Responding to responders: the therapist’s role in Critical Incident Stress Management (CISM)

From left to right, myself, Sheriff’s Department Mental Health Navigator Stephen Echols, and Assistant Clinical Director and Designated Crisis Responder Dana Milagrosa, all of Discovery Behavioral Healthcare in Port Townsend, WA. April 9, 2022.

NB: the following contains references to sexual violence and suicide.

People who become therapists want to help others, pure and simple. But we don’t get to stop very often and think about what it means to help other helpers, and that we ourselves are helpers who might sometimes need help. That’s where peer support comes in. As a psychotherapist, I’m ethically obligated to engage in supervision and consultation, and that’s where I find a lot of support. In my consulting groups with other therapists from differing backgrounds, I get to talk to others who understand and empathize with what it’s like to do this job. And I believe it is also an ethical obligation for me to continue to work with my own psychotherapist so that I never forget what it is like be on the receiving end of this service. A lot of the therapy I receive revolves around the therapy I offer to others!

But not every helping professional gets that same level of peer support when it comes to their own mental health. In fact, some helping professions, culturally speaking, are quite wary of perceived stigma around seeking mental health support. For people serving as law enforcement officers, coast guard, firefighters, EMTs, and other first responders to community distress, the culture of “serve and protect” doesn’t often come with “also be vulnerable and share your feelings.” As an officer for the Department of Corrections in my county recently put it to me, “There’s a lot of type A personalities in this line of work…”.

So for psychotherapists such as myself who work in a community mental health setting, I believe it is imperative that we take the “community” aspect of our jobs very seriously. It’s true that most of my day is spent speaking one-on-one with individuals in my office. But none of these interactions ever happen in a vacuum. Each individual I serve is usually involved in multiple areas of service, such as housing support, substance use recovery or addiction counseling, domestic violence advocacy, and/or the public schools. And if they’ve ever gone to the emergency room or been seen by providers at express medical clinics, they’re interacted already with potentially dozens of first responders and service workers. So, it is important for someone like me to understand that when I see a client in my office who has been arrested or hospitalized, or who has gone to court for any reason, or receives any kind of state aid, I am only one part of a larger network of service professionals. You might not think that a community mental health therapist has a lot in common with a firefighter or an EMT, but if you consider the kinds of helping professionals that people interact with as they navigate traumatic events and life transitions, the relationship should become very clear: when you interact with an individual, you already are interacting with them through their community.

Wanting to understand those relationships between helping professionals when communities and individuals respond to disasters, accidents, and other potentially traumatic events inspired me to volunteer for training to become part of my county’s Critical Incident Stress Management (CISM) team. A CISM team offers Critical Incident Stress Debriefings (CISD) to emergency responders. Emergency responders are personnel such as firefighters, EMTs, law enforcement officers, dispatchers, paramedics, first responders, search and rescue, and ER staff. A critical incident is any situation that emergency responders face that can generate unusually strong emotional or physical reactions that have the potential to interfere with their ability to perform their jobs. For example, a death in the line of duty, an on-the-job injury or death, any death or injury involving a child, anytime there are multiple casualties of an accident or incident, a suicide or a homicide, or a community-wide disaster—all of these could cause strong emotional reactions that could benefit from early intervention. A CISD is designed to help reduce the long-term effects of stress on responders, and are facilitated by specially trained peers in the field (for example, if a police department suffered a death of an officer in the line of duty, peers from another department in another city or county would offer that support), and by specially trained mental health professionals. The goal of the CISD is to reduce the impact of the critical incident on the emergency responders and accelerate the recovery process. As a mental health professional who might respond, it’s important for me to remember that this is not the same thing as therapy. Rather, it’s the preventative care that can help resolve problems so that things don’t get worse later on. If the initial trauma is like a cut that if not cared for can become a life-threatening infection, the CISD is like doing psychological “first aid” to prevent that infection from occurring.

If you’re a therapist reading this, I am sure you can think of multiple clients of your own who have come to you for therapy after carrying the burden of a trauma for years or decades because no one provided that “first response”. On the day before attending the first day of CISM training, I held a session with a client who, now in her mid-forties, spoke casually and dismissively of the multiple rapes she had suffered as a young teen, after we had spent many minutes exploring her desire to work on her low self-esteem. I suggested that the trauma of those rapes might continue to impact her in ways she might have repressed. It became clear that she never sought support for her violation because she didn’t believe it would do any good (and, sadly, given her context at the time, speaking out might have made her even more vulnerable), and internalized the blame for her victimization. It’s not an uncommon kind of story. How would this woman’s life be different now if someone had provided an immediate response, letting her know that her guilt, depression, and attempts to numb herself and withdraw from others were normal reactions of a normal person to a highly distressing and traumatic event? Recognizing the importance of psychological preventative care in my role as a therapist, how can I not volunteer to help my colleagues in the helping professions, especially first responders, continue to serve while maintaining optimum health?

A volunteer firefighter and professional EMT attends the CISM training to learn how to support other first responders.

The acute distress that first responders face is often overlooked, especially when the outcome of their actions is discussed in a positive light: they are brave heroes who deserve our special thanks and respect. But being held in positive regard as a “hero” by their community doesn’t necessarily attend to the psychic wound caused by a traumatic experience; in fact, it might distance the person suffering the trauma from their own pain, because it lionizes them, rather than allowing them to process the adverse reactions they might still be having. Our CISM instructor, Dr. Daniel Clark of Critical Concepts Consulting, gave an unforgettable example. In 1987, 18-month-old Jessica McClure fell into a well, becoming wedged into a casing pipe. A team of rescue personnel worked for 45 hours to free her, an operation that involved numerous setbacks as they attempted to dig through rock and cut the pipe while keeping Jessica safe. Paramedic Robert O’Donnell crawled through the tunnel parallel to the pipe and ultimately rescued the baby. The event garnered nationwide attention, even inspiring a film. While Jessica herself went on to live a full life (she is now 36, with children of her own) O’Donnell suffered effects of acute traumatic stress and developed PTSD. Apparently, when O’Donnell learned of the Oklahoma City Bombing in 1995, he watched first responders working tirelessly in the news coverage on television. “They [the first responders] are going to need a lot of help,” he said to his family. He then walked away and was found to have completed suicide with a shotgun not long after. Granted, many other factors could have played into O’Donnell’s decision to end his life, but lack of response and support for his ordeal with baby Jessica, and the displacement of his distress into narratives of bravery and heroism—that is, the invisibility of what became post traumatic stress disorder—could not have helped, whereas early intervention certainly could have. The first step is simply recognizing that first responders may be psychically wounded by acute stress, and that this is not a failure, but a human reaction. CISM provides that first recognition, which can then get the process rolling for further preventative care.

Dr. Daniel Clark shows an image of a NYPD sergeant leaning his head against his patrol car as victims of the 9-11 attack on the Twin Towers enter a bus behind him. Dr. Clark began this segment of his presentation by asking, “What’s wrong with this picture?”

After completing the introductory CISM training, I came away with a renewed understanding of myself as a helping professional in relationship to other professionals in my community who, like I do, respond to individuals in distress, pain, and crisis. This in turn affected my understanding of what it means to serve a community as an individual counselor who works one-on-one with individuals. In an interview, the famed group psychologist Irvin Yalom said, “I think all kinds of meanings in life transcend yourself. They’re linked to other generations of people around us, to our children and our family. We’re passing on something of ourselves to others. I feel that’s what makes our [lives] full of meaning.” I feel that what makes my work as a psychotherapist full of meaning is that the work I do with an individual transcends that single encounter. Like the rings spreading across the surface of a pond when you toss in a single stone, an encounter with an individual touches and reverberates within all of their context. And I am constantly being enveloped by those waves of connection when my clients interact with others beyond the confines of my office. We’re all in this together, all the time.

Trainees from Clallam and Jefferson counties in Sequim, WA in April of 2022 with their CISM instructor Dr. Daniel Clark (second from left, bottom row).

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