Critical incident stress management (CISM) is an intervention to support those experiencing traumatic events. Critical incident stress management (CISM) is a type of crisis intervention designed to provide support for those who have experienced traumatic events. CISM is comprised of multiple crisis response components that attempt address each phase of a crisis situation. It can be implemented with individuals, families, groups, organizations, and communities. Although some research has found CISM to be ineffective and even harmful, defenders of CISM argue that, when implemented properly, this intervention offers powerful crisis support.

How Does CISM Work?

Critical incident stress management is a system of crisis intervention meant to prevent psychological damage associated with unusual and stressful events, also called critical incidents. CISM is intended to support those who are prone to trauma exposure as well as those who have experienced an intensely traumatic event. According to one of its developers, Dr. Jeffrey Mitchell, CISM is not a type of psychotherapy. It is a system of support that is meant to do the following:

  • Lessen the impact of the critical incident
  • Normalize instinctive reactions to the incident
  • Encourage the natural recovery process
  • Restore the adaptive functioning skills of the person and/or group
  • Determine the need for further supportive services or therapy

Sometimes referred to as psychological first aid, CISM can be used to address a vast array of critical incidents. Critical incidents are defined as events that threaten physical or emotional safety or events that result in physical or psychological harm. Some examples include:

  • Death, or risk of death, in the line of duty

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  • Shootings in the workplace
  • Hostage situations
  • Terrorist attacks
  • Building collapse due to an earthquake or natural disaster
  • Natural disasters

CISM has multiple components that can be used before, during, and after a crisis. These components include but are not limited to:

  • Pre-Crisis Preparation: This component involves helpful procedures that encourage stress management, crisis education, and crisis planning.
  • Community Support Programs: Often referred to as “town meetings,” these programs support organizations, schools, and communities by providing structured opportunities for discussion and processing of disasters or events.
  • Critical Incident Stress Debriefing (CISD): CISD is a major component of the CISM crisis intervention system. Because critical incident stress management originated with the development of the CISD technique, the two terms are sometimes confused. CISD is not meant to be used as standalone intervention, but rather as a CISM technique for use with small groups. This seven-phase intervention attempts to mitigate traumatic stress, determine the need for further mental health treatment, and assemble a sense of psychological closure about an incident.
  • Defusing: This three-phase technique is similar to CISD in that it is a group intervention, but it is more immediate in nature. Intended to take place within hours of the event, defusing involves confidential discussion groups that promote stabilization and prevention of traumatic stress.
  • Other Crisis Interventions: Additional CISM components include one-on-one crisis counseling, crisis intervention for families, and aftercare follow up and referral procedures.

History of CISM

Critical incident stress management is rooted in crisis intervention theory, group therapy, and community psychology. Theorists like Eric Lindemann, Irvin Yalom, and Gerald Caplan provided the foundation for CISM developers Jeffrey T. Mitchell and George S. Everly, Jr. to begin their work in the 1970s. During the 1980s, Mitchell and Everly officially introduced critical incident stress debriefing as part of their critical incident stress management system of crisis intervention. The field expanded further with the establishment of the American Critical Incident Stress Foundation in 1989, later named the International Critical Incident Stress Foundation in 1991. In 1997, Mitchell and Everly fully integrated their crisis intervention techniques into the comprehensive system we call CISM. Though controversy surrounds the use and efficacy of CISM, it is still commonly used today for crisis intervention.

Who Provides CISM?

CISM is provided by many types of professionals, such as first responders (firefighters, law enforcement officials, etc.), medical personnel (nurses, doctors, medics), search and rescue personnel, military personnel, mental health professionals, clergy, hospital staff, and community leaders. The most important qualification for a professional who provides CISM is that they are thoroughly trained in its implementation. The International Critical Incident Stress Foundation manages the Approved Instructor Candidate Program, which trains individuals to become certified in critical incident stress management.

Some professionals, including first responders and military personnel, are not only trained to provide CISM interventions, but often face traumatic events more frequently than the general public. This can leave them vulnerable to things like acute stress, posttraumatic stress, panic attacks, depression, anxiety, and loss of self-confidence. That is why CISM is often made available to firefighters, police officers, and military personnel.

Is CISM Used with Other Treatments or Services?

Critical incident stress management can be used in conjunction with various types of crisis intervention. If the critical incident occurs at the workplace, CISM might be used as a part of the employer's employee assistance program (EAP). Additionally, CISM can be used as a precursor to psychotherapy.

Although CISM has therapeutic elements, it should not be mistaken for psychotherapy. People seeking help for mental health issues beyond an immediate response to a traumatic event should be directed to find a therapist or a similarly qualified mental health professional. An article in Psychiatric Quarterly (2002) outlines the differences between psychotherapy and CISM. CISM is short-term and focused on the here-and-now, whereas psychotherapy can be long-term and focused on the past, present, and future. Psychotherapy is always delivered by a mental health professional, but CISM can be provided by trained professionals of all kinds. The goal of CISM is to manage immediate trauma response and reduce distress, whereas psychotherapy involves a varied spectrum of short and long-term goals toward growth and change.

Concerns, Limitations, and Contraindications of CISM

Critical incident stress management has often been criticized for its lack of efficacy in preventing symptoms of posttraumatic stress and reducing the impact of acute stress response. According to a literature review published in Prehospital Emergency Care (2003)—the official journal of the National Association of EMS Physicians—some research indicates that CISM techniques like CISD can actually increase the likelihood that trauma will have a greater psychological impact.

Defenders of CISM insist that many of the studies that portray CISM as ineffective are scientifically flawed. Additionally, CISM supporters argue that these research studies incorporated techniques improperly or used non-CISM techniques such as single-session debriefings. Single-session debriefings are not sanctioned or encouraged by the developers of CISM or the International Critical Incident Stress Foundation.

Overall, conflicting research on the efficacy of CISM may be cause for caution. As with all interventions, therapies, and treatments, it is paramount that individuals seek support from trained professionals. In general, people on both sides of the CISM debate agree that CISM techniques should be delivered appropriately, by certified personnel, and with the utmost care.

References:

  1. Bledsoe, B. E. (2003, April). Critical incident stress management (CISM): benefit or risk for emergency services? Prehospital Emergency Care, 7(2), 272-279. Retrieved from National Institute of Health.
  2. Davis, J. A. (1998). Providing Critical Incident Stress Debriefing (CISD) to Individuals and Communities in Situational Crisis. In American Academy of Experts in Traumatic Stress. Retrieved from http://www.aaets.org/article54.htm
  3. Education and Training. (n.d.). In International Critical Incident Stress Foundation, Inc.. Retrieved from http://www.icisf.org/sections/education-training/
  4. Everly, Jr., G. S., Flannery, Jr., R. B., & Eyler, V. A. (2002). Critical incident stress management (CISM):a statistical review of the literature. Psychiatric Quarterly, 73(3), 171-182. Retrieved from http://old.impact-kenniscentrum.nl/doc/kennisbank/1000010729-1.pdf
  5. Everly, Jr., G. S., & Mitchell, J. T. (2011, May 20). A Primer on Critical Incident Stress Management. In International Critical Incident Stress Foundation, Inc. Retrieved from http://www.icisf.org/a-primer-on-critical-incident-stress-management-cism/
  6. Mitchell, J. T. (n.d.). Critical Incident Stress Management. International Trauma Life Support. Retrieved from http://www.info-trauma.org/flash/media-e/mtichellCriticalIncidentStressManagement.pdf
  7. Mitchell, J. T. (2003, February 10). Crisis Intervention & CISM: A Research Summary. In International Critical Incident Stress Foundation, Inc.. Retrieved from http://www.icisf.org/wp-content/uploads/2013/04/Crisis-Intervention-and-CISM-A-Research-Summary.pdf
  8. Mitchell, J. T. (2004, January 1). Crisis Intervention and Critical Incident Stress Management: A defense of the field. In International Critical Incident Stress Foundation, Inc. Retrieved from http://www.icisf.org/wp-content/uploads/2013/04/Crisis-Intervention-and-Critical-Incident-Stress-Management-a-defense-of-the-field.pdf
  9. Raphael, B., & Wilson, J. P. (Eds.). (2000). Psychological Debriefing: Theory, Practice and Evidence. New York, NY: Cambridge University Press.