Finally, A Stress Program Designed for First Responders

Dec. 17, 2003
Responders often resist the "touchy-feely" stuff but they are embracing Critical Incident Stress Management (CISM), a peer-led program designed for their world.

by Alan S. Brown

It's inevitable. Any serious police movie or television program shows cops drinking. Knotted together around the bar in a close-knit confraternity of the wounded, they talk out the stresses of the day.

This time, the media got it right. While not every law enforcer drinks, virtually all of them seek out fellow officers to blow off steam about duties that bring them into certain contact with stressful events and emotions. This is not just true for police, but for firefighters, emergency medical technicians, corrections officers and dispatchers as well.

Talking with friends works for most people most of the time. But it may fail to provide a safety net following critical incidents. These are sudden, shocking events, such as a coworker's line-of-duty death or the death of a child following a car crash, that shake even experienced responders. Often, responders are unwilling to talk about their reactions.

Such events lift stress far above normal background levels, and that stress shows up in many ways. Responders may grow irritable and have trouble concentrating. Their morale and productivity suffer. Some complain of physical ailments, while others are tardy or call in sick more often. Some take leaves of absence and early retirements. Others take their troubles home, acting inappropriately or having family and relationship difficulties.

At worse, stress can lead to suicide. This is especially true among police. Various studies suggest that police commit suicide at two to three times the rate of the general population. Nationally, about 300 police officers kill themselves each year, about twice as many as are killed in the line of duty.

Such high suicide rates are a reminder that first response is a high-stress occupation. Responders who fail to respond to the danger signs of stress do so at their own peril.


Many first response organizations have sought better ways to deal with stress. One of the most popular and fastest-growing solutions among emergency services is critical incident stress management (CISM), a peer-led approach to crisis intervention developed specifically for responders dealing with major stress-producing events.

CISM was developed about 15 years ago by Jeffrey T. Mitchell, a clinical associate professor at the University of Maryland's Emergency Health Services Department and George S. Everly Jr., who had taught at Harvard Medical School and Johns Hopkins University. Both had extensive experience working with first responders.

If CISM has one basic principle, it is that first responders already know how to cope with stress. They do it every day, both as individuals and as part of a group. But critical incidents are so sudden and powerful, they overwhelm the coping skills of even well- trained, experienced people. The emotions and thoughts that responders have afterwards are normal responses to abnormal events.

While CISM teams are supervised by such mental health professionals and encourage responders to talk about the incident, they are not therapy. The emphasis is on education. Sessions do more than encourage responders to "talk about it." They educate them about the signs and symptoms of stress (See sidebar on page 14), pointing out that such problems as sleeplessness, lack of concentration, and replaying the scene in their mind are common reactions to intense events.

Sessions also offer some proven, practical advice, says Riccardo B. Rivas, a therapist and CISM team member in Collier County, Fla. "We have learned that if you talk about it with someone you have confidence in, do hard aerobic exercise to flush the stress out of your system, eat right over the next 24 hours, and keep to your normal routines, you're going to reduce the amount of stress you feel and recover quicker."


Why are responders willing to embrace CISM when they previously spurned other types of intervention? The universal answer, say members of CISM teams, lies in the use of peer counselors. Sessions may include a psychologist or social worker, but a first responder is always in the driver's seat leading the way.

"The Red Cross and NOVA (National Organization for Victim Assistance) both have crisis intervention models, but they seem geared to the general citizenry," says Mike Haley, a retired police chief and program director of the Fraternal Order of Police of Ohio's Critical Incident Response Service.

"CISM is geared primarily for emergency services and the psychology of crisis-oriented people, and in the emergency services it is a must to incorporate peer leadership. If you can't tell people at a meeting that you're on the job somewhere, then they won't believe you can understand their world."

Pete Volkmann, an 18-year veteran of the Ossining, N.Y. Police Department as well as a certified social worker and CISM leader, agrees. "First responders are a culture in and of themselves," he explains. "Within that culture, they're very protective from outsiders."

Talking about a critical incident in a group works because it gives responders a chance to reprocess what they saw and how they reacted through both their eyes and the eyes of other group members, says Volkmann. But it only works if they talk with people they trust and feel safe around.

"People outside the group don't understand," he continues. "If you're perceived as weak, no one wants to work with you. You learn from your rookie year to hold it in.

"Most people think first and then act. First responders are trained to act without hesitation. To do that, they can't consider their feelings. They're taught to think and not feel or they'll make a mistake and someone might die. The normal human mechanism in a crisis is to feel. But we try to keep those feelings to ourselves because otherwise we'll be perceived as weak."

Not Psychotherapy

Another reason CISM works is because it is definitely not psychotherapy. That's important because most responders don't view a referral to a therapist as a positive development.

"A visit to the shrink is viewed as an invitation to the rubber gun squad," says Haley. "Especially in law enforcement, your certification and your badge are part of your personality. When someone has to see a mental health professional, they view it as a threat. They can take away your gun." Other responders worry about becoming unpromotable or losing their job.

Many times, those fears are exaggerated. Other times, they are justified. Some administrators consider responders showing the signs and symptoms of stress as liabilities, says Haley. When responders deal with stress before the symptoms get out of hand, most come away unscathed.

CISM has different goals than therapy. "You're only meeting with a group once, so you don't have time to figure out their dysfunctions or defense mechanisms," says Volkmann. "Instead, we help them begin their process of healing. After a debriefing, they're still angry or sad. But they have a plan to begin the process of healing. Just hearing they're normal helps."

CISM works because it gives responders a chance to talk about how an incident affected them at the scene, in the station and at home, explains Vaughn Donaldson, a district chief in the Midland Fire Department. Maybe they couldn't sleep last night because pictures of the scene were running through their head. The team reassures them that they're not out of control, that these are ordinary reactions.

Finding that others on the scene have similar reactions does not make the pain go away, but it does allow them to accept their own feelings more readily. "It binds the group, and when they talk, it helps them get through the event a bit quicker," says Vaughn.

Unfortunately, not everyone bounces back quickly. CISM teams always follow up meetings with individual contacts to see how responders are doing. "Most stress reactions get less and less, but if they keep hanging around we have mental health professionals to hand off to," says Donaldson. "If they've been exposed to mental health in a positive setting, they're more willing to use those services."


Education is another reason CIMS has been accepted by the emergency services. "For civilians, giving them a chance to ventilate and talk about their reactions to an event is good. But it's not enough for emergency personnel," says Rivas.

"Responders are much more cognitive and not as emotionally responsive as civilians. In operational mode, they're always thinking about what they should do next. The educational part of CISM helps them put it together in their heads, so the next time they encounters these signs and symptoms they know how to deal with them."

CISM does that by teaching responders about the typical emotional, cognitive, behavioral and physical signs of stress. More importantly, it provides very practical, reasearch-based guidelines to reduce stress. Suggestions range from exercising strenuously and keeping busy to eating well-balanced meals even if not hungry. It warns against numbing the pain with alcohol or drugs, and suggests talking to people or keeping a journal.

Perhaps the most important component of CISM is preincident preparation, says Donaldson. "If we do a good job, it lays the cornerstone for future interventions. We go over the signs and symptoms of stress. A lot of these feelings are normal, and so are the physical reactions like the pictures in our heads and smells that keep coming back. Not everybody has them, but we educate them about it before they ever experience it, so if we need to intervene they're not hearing it for the first time."

Hearing it a second time, during a CISM session, puts those feelings and reactions in context. It makes them just another hazard that responders face and enables those affected to begin to help themselves without feeling weak or isolated.

Measures of Success

Not everyone is a believer. Much of the controversy, says Volkmann, centers on the use of trained peers rather than professional therapists to lead sessions. "Mental health experts have reacted this way before," he says.

"When Alcoholics Anonymous began, the experts said, 'Wait a minute, a bunch of drunks struggling with their own sobriety are going to talk about drinking and help other drunks.' They laughed, but what made it work was peer support – 'I've been there, I've done that, you can't fool me.'"

The same thing happened in the 1980s, when paramedics were trained to give advanced medications. "The experts said, 'They're not doctors or registered nurses. These wannabe doctors are going to be killing people in the streets.' Many of the original paramedics were looked down upon by some medical professionals," says Volkmann.

Strict training and supervision to ensure they do not go beyond their training enables many responders to do what Volkmann calls triage: seeing how responders are doing, beginning the process of natural healing and getting help where needed.

Critics argue that CISM does not reduce post-traumatic stress disorder (PTSD) in responders. Volkmann counters that treating stress earlier may nip PTSD in the bud.

Rivas can point to research that shows organizations that implement CISM programs have measurable reductions in absenteeism and the number of people seeking disability leave for PTSD.

Capt. Mike Cobb of the Richland, Wash. Police Department sees the difference firsthand. A SWAT team instructor for the state of Washington, he has taught and stayed in contact with hundreds of responders. He has seen how stress hammered them.

"I've been there when friends were killed and saw the impact it had on the careers of the survivors. I've worked CISM teams for officers and firefighters across the Pacific Northwest, and I see a real difference in performance and positive relationships with family. People stay in field longer. There's less burnout, fewer alcohol problems and higher levels of performance."

CISM will never solve really serious emotional problems, but it does help normally healthy people bounce back from the shock of abnormal events faster and more completely. It finds help for those with more serious problems before they become an issue. Most responders are relieved to find their responses are perfectly normal and shared by most of their comrades. It works because peers lead the way.

"Responders never had a safety net," says Haley. "They would get called out for sudden infant death syndrome, multiple victim crashes, shooting incidents. They're like sponges, and each event is like a drop of water in the sponge. If they don't wring it out, it saturates and drips. What we want to do with CISM is deal with each event when it happens so that they don't accumulate."

Sidebar: Common Signs and Signals of Stress

During the Incident:

  • Confusion
  • Nondirected activity
  • Disorientation
  • Tunnel vision
  • Crying
  • Tense muscles, clenched teeth
  • Profuse sweating
  • Chest pain, pounding heart

Immediate Post-Incident:

  • Blurred vision
  • Memory loss
  • Confusion
  • Nondirected activity
  • Disorientation
  • Restlessness

Delayed Post-Incident:

  • Restlessness
  • Irritability
  • Chronic fatigue
  • Sleep disturbances
  • Anxiety/depression
  • Moodiness
  • Muscle tremors
  • Trouble concentrating
  • Increased substance abuse
  • Nightmares
  • Headaches
  • Vomiting
  • Diarrhea
  • Suspiciousness

Sidebar: Implementing CISM:

CISM programs don't just happen. Someone has to push for them, often against fierce resistance

from superiors and fellow responders. Here's how three people succeeded.

Maricopa Sheriff

With 20 years on the job, Lt. Geoffrey Leggett of the Maricopa County, Ariz. Sheriff's Office has seen critical incidents impact the county's 500 sworn deputies and 1,000 detention officers. He had begun talking with friends in Phoenix about their CISM team, but his superiors questioned the need and raised concerns about funding.

Then a sergeant was killed by his wife, who also worked for the office. "The command staff could see some of the personnel were not coping well," Leggett recalls. "Drinking was not an obvious problem, but people were irritable, productivity was going down and the dispatchers were still pretty emotional."

Leadership asked Leggett to call in the Phoenix CISM team to put on a debriefing. A few weeks later, in September 1994, a deputy died at a traffic accident scene. One week after that, a second deputy was killed while responding to a domestic violence incident.

"The administrators saw that it worked," says Leggett. "The deputies really appreciated that they were not left out hanging, but that something was being done to help them."

Only then did the sheriff's office give Leggett the green light to develop a CISM team. It was certified by the International Critical Incident Stress (CIS) Foundation in May 1995. Other than the initial training and work hours, the program has no real costs associated with it, says Leggett.

Richland Police

Capt. Mike Cobb of the Richland, Wash. Police Department, led a SWAT team for 16 years. He describes himself as "an over-achieving Type A personality who didn't need this touchy-feely stuff." His wife thought he did. She had become involved in CISM and signed him up for a class.

"I'd been teaching officers to stay alive since 1982. This showed me the other half of the equation – how to keep my guys well after being involved in crisis.

"It really came together after the first day, when I went to dinner with the trainer, Jeff Mitchell. He asked, 'Would you walk away from your people in the field and leave them hanging?'

"My back got straight and I said, 'Absolutely not. What would make you ask you that?' Mitchell replied, 'Then how can you not provide the best level of care after the incident?' I could give them the thumbs up and tell them to buck up, but I didn't know how to take care of my guys in the field."

Cobb was not an officer, but when he went back he began meeting with emergency services leaders in the Richland Tri-Cities region. "They were polite but not very supportive," he says. "They didn't see a problem because, frankly, in the old days, command officers didn't spend a lot of time with line personnel. We never found the guy who would say yes."

Instead, Cobb and his wife formed a grassroots nonprofit agency that serves all responders and answers to no single agency. The CISM team was there when there were four killings in eight weeks, and when regional departments lost four members in six weeks.

Cobb began his team three chiefs ago. Because the program has proven itself, he now enjoys outstanding cooperation. "After the Oklahoma City bombing, the chief just came to me, asked me how much time I would need, and gave me departmental leave so I didn't have to take vacation time."

Midland Fire/EMS

Vaughn Donaldson, a district fire/EMS chief in Midland, Texas, first heard about CISM from the Texas Department of Health. "We didn't know what it was, but we knew stress was an issue," he recalls. It took only an hour for Donaldson to see how CISM could work for his people.

The problem was getting the message out. Midland's chief didn't mind Donaldson learning CISM; he just didn't want him to use it. "We did it anyway," says Donaldson. "Our peers volunteered to come in after duty. They relieved members so they could attend sessions." When the chief retired, Midland selected a replacement from a larger department that already had a CISM program. He proved far more supportive.

It took years to build credibility among fellow responders. "They ridiculed us nonstop, and they were vicious, too," he remembers. "Some got very angry about the first interventions. They were saying, 'We don't need this stuff, we've done this for years.' Some didn't say anything."

Instead of trying to convert them, Donaldson focused on teaching younger firefighters and EMTs about stress during recruit school, continuing education and training courses. "There's been a paradigm shift," he says. "Now they know that we have something in place to treat stress. It's the way business is done, like putting on gloves in an EMS room."

And the older guys? "They're still around, but now they say, 'If it will help the other people, I'll do it.'"

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