Critical Incident Stress Management

Psychological First Aid (PFA) is a term that was first used by the military during World War II when historian S.L.A. Marshall developed his technique called Historical Events Reconstruction Debriefing (HERD). Since that time, PFA has become widely used as an important response to those who have experienced a critical incident. No longer considered a debriefing tool in the military sense, Psychological First Aid today is, as Dr. George Everly of the International Critical Incident Stress Foundation has said, “a supportive and compassionate presence designed to reduce acute psychological distress and/or facilitate continued support, if necessary.” The National Institute of Mental Health describes PFA as “a pragmatically oriented intervention with survivors or emergency responders targeting acute stress reactions and immediate needs.”  And no one who experiences a critical incident is totally untouched by it.


There are several models of PFA: Albert Robert’s 7-Stage Crisis Intervention Model; the Johns Hopkins RAPID-PFA model; the PFA-LPC model designed for educational settings and adopted by Homeland Security; the SFA model of the Miami, Florida Center for Disaster and Extreme Event Preparedness; and many, many more. But no matter what model is used, all of them have one thing that ties them together: to provide immediate help to those who are stressed by the situation.

Critical Incident Stress Management (CISM) also gives us a model for intervention. Critical Incident Stress Management, under the auspices of the International Critical Incident Stress Foundation, is a comprehensive and multicomponent system, which has been widely acclaimed as the standard of care in crisis intervention and the most widely used model worldwide. It is comprehensive because it addresses crises from three important perspectives — before, during and after. It is multicomponent in that it provides numerous tactical interventions to be used with both individuals and groups before, during and after a traumatic event. The CISM model has been followed by law enforcement, the fire service, emergency medicine, and the military, to name only a few, for many years. But now, it seems, a significant arm of the fire service has broken away from this tried and true method of intervention.

In a very thoughtful and thought-provoking article in the Spring 2014 issues of Carolina Fire Rescue EMS Journal, Shannon Pennington addressed what he very appropriately called “a dry hydrant crisis.”  In Life Safety Initiatives Section 13, the National Fallen Firefighters Foundation has apparently dropped the comprehensive Critical Incident Stress Management (CISM) model and replaced it with an After Action Reporting and Curbside Manner program.

At this point, I want to address a couple of myths and misunderstandings about CISM. First, CISM is not about psychotherapy. It is not the exclusive domain of mental health professionals. It is a peer driven program that is supported by mental health clinicians, not the other way around.  Secondly, CISM is not, and was never intended to be, used with primary victims of trauma. It was designed for use with First Responders — those who deal with the primary victims of trauma. And those who deal on a regular basis with the victims of trauma are the very ones who are at risk of secondary posttraumatic stress disorder. 

The “before” part of CISM includes pre-crisis training and education for First Responders; community consultation and education; strategic planning to assess potential need, identify target populations, and identify needed resources; and building a referral network to account for the needs of victims — medical, mental health, housing, transportation, etc. 

The “during” part addresses specific interventions to be used by properly trained peers — and, where indicated, clinicians — to mitigate the immediate effects of a psychological crisis. The concept of a psychological crisis was introduced to the field by psychiatrist Gerald Caplan in the 1960s and is a situation where our psychological balance has been thrown off kilter and our usual coping mechanisms just aren’t working. That results in emotional and physical distress and a general inability to function in an effective manner.

The “during” phase is the beginning of Psychological First Aid. In this phase, interventions are identified primarily by one-to-one contacts between a First Responder and a trained interventionist — usually a peer, but clinician if needed. The model of PFA used by the ICISF in CISM is called SAFER-R. But, again, the specific model is less important than the intended result, which is to mitigate the immediate effects of a psychological crisis.

It is in the “after” phase of crisis where we can address much of the aftermath of the critical incident. The comprehensive program of Critical Incident Stress Management provides a number of interventions that can be applied in this stage. Critical incident defusing, and the more formal Critical Incident Stress Debriefing are the most well known of these group processes. It is through these interventions that the normal healing and recovery that occur following a critical incident get “jump started.” It is here that we can start to mediate the potentially toxic effects of the recent traumatic event.

This “after-the-crisis” phase may also include one-to-one contacts between an affected individual and a trained interventionist. I emphasize the word “trained” here because it is vital. Peers can and do conduct these interventions far more often than do mental health clinicians. And more often than not these interventions are successful in reducing distress and promoting that normal recovery mechanism. But the success or failure of the intervention, and therefore its effect on healing, is directly related to the training and experience of the interventionist.

In the fire service, law enforcement, and EMS we have protocols to guide us. These protocols are based on experience and reflect best practices.  So too are there protocols for crisis intervention. When a properly trained interventionist, peer or mental health clinician follows the protocols, the results are predictably better than if the interventionist is either not trained or doesn’t follow the protocols.

This brings me back to Shannon Pennington’s “dry hydrant crisis.”  The National Fallen Firefighters Foundation has apparently dropped the Critical Incident Stress Management program — with its emphasis on protocols and proper training — and replaced it with its After Action Reporting and Curbside Manner program. In a recent meeting, a number of ICISF instructors were discussing the concept of Psychological First Aid and the various models used. Dr. George Everly remarked that, “there is truly nothing new under the sun. It’s about packaging. And, sometimes it’s about ownership.” We’ve all heard the maxim, “If it’s not broken, don’t fix it.” But in this case it might have been, “If it’s not broken, let’s pretend it is. We’ve got something new to offer.”

That is all well and good, except that After Action Reporting is the not proper venue for Psychological First Aid. By definition, PFA is a supportive process that addresses individual reactions to a critical incident. And by definition, A.A.R. is designed to be an operational critique to identify what went right, and more often what went wrong, so we can hopefully do the job better the next time. The Curbside Manner arm appears to be the supportive peer-to-peer piece without protocols or training. Instead, it relies on a 10 item self-report Trauma Screening Questionnaire (TSQ) to be administered three to four weeks after the critical incident. Three to four weeks is not, in my opinion, a “pragmatically oriented intervention” that provides an immediate intervention “to reduce acute psychological distress.”

So, let’s go back to the maxim of, “If it’s not broken, don’t fix it.” Critical Incident Stress Management is not broken. It’s not even bent. It is a tried and true method of crisis intervention. In the name of repackaging or ownership, let’s not lose sight of what really works.

Be safe out there.

A Certified Trauma Specialist, Dr. Jim Baxendale has over 35 years of experience in the mental health field, 25 of which have been focused on post-traumatic stress disorder and providing Critical Incident Stress Management services to emergency services personnel. As a paramedic, in addition to his mental health credentials, Dr. Baxendale brings added credibility to his consulting practice. For more information visit

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