CISM and Peer Support: My Thoughts
By: Robert Hogeland
Captain, Retired, Dayton Fire Department
It seems that the good things that have come into my life have done so in spite of me, rather than because of me. Oh, in some inadvertent way, I would make choices that would ultimately be of benefit to me – or teach me one of Life’s Lessons – but at the conscious level, there was no intention to do or be the things that I did or became! Such was the case with the Southwest Ohio Critical Incident Stress Management Team, or SWOCISM.
In the year, 2000, I was working for the Dayton Fire Department as a “Relief Lieutenant” (I carried my boots), “out in the district” I was just beginning to get my “sea legs” as a fairly green officer, when I was visited by the District Chief (equal in rank to a “Battalion Chief”) in charge of the section of Dayton where I normally worked. He informed me that the Fire Department had created a new position for a Lieutenant: The “Health and Wellness Coordinator” (HWC). For some reason, unbeknownst to me, I had been chosen to be the first one. I would start at the beginning of the following week.
I think it unlikely that I would have sought such a program out since, prior to the visit by the Chief, I’d had no idea that such a program might exist. Furthermore, I had been quite happy working every third day and spending the other two days doing what I felt moved to do in my own world. Nevertheless, Health and Wellness was, now, mine to do. Department’s orders – and maybe Providence’s orders, too!
My 24/48 schedule evaporated, and I went to a 40-hour work week like so many folks in business, public or private. I was to research, create a template, and then implement (after approval by the administration, of course) a wellness and fitness program that was to apply effectively to the members of the Department.
The Health and Wellness Program consisted of four basic elements:
- Physical Fitness
- Medical Health
- Mental/emotional Health
- Spiritual Health (Chaplaincy program)
CISM:
Pre-assignment, I had figured a wellness program was simply a process of “making fat firefighters fit” so they wouldn’t drop dead in Mrs. Smith’s front yard while they were fighting her kitchen fire! There was “that”, of course, but I was impressed at how comprehensive a fully formed program could actually be! Each of the four items listed above represented an important cornerstone in the overall health and wellbeing of the firefighter. I was surprised by the importance given to mental and emotional health, although I shouldn’t have been, really. When one thinks about it, every action begins with a thought – and every action or circumstance produces a thought and/or a feeling.
Under Mental/Emotional Health came a thing called Critical Incident Stress Management, or “CISM”. CISM is a process of using specifically trained peers (firefighters, police officers, EMS providers, et al.) to provide a pathway back to a semblance of sanity and functionality for first responders who have experienced critical (overwhelming – debilitating) incidents in the course of their duties. In short, it is psychological first aid for those suffering an acute response to tragedy.
Even before the assignment to Health and Wellness Coordinator’s position, I’d had some limited knowledge of CISM. Like many of my coworkers on the Department, I had participated in a “debriefing”, a few years prior, after an incident that included a Police Officer line-of-duty shooting death, the serious wounding of a second Officer, the bizarre shooting death of a potato chip vendor, and the death of the original shooter. We Fire Department members were involved because we provided treatment to the victims – all of them – regardless of their role in the incident. I remember being glad that such a program existed to help those who were seriously disturbed by the events that day; however, I recall little else – perhaps that’s because I had been struggling with the images and feelings, myself, having responded with my fellow crew members to the “potato chip guy” scene.
To the Dayton Fire Department’s credit, they had, like many other departments in the region, established a relationship with the Southwest Ohio Critical Incident Stress Management Team (SWOCISM), the team that served our region. They had Department members on the team, an established protocol for notification of the team when a critical incident had occurred, and guidelines in place for the requesting of their services.
One of the first CISM-related things that my supervisors asked me to do, as the new HWC, was to work with the administrators of the SWOCISM Team to offer a training session to firefighters in the Dayton area who might want to become team members. As a result, I met Jim Edrington and Linda King-Edrington, the founders of SWOCISM. They headed up this thriving organization, which served a large area of Southern Ohio, Eastern Indiana, and Northern Kentucky. In the year 2000, Jim and Linda were the face of CISM in this region. This dedicated couple had pioneered the movement from their Greater Cincinnati area home base, building the team from the ground up since the late 1980’s. Jim and Linda readily agreed to host a class for the Dayton Fire Department and its invited guests from other regional departments.
The class was well-attended, although many of the participants walked away with certificates but not applications to join the team. I was among those who hesitated to commit. As a result of taking the class, I had developed a strong appreciation of the Team and the work that it did, and I was better prepared to include CISM in the overall Health and Wellness Program that I was charged with developing. Not surprisingly, Jim and Linda invited me to become a member of the Team; however, I respectfully declined, declaring that I had “way too much on my plate” to begin yet another commitment at that time.
Four years later, after being cycled back into the district, and, later, doing a second “gig” as Health and Wellness Coordinator – and after taking a second CISM training class – I “caved” and applied to become a member of the Southwest Ohio Critical Incident Stress Management Team. The work was far too compelling to continue to ignore!
I was accepted into the fold after going through the application process, which included an in-depth interview and a presentation of worthy references – a thorough vetting operation. Once on board, I was gently but firmly encouraged to participate in interventions, as my schedule and priorities permitted, so that I could grow in experience and effectiveness as a team member. During this growing process I was always in the company of well-experienced team members who served as mentors as I gained my own experience – and who “rescued” me if I “went off the rails” during an intervention and started to take the conversation in a direction that was not helpful.
As I got to know the other folks on the team, I was impressed by the diversity of the disciplines in which they worked: Police, Fire, EMS, Dispatch, Medicine, Industry, Athletics, and Education, to name a few. There was a wide range of age and experience, and there was some real professional certification as well: Mental Health professionals, Clergy, Medical professionals, Attorneys – all had representation on the team. I learned that many of the team members had joined up after having experienced, firsthand, one or more critical incidents in the course of their professions, finding CISM to be of immense value as part of their personal healing and return to viability as professionals. Most importantly, I found a strong current of dedication and love for the work of Critical Incident Stress Management and for the overarching avocation of helping others when they are in serious need.
Among the crew were some real masters of the craft. While there is a lot of science involved in the various steps of an intervention, there is ample “art”, too. You could sense a “presence” in the old “sages” who had been on the team since its inception. With unflappable confidence and quiet wisdom, these folks could transform the mood during an intervention from hopeless and chaotic to hopeful and purposeful. I hoped to exude those qualities, as well.
Even when I was a new member of the team, my contribution as a firefighter with about thirteen years of experience was accepted as important in the same way that the highly trained Psychologist was: I was a peer who had “done the deed” and could, therefore, add that degree of legitimacy to the conversations that comprised “defusing’s”, “debriefings”, and “one-on-one’s” that were the substance of the services that were provided by the Team.
Training was in-depth and relevant. I had already taken the Group Crisis Intervention course and the Assisting Individuals in Crisis Intervention course (one-on-one), but monthly continuing education (first Thursday of each month) presentations added depth and understanding to the Work. Although, some of the presenters were from non-affiliated organizations, many of those who trained us were team members, themselves, and were able to share their particular perspectives on the subject of Critical Incident Stress, and how they related to the overall goals and operations of the team.
Serving on the team has not always been easy; however, it has been undeniably rewarding. I remember coming home from a busy 24-hour shift, one morning, scaring up some breakfast before a planned morning “recovery nap” and a day of personal activity options – and receiving a call from the Team Coordinator who was requesting that team members response to a fire department, over fifty miles away, which had just experienced a double line-of-duty fatality. Full disclosure demands that I say the temptation to “blow it off” and let others respond was strong, since I’d just finished a stressful day at work; however, I did not join the team to leave the work to others! The members of this department were in need. Those of us who have experienced a line-of-duty death in our own departments know this! What followed was a full week of supportive activity by the team, in cooperation with other agencies that would as a matter of course be assigned to the recovery process. People were helped; friendships at the team level and at the personal level were made throughout the unfolding of this enormous response.
We Help; We Do Not “Force the Issue”
During my twenty-plus years with SWOCISM, I have attended scores of interventions, many of which were on or near the scene, and in the middle of the night. The departments called, and the team answered. There was no compensation for time spent or miles travelled, the satisfaction came from performing a service according to one’s own “blueprint”. The team never initiated contact with any department beset with a critical incident; the request had to come from the affected organization. Individuals who had experienced a critical incident were neither compelled to come to a defusing or a debriefing; nor – once they were participants in the intervention – were they compelled to speak. Encouraged to speak to their own thoughts and feelings, only, they were not coerced or otherwise “made” to do so.
At the onset of the intervention, the team members assure participants that the conversation is not a critique; its purpose is to provide an opportunity to express their thoughts, feelings, and other reactions to the critical event in which they were involved with the expectation that doing so will help them begin the journey back to normalcy.
During an intervention, the team members serve as peer/guides who follow a protocol that safely takes the attendees through the discussion of the facts of the critical incident, the roles that each person played during the incident, and the effects that the incident had on them. The conversation then leads them to the present and the future, explaining that the things they are experiencing are normal for anyone who has been part of a critical incident, and suggesting ways they could enhance recovery.
After the formal intervention, team members remain on site for a short time in order to be available to mix informally with the folks we’d come to see. This helps those who may not have felt comfortable speaking in front of the group to express any lingering concerns that they may have.
One of the team members will be assigned to make a follow up phone call with the contact person for the organization in about three days. The purpose of the follow-up is to ensure that the people who experienced the critical incident are moving toward normalization of their lives both at work and at home. Are other interventions needed? Are there concerns about one or more of the individuals and how they are coping with the experience? Would it be helpful for the mental health professional on the team to evaluate the individual(s) and suggest further professional help? The response by the affected crew or individual is always at their option, and always confidential.
Confidentiality:
A critical incident, while often occurring in a very public venue – one which receives intense attention through the media – is usually experienced in a very personal way. Those who have experienced one will likely react with fear, embarrassment (at being so “un-tough”), disorientation, discouragement, and may have a host of physical symptoms that reflect a severe threat to their well-being – or even their existence! It is imperative that, while the participants in an intervention be able to speak freely among fellow crew members, they must be safe from public scrutiny. All conversation held during the intervention is to be held in strict confidence. With the exception of criminal activity allegedly committed by a participant, or where a participant threatens harm to himself or others, this imperative is protected by law. The person who has experienced a critical incident will only heal while in a position of safety.
Is CISM “Harmful”?
You may be aware of some recent opinion that CISM is, at best, ineffective and, at worst, dangerous. The idea that CISM can consist of “dredging up” traumatic memories that are better laid to rest, or left alone, has been expressed as a justification for declaring CISM obsolete and unwelcome in public safety organizations. I am not one to challenge peer-reviewed studies regarding this; however, over the course of my association with the team, I cannot recall a time when any individual was expected to speak, let alone, answer specifics beyond, “Please introduce yourself and tell us what your role was at the scene.” Any contribution made by a participant during an intervention is voluntary.
When our services are requested, we respond to a need that is either ongoing or very recent. The events with their corresponding reactions and responses are fresh and overwhelming. Often, the affected first responders are so overloaded with emotion they are unable to function. If there is any “dredging” going on it is a pretty shallow ditch; the thoughts and emotions are right up front.
Our purpose is to help with the unloading process in a safe and confidential atmosphere. Our function is structured, allowing the orderly sharing of information about the incident which helps to stabilize the group’s perception of what went on – and what is going on within each of them. In essence, our role is psychological first aide. More help is available through the evaluations and guidance of appropriately certified members of the Team.
CISM operations are built around the “Mitchell Model” (refer to Dr. Jeffrey Mitchell), a systematic technique of managing information from a critical incident, the goal of which is to expose and address the elements of the incident as they occurred in the field and as they affected the individuals who experienced the incident. The positive outcome is stabilization, normalization, and a return to functionality in the line of work to which the individual is dedicated.
A critical incident is a perilous thing for the heart and mind of the first responder or other helper. Experience has taught us that not all people respond in the same way to an incident, nor do they respond to the type of help offered. Not all people who emote or verbalize loudly during an intervention are the most in need; not all people who are quiet and calm are “on top of” the situation or their part in it. As with other aspects of the emergency services, part of the “maturing” of a CISM Team member is the development of the intuitive sense to either reach out to or step back from a person or a subject during an intervention.
Our stance is one not of assertiveness but of helpfulness. We are not fixers, but with CISM, we can provide a doorway through which one can step to lessen the uncommon burden of the Critical Incident.
Peer Support:
I was formally introduced to Peer Support in May of 2017, two years after I’d retired from the Fire Department. The IAFF Local with which I had been affiliated, was offering the course as part of their continuing effort to improve working conditions – and the general health and wellbeing – of the firefighters within their fold. As a retired firefighter, who had maintained a strong interest in things “health and wellness”, I was given the opportunity to join the class with the intent to be a resource for other retired members who were struggling with life issues.
The class lasted two days, and it was informative and hopeful. As a participant in the class, I offered commentary about similarities between what I was hearing and what I had experienced as a member of a CISM team. I was a bit puzzled at the response by the two presenters, as they spoke of the limitations of CISM. I was told that “CISM” was “reactive” whereas Peer Support was pro-active. CISM was, in my opinion, being cast as a has-been – a “good try” but a far too rigid version of the helping hand that a firefighter needs. I don’t know if it was just the attitude of the presenters or if it was a more comprehensive and official opinion of the Peer Support program that was being presented.
Setting aside their apparent disparagement of the CISM process, I will say that Peer Support as I was taught to see it, and at its best, is a very comprehensive and proactive system of providing help for first responders before their individual and very personal problems become true crises with drastic manifestations. The purview of the Peer Support program reaches into many areas of the responder’s life: personal behavioral issues (e.g. substance abuse, other addictive behaviors, etc.); relationships; financial problems – things that are very important but that don’t have the urgency added to them by a critical incident. The need to seek help in such matters is undeniable.
Peer support holds as one of its goals the increase of the responder’s resiliency – or as the most notable Lt. Col. Dave Grossman (U.S. Army, retired) put it, helping him or her to become “bulletproof”. A stronger and better balanced individual will be able to weather the storms around him or her, even to the point of the lessening or avoidance, altogether, of the most serious effects of a critical incident when it inevitably occurs.
Consider this metaphor: A fairly well accepted goal in life is to live in health and happiness as fully as possible. In order to accomplish this, one eats well; avoids destructive or dangerous behaviors, gets sufficient sleep, exercises in order to assure continued strength and stamina, and so forth. However, because life is not just a “bowl of cherries” things happen. They can be as small and seemingly insignificant as a tummy ache, or they can climb the ladder of severity to a much more challenging situation. We have spent much time and treasure shoring up our defenses against misfortune and illness, but when the drunk driver crosses the road and strikes our vehicle, we are put into a whole new paradigm. If we are blessed to survive the collision, we will likely be treated by medics and fire personnel, first. We will then be transported to a hospital, where we will be treated for the emergency. From that point, we will be either released to the care of family or friends, or moved up the scale to a more intense level of care.
Peer Support could be described as the preventative phase. It is, indeed, a proactive system, helping the individual avoid or at least lessen the impact of the daily problems that can add up. The lower the crisis level, the greater the options one has in the process of self-care.
Think of CISM as the team that arrives on the scene of a true crisis – an incident or circumstance that has the power to disrupt the normal balance in one’s life. CISM is part of the process of amelioration of the negative effects of the incident – just like the medic does at the accident scene. Beyond the team are mental health professionals who have increased levels of skills and certifications (permission to treat) for those who need more.
CISM and Peer Support Together: A Balanced Approach to Wellness
At the center of both CISM and Peer Support is communication. In each case, the motto, “That which is not spoken of cannot heal”, is vital to success. Rather than using comparison and contrast, I believe it would be far better to see the two approaches as contiguous, sharing many aspects in a common goal. While it is practical to avoid use of certain “crisis questions” (e.g., “What is the worst aspect of the incident for you?”) when you are helping one with, say, financial matters, it is also helpful to avoid asking a person about personal habits or daily challenges when he or she is reeling from the effects of a very disturbing run (critical incident)!
Not all situations or incidents require the same level of response, yet it is advantageous to have sufficient tools in your “toolbox” to address the dynamics of a situation as it presents itself. CISM and Peer Support each have their allotment of those tools – some shared – which can be called into service, as needed, to effect a balanced outcome to the challenge to the First Responder’s overall health and wellbeing.