# CISD Training



## Luno (Nov 11, 2008)

Okay, so I've found myself in the interesting position of creating a module and training for CISD, now I don't think that corporate or the insurance company would subscribe to my "bottle of Jack" decompression theory, I'm interested in what worked for other departments and organizations.  Go ahead guys/gals, let me know what you think...


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## Ridryder911 (Nov 11, 2008)

CISD should be totally removed from the wording of EMS and Public Safety profession. It has been proven to be harmful and detrimental to rescuers. In fact agencies such as the military, ARC, DMAT teams has totally abolished it. Debriefing is one thing, but CISD is another.

Place a true professional on call as if and need be.there are numerous Psychologist and Psychiatrist that have the education and experience.

R/r911


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## VentMedic (Nov 11, 2008)

Luno said:


> Okay, so I've found myself in the interesting position of creating a module and training for CISD, now I don't think that corporate or the insurance company would subscribe to my "bottle of Jack" decompression theory, I'm interested in what worked for other departments and organizations. Go ahead guys/gals, let me know what you think...


 
You list King County for your location. THE King County? Surely a department that large and holds itself out to be cutting edge for EMS technology and protocols has read the journals and moved on from "CISD". 

The only reference we make to that is an informal debriefing or meeting to update the situation, see if anyone is too distraught to continue the shift, remind silence to the press and pass out the telephone numbers for EAP or some employee referral system. There is also an open door policy to one of the supervisors, chief or whoever is in command who will then walk the person personally to the EAP office. 

Humans and their minds are too complex to be mucked with by someone with a "few hours of training". It is rarely the incident itself that causes the problems but the issues in someone's life and the way each individual is wired. 

It is funny that you mentioned the "bottle of Jack" since that was one of the things that got CISD a closer look. Too many providers did use drugs and alcohol to mask their problems both at home and at work. Unfortunately since EMS providers are not trained to recognize these issues, they got missed even with several "CISD" sessions. Co-workers also don't want to hear about someone's weaknesses and don't know what to say or do if they do know. Thus, it wasn't until the person's marriage is ruined, financial troubles are overwhelming, license is being reviewed, patient harmed and suicidal ideations or even suicide itself is commited that the real problems are identified. CISD was used as an excuse not to seek outside help since "they were being taken care of by their own". 

Do your co-workers a favor and promote care from an educated, well trained and licensed professional such as a clinical psychologist. 

In the meantime, surf up Dr. Bledsoe's articles on the subject. There are also many other well researched references listed with his articles as well as those that will pop up on a medical search engine.


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## Luno (Nov 11, 2008)

*Okay, this is what I was looking for...*

Rid, I have blanketed the start of the grief management and recognition under the CISD acronym.  I would agree that the traditional CISD model was flawed when it was implemented, but I also feel that there is a considerable kickback from the psychologically wounded rescuer when a mental health professional is added to the mix.  I keep reflecting back to an incident in the past year and how there wasn't a plan to manage the psychological trauma to the rescuers.  I was told "find what works, write it up, and we'll look at implementing it."  That being said, what worked last time was a peer discussion of grief, emotion, and depression with recogition of the various stages of grief so that the people who were new the rollercoaster would at least have an idea of what they're going to go through.

Vent, yes, I live in the "The King County."  That being said, this isn't for a direct KC EMS agency, well it is and it isn't...  


> The only reference we make to that is an informal debriefing or meeting to update the situation, see if anyone is too distraught to continue the shift, remind silence to the press and pass out the telephone numbers for EAP or some employee referral system. There is also an open door policy to one of the supervisors, chief or whoever is in command who will then walk the person personally to the EAP office."


I couldn't think of a worse way to handle this sort of situation.  I'm am going to throw in a caveat here, that I am not a mental health professional, I am a medical professional.  That being said, I have had the opportunity to deal with people in the mental trauma of a hard loss of a patient, as well as other people with PTSD, and the majority of them do not call the employee referral system.  There is a stigma to asking for help.  I know on my first loss I didn't use it, and I woke up in cold sweats and nightmares.  It wasn't every night, but it lasted for a good 6 months.  I won't accept that anyone working for me doesn't have every chance to not go through the nightmare that I went through.  


> "Humans and their minds are too complex to be mucked with by someone with a "few hours of training". It is rarely the incident itself that causes the problems but the issues in someone's life and the way each individual is wired."


While you are partially right, you couldn't be more wrong.  The stages of grief are fairly universal with the exception of some mental illnesses.  


> Do your co-workers a favor and promote care from an educated, well trained and licensed professional such as a clinical psychologist.


Well, as luck would have it, I do have access to a clinical psychologist, who I am bouncing these ideas off of, so I'm not going to go too far overboard without oversight... 


> "In the meantime, surf up Dr. Bledsoe's articles on the subject. There are also many other well researched references listed with his articles as well as those that will pop up on a medical search engine."


I've reviewed a few of Dr. Bledsoe's articles, and I will probably be contacting him shortly, but I'm slightly concerned of the defensibility of his controversial approach.  

Thank you for your comments, and I look forward to more people sounding off and saying how they feel.


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## VentMedic (Nov 11, 2008)

Luno said:


> *I couldn't think of a worse way to handle this sort of situation*. I'm am going to throw in a caveat here, that *I am not a mental health professional,* *I am a medical professional. *That being said, I have had the opportunity to deal with people in the mental trauma of a hard loss of a patient, as well as other people with PTSD, and the majority of them do not call the employee referral system. There is a stigma to asking for help. I know on my first loss I didn't use it, and I woke up in cold sweats and nightmares. It wasn't every night, but it lasted for a good 6 months. I won't accept that anyone working for me doesn't have every chance to not go through the nightmare that I went through.


 
Referring to a *qualified* licensed professional or having an open door to get the person some help confidentially is a bad thing? Not everyone wants their problems sorted out publicly or to admit they have other issues amongst their peers. 

As a medical professional you should know your limitations as well as your responsibilities. Even physicians are refer to other physicians who are better suited for that problem. Those in EMS are barely trained to deal with some psych situations for the few minutes they are with the patient. That is one of the weakest areas in EMS training. 

How much do you think someone is going to open up about their home life? How much of it is even your business? By advocating the "we take care of our own" you are merely looking at a small part of the situation and not addressing the root wiring. The stages of grief do not apply in order to everyone and even Kubler-Ross and Kalish have readdressed earlier theories. 

Maybe there should be a change in attitude about EAP. The "we take care of our own" is not always appropriate especially when it comes to some of life's problems. Problems are not always solved as easily as some in EMS want them to be nor does the "bottle of Jack" advice solve anything. Some issues may be awakened that may take years to deal with.   

No two people will experience things the same.  Your situation may also have had other issues, some you may not even be aware of, and it would be very wrong to assume others will respond exactly like you.  It sounds like *you did not seek out* professional help and/or nobody offered. There lies the problem.


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## Ridryder911 (Nov 11, 2008)

The reason they (Dr. Bledsoe) are controversial is that it opened up the truth. Many were making thousands to millions of the debunked CISD scam. 

Like I described debriefing is fine and having the ability to turn to a professional is the main point. Hopefully your psychologist friend can help develop a program for you. 

R/r 911


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## Luno (Nov 11, 2008)

VentMedic said:


> Referring to a *qualified* licensed professional or having an open door to get the person some help confidentially is a bad thing? Not everyone wants their problems sorted out publicly or to admit they have other issues amongst their peers.



Perhaps I didn't explain myself adquately, I feel that there is a place for mental health professionals, but I feel that incident specifics should be debriefed.  Is having the option to see someone in the mental health field beneficial?  Absolutely, but our responsibilities as team members and leaders do not stop there, and the option to see someone is the absolute least we can do.



> As a medical professional you should know your limitations as well as your responsibilities. Even physicians are refer to other physicians who are better suited for that problem. Those in EMS are barely trained to deal with some psych situations for the few minutes they are with the patient. That is one of the weakest areas in EMS training.


I will agree with you in regards that it is the weakest area in EMS training.  I will also agree that there are specialists who are far better to address these issues.  I do question your analogy, as who recommends those specialists?  Do we look at our patients and say, "well, you look like you might have a broken bone, here's a surgeon's number, you know, just incase you want to call?"  



> Maybe there should be a change in attitude about EAP. The "we take care of our own" is not always appropriate especially when it comes to some of life's problems. Problems are not always solved as easily as some in EMS want them to be nor does the "bottle of Jack" advice solve anything. Some issues may be awakened that may take years to deal with.


I completely agree with you here, I've watched too many people spin out.  We can't take care of our own by ourselves.  We aren't the ones who provide definitive care, medical or otherwise.  We provide a stopgap measure to stabilize until we can get someone to definitive care.  I would like a program to mirror this.  Let's just say it's like talking someone you believe is having an MI into going to the ER.  



> No two people will experience things the same.  Your situation may also have had other issues, some you may not even be aware of, and it would be very wrong to assume others will respond exactly like you.  It sounds like *you did not seek out* professional help and/or nobody offered. There lies the problem.



I'm going to differ with you on some points here, professional help was not offered, and I would of benefited by the counseling of people who had been through it before.  Not so much of me talking through my feelings, but to have someone tell me what could happen if I didn't get/seek help.  It could just be the eternal optimist in me, but I think that many ideas have good elements to them, but when they've been rigidized, and turned into profit opportunities, they join the hacks and snake oil dealers of the past....


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## BossyCow (Nov 12, 2008)

> It could just be the eternal optimist in me, but I think that many ideas have good elements to them, but when they've been rigidized, and turned into profit opportunities, they join the hacks and snake oil dealers of the past....



Best post made on the topic so far!  Our local CISD team is made up of volunteers and the team always includes at least one mental health professional with experience in dealing with PTSD issues. The debriefing is very tightly controlled and has proven of benefit on several incidents. 

Just because some systems choose to implement a program poorly doesn't mean the entire system needs to be tossed. In my district the peer to peer discussion has proven very helpful. Of course it has been done under the watchful eye of the above mentioned MHP. Part of our program also presents the resources for professional help and guidance with a clear list of symptoms that would indicate the need for that extra help.


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## pmedicchris (Jul 2, 2011)

*EAP and CISD*

I've had poor experiences with both EAP and CISD. Several years ago, a co-worker died of a MI. Our employer brought in CISD and encouraged everyone to attend. First thing out of the woman's mouth was "I've never worked in EMS and I don't understand your job." 

Years later when I had my first infant cardiac arrest, I needed help. I called a supervisor who made phone calls to EAP and no one ever called him back. When I returned to work my next shift, my supervisor gave me the number to call EAP myself. When I called, they didn't know my branch of my department existed. I was like screw them! 

When i have a tough call, I don't want to a mental health professional who doesn't understand EMS and doesn't really have a clue what we do/see. I'd much rather talk to someone who has been there and understands what I'm feeling/thinking/going through. The department I work for now has two chaplins available and I talk to a particular one of the two. Just cuz its a chaplin doesn't mean he will go all religious on you either lol. And the one here is also a paramedic/fire fighter, so he really does get it. When I have a bad call, I want to talk through it and have someone tell me I did everything I could do or give me suggestions of how to do things better next time. 

Its just been my experience that EAP and CISD are poor resources. I won't ever use them.


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## mikie (Jul 2, 2011)

*Hey, i didn't reopen the thread...*



Ridryder911 said:


> The reason they (Dr. Bledsoe) are controversial is that it opened up the truth. Many were making thousands to millions of the debunked CISD scam.



And where is your documentation for this?

Haven been taught by the father of CISM, I think there is more to it than the crap Dr. Bledsoe remarks to which he lacks in empirical data, or any at all...

---
To the last post: In my experience, poor CISM/D is typically the result from a poor debriefer lacking proper training or an issue that requires deepr interventions.  No, CISM/D is not the end-all-be-all for emotionally traumatic events, but it is one intervention in the process.  

Have you/encouraged anyone into looking into hypnosis or EMDR?  (From an experienced provider?)


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## pmedicchris (Jul 2, 2011)

I've just started looking into EMDR. Honestly, it sounds hokey. LOL! But I'm still reading up on it.


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## mikie (Jul 2, 2011)

*What to you have to lose?*



pmedicchris said:


> I've just started looking into EMDR. Honestly, it sounds hokey. LOL! But I'm still reading up on it.



I've never done it but I know multiple professionals that have attested to it.


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## parapaulieFL (Jul 2, 2011)

I think there should be more training on how to recognize the signs and symptoms of incident related stress and how it can affect the rescuer. The mind is such a complex thing and different people will react in different ways. The benefit of talking to a more experienced colleague is nice to get a handle on how they have felt/handled these situations in the past. If there is complex issues, a mental health pro can help with the clinical aspect of things and it should be required that they have experience in EMS. I have been in the field about 9 years and definitely seen my share of things. However, I have never experienced any negative side effects. I'm a very compassionate and emotional person, but I guess I am able to let it go, unaffected.? ? But it doesn't mean I won't ever have an issue in the future....


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## usafmedic45 (Jul 2, 2011)

> Haven been taught by the father of CISM, I think there is more to it than the crap Dr. Bledsoe remarks to which he lacks in empirical data, or any at all...



Hello confirmation bias....



> I've never done it but I know multiple professionals that have attested to it.



....and goodbye need for empirical data. LOL


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## BEorP (Jul 2, 2011)

mikie said:


> And where is your documentation for this?
> 
> Haven been taught by the father of CISM, I think there is more to it than the crap Dr. Bledsoe remarks to which he lacks in empirical data, or any at all...
> 
> ...



Let's start with this.... what reputable, peer reviewed medical journal did this "father of CISM" publish the concept in initially?


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## mikie (Jul 2, 2011)

BEorP said:


> Let's start with this.... what reputable, peer reviewed medical journal did this "father of CISM" publish the concept in initially?



*When disaster strikes: The critical incident  stress debriefing process*. Journal of Emergency Medical  Services_ vol 8: 36-39)


_


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## BEorP (Jul 2, 2011)

mikie said:


> *When disaster strikes: The critical incident  stress debriefing process*. Journal of Emergency Medical  Services_ vol 8: 36-39)
> 
> 
> _



Yes, this is where the first presentation of CISD was made. The problem is that JEMS is not a medical journal and is instead a trade magazine (particularly in its form 30 years ago). If his program was really of value and would hold up to review by experts in the field, Mitchell should have sought publication in a peer reviewed medical journal. There have been many articles published since then that debunk the CISD myth.


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## mikie (Jul 2, 2011)

*Check out PubMed...you'll get quite a few results.*



BEorP said:


> Mitchell should have sought publication in a peer reviewed medical journal. There have been many articles published since then that debunk the CISD myth.



He has, that was the first publication; and I'd like to see some of the debunking articles.  I'm not trying to spark controversy or an argument, I would just like to see data that disproves.  Psychology is not always a science after all...

And i couldn't agree more about JEMS being a trade magazine...personally, i think PhysioControl or Laerdal is their chief advertiser  (though they do have a formal /peer-reviewed process, just not as prestigious as the NJEM or JAMA).


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## BEorP (Jul 2, 2011)

mikie said:


> He has, that was the first publication; and I'd like to see some of the debunking articles.  I'm not trying to spark controversy or an argument, I would just like to see data that disproves.  Psychology is not always a science after all...
> 
> And i couldn't agree more about JEMS being a trade magazine...personally, i think PhysioControl or Laerdal is their chief advertiser  (though they do have a formal /peer-reviewed process, just not as prestigious as the NJEM or JAMA).


Though JEMS has a peer review process of sorts in place now, I suspect that may not have been the case in 1983. Regardless, here are a few to take a look at:

Prehosp Emerg Care. 2003 Apr-Jun;7(2):272-9.
Critical incident stress management (CISM): benefit or risk for emergency services?
Bledsoe BE.

Lancet. 2002 Sep 7;360(9335):766-71.
Single session debriefing after psychological trauma: a meta-analysis.
van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM.

Br J Med Psychol. 2000 Mar;73 ( Pt 1):87-98.
The influence of occupational debriefing on post-traumatic stress symptomatology in traumatized police officers.
Carlier IV, Voerman AE, Gersons BP.


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## usafmedic45 (Jul 2, 2011)

> I'd like to see some of the debunking articles....



Then take a look at the references Dr. Bledsoe gives....he's such an advocate of EBM that he's very cautious not to stick his neck out unless he's got the science to underpin it.

http://www.bryanbledsoe.com/data/pdf/mags/Debates.pdf
http://www.bryanbledsoe.com/data/pdf/mags/CISM (GA).pdf
http://www.bryanbledsoe.com/data/pdf/mags/CISM (BP).pdf
http://www.bryanbledsoe.com/data/pdf/journals/CISM (Bledsoe).pdf

Just one of those articles has 53 references so I guess it's your own fault that you decide to criticize without first doing the legwork to find the "debunking articles".  

The primary problem with Mitchell's work is that the data to back it up comes from studies that are riddled with methodological errors or are frankly put out by folks with far too great of a stake in "business" of CISD to be take at even face value.  They were actually used in one of the psych research classes I took as an example of "junk science".  It's not just Bledsoe that has called him out on it.  Pretty much everyone who has any strong grounding in the principles of research that has taken a look at the lack of credible supporting data and didn't spend too much time suckling the CISD teat beforehand has found it to be at best of no appreciable effect and at worst flat out harmful.


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## mikie (Jul 3, 2011)

usafmedic45 said:


> Just one of those articles has 53 references so I guess it's your own fault that you decide to criticize without first doing the legwork to find the "debunking articles"



Of course he has many references; it's preventing plagiarism when you're using other people's work.  

And I've read those articles- all from his website.  They're all written and sponsored by him.  Didn't you already mention confirmation bias? 

What background does Dr. Bledsoe have in clinical psychology? It seems more of a vendetta against CISM and/or Mitchell


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## BEorP (Jul 3, 2011)

mikie said:


> He has, that was the first publication; and I'd like to see some of the debunking articles.  I'm not trying to spark controversy or an argument, I would just like to see data that disproves.  Psychology is not always a science after all...
> 
> And i couldn't agree more about JEMS being a trade magazine...personally, i think PhysioControl or Laerdal is their chief advertiser  (though they do have a formal /peer-reviewed process, just not as prestigious as the NJEM or JAMA).





mikie said:


> Of course he has many references; it's preventing plagiarism when you're using other people's work.
> 
> And I've read those articles- all from his website.  They're all written and sponsored by him.  Didn't you already mention confirmation bias?
> 
> What background does Dr. Bledsoe have in clinical psychology? It seems more of a vendetta against CISM and/or Mitchell



Did you look at any of the journal articles I posted? You said you weren't looking for a debate, but I don't understand why you seem so set on believing in CISD when there isn't evidence to support it.

I don't think that it is fair for you to suggest that Dr. Bledsoe has some kind of bias. What does he have to gain from debunking CISD? Or what do you think Mitchell ever did to him? Dr. Bledsoe is probably the strongest proponent of a shift to evidence based practices in EMS and he certainly shouldn't be criticized for this.


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## usafmedic45 (Jul 3, 2011)

> And I've read those articles- all from his website. They're all written and sponsored by him. Didn't you already mention confirmation bias?



I posted the links simply because I could not cut and past the original references from the PDFs.  I figured you'd be smart enough to figure that out on your own.



> Of course he has many references; it's preventing plagiarism when you're using other people's work.



Oh...you did apparently pay attention in whatever rudimentary level science courses you have taken.



> What background does Dr. Bledsoe have in clinical psychology?



Let's see:  physician with nothing to gain by debunking myths or clinical psychologist who has made a name for himself and a fair amount of money based off of a theory.  



> It seems more of a vendetta against CISM and/or Mitchell



Dr. Mitchell, is that you? LOL


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## ffemt8978 (Jul 3, 2011)

This thread is going nowhere in a hurry, so it belongs to me for the next 24 hours, at least.


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