It's fun, on occasion, to challenge the status quo. Several years ago, I did this in a series on EMS myths. While the eight articles were generally well-received, the ones on Critical Incident Stress Management (CISM) and the overuse of medical helicopters generated the most passionate response from readers. For several years, I gave lectures on the problems with CISM and officially retired the presentation several years ago. However, on a few occasions, I have presented it again after certain conference coordinators twisted my arm. Occasionally, in my travels, I still run into people who use CISM. The mantra "trained counselors will be on hand" has become a part of our lexicon. Of course, this begs the question: If it's necessary to say that "trained counselors" will be on hand, it implies a problem with "untrained counselors" must exist. Have you ever seen a hospital with a sign that states that trained neurosurgeons are on hand?
If EMS is ever going to evolve into a bona fide profession, we have to give up these anecdotal practices. Why do EMS professionals not go away in the face of overwhelming scientific evidence? Sometimes, convincing them is akin to killing vampires.
CISM has been debunked repeatedly through scientific scrutiny by some of the world's foremost authorities on psychological trauma. In fact, it has almost become a punch line or poster child for pseudoscientific practice. In a recent academic debate by the British Psychological Society (BPS) on "the worst idea on the mind," post trauma debriefing (e.g., Critical Incident Stress Debriefing, or CISD) scored third behind prefrontal lobotomy and the chemical imbalance model of mental illness as a pseudoscientific practice. Numerous randomized controlled trials, some conducted in the last two years, have repeatedly shown CISM to be ineffective and potentially harmful. Dr. Scott Lilienfeld, a prominent researcher into pseudoscientific practices in psychology, listed CISM at the top of his list of potentially harmful therapies. Interestingly, the volume and quality of the evidence against CISM was much greater than all other therapies he listed. Other seemingly intuitive therapies -- such as "Scared Straight" and "D.A.R.E." -- have also proven harmful. In addition, simple grief counseling for those with normal bereavement reactions is also considered harmful. One has to wonder whether the "shattered dreams" program, so popular in EMS, is beneficial or harmful.
Prominent researchers in psychological trauma recently published an interesting study that showed that false memories can be induced in participants of CISD. Participants were randomized into three groups: a debriefing group; a debriefing group where a planted experimenter supplied three pieces of misinformation to the group regarding the stressful event; and a group that receive no treatment. All groups were shown a very stressful video and were again reviewed after one month. Members of the debriefing group where a planted experimenter provided misinformation were more likely to recall this misinformation as fact than members of the other two groups.
CISM has become so notorious for causing problems that researchers have used it as an example of the nocebo effect (a procedure or practice that causes harm). Australian psychologist Grant Devilly probably summed things up the best. He wrote, "Hence, whilst the buyer should beware (caveat emptor) when buying debriefing services, the evidence of a defective product is mounting to the point where it may be time for the seller to beware (caveat venditor)."
So folks, let's move on. There is nothing here to see. CISM is not in the current drafts of the new EMS curricula. It's important to remember that people cope with stress in different ways. People who repress their feelings do just as well as those who don't. Most people are amazingly resilient to stress. In fact, some stress is actually beneficial. Very few will develop psychiatric disorders (e.g., acute stress disorder, post-traumatic stress disorder) following psychological trauma. And, those people will usually have predisposing psychiatric or social issues (e.g., depression, substance abuse, marital problems, and/or financial problems).
The leading authorities in stress now recommend two things. First, develop personal and departmental stress management strategies. This is referred to as "resiliency-based strategies." You can't treat stress after it occurs. You can only prevent or mitigate it through appropriate stress management strategies (CISD/M is not an appropriate strategy). Also, practice psychological first aid. Make sure people's personal needs are met (e.g., food, drink, warmth, companionship). If people don't want to talk, don't make them. What most people need in a stressful situation is information. Provide accurate information as soon as possible. This will often do more to mitigate stress than anything else you can provide.
I just got a new DEWALT miter saw. Now, I can make the angles on my wooden stakes absolutely perfect. Vampires beware!
- British Psychological Society: "The worst idea on the mind (News section)." The Psychologist. 19(9):518-519, 2006.
- Sijbrandij M, Olff M, Reitsma JB, et al: "Emotional or educational debriefing after psychological trauma: randomised controlled trial." British Journal of Psychiatry.189:150-155, 2006.
- Lilienfeld SO: "Psychological treatments that cause harm." Perspectives on Psychological Science. 2(1):53-70, 2007.
- Devilly GJ, Varker T, Hansen K, et al: "An analogue study of the effects of psychological debriefing on eyewitness memory." Behaviour Research and Therapy. 45(6):1245-1254, 2007.
- Bootzin RR, Bailey ET: "Understanding placebo, nocebo and iatrogenic effects." The Journal of Clinical Psychology. 61(7):871-880, 2005.
- Devilly GJ, Cotton P: "Caveat Emptor, Caveat Venditor, and Critical Incident Stress Debriefing/Management (CISD/M)." Australian Psychologist. 39:35-40, 2004.