By Daniel W. Clark, Department Psychologist, Washington State Patrol; and Michael Haley, Chief of Police (retired), Clinton Township, Franklin County, Ohio
ublic safety personnel are exposed daily to a variety of potentially traumatic events, including human tragedies such as abused and distressed children, the aftermath of domestic violence, horrific motor vehicle accidents, disturbing crime scenes, disasters, and acts of terrorism.1 Critical Incident Stress Management (CISM) is an effective and valuable crisis intervention system designed to mitigate the impact of these traumatic incidents on police officers and other emergency responders.
Law enforcement has long since upgraded from horses to cruisers, from call-boxes to radios, and from revolvers to semiautomatic pistols—but equipment is not the only aspect of policing that has changed. With each innovation and improvement in equipment, the training and mindset of the officers who serve their communities must also change. With these changes comes increased exposure to stress and traumatic events. It is incumbent upon visionary administrators to find ways to provide for the psychological wellbeing of their law enforcement officers so that these officers can continue to pro vide their valuable service.2
This article demonstrates three aspects of CISM: how the system applies recognized crisis intervention principles to the high-risk/high-exposure population of law enforcement; how its interventions effectively encourage personnel to talk about these critical events; and how research supports its effectiveness.
CISM is an integrated, multicomponent crisis intervention system.3 The system contains a range of specific intervention tools spanning the spectrum of crisis experience, from before the incident to after the crisis has been resolved. Each tool, when applied appropriately and within the scope of its design by trained CISM personnel, is effective in assisting individuals and groups in crisis.
A Critical Incident Stress Debriefing (CISD) is a structured, small-group crisis intervention scheduled typically 2 to 14 days after a critical incident. It focuses on discussing critical incidents such as death in the line of duty, serious injury, mass casualty incidents, disasters, acts of terrorism, sui-cide, officer-involved shootings, serious motor vehicle accidents, injury or death of children, and so on. A team composed of a CISM-trained mental health professional (MHP) and at least one CISM-trained peer supporter facilitates the CISD. The emphasis during a CISD is on mitigating distress, facilitating psychological normalization, providing effective stress management education, identifying external coping resources, and restoring unit cohesion and performance. A CISD is not psychotherapy or counseling but a group support process.4
The term debriefing has been used in several ways, leading to significant confusion. SWAT teams or military units typically “debrief” after an operation, focusing on the operational or tactical elements. Mental health professionals, working with law enforcement agencies, may “debrief” individual officers after a critical incident such as an officer-involved shooting.5 Within the field of CISM, an intervention by a single MHP is not considered a CISD/debriefing but an individual crisis intervention, because a debriefing is defined as a small-group intervention facilitated by a team. This article will use the term CISD to refer only to the group intervention described in the previous paragraph.
A traumatic event is defined as any event that has sufficient impact to overwhelm the usually effective coping skills of either an individual or a group. These events are typically sudden, emotionally powerful, and outside the range of usual human experience. These events may have a strong emotional effect even on well-trained and experienced individuals.6
In a crisis, an individual’s sense of psychological balance is disrupted by an adverse event or stressor. Most importantly, the individual’s usual coping mechanisms become temporarily ineffective. This leaves the individual potentially feeling overwhelmed, vulnerable, and/or agitated. In extreme circumstances, job performance and personal health may be impaired.
CISM As Crisis Intervention
Crisis intervention techniques grew out of disaster response and military writings in the early 20th century.7 Although various models of crisis intervention exist, most recognize several common core principles, including proximity, immediacy, expectancy, and simplicity. Interventions are begun as soon as possible in an effort to restore traumatized individuals to precrisis functioning levels, with the immediate goal of stabilizing them and helping them rally their resources and support networks. The focus is on problem solving in order to regain control, facilitating understanding of what occurred, and encouraging self-reliance. One of the key mechanisms of action is cathartic ventilation, or talking about the event.
In the evolution of crisis intervention, CISM represents a new generation of collective intervention strategies that focus on managing the stressors of the job. In the 1980s, Jeffrey Mitchell and George Everly Jr., cofounders of the International Critical Incident Stress Foundation, began applying established crisis intervention principles to the high-risk/high-exposure populations of public safety and emergency responders. Combining their experiences in working with emergency responders and dealing with trauma, they built upon what firefighters and police officers were already doing—“tailboard talks” and “choir practice,” as they were sometimes called—added a structure, and called the process a CISD, defining it as a small-group intervention within CISM.
This support program for emergency personnel, which began with only a few crisis intervention services (including the CISD small-group process), has been refined and expanded into the current multicomponent CISM system over the past 30 years.8
Among the intervention tools are preincident education, which provides an introductory overview of stress, basic stress management techniques, and examples of when CISM might be helpful. One goal is educating officers that the signs and reactions generated by critical incidents are normal reactions to abnormal situations.9
A Crisis Management Briefing (CMB) combines factual information about an event with typical physical and emotional responses, as well as basic coping techniques, in a small- or large-group format. CMBs appear to be particularly adaptable with police officers.10
Most crisis interventions are performed on an individual basis. Chaplains or psychologists who talk with emergency responders following a critical incident are providing individual crisis intervention or “emotional first aid” for someone in crisis.
Peer support is a form of individual crisis intervention with someone who does the same job, or a similar one. Peer supporters are typically not counselors or therapists but are individuals trained to provide support to their coworkers. Peer supporters may be police officers, firefighters, dispatchers, support or administrative personnel, nurses, soldiers, and so on. As an example, teams of trained peer supporters are deployed by a nonprofit organization called Concerns of Police Survivors (COPS) each May during National Police Week to assist survivors as they remember and mourn their fallen officers. Peer support is very effective with police officers, who are often reluctant to cross the “thin blue line” to talk about their experiences with nonofficers. Typical police peer support teams train other police officers, their “peers,” in listening skills, problem solving strategies, stress management techniques, and referral options—thus allowing cops to take care of cops.11
Officer Marlene Loos, of the Suffolk County, New York, Police Department, was shot while responding to a disturbance. Recounting her subsequent struggles, she stated, “Fellow officers who experienced similar traumas have given me the most help,” illustrating the power of peer support. She remembered that in the psychological aftermath of her ordeal, she asked herself, “Who will rescue the rescuers?”12 Here CISM and peer support can play a vital role: by having peers who have “been there, done that,” and survived assist fellow officers.
Some critical incidents may be so overwhelming to certain individuals that acute intervention techniques are insufficient. Follow-up and referral allows CISM teams to identify those who may need additional services and provide appropriate referrals to the next, higher level of care.
Additional crisis interventions, such as support from significant others or family as well as pastoral crisis intervention services, are common in well-developed CISM programs but are beyond the scope of this article. Effective CISM programs employ a range of crisis intervention procedures.13 A key challenge is to intervene only where and when needed, using the type of intervention most appropriate for the specific situation.
When asked how they deal with their emotional reactions to events, most police officers will respond that they “stuff them.” Emergency responders tend to be resilient, successfully coping with stress, crises, and trauma. Most responders cope with the exposure to others’ crises day in and day out, maintaining good psychological dispositions. Only a few may be adversely affected following a critical incident. For such individuals, it seems reasonable to provide the option of talking about their reactions via crisis intervention tools. CISM interventions effectively encourage police officers to talk about the events they experience, despite their traditional reluctance.
How do we know talking helps? Self-disclosure, or talking about one’s own experiences, helped military personnel in multinational peacekeeping operations in Somalia successfully adapt to their stressful deployment. Increased self-disclosure was found to be related to lower levels of posttrauma symptoms, especially when talking with supportive significant others, friends, or military personnel.14
Police psychologist Nancy Bohl compared 40 police officers who attended a CISD within 24 hours of a critical incident with 31 officers who did not.15 She found that at follow-up three months later, the officers who attended the CISD were less depressed, less angry, less anxious, and had fewer posttrauma symptoms. A second study using firefighters found similar results.16
David Wee, Dawn Mills, and Gus Koehler studied emergency medical personnel who responded to the Los Angeles civil disturbance in 1992.17 They compared 42 emergency medical personnel who attended a CISD within 24 hours of the incident with 23 emergency medical personnel who did not attend a CISD. They found those who did attend reported fewer posttraumatic symptoms three months after the incident.
In the positive-outcome studies cited here, researchers evaluated only one crisis intervention technique. When several techniques are combined, the positive results are strikingly stronger.18
As a result of these findings, a 2002 National Institutes of Mental Health document supports early intervention and the use of a comprehensive, systematic, and multicomponent approach to crisis intervention.19 It affirms the role of designated peer supporters and paraprofessionals in early intervention. It also supports the concept that only properly trained individuals should provide early intervention services.
In addition, the IACP recommends debriefings and peer support following acts of domestic terrorism.20
Research and the Debriefing Controversy
Crisis interventions in general, and specifically CISM, have been the target of criticism in recent years. However, careful review of these detracting studies reveals that many have serious flaws in their research methods. Most articles purporting to prove that CISM is ineffective are based on findings of researchers who intervene inappropriately, do not apply the CISM model as constructed, and/or apply CISM with population groups for which it was not designed.21
For example, Bisson and others concluded that debriefings had questionable utility after comparing severely burned patients who did not receive an individual “debriefing” with burn patients who did receive an individual “debriefing.”22 Note that the researchers inappropriately applied a group crisis intervention process to individuals. In addition, these patients were still hospitalized and in significant pain. One of the core aspects of proper CISDs is that they are performed in a neutral location 2 to 14 days after a traumatic incident has concluded. Clearly, individual burn patients “debriefed” in their hospital room while still being treated do not meet this criterion.
A meta-analysis of published studies reported that CISDs did not reduce the effects of posttraumatic stress disorder (PTSD) and other trauma-related symptoms when compared to non-CISD interventions or control groups.23 The authors selected seven studies to include in their meta-analysis; however, only one was a group debriefing (which did not follow the standard protocol for a CISD). Six were “individual debriefings” on primary victims, for whom the process was never intended. Furthermore, the seven studies included a mixture of CISDs, “process debriefings,” and “Raphael model debriefings”—interventions the authors describe as “differing in their emphasis on structure and in certain aspects of content.”24
To underscore the importance of using tools appropriately and effectively, consider a technique with which most law enforcement personnel are very familiar: cardiopulmonary resuscitation (CPR). When a trained individual performs CPR correctly, it can be a lifesaving intervention. However, if the individual performing CPR does not apply the technique as developed and taught, grievous harm and even death may result from applying insufficient force (ineffective use) or from applying too much force (causing broken ribs that can puncture the lungs, heart, or major blood vessels).
Finally, a recent review of published studies concerning CISD suggests that a more appropriate research question may be, “With whom is CISD effective?” rather than, “Is CISD effective?” Julie Jacobs, Lynn Horne-Moyer, and Rebecca Jones conclude that CISDs may be an effective means of reducing symptoms in emergency responders but may be less effective when applied to primary victims—those directly affected by the incidents.25 The majority of studies that claim CISDs and CISM do not work involve primary victims, not emergency personnel.26
There are more than 60 positive-outcome studies on the CISM system and CISD small-group process. More detailed research reviews are available.27
We offer the following recommendations to chiefs and other law enforcement executives:
- Increase awareness not only of the risks of a law enforcement career to officers and their families but also of support options, such as CISM, mental health professionals, peer support personnel, faith-based interventions, and employee assistance programs.
- Ensure that the CISM teams you recruit to assist employees and family members use fully trained and experienced personnel.
- Increase awareness and implementation of the guidelines published by the IACP Police Psychological Services Section, available on pages 88-93 of this issue or online at www.theiacp.org/div_sec_com/sections/psych.htm.
CISM is an effective and valuable crisis intervention system that can mitigate the impact of traumatic incidents on police officers and other emergency responders. When applied appropriately and within the scope of its design by trained personnel, CISM is effective in assisting individuals and groups in crisis.
One of the challenges is intervening only where and when needed, using the most appropriate intervention for the situation. Early psychological intervention should be based on recognition of need, not strictly the occurrence of an event.
The most valuable resource in any organization is its personnel. An organized and systematic approach to managing psychological crises can go far in maintaining the health and effective performance of law enforcement and emergency services personnel.■
|Daniel W. Clark, Ph.D., is a licensed clinical psychologist with the Washington State Patrol, where he is the clinical director of the patrol’s peer support and CISM teams. A member of the International Critical Incident Stress Foundation faculty since 1998 and a recognized trainer since 1996, he is also past president of the Washington Critical Incident Stress Management Network.|
|Michael Haley served as a police officer for 26 years and retired in March 2001 as the chief of police for Clinton Township, Franklin County, Ohio. He is currently chairperson of the National Fraternal Order of Police Critical Incident Program and director of the Fraternal Order of Police of Ohio’s Critical Incident Response Service, which he has chaired since 1996. Haley responded, on multiple occasions, to the World Trade Center disaster as part of a law enforcement CISM response, as well as provided CISM services to the New Orleans Police Department during the aftermath of Hurricane Katrina. |
1See, for example, John M. Violanti and Anne Gehrke, “Police Trauma Encounters: Precursors of Compassion Fatigue,” International Journal of Emergency Mental Health 6, no. 2 (2004): 75–80; and Tara A. Hartley et al., “Associations between Major Life Events, Traumatic Incidents, and Depression among Buffalo Police Officers,” International Journal of Emergency Mental Health 9, no. 1 (2007): 25–35.
2Richard L. Levenson Jr. and Lauren A. Dwyer, “Peer Support in Law Enforcement: Past, Present, and Future,” International Journal of Emergency Mental Health 5, no. 3 (2003): 147–152.
3George S. Everly Jr. and Jeffrey T. Mitchell, Critical Incident Stress Management (CISM): A New Era and Standard of Care in Crisis Intervention (Ellicott City, Md.: Chevron, 1999).
4George S. Everly Jr. and Jeffrey T. Mitchell, “The Debriefing ‘Controversy’ and Crisis Intervention: A Review of Lexical and Substantive Issues,” International Journal of Emergency Mental Health 2, no. 4 (2000): 211–225.
5Laurence Miller, “Officer-Involved Shooting: Reaction Patterns, Response Protocols, and Psychological Intervention Strategies,” International Journal of Emergency Mental Health 8, no. 4 (2006): 239–254.
6Hartley et al., “Buffalo Police Officers,” 26; Laurence Miller, “Critical Incident Stress Debriefing for Law Enforcement: Practical Models and Special Applications,” International Journal of Emergency Mental Health 8, no. 3 (2006): 189–201.
7Raymond B. Flannery and George S. Everly Jr., “Crisis Intervention: A Review,” International Journal of Emergency Mental Health 2, no. 2 (2000): 119–125.
8See Everly and Mitchell, Critical Incident Stress Management; Miller, “Officer-Involved Shooting”; Miller, “Critical Incident Stress Debriefing for Law Enforcement”; Jeffrey T. Mitchell and Richard L. Levenson, “Some Thoughts on Providing Effective Mental Health Critical Care for Police Departments after Line-of-Duty Deaths,” International Journal of Emergency Mental Health 8, no. 1 (2006): 1–4; Nancy Bohl, “Measuring the Effectiveness of CISD,” Fire Engineering 148, no. 8 (1995): 125–126; and David F. Wee, Dawn M. Mills, and Gus Koehler, “The Effects of Critical Incident Stress Debriefing (CISD) on Emergency Medical Services Personnel following the Los Angeles Civil Disturbance,” International Journal of Emergency Mental Health 1, no. 1 (1999): 33–38.
9Shannon Bohrer, “After Firing the Shots, What Happens?” FBI Law Enforcement Bulletin 74, no. 9 (2005): 8–13. For an example of a preincident presentation, see Daniel W. Clark, “Basic Critical Incident Stress Management,” http://www.criticalconcepts.org/Pre_Incident%20Education_V.ppt (accessed July 3, 2007).
10Daniel W. Clark and Peter Volkmann, “Enhancing the Crisis Management Briefing,” International Journal of Emergency Mental Health 7, no. 2 (2005): 133–140.
11Donald C. Sheehan, George S. Everly Jr., and Alan Langlieb, “Current Best Practices: Coping with Major Critical Incidents,” FBI Law Enforcement Bulletin 73, no. 9 (2004): 1–13. The Police Psychological Services Section of the IACP has posted recommended guidelines for peer support teams (revised in 2006), available online at http://www.theiacp.org/div_sec_com/sections/PeerSupportGuidelines.pdf (accessed July 3, 2007).
12Marlene Loos, quoted in Anna Knight, “In the Line of Duty: 2001 Survivor’s Club Update,” The Police Chief 68, no. 5 (2001): 33.
13Sheehan, Everly, and Langlieb, “Current Best Practices,” 1–13.
14Elisa E. Bolton et al., “The Relationship between Self-Disclosure and Symptoms of Posttraumatic Stress Disorder in Peacekeepers Deployed to Somalia,” Journal of Traumatic Stress 16, no. 3 (2003): 203–210.
15Nancy Bohl, “The Effectiveness of Brief Psychological Interventions in Police Officers after Critical Incidents,” in James T. Reese, James Horn, and Christine Dunning, eds., Critical Incidents in Policing, rev. ed. (Washington, D.C.: U.S. Department of Justice, 1991), 31–38.
16Bohl, “Measuring the Effectiveness of CISD,” 126.
17David Wee, Dawn Mills, and Gus Koehler, “The Effects of Critical Incident Stress Debriefing,” 33–38.
18David Richards, “A Field Study of Critical Incident Stress Debriefing versus Critical Incident Stress Management,” Journal of Mental Health 10, no. 3 (2001): 351–362.
19National Institutes of Mental Health, Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence: A Workshop to Reach Consensus on Best Practices, NIH Publication No. 02-5138 (Washington, D.C.: U.S. Government Printing Office, 2002), http://www.nimh.nih.gov/publicat/massviolence.pdf (accessed July 3, 2007).
20International Association of Chiefs of Police, Leading from the Front: Law Enforcement’s Role in Combating and Preparing for Domestic Terrorism, IACP Project Response (Alexandria, Va.: IACP, 2002), http://www.iacp.org/documents/pdfs/Publications/Terrorism.pdf (accessed July 3, 2007).
21Michelle R. Tuckey, “Issues in the Debriefing Debate for the Emergency Services: Moving Research Outcomes Forward,” Clinical Psychology: Science and Practice 14, no. 2 (2007): 106–116.
22Jonathon I. Bisson et al., “Randomized Controlled Trial of Psychological Debriefing for Victims of Acute Burn Trauma,” British Journal of Psychiatry 171 (1997): 78–81.
23Arnold A. P. Van Emmerick et al., “Single Session Debriefing after Psychological Trauma: A Meta-analysis,” The Lancet 360, no. 9335 (2002): 766–771.
25Julie Jacobs, H. Lynn Horne-Moyer, and Rebecca Jones, “The Effectiveness of Critical Incident Stress Debriefing with Primary and Secondary Trauma Victims,” International Journal of Emergency Mental Health 6, no. 1 (2004): 5–14.
26Jeffrey T. Mitchell, “Crisis Intervention and CISM: A Research Summary,” International Critical Incident Stress Foundation, 2003, http://www.icisf.org/articles/cism_research_summary.pdf (accessed July 3, 2007).
27See Everly and Mitchell, “The Debriefing ‘Controversy’”; Mitchell, “Crisis Intervention and CISM”; Tuckey, “Issues in the Debriefing Debate”; and Shannon L. Wagner, “Emergency Response Service Personnel and the Critical Incident Stress Debriefing Debate,” International Journal of Emergency Mental Health 7, no. 1 (2005): 33–41.