You may already be familiar with and a believer in the enormous benefits and success of CISM (Critical Incident Stress Management). For years, in my work as a volunteer lieutenant in fire-rescue, a licensed clinical therapist, and an international disaster mental health and first responder, I have had the privilege of utilizing and witnessing CISM’s power when applied in the immediate aftermath of trauma as well as over ensuing weeks and months.
We have seen CISM’s efficacy in situations such as fire departments coping with the loss of a member, families grieving after a suicide, hurricane victims facing devastation of their home and belongings, and substance users grappling with how to liberate themselves from addiction. I’ve been astonished to see it work even when language was a barrier, for example, on a mountaintop in the Himalayas following an earthquake.
What is less widely known, however, is that the value of CISM can be significantly increased when coupled with Eye Movement Desensitization and Reprocessing (EMDR). This can even lead to post-traumatic growth (PTG), a finding that is remarkable and exciting.
There is ample evidence demonstrating that EMDR is the gold-standard and preferred modality for undoing the neurological knots of Post-Traumatic Stress Disorder (PTSD) as well as Complex-PTSD (C-PTSD). The only other modalities that researchers believe approximate EMDR’s efficacy involve potent psychedelics such as psilocybin and MDMA (or Ecstasy). However, psychedelics unfortunately remain illegal or severely restricted in many places, even for therapeutic use. Hopefully that will change.
Breathwork also holds promise, but here, too, more research is needed. So how do we optimize treatment for first responders, many of whom repeatedly experience trauma and PTSD?
CISM + EMDR = PTG (Post-Traumatic Growth). What’s that mean, anyway? Try to imagine clients who emerge on the other side of trauma as stronger, healthier humans than before the traumatic event. In other words, the trauma has improved their mental health as a result of how it was managed. This is not to suggest we should be seeking trauma to attain greater mental wellness. Rather, it questions the assumption that trauma in and of itself is necessarily debilitating. Just as a branch can benefit from being pruned, new neuro-growth can happen following trauma. To achieve this, we need to think of CISM as having a tail that involves ongoing resourcing – self-care, mindfulness, and, importantly, therapeutic support like EMDR.
Will first responders embrace therapy as a key component of the CISM “tail?” I think so. Just look at the trend line: until the last decade or so, the very term CISM was
mostly unknown in the world of fire-rescue beyond a limited number of idealists. Additionally, there was enormous resistance (some of which continues) to the idea of tending to one’s mental health. That stigma did the fire-rescue service an enormous disservice: the very people who most needed mental health support – those on the front lines who were witnessing and absorbing trauma on a daily basis - were being denied the most crucial tools for dealing with their own exposure and secondary trauma. CISM (and the pandemic) changed that.
Take my home region of the DMV (the District, Maryland, and Virginia), for example, where CISM teams have greatly expanded over the past decade. Mental health is no longer a term that’s whispered out of ear-shot. Indeed, in fire departments I’ve overheard “my therapist says” or “our marriage counselor told us” or even “EMDR saved my life.” That last one is a biggie. And just imagine: most fire-rescue departments offer free therapy with a market value of $200 or more per hour. An economic analysis of the benefits of EMDR was performed by the Trauma Institute. Consider the cost savings as a result of increased productivity: better mental health means fewer sick days. And, with apologies for the pun, it is contagious! When you feel well, that has a ripple effect, spreading to others with whom you come in contact. Conversely, untreated mental illness can contribute to a more challenging or even toxic work environment, with the potential to trigger others.
How does EMDR work? Invented by therapist Francine Shapiro in the late 1980s, the mechanism of EMDR’s efficacy is similar to the brain repair that occurs during the REM (Rapid Eye Movement) phase in sleep. The movement of the eyes has a positive effect on the brain that is not entirely understood: we know it works; we’re not certain why.
During EMDR sessions, the practitioner asks the client to identify a target image they want to work on (as well as a host of other questions at the beginning of the session), and then guides them through repetitive bilateral stimulation using bilateral stimulation (BLS) via a dual-action stimulus (DAS) that the client selects. Perhaps the best known DAS involves the practitioner rapidly moving their fingers back and forth and having the client follow the movement with their eyes. However, there are several other DAS techniques that have also been proven effective, such as having the client cross their arms over their chest in a sort of butterfly hug and quickly tap themselves. The therapist will establish safe harbors, such as a calm place and a trusted person the client can envision if they feel they need that support, or if the session becomes difficult. Establishing trust is key to the success of the process.
Over a series of sessions, the sensory recall and feelings the client originally associated with the target image lessen, until they have disappeared. For more information on EMDR, check out Francine Shapiro’s book: Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures, 3rd Edition, 2017.
What else might comprise the CISM tail to ensure long-term success? Teaching our clients to utilize mindfulness: (meditation, breathing techniques, learning to pause when triggered) can have a profound and positive impact. There are numerous, free, guided meditations online and apps such as InsightTimer. It is important to encourage clients to adopt and incorporate these methods into their regular routine, along with other self-care rituals, such as: healthy eating; journaling; exercising daily; cultivating good sleep habits and hygiene; massage; medical checkups and being medication-compliant; spending time outside in the natural world; cultivating a network of support by choosing friends who also embrace a healthy lifestyle; and avoiding toxic coping mechanisms such as cigarettes, alcohol and other substances -- all of these can contribute to a positive long-term outcome.
By adding them to our CISM toolbox, along with proven therapeutic techniques such as EMDR, we establish the compelling “tail” that can greatly enhance the power of treatment.
Post-Traumatic Growth goes beyond healing: it takes the client to a level of healthiness that exceeds their pre-traumatic state. This is already known to occur from EMDR alone – but coupling it with CISM adds a powerful and life-long boost that can be a gift of - and for – life.