Providing public safety is a critical component of local government. While first responders respond to traumatic events and protect the public, who tends to their mental health needs?

Many local governments are searching for ways to support employees who have been exposed to traumatic incidents such as fire, accidents, and acts of violence, and suffer because of that exposure. A method to address these ever-growing issues is the development of a comprehensive critical incident stress management (CISM) program.

CISM is an integrated, multi-component, crisis intervention model that deals with pre-crisis, acute crisis, and post-crisis phases. The goal of CISM is to proactively minimize acute psychological distress and prevent (or mediate) the intensity of post-trauma sequelae, or rather, the aftereffects of the traumatic event.¹ CISM is used when individuals are exposed to critical incidents, such as deaths, burnt bodies, victims of traumatic accidents, or violence.

A comprehensive stress management program will involve three crucial components:

1. Reduction/elimination of mental health stigmas.
2. Reducing negative impacts of stress by institutionalizing family support.
3. Recruitment of a CISM team composed of carefully selected personnel, from inside as well as outside the organization, who themselves are emotionally stable and capable of dealing with stressful situations that they will face. This team will be involved in pre-crisis, acute crisis, and post-crisis phases of the program.²

Reducing/Eliminating Mental Health Stigmas

One of the leading obstacles to implementing an effective CISM program and reducing the negative impacts of first responders’ stress and trauma is hurdling the detrimental effects of mental health stigmas. This can be defined as when “someone views you in a negative way because you have a distinguishing characteristic or personal trait that is thought to be, or actually is, a disadvantage.”³ While intervention programs and policies can be developed to address critical incidents, “anecdotal evidence within the emergency responder community holds that law enforcement and firefighter personnel are more hesitant to accept post-incident intervention, compared to emergency medical services (EMS) and emergency dispatch (ED) personnel.”⁴

Mental health stigmas are particularly significant in firehouses, as rates of mental health disorders and suicide are much higher than in the general population. Firefighter suicide ideation rates are 33 percent higher, plan rates 15 percent higher, and attempts 20 percent higher than the general population.⁵ Firefighters are at an increased risk for post-traumatic stress disorder (PTSD), with an estimated 22 percent reporting PTSD symptoms.⁶

In addition, in 2019, the Chicago Fire Department found that 28 percent of firefighters believe seeking treatment for behavioral health disorders could hurt their reputation, and have concerns about the confidentiality of sensitive information. Many reported they were not aware of the availability of services that address behavioral health issues.⁷

Institutionalized Family Support

As described in the journal Family Relations, “support of family is paramount in reducing the impact of highly stressful work on firefighters. Those who had higher levels of family support  were less likely to take mental health stress leaves from work following a traumatic event.”⁸ The Work Family-Fit Theory emphasizes the interconnectedness of firefighters and their families. The two cannot be viewed as separate entities. The balance between the two is measured by the “demands and rewards of the work environment…high stress and trauma situations threaten the family equilibrium and thus produce strain in the work family-fit. Organizational policies and programs that support workers and reduce the stress brought home to families may enhance the work-family fit and therefore enhance commitment.”⁹ An institutionalized family peer support group ensures the backing of the invaluable resource of the family by increasing positive social relationships, a family’s feeling of inclusion, and decreasing fears related to mental health stigmas and lack of effective communication.

Recruitment of a CISM Team

As identified in the Crisis Intervention Handbook: “There are three traits that are frequently mentioned in the helping profession: empathy, genuineness, and warmth. Empathy allows one to stand in another’s shoes and understand their perspective. Genuineness is being true to oneself or being real. Warmth is that liveliness of feelings, emotions, or sympathies. These three traits are the often the keys to predicting a positive treatment outcome.”¹⁰ CISM programs require the membership/team members to obtain a minimum of 16 hours of basic classroom training. Live or online training can be provided by the International Critical Incident Stress Foundation, Inc. An additional eight hours of training each year is sufficient to maintain  proficiency.

Other programs also suggest the use of chaplains to provide support for membership. They can provide comfort, counsel, spiritual and emotional support to members exposed to critical incidents. Whether this is appropriate is up to the leadership.

CISM Team Standard Operating Procedures

Any CISM program should have a standard operating procedure (SOP) that outlines the duties and responsibilities for each position on the CISM team. The program should incorporate all pre-crisis, acute crisis, and post crisis phases. It is suggested the program provide the following elements:
1. Pre-crisis preparation (individuals and organization).
2. Large-scale mobilization and demobilization procedures for large-scale disasters.
3. Individual acute crisis counseling available.
4. Small group discussions for acute phases that are brief are the primary means of dissemination of information and discussion of feelings.
5. Small group discussions that are longer include critical incident stress debriefing, which is a trademark of this intervention, especially with crisis workers, to prevent further emotional harm to them.
6. Family crisis intervention techniques when entire families are involved.
7. Follow-up procedures and referral for long-term therapy where needed.¹¹

Crisis Intervention Models

There are three models that are recommended for crisis intervention: Roberts’ Seven- Stage Crisis Intervention Model, Greenstone and Leviton Crisis Model, and SAFER-R Model or Mitchell Model.

Roberts’ Seven-Stage Crisis Intervention Model

1. Plan and Conduct a Crisis Assessment—A thorough assessment of stressors, coping skills, and available resources. Ongoing assessment should include the provoking event, responses, and both risk and protective factors.¹² This stage is intertwined with stage 2.
2. Establish Rapport—The crisis worker attempts to establish a supportive relationship with the client while gaining critical information.¹³ A calm, patient style is the most effective approach to gaining trust and establishing rapport.
3. Identify Pertinent Issues—Attempts are made to gain information about what has led to the current crisis state. Conferring with other collateral persons may also be needed during this step.¹⁴
4. Deal with Feelings/Emotions—Letting the client vent his or her emotions while the crisis worker validates and listens. Active listening is considered “attending, observing, understanding and responding with empathy, genuineness, respect, acceptance, non-judgment, and caring.”¹⁵ Information gained in the first four stages helps to inform the final three steps.
5. Generate and Explore Alternatives—The crisis worker takes a more active approach to explore options. Using information previously gained, the crisis worker can potentially encourage the client to use prior coping strategies or resources.
6. Implement a Concrete Action Plan—Initiating the necessary steps to assure client safety or implementing a plan for obtaining further assistance.¹⁶
7. Follow Up—Planning appropriate follow-up. For example, determining when and how often to check in with a client or care provider to ascertain the client’s post-crisis status.

Greenstone and Leviton Crisis Model

The goal of crisis intervention is to help the client transition from a state of crisis back to his or her baseline level of functioning. Crises are unpredictable, so it is helpful to use a step-by-step method for a more successful intervention.¹⁷
1. Immediacy—Responding quickly to relieve emotional distress. To accomplish this, the responder aims at decreasing anxiety that the client is experiencing and preventing harm to self or others.
2. Control—Accomplished by first identifying your role in the crisis intervention, while also providing structure until the client can regain self-control. It is important to appear calm, confident, and supportive to provide reassurance to clients. If possible, relocate the person away from the crisis or vice versa. Crisis workers should be genuine in their approach as this will aid in gaining the client’s trust and directing the intervention.
3. Assessment—When the crisis worker attempts to gain a complete understanding of the situation. Crisis workers should attempt to learn more about the crisis, and determine the person’s point of view on the crisis, and what the crisis means to him or her. The client needs to be empowered at this time, not chastised or reprimanded for his or her experience.
4. Disposition—The decision-making stage, at which point the crisis worker helps the client consider possible options for resolution, provides hope that a resolution is possible, and then create a plan with the client.
5. Referral—The point at which the client connects with necessary services.
6. Follow-up—The intervenor follows up with the client to make sure that he or she contacted the agency.¹⁸

Safer-R Model or Mitchell Model

The third model of intervention for responding to individuals is the SAFER-R model, an acronym created from the first letters of its five steps, also known as the Mitchell Model.¹⁹
1. Stabilize—Stabilizing a potentially volatile situation is a critical first step to lessen the likelihood of further escalation or harm to the client or others.
2. Acknowledge—The worker uses his or her listening and communication skills to ascertain what has happened and how the person is reacting to the situation.²⁰
3. Facilitate Understanding—The worker and the client gain an increased understanding of the crisis, and the worker begins to actively respond to what they have learned.²¹ Both the worker and the client gain information about what is needed.
4. Encourage Adaptive Coping—This is the active stage of intervention, and involves the facilitation of various interventions and coping strategies.²² For example, if a worker learned that the client had a former therapist, the worker could assist in making a reconnection for the client.
5. Restore Functioning or Refer—The final stage occurs when the individual has successfully resolved the crisis or has a plan for resolution. At times, however, a client may need a higher level of care. At this time, a referral may be indicated to a hospital or other resource.²³

Legal Issues

A critical incident stress management group created by a local government would be voluntary. Confidentiality agreements between the members and any involved firefighter/police would cover any discussions or outreach not held in group sessions. HIPAA is not applicable here as the information provided is supported in nature with no clinical intervention taking place. A referral to a clinical provider is the last step of the process. Collective bargaining agreements do not prohibit or limit the use of critical incident stress management groups.²⁴

Conclusion

It is up to city administrators and community leaders to be diligent in their efforts to create and support policies that protect the mental health of their first responders and families. The creation of these programs should follow existing literature and best practices that protect the wellbeing of these essential frontline employees, safeguarding local government’s capacity to provide quality, reliable, and critical services for their community.

 

RENE HERNANDEZ is an attorney with the Law Office of Rene Hernandez, P.C.

DENISE ARRELL-ROSENQUIST is director of operations for the village of Long Grove, Illinois.

AARON LEWIS is a grant and data specialist for the Region 1 Planning Council.

 

Endnotes and Resources

1 Dorfman, William I., Walker, Lenore E., First Responder’s Guide to Abnormal Psychology, (2007).
2 See Note 1.
3 Mayo Clinic. “Mental health: Overcoming the stigma of mental illness” May 2017. Retrieved at https://www.mayoclinic.org/diseasesconditions/mental-illness/in-depth/mental-health/art-20046477
4 Clampett, C. A. (2019). Willingness of medical versus non-medical emergency responders to accept post-incident intervention. Ann Emerg Dispatch & Resp, 7(2), 23-27.
5 Dreiman, Brandon. Firehouse Magazine. “Health and Wellness: Firefighter Peer Support”. August 2018.
6 Lee, Jong-Sun, Yeon-Soon Ahn, Kyoung-Sook Jeong, Jeong-Ho Chae, and Kyeong-Sook Choi. “Resilience buffers the impact of traumatic events on the development of PTSD symptoms in firefighters.” Journal of affective disorders 162 (2014): 128-133.
7 IAFF. “How Mental Health Stigmas Impact the Fire Service” July 2019. Retrieved from: https://www.iaffrecoverycenter.com/blog/how-mentalhealth-stigma-impacts-fire-service/
8 Regehr, C., Dimitropoulos, G., Bright, E., George, S., & Henderson, J. (2005). Behind the Brotherhood: Rewards and Challenges for Wives of Firefighters. Family Relations, 54(3), 423-435.
Retrieved March 21, 2021, from http://www.jstor.org/stable/40005295 Copy Chicago.
9 See Note 7
10 Eaton, Y. (2005). The comprehensive crisis intervention model of Safe Harbor Behavioral Health Crisis Services. In A. R. Roberts (Ed.), Crisis intervention handbook (3rd ed., pp. 619–631). New York: Oxford University Press.
11 See Note 1.
12 Jackson-Cherry, L. R., & Erford, B. T. (2014) Crisis assessment, intervention, and prevention. Upper Saddle River, NJ: Pearson Education.
13 Roberts, A. R., & Yeager, K. R. (2009). Pocket guide to crisis intervention. New York: Oxford University Press.
14 Greenstone, J. L., & Leviton, S. C. (2011). Elements of crisis intervention (3rd ed.). Belmont, CA: Cengage Learning.
15 James, R. K., & Gilliland, B. E. (2005). Crisis intervention strategies (5th ed.). Belmont, CA: Thomson Brooks/Cole.
16 See Note 14.
17 See Note 14.
18 See Note 14.
19 Everly, G. S., & Mitchell, J. T. (2008). Integrative crisis intervention and disaster mental health. Ellicott City, MD: Chevron.
20 See Note 14.
21 See Note 14.
22 See Note 14.
23 See Note 14.
24 See Note 1.