Like most, I did not give Critical Incident Stress Management
(CISM) much thought when it was introduced into EMS in the 1980s.
Intuitively, it seemed like a good idea. Although I was unsure whether
stress was more severe or different in EMS than in other occupations,
CISM seemed like a benign method of mitigating EMS stress. CISM was
integrated into the EMT and paramedic curricula, and we included it in
our textbooks. Without looking into it significantly, I made CISM
mandatory for all agencies I served as medical director. In fact, I
attended a CISM session following a bad accident where two adult women
and a six-year-old child burned to death in their car following the
impact. I had been at the accident scene and was not particularly
distressed following it, but attended the CISM session to show
solidarity with the field personnel. The session seemed to go well,
although I felt most there were uncomfortable with the process. A few
weeks later, I received communications from several firefighters, who
basically threatened to get the union involved CISM continued to be
mandatory. They provided research that made me question whether CISM
was beneficial. When I looked into it further, I found that CISM in EMS
may not hold the promise of continued emotional well-being that its
proponents believe.1, 2
CISM was introduced to EMS in 1983
through an article by Dr. Jeffrey Mitchell published in a trade
The process was called Critical Incident Stress Debriefing (CISD) and
was described as "an organized approach to the management of stress
responses in emergency services. It entails either an individual or
group meeting between the rescuer and a caring individual (facilitator)
who is able to help the person talk about his feelings and reactions to
the critical incident." Later, the goals of CISD were expanded to
include prevention of disorders that may develop as a result of
traumatic stress, such as post-traumatic stress disorder (PTSD). It
also came to serve as a tool to help identify personnel who should be
referred for further treatment; to facilitate verbalization of
experiences; to normalize reactions to stressful events; and to improve
peer group support and cohesion.4–6 The name of the process was changed to CISM, purportedly to reflect these more global objectives.7
The Scientific Evidence
Although there are numerous studies
pertaining to CISM and psychological debriefing, most are anecdotal and
of poor scientific quality. The better studies seem to indicate that
CISM is, at best, ineffective. Furthermore, some research seems to
indicate that CISM may actually make people worse.
Two of the better studies were
meta-analyses of other published studies of CISM and psychological
debriefing. Meta-analyses of randomized controlled trials, when
properly conducted, represent the highest level of scientific validity.
The more valid the study, the closer it is to the truth. A
well-conducted meta-analysis allows for a more objective appraisal of
the evidence, thus leading to resolution of uncertainty and
disagreement. In addition, it may reduce the probability of false
negative results and thus prevent undue delays in the introduction of
effective treatments into clinical practice.
The first meta-analysis evaluated
seven studies that specifically examined single-session debriefings
performed within one month after a traumatic event. Five of the studies
specifically evaluated CISM, and three evaluated non-CISM interventions
(a historical group debriefing, a 30-minute counseling session, and
education). Six of the reviewed studies utilized non-intervention
controls. The researchers reported that non-intervention and non-CISM
interventions were found to have improved symptoms of PTSD, but CISM
did not improve symptoms and may, for some, have retarded natural
resolution. Stated another way, persons who received no intervention
and those who received non-CISM interventions actually fared better
than those who received CISM interventions. Furthermore, the
researchers found that CISD did not improve natural recovery with
respect to other trauma-related disorders.8
The second meta-analysis evaluated
11 studies where single-session psychological debriefings were provided
within one month after a traumatic event. These authors found CISM
neither reduced psychological distress nor prevented the onset of PTSD.
They concluded there was no evidence that CISM is a useful treatment
for the prevention of PTSD.9
Proponents of CISM attempted two meta-analyses of studies they felt supported CISM.10,11
These, however, were extremely flawed and highly criticized by
mainstream psychologists. In fact, researchers from the Department of
Psychiatry at the Uniformed Services University of the Health Sciences
in Bethesda, MD, criticized these two meta-analyses, stating, "Reports
cited in a meta-analysis by Everly, Boyle and Lating; and Everly and
Boyle, are not representative outcome studies."12
Several other studies have
questioned the validity of CISM. FEMA commissioned a three-year study
on the effectiveness of CISD as an early intervention for traumatic
stress in firefighters.13,14
Thorough assessments were made of 660 firefighters exposed to critical
events, including some involved in the Oklahoma City bombing response.
Of these, 264 had attended one or more CISM sessions. Standard
objective psychological measures found a weak inverse relationship with
negative affectivity and a weak positive correlation with positive
world assumptions. That is, participants actually felt worse after the
sessions, but overall had better images of the world and their places
in it. No relationship was found between debriefing and PTSD.
In the Netherlands, researchers
studied 243 traumatized police officers who were assigned to a
debriefing group or to one of two control groups. Pre-tests and
post-tests were administered. No differences in psychological morbidity
were found between the groups at pre-test, at 24 hours post-trauma, or
at six months post-trauma. At one week post-trauma, however, they found
that debriefed subjects exhibited significantly more PTSD symptoms than
These findings were consistent with an earlier study of debriefing for
police officers, conducted by these same researchers, in which a
comparison of 46 debriefed and 59 non-debriefed officers found no
differences at eight months post-exposure, but significantly more
disaster-related hyperarousal symptoms at 18 months post-event in the
group that received debriefing.16
Following the crash of an air
ambulance in British Columbia in which five people died, Canadian
researchers evaluated the effectiveness of CISM provided for
paramedics, physicians and nurses.17
They found that CISM did not appear to affect the severity of stress
symptoms. They also found that those who had pre-existing
stress-management routines appeared to have less severe symptoms at six
Several studies have demonstrated
an actual worsening of stress symptoms in people who have received
debriefings. In one study, the levels of anxiety and somatization at
four months post-accident had declined more in the non-debriefed group,
while levels of hostility and psychiatric symptoms had actually risen
in the debriefed group.18
In the same study group three years post-accident, patients in the
debriefed group had marginally more severe psychiatric symptoms, more
severe pain, had recovered less well, reported more impaired
functioning and had greater financial problems as a result of the
accident.19 At 13 months following their injuries, burn
patients who had received debriefings actually had worse anxiety,
depression and PTSD symptoms compared to the non-debriefed control
An early Norwegian study evaluated
115 firefighters involved in a major hotel fire that 47% described as
the worst experience they'd ever had.21
Of these firefighters, 39 underwent formal debriefing. The results
showed no significant difference between the debriefed group and the
group that simply talked to their colleagues. In addition, they found
that in spite of an extreme stress situation, the frequency of
disturbing stress reactions following the event was low.
"No Longer Recommended"
Because research is starting to
show that CISM and similar interventions are harmful, numerous
organizations are dropping or forbidding the practice. The National
Institute of Mental Health (NIMH), in conjunction with the U.S.
Department of Health and Human Services, Department of Defense,
Department of Veterans Affairs, Department of Justice and American Red
Cross, held a workshop to reach consensus on best practices in
evidence-based early psychological intervention for victims/survivors
of mass violence. In its report, following an exhaustive review of
world literature on the subject, that panel specifically did not
recommend CISM or psychological debriefing as an early-intervention
In a recent document on mental
health in emergencies, the World Health Organization (WHO) stated,
"Because of the possible negative effects, it is not advised to
organize forms of single-session psychological debriefing that pushes
persons to share their personal experiences beyond what they would
Following a systematic
evidence-based review, backed by an expert consensus panel, the British
Health Service listed routine debriefing as a contraindicated
procedure. They concluded, "Review of the best-designed studies
suggests that routine debriefing (a single-session intervention soon
after the traumatic event) is not helpful in preventing post-traumatic
The North Atlantic Treaty
Organization (NATO)-Russia Advanced Research Workshop on Social and
Psychological Consequences of Chemical, Biological and Radiological
Terrorism, convened to discuss the social and psychological
implications of terrorism, similarly concluded, "There is still no
consensus on the role, if any, of very acute interventions. CISD can no
longer be recommended."25
In its guidelines for the 2000
Olympic Games in Sydney, the New South Wales (Australia) Health
Department, did not recommend CISD. They concluded that, "There is no
evidence that [CISD] prevents PTSD or other psychological morbidity,
and it may make some people worse."26
The Australasian Critical Incident
Stress Association (ACISA), in their Guidelines for Good Practice for
Emergency Responder Groups, stated, "Experience and systematic
investigations have revealed a marked discrepancy between outcomes once
presumed to be achievable (Mitchell, 1983; Mitchell and Everly, 1995)
and those that can be reliably delivered (Rose and Bisson, 1998)."27
British Navy researchers performed
a narrative review of various studies related to psychological
debriefing and CISD with particular emphasis on how it impacted the
British Royal Navy and Royal Marines. They concluded that,
"Psychological debriefing cannot be considered safe, and thus it should
not be routinely used."28
Why doesn't CISM work? It appears
that CISM and other forms of psychological debriefing may actually
interfere with the natural recovery process inherent in normal
individuals. The alternation of intrusive and avoidant thoughts
characterizes normal psychological processing following a traumatic
event that may be disrupted by this approach to intervention. CISM may
also lead affected personnel to bypass established personal support
systems (family, friends, coworkers, clergy) usually used for
non-occupational-related crises in the belief that the CISM session
should be sufficient to alleviate their distress. Furthermore, a
certain amount of time appears necessary for an individual to process
the psychological impact of exposure to a traumatic event, and no
external stimulus or program may be capable of shortening this interval.13
Thus, what role should mental
health play in modern emergency services? Several organizations and
researchers have addressed this issue. Leading psychological
researchers who specialize in traumatic stress,29
NIMH22 and the WHO23 have recommended that competent mental health
personnel provide psychological first aid to trauma survivors. This
includes such things as listening to rescuer concerns, conveying
compassion, assessing needs, ensuring that basic physical needs are
met, and protecting the rescuer from further harm. Most important,
those who do not wish to talk should not be compelled to talk. For
those who want to talk, somebody should be there simply to listen—not
to provide any sort of care or intervention. In addition, education and
information can be provided to better help personnel understand
psychological trauma, specifically what to expect and where to get help
if needed. If additional help is needed, affected personnel should be
referred to competent, licensed mental health professionals with
experience treating trauma-related stress. Psychological first aid is
not an intervention technique, but only provides practical supportive
care while at the same time respecting the wishes of those who may not
want to discuss what happened or are not ready to deal with a possible
onslaught of emotional responses in the early days following exposure.
They do, however, recommend that competent mental health personnel be
available within two months of a critical incident to screen and assist
any personnel who may be developing stress-related symptoms or PTSD.
Recently, the negative effects of
CISM were described to me by a paramedic who works in a small town in
Texas. Following a call where a child died, she and coworkers were
forced to attend a CISM session. She reported that none of the
personnel involved were particularly distressed after the call, and she
felt the CISM session was unnecessary. After the session, she reported
that all who attended were uncomfortable and actually felt worse. She
felt the facilitator chastised them for not feeling particularly bad
after the call. It was not a positive experience.
Several years later, this
paramedic's partner was accidentally killed. Following this tragedy,
the EMS service she worked for assured that her physical and emotional
needs were met. No CISM or debriefing was provided, but they arranged
for her to speak with a professional therapist, who simply allowed her
to talk. She reported that in contrast to her earlier CISM session, she
felt much better after the latter approach and was able to return to
work sooner than expected.
The last thing we want to do is
provide a service that may actually harm our colleagues. Like many
archaic and anecdotal EMS practices, CISM is a bad idea and does not
work. Let's put it behind us and practice, instead, simple
psychological first aid.
1. Bledsoe BE. Critical Incident Stress Management: Benefit or risk for
emergency medical services? Preh Emerg Care, 2003 (in press).
2. Bledsoe BE. CISM: Possible liability for EMS services? Best Prac in Emerg Serv 5(6):66–67, 2002.
3. Mitchell JT. When disaster strikes…the critical incident debriefing process. JEMS 8:36–39, 1983.
4. Robinson RC, Mitchell JT. Evaluation of psychological debriefings. J Traumatic Stress 6:367–382, 1993.
5. Everly GS, Flannery RB, Mitchell JT. Critical incident stress
management (CISM): A review of the literature. Aggress Violent Behav
6. Mitchell JT, Everly GS. Critical Incident Stress Debriefing: An
Operations Manual for CISD, Defusing and Other Group Crisis
Interventions (3rd ed.). Ellicott City, MD: Chevron Publishing, 1997.
7. Everly GS, Mitchell JT. The debriefing controversy and crisis
intervention: A review of lexical and substantive issues. Int'l J Emerg
Mental Health 2(4):211–225, 2000.
8. Van Emmerik AAP, Kamphuis JH, Hulsbosch AM, Emmelkamp PMG.
Single-session debriefing after psychological trauma: A meta-analysis.
Lancet 360:766–771, 2002.
9. Rose R, Bisson J, Wessley S. Psychological debriefing for preventing
post traumatic stress disorder (PTSD). Cochrane Review, The Cochrane
10. Everly GS, Flannery RB, Eyler VA. Critical Incident Stress
Management (CISM): A statistical review of the literature. Psychiatric
Quarterly 73(3):171–182, 2002.
11. Everly GS, Boyle SH. Critical incident stress debriefing (CISD): A
meta-analysis. Int'l J Emerg Mental Health 3:165–168, 1999.
12. Fullerton CS, Ursano RJ, Vance K, Lemming W. Debriefing following trauma. Psychiatric Quarterly 71:259–276, 2000.
13. Harris MB, Stacks JS. A three-year five-state study on the
relationships between critical incident stress debriefings,
firefighters' disposition, and stress reactions. USFA-FEMA CISM
Research Project. Commerce, TX: Texas A&M University, 1998.
14. Harris MB, Balolu M, Stacks JR. Mental health of trauma-exposed
firefighters and critical incident stress debriefing. J Loss Trauma
15. Carlier IVE, Voerman AE, Gersons BPR. The influence of occupational
debriefing on post-traumatic stress symptomatology in traumatized
police officers. British J Med Psych 73:87–98, 2000.
16. Carlier IVE, Lamberts RD, van Ulchelen AJ, Gersons BPR.
Disaster-related post-traumatic stress in police officers: A field
study of the impact of debriefing. Stress Medicine 14:143–148, 1998.
17. Macnab AJ, Russel JA, Lowe JP, Gagnon F. Critical incident stress
intervention after loss of an air ambulance: Two-year follow-up. Preh
Dis Med 14(1):8–12, 1999.
18. Hobbs M, Mayou R, Harrelson B, Worlock P. A randomized controlled
trial of psychological debriefing for victims of road traffic
accidents. Br Med J 313:1,438–1,439, 1996.
19. Mayou RA, Ehlers A, Hobbs M. Psychological debriefing for road
traffic accident victims: Three-year follow-up of a randomized
controlled trial. Br J Psych 176:589–593, 2000.
20. Rose S, Brewin CR, Andrews B, Lirk M. A randomized controlled trial
of individual psychological debriefing for victims of violent crime.
Psych Med 29:793–799, 1999.
21. Hytten K, Hasle A. Fire fighters: A study of stress and coping. Acta Psychiatr Scand 80:50–56, 1989.
22. National Institute 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, DC: U.S.
Government Printing Office, 2002,
23. World Health Organization. Mental Health in Emergencies: Mental and
Social Aspects of Populations Exposed to Extreme Stressors. Geneva:
World Health Organization, www5.who.int/mental_
24. Parry G, Chair, Development Group. Evidence-Based Treatment
Guidelines in Psychological Therapies and Counselling. Department of
Health, National Health Service, United Kingdom,
25. North Atlantic Treaty Organization. North Atlantic Treaty
Organization (NATO)-Russia Advanced Research Workshop on Social and
Psychological Consequences of Chemical, Biological, and Radiological
Terrorism, www.nato.int/sci ence/e/020325-arw2.htm.
26. New South Wales Health Department. Disaster Mental Health Response
Handbook: An educational resource for mental health professionals
involved in disaster management. NSW Health Department, Sydney, NSW,
2000, www.nswiop. nsw.edu.au.
27. Australasian Critical Incident Stress Association. Guidelines for
Good Practice for Emergency Responder Groups in Relation to Early
Intervention after Trauma and Critical Incidents (Glenelg Declaration),
28. Greenburg N. A critical review of psychological debriefing: The
management of psychological health after traumatic experiences. J Royal
Naval Med Serv 87(3):158–161, 2001.
29. Litz BT, Gray MJ, Bryant RA, Adler AB. Early intervention for
trauma: Current status and future directions. Clin Psychol Sci Prac
Bryan Bledsoe, DO,
FACEP, EMT-P, is an emergency physician, author and former paramedic
whose writings include: Paramedic Care: Principles and Practice and
Paramedic Emergency Care.