Another nail in CISD's coffin

[akflightmedic]

I will post my questions and comments with the understanding that I have absolutely no clinical psychological training nor do I have any hard stats, studies or figures to quote at this very moment. I for one am pro-CISD, I have seen it work many times in my personal experience and I have seen people who were unsure of it at first become very thankful that they did it later on.

now the questions I will ask purely to stimulate conversation not debate are:

A quote was made of treating the pt and not the disease. Do we want to wait until the disease is present before we try to fix it, or do we want to prevent it from ever happening?

Not saying CISD will prevent all bad things from occurring, but do we want to lose even one coworker to ETOH abuse, drugs, suicide or even something that seems as benign as "marriage problems' , all becasue we didnt feel it was neccessary to help them out mentally.

It seems to me that this is a nice prophylactic treatment and like all vaccines or drugs, some people will experience adverse reactions, however this is a minimal percentage of the population so it is safe or recommended for most.

How do we quanitfy whether or not a CISD helped or didn't help. Since we are possibly preventing a series of misfortunate events secondary to PTSD, how can we say it didn't help. If the treatment actually worked, we can not say it didn't help because there is no way to know what may or may not have happened had we not treated.

So basically, I think it should always be made readily avaliable and encouraged. Those that need it will use it and hopefully those that have not used it will try it.

Just a small comment, but the presentaion of the CISD is most critical. It sounds as if many of you have had some bad experiences which unfortunatley has left a sour taste in your mouth with regards to CISDs. The ones you guys have described have sounded most inappropriate and I would probably feel the same had it occurred to me. However, I do not think you should criticize anyone that requests one nor should you think any lesser of them for choosing to do so. If your partner asks for one and you were on the call and you feel fine, you should still attend and support your partner. We need to take care of each other out there cause no one else is going to.

For those of you that have trotted over and through dead bodies, babies and just been to hell and back....we all have been there one time or another in some form or fashion of our own personal hell, I am glad that you are ok and do not need anything to assist you--some people are just not as strong as you and nor should they be. We can not all be perfect...

[Dustdevil]

I have seen it work many times in my personal experience and I have seen people who were unsure of it at first become very thankful that they did it later on.

How do you know it worked? What evidence do we have that they would have suffered PTSD without it? That's kind of like assuming that the St. Christopher's medal around your neck is protecting you from sabertooth tigers. There is no proof to support it. The statistical evidence indicates overwhelmingly that more people develop PTSD with CISD than do without it.

Do we want to wait until the disease is present before we try to fix it, or do we want to prevent it from ever happening?

The question isn't particularly valid to PTSD or CISD. If we could prevent it, we certainly would want to do so. The problem is, as of now we have no proven way of doing so. CISD is like giving chemotherapy to everybody just in case they might have cancer. Would you want that? Heck no! You know there is a good chance the chemo is going to do serious harm to you, and that you probably aren't going to get cancer anyhow. And then if the incidence of cancer actually went UP in those treated, wouldn't you immediately start re-thinking your theory? That is what has happened with CISD.

Not saying CISD will prevent all bad things from occurring, but do we want to lose even one coworker to ETOH abuse, drugs, suicide or even something that seems as benign as "marriage problems' , all becasue we didnt feel it was neccessary to help them out mentally.

I completely agree with the need to find more and better ways to deal with stress and prevent it from becoming morbid. But the point here is that CISD has been PROVEN to not be that way. This is one of those times that doing nothing is actually better than doing something.

It seems to me that this is a nice prophylactic treatment and like all vaccines or drugs, some people will experience adverse reactions, however this is a minimal percentage of the population so it is safe or recommended for most.

The studies say otherwise. They're not just saying it is ineffective. They are saying it is dangerous, and that it actually causes the disease it was designed to prevent.

How do we quanitfy whether or not a CISD helped or didn't help. Since we are possibly preventing a series of misfortunate events secondary to PTSD, how can we say it didn't help.

How can we say it did? The question is a double edged sword. Since there is no crystal ball that tells us who will and will not develop PTSD, the best we can do is follow the general statistics which clearly indicate that more people develop problems with CISD than those who do without.

If the treatment actually worked, we can not say it didn't help because there is no way to know what may or may not have happened had we not treated.

The problem is, you simply cannot ethically or medico-legally subject people to a non-proven procedure of prophylaxis when you know beyond any doubt whatsoever that it will cause some of them harm, and has no proven ability to prevent harm to others. If it were a drug, the developers would be bankrupt from legal liability by now.

So basically, I think it should always be made readily avaliable and encouraged. Those that need it will use it and hopefully those that have not used it will try it.

The problem is, while most people do need to talk about their experiences, there is zero evidence whatsoever that they benefit from a structured process like CISD. And to force -- or even strongly encourage -- them to attend group sessions led by amateurs only induces stress upon them. When you take away people's free will to choose, you take away their sense of self-control, which is key to successful coping.

Think about it; talking about your experiences is cathartic and allows you to diffuse stress. But when you cram two hundred people into a room to all rant about the same disaster, you aren't diffusing anything. You are concentrating it! How in the hell can that possibly be therapeutic? The answer is, it is not therapeutic. And the experts (psychologists and psychiatrists, not CISD weenies) confirm that.

It sounds as if many of you have had some bad experiences which unfortunatley has left a sour taste in your mouth with regards to CISDs.

Nope. I thought they were wonderful at the time, and maintained that belief for years. It's just that now we know better. The evidence is in and so is the verdict. We were duped. And as a result, many of us are left with the scars.

However, I do not think you should criticize anyone that requests one nor should you think any lesser of them for choosing to do so. If your partner asks for one and you were on the call and you feel fine, you should still attend and support your partner. We need to take care of each other out there cause no one else is going to.

If you need to talk, talk. If you need to talk to a group, talk to a group. If you need counseling, get counseling. If you need time off, take time off. But choose what YOU need, not what the cookbook written by some amateur with no professional education says you need.

[akflightmedic]

I think we have made our points and like I said before in a previous post, for every procedure, medication, intervention, or whatever, we can find a dozen studies for and a dozen studies against. WHo is right or who is wrong...who knows? But it certainly isn't the first time we have proceded with flawed knowledge. I personally think the ends justifies the means in this case. The CISD has benefited me and I have seen it benefit close friends/co workers. Will it help everyone, probably not, I never made that claim. Another claim I never made was the use of amatuers in this sensitive area. Several times you said amatuer this or amatuer that. I agree with you, an amatuer should not handle a CISD. Here are a couple of links for your reading pleasure. There are just as many studies here promoting CISD as you can produce debating it. Guess it depends which side of the fence you are on. The studies range from the early 70's to the current times. No matter what study you produce, I personally will never change my opinion because I have benefited first hand from a properly handled CISD. Never is a strong word for me to use, but I know that I will stand fast by this treatment regimen for my lifespan. Other than us bouncing back and forth studies that is going to change neither of our minds, I think we should let it die as it does nothing but form negative impressions of the entire process in newbie's minds and may prevent them from reaching out at a time when they truly need it.

http://www.icisf.org/articles/

http://www.icisf.org/articles/Acrobat%20Do...se_of_Field.pdf

[Dustdevil]

...for every procedure, medication, intervention, or whatever, we can find a dozen studies for and a dozen studies against.

Have you read the studies against? I am thinking not. Otherwise, there is no possibly way you could stand by this statement. There has been NO scientifically valid, peer reviewed study which confirms the efficacy of CISD. None. Not one. Ever. Read them carefully. Read them critically. Look for the evidence that proves the efficacy of CISD. You won't find it even in their own "studies." It's all smoke and mirrors. It's a lot of psychobabble and doublespeak that implies theories, but never confirms effects. If you're impressed by that sort of thing, I have a few cases of Bretylium I'll sell you really cheap!

The CISD has benefited me and I have seen it benefit close friends/co workers.

Where is your proof? What evidence do you have that it helped you or anybody else? There is none. Again... none. You are assuming that since you did not develop PTSD that CISD is the reason. Again, that is no more scientifically valid than the assumption regarding your St. Christopher medal repelling sabertooth tigers. There is no proof. The truth is, you are simply a person who is strong and psychologically stable enough to deal with adversity without wigging out. The CISD had nothing to do with your success.

Will it help everyone, probably not, I never made that claim.

But what you are claiming is that it is okay to kill a lot of people if it *might* perhaps help one or two people.

Another claim I never made was the use of amatuers in this sensitive area. Several times you said amatuer this or amatuer that. I agree with you, an amatuer should not handle a CISD.

An amateur is exactly what somebody with a weekend con-ed cert in CISD is. He/she is not a mental health professional. And interestingly enough, there aren't any mental health professionals involved in the upper levels of CISD. That's because it is pretty damn hard to find one who would leave sensitive procedures like debriefing to amateurs. They simply don't support CISD.

There are just as many studies here promoting CISD as you can produce debating it. Guess it depends which side of the fence you are on.

There is the crux of the problem. You are looking for something to validate your own beliefs. I am not. I allowed scientific evidence (and lack of same) to influence my beliefs. It's only a matter of opening your eyes and your mind.

No matter what study you produce, I personally will never change my opinion because I have benefited first hand from a properly handled CISD. Never is a strong word for me to use, but I know that I will stand fast by this treatment regimen for my lifespan.

My point exactly. A closed mind shall never be penetrated by knowledge.

I think we should let it die as it does nothing but form negative impressions of the entire process in newbie's minds and may prevent them from reaching out at a time when they truly need it.

No it doesn't. It does no such thing. Nobody is discouraging anybody from seeking assistance or engaging in therapeutic dialogue after a critical incident. What is being discouraged is the rounding up of people and forcing them into destructive behaviour, moderated by non-professionals, which derails their normal coping mechanisms and stands a good chance of causing them to suffer something they would not have otherwise suffer.

Do we need to be educating responders regarding their options? Of course! Do we need to make those options readily available to them? Definitely! But to demand that they follow a structured course of action which is statistically more likely to harm them than help them is just plain craziness. I simply find it extremely hard to believe that you of all people here are espousing cookbook medicine. And that you are espousing practicing medicine without evidence. It just boggles my mind.

[manicmedic]

I have to at least post a short reply to this topic. I am trained as a peer debriefer for CISD, and the first thing I see that throws a wrentch into things is all this talk of forcing people to go to CISD. I don't know how they are run in the US but here in Canada where I work NOBODY should be forced to go to a debrief is the first thing we are taught. I don't have studies to back up my belief it works, but I have seen it. I have had peers from both fire and ems come up to me after an event(anywhere from a week to a year after) and tell me what they are experincing, often symptoms of PTSD. We do some CISM talks and they often say it gave them the first night sleep in a long time. I also want to say that I am not someone with a $$ interest in this, I don't get paid to do it and often have to travell to other bases to sit in as a peer and that costs me $$ for travell.

No CISM is not for everyone, but don't write it off as it does help some greatly. It's trying to offer the best for the most. Does your service run evidence based protocols? If not wheres your back up for them, your just trying to offer the best, same as CISM should be offered but not forced

[xselerate]

I am trained as a peer debriefer for CISD

This is how it should be... I don't mind talking about something that bothers me on the job (I havn't had to yet) but I'm not talking to some ass doctor. I would talk to a fellow member in the field.

NOBODY should be forced to go to a debrief

It's nice to have something there for those who want it... but I will admit that if you run off to talk to CISD every time you have a pediatric arrest.... I mean CISD has to be very very serious.... something would have to blow up big time for me to think about it.

[chipps]

Hello.

Thanks for a great discussion re PTSD, CISD, CISM & Peer Support etc.

I have very limited knowledge / qualification in this area, but would like some feedback, just don't flame me heaps

Is a Peer Support officer the appropriate person to counsel fellow workers ?

IE:Is it appropriate for an officer needing assistance to consult a layperson ?

I understand that we have different levels of skill & experience from one service to the other & as an Ambo, dealt with psych/stressed patients on a regular basis, however, ambo's as counsellors, isn't that exceeding qualification ?

PTSD diagnosis & ongoing management is a highly skilled role, one that even experienced pshyciatrists & psychologist differ in prevention / management.

How often has a peer support officer stated to you, that there are alternative therapies, or if there are currently negative findings re CISD ?

Please understand, I have a lot of time for these people, just I feel they are way out of their depth.

[Dustdevil]

I have had peers from both fire and ems come up to me after an event(anywhere from a week to a year after) and tell me what they are experincing, often symptoms of PTSD. We do some CISM talks and they often say it gave them the first night sleep in a long time.

So, what you are offering is empirical evidence that talking about a stressful event is cathartic. That's not earthshaking news. But you don't have to go to CISM to talk something out, as all the CISM weenies would have you believe. Where is your evidence that they wouldn't have been just as well off talking to any other medic? Where is your evidence that they would not have been better off talking to a mental health professional instead of you?

It's a good thing you don't need proof, because you wouldn't find any.

Beating the CISM drum and recommending it to everybody is tantamount to forcing it. You are promoting it as a standard of care. You're saying, "Hey, all the cool kids are doing it! You need to do it too!" You're promoting results that you have zero valid clinical evidence to support. You are endorsing it as both safe and effective. There is scientifically validated evidence showing that it is neither safe nor effective. And anywhere that standards are maintained based upon current evidence, it is not a standard of care. In fact, it is contraindicated. It is, at best, a stupid idea. But continuing to endorse it after being disproven is worse than stupid. It's fraud.

[AnthonyM83]

Interesting post Dust. I specifically like the talk about a rescue personality. I've been taught that it's something that develops, not usually innately born with it, so not an actual psychological "personality" though some personalities are more pre-disposed to those behaviors they mentioned than others.

I didn't read the whole article, but the intro seemed to be making the point that CISD was strongly dependent on whether emergency workers were of that "rescue personality". Why? Is the point that if you are, then you don't need CISD?

I can offer that as far as children go, CISD will help decrease the chances of developing post traumatic stress disorder in children who WANT it. BUT in those who are forced to talk about and relive the event when that's not how they want to deal with it, it will INCREASE chances of developing PTSD. I'm sure there's a similar pattern in adults and it surprises me that those who run the CISD programs don't know this (or listen to this), as it's not obscure or new knowledge.

[nwoparamedics]

Thought these press releases would be relevant:

Attention News Editors:

Study on Post Traumatic Stress among EMS Personnel

TORONTO, Dec. 16 /CNW/ - The Tema Conter Memorial Trust announced the funding of a new research study on the prevention and management of post-traumatic disorder (PTSD) among Emergency Medical Service (EMS) personnel. The study will be conducted by researchers from Mount Sinai Hospital, the Centre for Addiction and Mental Health, Sunnybrook and Women's College Hospital and Ryerson University.

Due to the nature of their work, EMS personnel are exposed to emotionally traumatic situations every day. They often witness violent, tragic and gruesome situations that put them at risk of experiencing PTSD at two to three times higher than that of the general population.

"Although many EMS organizations provide psychological debriefing such as critical incident stress debriefing (CISD) immediately after a traumatic event, research indicates that this type of approach may not only be ineffective," says one of the principal investigators Dr. Janice Halpern, of Mount Sinai Hospital, "but may also actually increase the risk of developing PTSD."

By interviewing Toronto EMS personnel to learn first hand their experiences and needs, the researchers hope to gain information that will lead to a new form of intervention that ultimately reduces stress and psychological disorders among paramedics.

"Not everyone has the same needs and coping skills when faced with a traumatic event" says principal investigator, Dr. Scott Bishop of the Centre for Addiction and Mental Health. "We need to develop a better model that takes into consideration the range of personal and social resources people draw from in times of stress."

The Tema Conter Memorial Trust takes particular interest in this type of research because of their mandate to address PTSD among Emergency Service personnel.

Established by Vince Savoia, the Trust was created to honour the memory of Halifax native, Tema Conter who, in 1988 at the age of 25, was brutally murdered in Toronto, Ontario. Vince Savoia was one of the attending paramedics, and was deeply affected by the horrific scene. This episode led to critical incident stress, which greatly affected his life.

With a mission to better understand the effects of Post Traumatic Stress on emergency services personnel, The Tema Conter Memorial Trust invests not only in important research but also in prevention and training. An important additional component is public education so that people understand the sacrifice emergency workers and their families make by serving their community.

"Paramedics, their families and emergency organizations are all profoundly affected by post traumatic stress", says Vince Savoia, Executive Director of the Tema Conter Memorial Trust. "New options for support and treatment of PTSD have both important emotional and economic benefits. The knowledge we gain from this study may benefit all trauma survivors."

Principal investigators, Dr. Janice Halpern of Mount Sinai Hospital, Dr. Scott Bishop, Centre for Addiction and Mental Health, and co-investigators, Dr. Brian Schwartz of Sunnybrook and Women's College Hospital and Dr. Maria Gurevich of Ryerson University will conduct the research.

EMS personnel themselves welcome and support the research study.

"Our people are highly trained professionals and they are also human", says Dave Doiron, Chairman of the CUPE Local 416 Ambulance Unit. "EMS personnel serve the city well, they love their jobs, but they are not immune to the tragedy and suffering they see around them every day. They sometimes need help and we need to be sure that we can provide the right kind of help for the sake of their health, their families and the safety of the city."

For further information: Contact: Jennifer Faulkner, Communications Consultant, Impact Communications, (902) 423-6610, jfaulkner@impactcommunications.ca; Vince Savoia, The Tema Conter Memorial Trust, Toll free 1-888-288-8036, info@temaconter.com, www.tema.ca

Attention News/Health Editors:

Peer and Supervisor Support may be Critical Coping Strategies for Emergency Medical Services Personnel, Research Indicates

TORONTO, Jan. 25 /CNW/ - The preliminary results of a new study show that emergency medical services (EMS) personnel believe they are much more likely to recover from traumatic critical incidents if given brief time-out periods with peers and expressions of support from supervisors.

EMS personnel are two to three times more likely than the general public to suffer from Post-traumatic Stress Disorder (PTSD), a disorder that can cause emotional difficulties as a result of dealing regularly with traumatic calls. These difficulties often lead to increased absenteeism, a troubled family life, and increased drug and alcohol abuse.

A team of researchers from Mt. Sinai Hospital, Ryerson University, Sunnybrook-Osler Centre for Pre-Hospital Care, and the University of Toronto, presented the first-year findings of a three-year study at the recent National Association of Emergency Medical Services Physicians, in Tucson, Arizona. The study is funded by The Tema Conter Memorial Trust, an organization dedicated to better understanding the effects of Post Traumatic Stress on emergency services personnel.

Using a qualitative interview method with Toronto EMS personnel, the team found that EMS organizations may be able to facilitate employee recovery by implementing simple and straightforward administrative policies such as allowing for brief periods of downtime immediately after an incident.

"Paramedics are telling us a brief unwinding with peers is critical," says principal investigator Dr. Janice Halpern, of Mount Sinai Hospital. "A simple chance to calm down and decompress, combined with a supportive word or expression of support from a supervisor could relieve a lot of suffering."

Past studies have suggested that the commonly used Critical Incident Stress Debriefing (CISD) is not only ineffective in preventing PTSD, but potentially harmful. In those studies, a group intervention was carried out by experts days after a traumatic call or 'critical incident'. The current study aims to develop a new approach to critical incident stress, and the investigators began by interviewing the paramedics themselves.

Dr. Halpern and her co-investigators, Dr. Maria Gurevich of Ryerson University, Dr. Brian Schwartz of Sunnybrook-Osler Centre for Pre-Hospital Care, and Ms. Paulette Brazeau and Dr. Scott Bishop of the University of Toronto, believe these findings could make a tremendous difference in how interventions for coping with critical incidents are structured.

The study's initial findings have been well received by Toronto EMS personnel and administration, and they are committed to participating in the next phase of research, which will build on the initial results using a quantitative approach.

"These results point to the potentially crucial impact of early, relatively simple interventions within the workplace, relying on personnel with whom they are already familiar," added Dr. Halpern. "This makes good intuitive sense, and is well worth studying further. What they're talking about is emotional first-aid for paramedics. What could be more appropriate?"

"Many paramedics have trouble reaching out for help," explains Vince Savoia, founder and Executive Director of The Tema Conter Memorial Trust. "If research like this can help alleviate PTSD, we really are in a much better position to understand and help the EMS personnel who help so many of us."

About The Tema Conter Memorial Trust

With a mission to better understand the effects of Post Traumatic Stress on emergency services personnel, The Tema Conter Memorial Trust invests not only in important research but also in education and awareness. An important additional component is public education so people understand the sacrifice emergency workers and their families make by serving the community. For more information about The Tema Conter Memorial Trust, visit www.tema.ca

For further information: Contact: Jennifer Faulkner, Communications Consultant, Impact Communications, (902) 423-6610 ext 304, faulkner@impactcommunications.ca; Vince Savoia, The Tema Conter Memorial Trust, Toll free 1-888-288-8036, info@temaconter.com, www.tema.ca