History of CISM

Utah Critical Incident Stress Management Team: A Brief History

By Greg Rynders, Battalion Chief-Retired

In 1983, Jeff Mitchell PhD introduced Critical Incident Stress Debriefing (CISD) after nine years of groundwork. With experience as a paramedic for the Baltimore Fire Department, Mitchell was uniquely positioned to research workplace stress in the fire service and develop a method to address traumatic stress. Before CISD, emergency service workers often dealt with traumatic incident stress by ignoring it, "sucking it up," self-medicating, or leaving their professions.

L.S. Ostrow, in 1996, discussed four elements that contributed to CISD's acceptance by emergency service workers:

• First, the plight of Vietnam veterans in the late 1970s raised awareness about the dangers of stress, later diagnosed as post-traumatic stress disorder (PTSD).

• Second, by the early 1980s, Emergency Medical Services (EMS) became a recognized profession, allowing workers to shift focus from job completion to "quality of life" issues like burnout, stress, grief, and anxiety.

• Third, during this period, several national tragedies occurred, including the Hyatt Regency Skywalk collapse (1981), the MGM Grand fire (1982), and two jet airliner crashes (1982).

• Finally, there was a shift in how Americans thought about their health.

A 1993 study by D.W. Corneal confirmed the dose-response effect of traumatic event exposure and PTSD prediction. Corneal found a 16.2% PTSD rate in Toronto firefighters, similar to the rate in Vietnam veterans and significantly higher than the general population's rate of 1.97%. Identifying stress as a significant factor in emergency service workers' health has reduced resistance to stress management interventions. For over forty years, CISD has effectively reduced psychological distress in emergency service workers following critical incidents.

In January 1987, a mid-air collision over Kearns, Utah, involving a Sky West commuter jet and a private plane, resulted in 10 fatalities. Law Enforcement, Fire Departments, and EMS agencies from across the Salt Lake Valley responded. Crash debris and body parts were scattered for miles, with law enforcement controlling the incident area and bearing the primary responsibility. Fire and EMS searched for bodies and body parts during this prolonged, multi-day event with continuous media coverage in single-digit temperatures.

At that time, Utah emergency service agencies had experienced similar traumatic incident stress for years without mental health intervention. While some agencies had Employee Assistance Programs (EAP), most did not. Emergency service publications had been discussing workplace stress, CISD, and stress management since 1975, leading agencies to establish minimally trained "in house" support groups to mitigate critical incident stress.

In June 1987, the Utah Bureau of EMS received reports from paramedics and EMTs about burnout, grief, stress, and anxiety. Agency directors were also concerned about increasing paramedic turnover after five years of service, which resulted in additional training costs. Jan Buttrey, Director of the Bureau of EMS, and Evelynn Draper, Director of Paramedic Training at Weber State College, collaborated to create a Utah CISD Team. They recruited Dick Southwick PhD, Director of the Student Counseling Center at Weber State College, to be the Clinical Director of the new team.

A plan was developed, and emergency service agency members from across Utah were recruited for the first two-day basic training session with Jeff Mitchell. From November 17-19, 1987, sixty candidates attended the training, and forty-five went on to organize the Utah Critical Incident Stress Debriefing Team (UTCISDT). The first debriefing of the newly formed UCISDT occurred on the evening of November 19, 1987, following a Murray City Police Department shooting. A response team was sent to Murray City. Approximately 60 people attended the debriefing; however, many were not appropriate attendees, a lesson learned from this first experience.

The UCISDT is a statewide, volunteer organization. Its membership typically numbers around 100, consisting of 25% Mental Health Professionals and 75% Emergency Service Peers. The team delivers approximately 100 interventions and training sessions annually, always free of charge.

To provide the best service, the state is divided into seven regions corresponding to state emergency response districts. The Team operates with formal by-laws, operating descriptions, and job descriptions. Leadership is provided by an Executive Committee with elected and appointed positions. Elected positions represent all emergency service professions and serve two-year terms, while appointed members serve at the pleasure of the Executive Committee.

From 1987 to 1993, the Team was funded by a Utah Department of Health, Bureau of EMS demonstration grant. In 1993, the Bureau of EMS requested the team to draft legislation and find a sponsor for funding through the Utah General Fund. With the Bureau of EMS's help, Rep. Blake Chard of Layton sponsored HB 409. During the committee meeting, several fire chiefs from volunteer agencies supported the UCISDT, wishing the team had been available 20 years earlier to help them with stress. HB409 passed on the last day of the 1993 session, with original funding set at $23,000, though this amount has been significantly cut over the years. Fortunately, the Bureau of EMS has consistently met the team's operating requirements to deliver interventions for Utah emergency service workers.

The Team has two part-paid positions: the Clinical Director and the Secretary. The bulk of expenses are operating costs, including per diem, mileage, pamphlets, supplies, and annual training for team members. Since its inception, the legislature has mandated that UCISDT interventions must be free of charge to all Utah emergency service workers and that the team cannot compete with private mental health agencies. It was around this time that CISD evolved into CISM.

Critical Incident Stress Management (CISM), from its inception and still today, is a systemic and comprehensive approach to mitigate stress, according to Jeff Mitchell PhD. CISM is a subset of the broader field of "Crisis Intervention," which has existed for decades. CISM components include pre-incident stress education programs, on-scene support, peer and significant other support programs, defusings, debriefings, follow-up services, and referral procedures. CISD is only one aspect of CISM. The Utah CISM Team (UCISMT) transitioned from CISD to CISM many years ago.

Mitchell defines CISD as a group intervention technique applied after a traumatic event, designed to mitigate the impact of the traumatic event and accelerate normal recovery. Mitchell adds that CISD is based on crisis intervention and educational principles and was not designed as, nor is it considered a substitute for, psychotherapy. A CISD follows a specific structured format, both in 1987 and in 2023. The Mitchell model has seven unique phases:

1. Introductory phase: Rules and process explained.

2. Fact phase: What participants saw, heard, smelled, touched, and did.

3. Thought phase: First thoughts.

4. Reaction phase: Emotional reactions.

5. Symptom phase: Physical or psychological symptoms.

6. Teaching phase: Stress response syndrome.

7. Re-entry phase: Summary statements and referral.

A specially trained team provides CISD, including at least one mental health professional and several peer support members. "Peers" are emergency service workers trained in CISD and other interventions who provide support and credibility to the process. A debriefing typically lasts about two hours and is conducted 24 to 72 hours after the incident. Other CISM interventions may have different timeframes as requirements dictate.

Finally, emergency service workers should believe in a few simple life principles: people are generally tough; friends and family are important; conversation helps; and time heals all wounds. While CISD may not be for everyone, anecdotally, CISM helps many people feel better after some of life's most horrible events.