PRIMER ON CRITICAL INCIDENT STRESS MANAGEMENT (CISM)
George S. Everly, Jr., Ph.D., C.T.S. and Jeffrey
T. Mitchell, Ph.D., C.T.S.
The International Critical Incident Stress Foundation
As crises and disasters become epidemic, the need for effective
crisis response capabilities becomes obvious. Crisis intervention
programs are recommended and even mandated in a wide variety of
community and occupational settings (Everly and Mitchell, 1997).
Critical Incident Stress Management (CISM) represents a powerful,
yet cost-effective approach to crisis response (Everly, Flannery,
& Mitchell, in press; Flannery, 1998; Everly & Mitchell,
1997) which unfortunately is often misrepresented and misunderstood.
is CISM? CISM is a comprehensive, integrative, multicomponent
crisis intervention system. CISM is considered comprehensive because
it consists of multiple crisis intervention components, which
functionally span the entire temporal spectrum of a crisis. CISM
interventions range from the pre-crisis phase through the acute
crisis phase, and into the post-crisis phase. CISM is also considered
comprehensive in that it consists of interventions which may be
applied to individuals, small functional groups, large groups,
families, organizations, and even communities. The 7 core components
of CISM are defined below and are summarized in TABLE 1.
CRITICAL INCIDENT STRESS MANAGEMENT
THE SEVEN CORE COMPONENTS
(Adapted from: Everly and Mitchell, 1997)
expectations. Improve Coping Stress management.
Demobilization & Staff Consult (rescuers); Group
Info. Briefing for civilians, schools, businesses.
or Shift dis-engagement.
inform, consult. Allow psychological decompression Stress
mitigation. Possible closure. Triage.
Critical Incident Stress Debriefing (CISD)
(1 to 7 days)
Can be event driven
psychological closure. mitigation. Triage.
Individual crisis intervention (1:1)
mitigation. Return to function, if possible. Referral, if
Family CISM; Org. consultation.
symptom driven or event driven.
support, communications. Symptom mitigation. Closure, if possible.
Referral, if needed.
Assess mental status. Access higher level of care.
Everly, G. & Mitchell, 3. (1997) Critical Incident Stress
Management (CISM). A New Era and Standard of Care in Crisis Intervention.
Ellicott City, MD: Chevron Publishing.]
As one would never attempt to play a round of golf with only one
golf club, one would not attempt the complex task of intervention
within a crisis or disaster with only one crisis intervention
crisis intervention, generically, and CISM, specifically, represent
a subspecialty within behavioral health, one should not attempt
application without adequate and specific training. CISM is not
psychotherapy, nor is it a substitute for psychotherapy. CISM
is a form of psychological "first aid."
noted earlier, CISM represents an integrated multicomponent crisis
intervention system. This system's approach underscores the importance
of using multiple interventions combined in such a manner as to
yield maximum impact to achieve the goal of crisis stabilization
and symptom mitigation. Although in evidence since 1983 (Mitchell,
1983), this concept is commonly misunderstood as evidenced by
a recent article by Snelgrove (1998), who argues that the CISD
group intervention should not be a stand-alone intervention. This
point has, frankly, never been in contention. The CISD intervention
has always been conceived of as one component of a larger functional
intervention framework. Admittedly, some of the confusion surrounding
this point was engendered by the fact that in the earlier expositions,
the term CISD was used to denote the generic and overarching umbrella
program/ system, while the term "formal CISD" was used
to denote the specific 7-phase group discussion process. The term
CISM was later used to replace the generic CISD and serve as the
overarching umbrella program/system, as noted in Table 1 (see
Everly and Mitchell, 1997).
effectiveness of CISM programs has been empirically validated
through thoughtful qualitative analyses, as well as through controlled
investigations, and even meta-analyses (Everly, Boyle, & Lating,
in press; Flannery, 1998; Everly & Mitchell, 1997; Everly
& Boyle, 1997; Mitchell & Everly, in press; Everly, Flannery,
& Mitchell, in press; Dyregrov, 1997). Unfortunately, this
is a fact often overlooked (e.g. see Snelgrove, 1998).
there is a misconception that evidence exists to suggest that
CISD/ CISM has proven harmful to its recipients (e.g. see Snelgrove,
1998); this is a misrepresentation of the extant data. 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 (e.g. see Snelgrove, 1998).
sum, no one CISM intervention is designed to stand alone, not
even the widely used CISD. Efforts to implement and evaluate CISM
must be programmatic, not unidimensional (Mitchell & Everly,
in press). While the CISM approach to crisis intervention is continuing
to evolve, as should any worthwhile endeavor, current investigations
have clearly demonstrated its value as a tool to reduce human
suffering. Future research should focus upon ways in which the
CISM process can be made even more effective to those in crisis.
the roots of CISM can be found in the emergency services professions
dating back to the late 1970s, CISM is now becoming a "standard
of care" in many schools, communities, and organizations
well outside the field of emergency services (Everly & Mitchell,
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