Critical incident stress management

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Critical incident stress management
Other namesCISM

Critical incident stress management (CISM) has been misunderstood and unfairly criticized as a controversial, non-empirical, adaptive, short-term psychological helping-process that focused solely on an immediate and identifiable problem. Much of the "controversy" stems from confusion of terms.[neutrality is disputed] The overall ICISF Model of Critical Incident Stress Management includes several tactics to help mitigate the effects of a critical incident. It includes pre-incident preparedness to acute crisis management through post-crisis follow-up. Its purpose is to enable people to return to their daily routine more quickly and with less likelihood of experiencing post-traumatic stress disorder (PTSD).[1] The term CISM is frequently confused with one of the group intervention tactics under the model. That is the Critical Incident Stress Debriefing (CISD).

Further, many researchers[who?] appear to consider CISM to be some form of treatment when in fact it is a model of psychological first aid.

Although the creators of CISM have never proposed it as prevention of PTSD, researchers criticize it with evidence that debriefing techniques do not decrease rates of PTSD,[2] Whether that is the case or not, CISM is used by thousands of organizations around the world. Some organizations have adapted their practices of immediate psychological care techniques that do not use debriefing such as those endorsed by the CDC, Red Cross, WHO, American Psychological Association and National Center for Post Traumatic Stress Disorder (NC-PTSD).

A 2002 workshop whose goal was to reach consensus on the mental health response to mass violence recommended ending use of the word "debriefing" in reference to critical incident interventions.[3] Recent evidence-based reviews have concluded that CISM is ineffective and sometimes harmful for both primary and secondary victims,[4] such as responding emergency services personnel. CISM was never intended to treat primary victims of trauma.[5][6][7][8][9][10][11][12][13] One analysis of the psychological debriefing method used in CISM linked it to increased rates of PTSD one year after an event.[2] As of 2022, peer-reviewed meta-analysis specifically warn against the clinical use of CISM for all patients, primary or secondary, stating, "clinical guidelines for managing post-traumatic stress recommend not to practice psychological debriefing".[4] The International Critical Incident Stress Foundation refutes these analyses by citing Snelgrove [14] and others who argue that the critics have misapplied the established protocols.


CISM is designed to help people deal with their trauma one incident at a time, by allowing them to talk about the incident when it happens without judgment or criticism. The program is peer-driven by people who have completed one or more classes covering topics such as individual and group responses[15][16]) and the people conducting the interventions may have come from all walks of life, but most were first responders (Police, Fire, emergency medical services) or worked in the mental health field. The use of peers in the provision of Psychological First Aid and other interventions under the CISM model is a key to its continued success.


Critical incidents are traumatic events that cause powerful emotional reactions in people who are exposed to those events. The most stressful of these are often seen as being line of duty deaths, co-worker suicide, multiple event incidents, delayed intervention and multi-casualty incidents.[17] Every profession can list their own worst-case scenarios that can be categorized as critical incidents. Emergency services organizations, for example, usually list the Terrible Ten.[18] They are:

  1. Line of duty deaths
  2. Suicide of a colleague
  3. Serious work related injury
  4. Multi-casualty / disaster / terrorism incidents
  5. Events with a high degree of threat to the personnel
  6. Significant events involving children
  7. Events in which the victim is known to the personnel
  8. Events with excessive media interest
  9. Events that are prolonged and end with a negative outcome
  10. Any significantly powerful, overwhelming distressing event

While any person may experience a critical incident, conventional wisdom says that members of law enforcement, fire fighting units, and emergency medical services are at great risk for experiencing traumatic events.

Types of intervention[edit]

The type of intervention used depended on the situation, the number of people involved, and their proximity to the event. One form of intervention was a three-step approach, whereas different approaches include as many as five stages.[citation needed] However, the exact number of steps is not what is important for the intervention's success.[citation needed] The goal of the intervention is to address the trauma along the general progression: defusing, debriefing, and followup.[19]


A defusing is done the day of the incident before the person(s) had a chance to sleep. The defusing was designed to assure the person or people involved that their feelings are normal, to tell them what symptoms to watch for over the short term, and to offer them support, usually in the form of contact with a peer support person from their organization. Defusings are used to support groups, not individuals, who have shared the same traumatic experience. Never is a defusing done at the scene of an incident as this would violate the CISM principle of not interfering with operations. The purpose of a defusing is to assist groups in coping in the short term, address acute needs, facilitate a normalization of any symptoms that arise, and bring awareness of available resources if difficulties are encountered.


Debriefing is controversial and there is claimed to be empirical evidence that it may cause harm.[11][10][12][13] The International Critical Incident Stress Foundation rejects these claims, writing that "There is no extant evidence to argue that the “Mitchell model” CISD, or the CISM system, has proven harmful! The investigations that are frequently cited to suggest such an adverse effect simply did not use the CISD or CISM system as prescribed, a fact that is too often ignored".[20]

ICISF specifies that defusings and debriefings are only intended for use with groups.[21] The individual intervention technique used in CISM is a version of psychological first aid.[22] A literature review concluded that a primary flaw in criticism of CISM is "the lack of consistent terminology," which has led investigators to evaluate distinct interventions as if they were identical, and to use variable outcome measures, making it difficult to compare outcomes across different studies. The review authors concluded that CISM "should continue to be offered to secondary victims of trauma."[23]

For teams, group debriefings are suggested 48–72 hours after a critical incident giving the group an opportunity to support each other by talk about their experience, how it has affected them, brainstorm coping mechanisms, identify individuals at risk, and inform the individual or group about services available to them in their community.[24] The final step was to follow up with them the day after the debriefing to ensure that they are safe and coping well or to refer the individual for professional counselling. CISM protocols clearly state that no one should ever be pressured or coerced to speak, contrary to some of the criticisms offered (e.g., one firefighter's account of CISM properly offered[25]).

Although many co-opted the debriefing process for use with other groups, the primary focus in the field of CISM was to support staff members of organizations or members of communities which have experienced a traumatic event. The debriefing process (defined by the International Critical Incident Stress Foundation [ICISF]) has seven steps: introduction of intervenor and establishment of guidelines and invites participants to introduce themselves (while attendance at a debriefing may be mandatory, participation is not); details of the event given from individual perspectives; emotional responses given subjectively; personal reaction and actions; followed again by a discussion of symptoms exhibited since the event; instruction phase where the team discusses the symptoms and assures participants that any symptoms (if they have any at all) are a normal reaction to an abnormal event and "generally" these symptoms will diminish with time and self-care; following a brief period of shared informal discussion (generally over a beverage and treat) resumption of duty where individuals are returned to their normal tasks. The intervenor is always watching for individuals who are not coping well and additional assistance is offered at the conclusion of the process.[17]

Follow-up and referral[edit]

The important final step is follow-up and referral where indicated. This is generally done within a day and again the week following the debriefing by team members as a check-in. This step is important as symptoms may have developed or worsened during this time. One of the key components of the ICISF model is to ensure that anyone who is exposed to a critical incident and who continues to experience symptoms is referred to an appropriate mental health professional for treatment.


Studies have shown that CISM protocols as described by the ICSIF have demonstrable benefits[26][27][28] and that the benefits exceed the costs.[29] Benefits include reduced alcohol consumption and increased quality of life.[30]

Some meta-analyses in the medical literature have found no benefit to CISM. A three-year five-state study on the relationships between critical incident stress debriefings, firefighters' disposition, and stress reactions.[31][9] very low quality evidence of benefit or negative impact for those debriefed.[10][11][12][13]

,[32][33][34][35] although like many of the other studies cited here, the analysis focused on the CISM for preventing PTSD, a claim that ICISF and its founders have never made.

The ICISF's founders have argued that analyses raising questions about CISM, especially the idea that it could cause harm, are based in poor research quality or misapplications of CISM principles and protocols.[36]

See also[edit]


  1. ^ "Critical Incident Stress Management: Purpose" (PDF). Virginia Beach Department of Emergency Medical Services. Retrieved July 16, 2009.
  2. ^ a b Rose, S.; Bisson, J.; Churchill, R.; Wessely, S. (2002). "Psychological debriefing for preventing post traumatic stress disorder (PTSD)". The Cochrane Database of Systematic Reviews (2): CD000560. doi:10.1002/14651858.CD000560. ISSN 1469-493X. PMC 7032695. PMID 12076399.
  3. ^ "Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence: A Workshop to Reach Consensus on Best Practices" (PDF). PsycEXTRA Dataset. 2002. Retrieved 2023-01-10.
  4. ^ a b Arancibia M, Leyton F, Morán J, Muga A, Ríos U, Sepúlveda E, Vallejo-Correa V (January 2022). "Debriefing psicológico en eventos traumáticos agudos: síntesis de la evidencia secundaria". Medwave (in Spanish). 22 (1): e8517. doi:10.5867/medwave.2022.01.002538. PMID 35100248. S2CID 246443705. Las principales guías clínicas para el manejo del estrés postraumático recomiendan no practicar debriefing psicológico.
  5. ^ Mitchell JT (February 10, 2003). "CRISIS INTERVENTION & CISM: A Research Summary" (PDF). International Critical Incident Stress Foundation. Retrieved January 29, 2016.
  6. ^ Rose S, Bisson J, Churchill R, Wessely S (2002). "Psychological debriefing for preventing post traumatic stress disorder (PTSD)". The Cochrane Database of Systematic Reviews (2): CD000560. doi:10.1002/14651858.CD000560. PMC 7032695. PMID 12076399.
  7. ^ Roberts NP, Kitchiner NJ, Kenardy J, Robertson L, Lewis C, Bisson JI (August 2019). "Multiple session early psychological interventions for the prevention of post-traumatic stress disorder". The Cochrane Database of Systematic Reviews. 8 (8): CD006869. doi:10.1002/14651858.CD006869.pub3. PMC 6699654. PMID 31425615.
  8. ^ 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.
  9. ^ a b Harris MB, Balolu M, Stacks JR (2002). "Mental health of trauma-exposed firefighters and critical incident stress debriefing". J Loss Trauma. 7 (3): 223–238. doi:10.1080/10811440290057639. S2CID 144946218.
  10. ^ a b c van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM (September 2002). "Single session debriefing after psychological trauma: a meta-analysis". Lancet. 360 (9335): 766–771. doi:10.1016/S0140-6736(02)09897-5. PMID 12241834. S2CID 8177617.
  11. ^ a b c Carlier IV, Voerman AE, Gersons BP (March 2000). "The influence of occupational debriefing on post-traumatic stress symptomatology in traumatized police officers". The British Journal of Medical Psychology. 73 (Pt 1): 87–98. doi:10.1348/000711200160327. PMID 10759053.
  12. ^ a b c Carlier IVE, Lamberts RD, van Ulchelen AJ, Gersons BPR (1998). "Disaster-related post-traumatic stress in police officers: A field study of the impact of debriefing". Stress Medicine. 14 (3): 143–148. doi:10.1002/(sici)1099-1700(199807)14:3<143::aid-smi770>;2-j.
  13. ^ a b c Rose S, Brewin CR, Andrews B, Kirk M (July 1999). "A randomized controlled trial of individual psychological debriefing for victims of violent crime". Psychological Medicine. 29 (4): 793–799. doi:10.1017/s0033291799008624. PMID 10473306. S2CID 35346492.
  14. ^ Dass-Brailsford, Priscilla (2007). A Practical Approach to Trauma: Empowering Interventions. doi:10.4135/9781452204123. ISBN 978-1-4129-1638-7.
  15. ^ "ICISF". Retrieved 2024-02-19.
  16. ^ "Education & Training - ICISF". Retrieved 2023-01-10.
  17. ^ a b Pulley SA (March 21, 2005). "Critical Incident Stress Management". eMedicine. Archived from the original on August 11, 2006. Retrieved July 16, 2009.
  18. ^ Mitchell JT. "Stress Management" (PDF). Szkoła Główna Służby Pożarniczej. Archived from the original (PDF) on June 25, 2008. Retrieved July 16, 2009.
  19. ^ Mitchell JT, Everly GS (2000). "Critical incident stress management and critical incident stress debriefings: Evolutions, effects and outcomes.". In Raphael B, Wilson J (eds.). Psychological debriefing: Theory, practice and evidence. New York, NY.: Cambridge University Press. pp. 71–90. doi:10.1017/CBO9780511570148.006. ISBN 9780521647007.
  20. ^ "A Primer on Critical Incident Stress Management (Cism) - Icisf".
  21. ^ "A Primer on Critical Incident Stress Management".
  22. ^ "Assisting Individuals in Crisis - ICISF".
  23. ^ "Is Critical Incident Stress Management Effective?" (PDF).
  24. ^ "Critical Incident Stress Management". Corrective Service of Canada. Archived from the original on September 27, 2009. Retrieved July 16, 2009.
  25. ^ "CISM and Peer Support: My Thoughts - ICISF".
  26. ^ Adler, Amy B.; Litz, Brett T.; Castro, Carl Andrew; Suvak, Michael; Thomas, Jeffrey L.; Burrell, Lolita; McGurk, Dennis; Wright, Kathleen M.; Bliese, Paul D. (2008). "A group randomized trial of critical incident stress debriefing provided to U.S. Peacekeepers". Journal of Traumatic Stress. 21 (3): 253–263. doi:10.1002/jts.20342. PMID 18553407.
  27. ^ Caponnetto, Pasquale; Magro, Rosanna; Inguscio, Lucio; Cannella, Maria Concetta (2018). "Quality of life, work motivation, burn-out and stress perceptions benefits of a stress management program by autogenic training for emergency room staff: A pilot study". Mental Illness. 10 (2): 67–70. doi:10.1108/mi.2018.7913. hdl:11573/1326359.
  28. ^ Vogt, Joachim; Leonhardt, Jörg; Pennig, Stefan (2007). "Critical Incident Stress Management in Air Traffic Control and Its Benefits". Air Traffic Control Quarterly. 15 (2): 127–156. doi:10.2514/atcq.15.2.127.
  29. ^ Vogt, Joachim; Pennig, Stefan (2016). "Cost Benefit Analysis of a Critical Incident Stress Management Program". Critical Incident Stress Management in Aviation. pp. 153–170. doi:10.4324/9781315575001-12. ISBN 978-1-315-57500-1.
  30. ^ Tuckey, Michelle R.; Scott, Jill E. (2014). "Group critical incident stress debriefing with emergency services personnel: A randomized controlled trial". Anxiety, Stress, & Coping. 27 (1): 38–54. doi:10.1080/10615806.2013.809421. PMID 23799773. S2CID 27769659.
  31. ^ USFA-FEMA CISM Research Project. Commerce, TX: Texas A&M University, 1998.
  32. ^ Strange, Deryn; Takarangi, Melanie K. T. (2015-02-23). "Memory Distortion for Traumatic Events: The Role of Mental Imagery". Frontiers in Psychiatry. 6: 27. doi:10.3389/fpsyt.2015.00027. ISSN 1664-0640. PMC 4337233. PMID 25755646.
  33. ^ Kagee A (February 2002). "Concerns about the effectiveness of critical incident stress debriefing in ameliorating stress reactions". Critical Care. 6 (1): 88. doi:10.1186/cc1459. PMC 137400. PMID 11940272.
  34. ^ Brainerd, C.J.; Stein, L.M.; Silveira, R.A.; Rohenkohl, G.; Reyna, V.F. (September 2008). "How Does Negative Emotion Cause False Memories?". Psychological Science. 19 (9): 919–925. doi:10.1111/j.1467-9280.2008.02177.x. ISSN 0956-7976. PMID 18947358. S2CID 37001782.
  35. ^ Blaney LS (2009). "Beyond 'knee jerk' reaction: CISM as a health promotion construct". The Irish Journal of Psychology. 30 (1–2): 37–57. doi:10.1080/03033910.2009.10446297. hdl:10613/2581. ISSN 0303-3910.
  36. ^ Everly, George S.; Flannery, Raymond B.; Mitchell, Jeffrey T. (2000). "Critical incident stress management (Cism)". Aggression and Violent Behavior. 5: 23–40. doi:10.1016/S1359-1789(98)00026-3.