Critical Incident Stress Management, 2e

While sufficiently discredited by research, many first responding organizations continue to use Critical Incident Stress Management (CISM) as a part of their strategy for employee wellness, particularly after a big event or a mass casualty.  I’ve not made it a secret that I think CISM is harmful (which is consistent with research).  I most thoroughly discussed some of the problems in my review of Opening Up.  One could easily wonder why I read this book.  The answer has to do with intentionally trying to give it a chance – to extract some of the good things from the approaches.  I found a few nuggets, but it was hard to find the things that are good and should be a part of any trauma response program.

Take Two

Before I continue, I should say that I read another book about CISM, titled CISM: Group Crisis Intervention, that was so bad I couldn’t find enough to write a separate review for it.  I share this here to reinforce the statement that I’m trying to find value.

Emotional First Aid

Crisis intervention is sometimes considered emotional first aid.  The analogy breaks down pretty quickly.  The direct quote from the book is, “Urgent and acute emotional ‘first aid’ designed to stabilize and reduce symptoms of distress, while assisting the person in crisis to return to a state of adaptive functioning.”  The problematic part of this statement is the “in crisis to return to a state of adaptive functioning.”  It’s problematic, because it treats the person as if they’re misbehaving machine that just must be patched up long enough to get through the crisis.  It ignores the ways that we know humans respond.

Certainly, for a non-zero number of people, they’ll encounter a crisis, and they’ll be unable to continue.  However, this is a rare case in general and particularly in the first responder communities where CISM is still used.  It’s more likely that our automatic defenses will kick in – at least in the short term.

As humans, we have the ability to compartmentalize trauma so that we can remain functional by temporarily blocking out information related to the trauma.  (See Trauma Therapy and Clinical Practice.)  If that fails, the second-line defense of detachment makes it seem as if the trauma didn’t happen to us – or to the people we care the most about.  It’s like we’re watching from above or outside of the situation.  (See In an Unspoken Voice.)

At some point, either when our defenses have been exhausted, or a relative degree of safety is encountered, we’ll attempt to process the trauma and convert it from an implicit memory to an explicit memory.  This happens mostly during REM sleep.  (See Trauma and Memory for more.)

So, fundamentally, the premise that we’re patching someone up in situ (in the crisis or in the moment) is inconsistent with how we operate as humans (in most cases).

Immediacy, Proximity, and Expectancy

Everly and Mitchell refer back to a 1947 book, titled War Stress and Neurotic Illness.  They explain that the authors believe the key to crisis response are immediacy, proximity, and expectancy.  The problem is that the three of these are expressions of a single belief that the person will be supported.  In The Psychology of Hope, Rick Snyder explains the need for willpower and waypower for the cognitive process of hope.  However, when you consider Richard Lazarus’ work in Emotion and Adaptation or Lisa Feldman Barrett’s work in How Emotions Are Made, one realizes that there are expectations of how support will be received by others that influence the way that events are processed.

In short, the authors of War Stress and Neurotic Illness can be forgiven for not recognizing their articulation is about external expectancies of support.  In reviewing the subsequent research, it should be obvious that it’s about the belief that help will be provided.

Mandates

Everly and Mitchell claim that the US Air Force required “CISM-oriented” crisis response programs on all bases, but the cited AF144 153 doesn’t actually say this.  It does indicate that the Air Force needs to be able to care for personnel involved in a crisis – but that’s different.  They similarly claim that the US Coast Guard requires CISM teams via Commandant Instruction 1754.3.  It actually says they need to support personnel when they encounter stress – but it doesn’t specify the program or approach.

I think that’s part of my challenge with CISM: the statements are almost – but not quite – true.

Pennebaker

James Pennebaker has been kind enough to answer some questions about his work after my review of his book, Opening Up.  Everly and Mitchell refer to his work as the authority. That’s why the disconnect between what CISM is and what he recommends is so striking to me.  Pennebaker’s work calls out the need to develop a narrative in a safe way.  Specifically, his research showed a written narrative that could be destroyed without anyone seeing it was best.  This has no place in CISM as defined.

In personal communications with Pennebaker, he expressed some level of surprise that CISM was still in use after the research that had been done that indicated some degree of hazard.

The Core Components

Table 1.2 of the book is reproduced below, as it is the most succinct version of the overall program.

Without going into details, you’ll notice that many of the timeframes are inconsistent with what we know about how trauma is processed and what we need to do to recover.  In fact, it appears that some of these interventions can interfere with normal processing – making things worse.

What people need is to know they’re supported.  What can happen is these CISM interventions can feel more intrusive than supportive.  (For more on supportive environments, see Servant Leadership, and The Fearless Organization.)

Research

It’s normal for me to review the research that underpins books.  Sometimes, I’m so intrigued by an author’s summary of an article that I must read it to get the details.  Normally, this process isn’t that complicated.  However, for this book, it was.  In some cases, like Pennebaker’s work mentioned above, the book said nearly opposite of what the study said.  In other cases, I found that the articles being referenced were retracted.  In still others, I couldn’t find the article at all.  While this can happen to even the best researchers, the breadth and volume of the challenges I found gave me reason to pause and wonder what was going on.

Trauma Informed

By the very nature of a crisis response, we must expect psychological trauma involvement.  It’s possible for someone to navigate a crisis without psychological trauma – or lasting trauma.  However, the principles of trauma-informed care apply whether the person is impacted by a trauma or not.  (See Restoring Sanctuary for trauma-informed care.)

CISM correctly identifies that sometimes telling a person in crisis what to do is the wrong thing – because they need to be given a sense of control.  Telling the person what to do is certainly appropriate if someone is at eminent risk that they don’t understand, and you need immediate reaction.  However, in most cases, the best response is to try to create choice and options.

Evidence

In the end, CISM has some “evidence” that indicates a positive response.  The problem is that the evidence is very weak “sentiment” type research rather than results research (which is admittedly hard).  It reminded me of the “smile sheets” that Kirkpatrick rails against in the education market.  (See How People Learn.)  On balance, I think people like CISM because it makes them feel better – but it’s not clear that it makes them better.  It’s still worth learning about Critical Incident Stress Management.