Porritt, 1979, Soc Sci & Med; Bunn & Clarke,
1979, Br. J Med. Psychol; Campfield & Hills, 2001, JTS;
Flannery & Everly, 2004, Aggression & Violent Beh.)

Lessons Learned From

Community Mental Health

Early psychological Intervention may reduce EtOH

use.
(Deahl, et al, 2000, Br J Med Psychol; Boscarino, et al., 2005)

Lessons Learned From

Consultation Psychiatry

(Stapleton, Medical Crisis Intervention, 2004)

Early Psychological Intervention is improved

by increased training in a standardized CI
paradigm
Results:
trained

d=.57 vs.
untrained d=.29

Lessons Learned From

Consultation Psychiatry

(Stapleton, Medical Crisis Intervention, 2004)

Early Psychological Intervention outcome is

enhanced via multiple sessions
(multiple contacts d=.60 vs. single contact d=.33)
(plateau at 2-3 sessions, Boscarino, et al., 2005)

Early Psychological Intervention is enhanced

via the use of multiple interventions on PTS
(multiple interventions d=.62 vs. single interventions d=.55)

Lessons Learned From The Workplace

Post disaster crisis intervention (CISM) was

associated with reduced risk for:

binge drinking (d=.74)

alcohol dependence (d=.92)
PTS symptoms (d=.56)

(Boscarino, et al, IJEMH, 2005).

Lessons Learned From The Workplace

Post disaster crisis intervention (CISM) was
associated with reduced risk for:

major depression (d=.81)

anxiety disorder (d=.98)
global impairment (.66)
compared with comparable individuals who did not receive
this intervention

(Boscarino, et al, IJEMH, 2005).

There is now emerging evidence that prompt delivery of

brief, acute phase services in the first weeks after an
event can lead to sustained reduction in morbidity years
later, reducing the burden of secondary functional
impairment, presumed daily average life years lost
(DALYS), and costs to both the individual and the
public (p. 15).
Schreiber, M. (Summer, 2005). PsySTART rapid mental health triage and
incident command system. The Dialogue: A Quarterly Technical Assistance
Bulletin on Disaster Behavioral Health, 14-15.

Value Added of Crisis Intervention:

Screening & Increasing Access To Care

Only 11% of victims of violent crime responded to institutional

invitations to express attitudes regarding crime & punishment
Less than 7% of sexual assault victims chose to utilize free
psychotherapy within walking distance of their home
(Rose, et al., Psychological Medicine, 1999).

Formal mental health utilization post 9/11 increased only ~3%

in civilians and emergency personnel even though prevalence
of PTSD estimated at 7-20% and depression at ~9%
(see Johns Hopkins Center for Public Health Preparedness -- JHCPHP,
2005)

Value Added of Crisis Intervention:

Screening & Increasing Access To Care

First responders are often resistant to seeking Mental Health

treatment, therefore crisis intervention may be their only access
to mental health services
(North, et al., 2002, J. T. Stress)

While ~ 85% of military sampled who served in

Iraq/Afghanistan recognized problems, only ~44% were
willing to seek assistance
(Hoge et al., NEJM, 2004)

Less than 50% of civilian disaster workers, who screened + for

mental health concerns sought treatment
(Jayasinghe, et al, 2005, IJEMH)

Reasonable Evidence-based Conclusions

More and better controlled research is still needed

Care must be taken in setting up a support response

Data reviewed support use of group debriefing with

emergency services personnel (Arendt & Elklit, 2001)

Data reviewed tend to support use of group

debriefing subsequent to disasters, war, robbery
(see NIMH, 2002, tables 2-3)

Reasonable Evidence-based Conclusions

The research does not support single session,

individualized interventions after medical, surgical
distress with minimal training (nurses with 15 min
training)
The research does support multi-component
intervention systems
NIMH (2002), Institute of Medicine (2003), NVOAD
(2005) recommend acute phase psychological first
aid

In all the controversy, criticism and research debate on

the merits of debriefing [early intervention], certain
constants are emerging. The most effective methods for
mitigating the effects of exposure to trauma, those
which will help keep our people healthy and in service,
are those which use early intervention, are multi-modal
and multi-component. That is, they use different active
ingredients , and these components are used at the
appropriate time with the right target group.
Dr. Hayden Duggan
International Association of Fire Chiefs ICHIEFS
on-line resource, Sept 1, 2002

Acceptance of Psychological Debriefings (PD)

Since PD is fully accepted as standard practice for
emergency services personnel and well-received by
group members and organizations, it is hard to find
fault in its application in a mass disaster
such as the terrorist attackson september 11, 2001.
(Litz, et al., Clin. Psyc. 2002)

Crisis Intervention (CI): Key Points

Crisis Intervention is not intended to be the practice of

psychiatry, psychology, social work, nor counseling, per se, it
is simply psychological/emotional first aid

Consistent with NIMH guidelines and Federal crisis

counseling models, crisis intervention may be practiced by
mental health clinicians, as well as, medical personnel, clergy,
& community volunteers (although we believe mental health
guidance, supervision, or oversight is essential)

AGAIN, Crisis intervention does not appear to

prevent PTSD in primary victims.

Resistance, Resilience, & Recovery

In the present context, the term Resistance

refers to the ability of an individual, a group,
an organization, or even an entire population,
to literally resist manifestations of clinical
distress, impairment, or dysfunction associated
with critical incidents, terrorism, and even
mass disasters.

Resistance, Resilience, & Recovery

Resistance may be thought of as a form of

psychological/ behavioral immunity to distress
and dysfunction.

Pre-incident training/preparation may be best

way to build resistance

Resistance, Resilience, & Recovery

In the present context, the term Resilience

refers to the ability of an individual, a group,
an organization, or even an entire population,
to rapidly and effectively rebound from
psychological and/or behavioral perturbations
associated with critical incidents, terrorism,
and even mass disasters.

Resistance, Resilience, & Recovery

Resilience is an ordinary, not extraordinary response

associated with:

Capacity to make and follow out realistic plans

Positive view of self, strength, and abilities
Communication and problem solving skills
Capacity to manage strong feelings

Crisis and disaster mental health intervention may be

the best way to enhance natural Resiliency, in
addition to pre-incident preparation.

Resistance, Resilience, & Recovery

The term Recovery refers to the ability of an

individual, a group, an organization, or even an entire
population, to literally recover the ability to
adaptively function, both psychologically and
behaviorally, in the wake of a significant clinical
distress, impairment, or dysfunction (PTS/CIS)
subsequent to critical incidents, terrorism, and even
mass disasters.
Crisis intervention, Treatment, and rehabilitation
speeds Recovery.

Goals of a Multi-Component Crisis

Intervention System

An outcome-driven continuum of care

Create Resistance

Enhance Resiliency

Speed Recovery

Assessment
Intervention
Evaluation

Assessment
Intervention
Evaluation

Assessment
Intervention
Evaluation

[Kaminsky, et al, (2005) RESISTANCE, RESILIENCE, RECOVERY. In Everly & Parker,

Mental Health Aspects of Disaster: Public Health Preparedness and Response. Balto: Johns

CISM is a strategic intervention

system.
It possesses numerous
tactical interventions of which
CISD is one.

The challenge in crisis intervention is not only

developing TACTICAL skills in the core
intervention competencies,
but is in knowing when to best
STRATEGICALLY employ the most
appropriate intervention for the situation.

Core Competencies Of Comprehensive

Crisis Intervention

Assessment/triage benign vs. malignant symptoms

Strategic planning and utilizing an integrated multicomponent crisis intervention system within an
incident command system
One-on-one crisis intervention
Small group crisis intervention
Large group crisis intervention
Follow-up and Referral

Can Intervention Be Harmful ?

The Case of Psychotherapy...

Smith, Glass, & Miler (Benefits of Psychotherapy,

1980) meta-analytic review of 400 studies --> 9%
negative outcome

Shapiro & Shapiro (Psychol. Bulletin, 1982) over

1800 effects --> 11% negative, 30% null effect

Lambert (2003) estimated 5-10% of patients

deteriorate during treatment

Can Crisis Intervention Be Harmful ?

Theoretical Mechanisms/ Issues
(see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003)

Excessive catharsis, disclosure, rumination

Pathologizing otherwise normal reactions

Vicarious traumatization in groups

Coercive peer pressure in groups

Scapegoating in groups

Can Crisis Intervention Be Harmful ?

Theoretical Mechanisms/ Issues
(see Dyregrov, IJEMH, 1999; Watson, et al., in Ursano & Norwood, 2003)

Triggering of previous traumatic memories

Intervention may be premature (inappropriate timing)

May be inappropriate with highly aroused persons

May interfere with natural coping mechanisms

May not be accompanied by adequate assessment or follow-up

7 Phases of a CISD
COGNITIVE
INTRODUCTION

Re-entry

FACT

TEACHING

THOUGHT

SYMPTOMS

REACTION

AFFECTIVE

Reducing Risk of Adverse Reactions

Keep CISD within the multi-component

context of CISM:
CISD should never be a stand alone intervention. It
should only be used when it is part of a package of
interventions which includes follow-up services.

Reducing Risk of Adverse Reactions

The group CISD process should never be used

for individuals since it was designed for
groups

CISD should not be used to achieve

psychotherapeutic outcome: CISD is not
psychotherapy nor a substitute for
psychotherapy

Reviews which have been critical of small

group debriefing cite 3 primary concerns:

Traumatic story-telling may traumatize other participants

(Watson, et al., 2003, in Trauma & Disaster; Stokes, 2002, Cautions
& Contraindications for Debriefings)

Probing into affective domain with those who experience

numbing & avoidance may trigger pathognomonic retraumatization
(North, 2003, in Trauma & Disaster; Stokes, 2002)

Inappropriate timing for hyper-aroused individuals

(NIMH, 2002)

To address concerns related to

group debriefing

Maintain/facilitate an educational and story-telling format

(Shalev, et al., 2003, Terrorism & Disaster)

Utilize homogeneous groups so as to prevent

traumatization from new information (similar levels of
exposure and function:

do not include bystanders, etc. with professionals

Judgement call about mixing professions (Fire, EMS, Law
Enforcement) note: ICISF discourages mixing

Avoid delving into the affective aspects with groups that

are experiencing heightened arousal, avoidance, or
numbing (North, 2003; Stokes, 2002)

To address concerns related to

group debriefing

Unless the magnitude of impairment is such that the

individual represents a threat to self or others, crisis
intervention should be voluntary.

The interventionist must be careful not to interfere with

natural recovery or adaptive compensatory
mechanisms.

The CISD has not ended until the majority of the group
has returned to the cognitive domain and/or may
require individual referrals to higher level of care

Summary Risks vs. Benefits of CISM

The risk of adverse outcome is associated with

all human intervention and helping practices including
medicine, surgery, and counseling.
Improper, inadequate training would appear
the greatest risk factor associated with crisis
intervention, as well as those practices just mentioned.
Thus, training and supervision may be the best way to
reduce the risk of adverse outcome, rather than simply
calling for an end to such helping practices.

Effectiveness Of
Peer Support Personnel References

Peer Support Personnel are essential in the CISM process

Authentic Normalization
Rapport
Clarification of protocol/process
Etc.

Truax & Carkhuff, 1967,

Toward Effective Counseling

Durlak, 1979,

Psychological Bulletin

Hattie, Sharpley, Rogers, 1984,

Psychological Bulletin

Important CISD Considerations &

Ground Rules

Strict Confidentiality agreed upon by participants and team

Timing is important
Location and physical environment appropriate
Closed circle format
Participation voluntary
No notes, recording devices
No breaks (Try to limit breaks until after group is finished)
Not operational critique, not investigation
Not a blame session
Not therapy, nor substitute for treatment

Q
ue
sti
on
s?

Additional Information
and More Slides

International Critical Incident Stress Foundation

http://www.icisf.org/
http://www.icisf.org/articles/

Crisis Intervention and Critical Incident Stress Management: A

Defense of the Field
http://www.icisf.org/articles/Acrobat%20Documents/CISM_Defense_o
f_Field.pdf

National Organization for Victim Assistance NOVA

http://www.trynova.org

THE NEED

Over 80% Americans (general population) will be

exposed to a traumatic event (Breslau) About 9% of
those exposed develop PTSD (40-70% in cases
involving rape/torture)
(Surgeon General, 1999, Report on Mental Illness)

Disasters may create significant impairment in 4050% of those exposed

(Norris, 2001, SAMHSA)

THE NEED

About 50% of disaster workers likely to develop

significant distress
(Myers & Wee, 2005, Dis. Men. Hlth)

As many as 45% of those Directly Exposed to mass

disasters may develop PTSD or Depression
(North, et al., 1999, JAMA)

Dose-response relationship with exposure is a key

factor in development of PTSD (DSM-IV R)

THE NEED

PTSD PREVALENCE: 10-15% OF LAW

ENFORCEMENT PERSONNEL
(see Everly & Mitchell, 1999)

PTSD PREVALENCE: 10-30% OF THOSE IN FIRE

SUPPRESSION (see Everly & Mitchell, 1999)

By comparison: PTSD PREVALENCE: VIETNAM

VETERANS 16% (National PTSD Study)

THE NEED

PTSD PREVALENCE: ~12%, Iraq Desert Storm

VETERANS (Hoge, et al., 2004, NEJM)

PTSD PREVALENCE: unknown% with current

Iraq/Afghanistan
War Veterans
Iraq/
(VA system receiving public criticism for lack of support and
experts anticipating high numbers, May 2007 NYTimes)

By way of background
The National Volunteer Organizations
Active in Disaster (NVOAD)
represents a consortium of
non-governmental agencies
providing disaster relief.
NVOAD member organizations represent
the largest group of non-governmental
providers of disaster mental health services
in North America.

NVOAD Consensus Points (2005)

Early Psychological Intervention ( EPI) is

valued
EPI is a multi-component system to meet
the needs of those impacted
Specialized training in early psychological
intervention is necessary

NVOAD Consensus Points (2005)

EPI is one point on a continuum of

psychological care. This spectrum ranges
from pre-incident preparedness to postincident psychotherapy -- when needed
Cooperation, communication, coordination
and collaboration are essential to the
delivery of EPI

NVOAD Interventions (2005)

Pre-incident preparation
Incident assessment and strategic planning
Risk and crisis communication
Acute psychological assessment and triage
Crisis intervention with large groups
Crisis intervention with small groups
Crisis intervention with individuals, face-toface and hotlines

NVOAD Interventions (2005)

Crisis planning and intervention with

communities
Crisis planning and intervention with
organizations
Psychological first aid (PFA)
Facilitating of access to appropriate levels of
care when needed

NVOAD Interventions (2005)

Assisting special and diverse populations

Spiritual assessment and care

All NVOAD recognize need for spiritual care

Self care and family care including safety and

security
Post incident evaluation and training based on
lessons learned

Employee Assistance Professionals Association

Disaster Response Task Force
(EAPA, 2002)

EAPS should develop workplace disaster plans

Plans should consist of a continuum of
interventions, including:

Pre-Incident Training/Coordination (early CISM

intervention training, resiliency training, risk
assessment, policy development)
Acute response protocols

Employee Assistance Professionals Association

Disaster Response Task Force
(EAPA, 2002)

Plans should consist of a continuum of

interventions including:

Post-Incident Response (defusing, CISD, crisis

management briefings, assessment/ referral, selfcare)
Follow-up (supervisory briefings, assessment,
training)
Post-Incident Review and Plan Reformulation