Aggression and Violent Behavior

9 (2004) 319 329

Critical Incident Stress Management (CISM): updated

review of findings, 19982002
Raymond B. Flannery Jr.a,*, George S. Everly Jr.b,c
a
Massachusetts Department of Mental Health and Harvard Medical School, Boston, MA, USA
b
Johns Hopkins University, Baltimore, MD, USA
c
Loyola College in Maryland, Baltimore, MD, USA
Received 2 September 2002; accepted 3 February 2003

Abstract

Critical incident stress management (CISM) represents a departure from earlier univariate crisis
intervention strategies. CISM is a comprehensive, multicomponent, crisis intervention approach that
includes preincident training, acute care interventions, and postincident response follow-up. The first
review of this literature included published reports through 1997. This report covers the period from
1998 2002. A databased search revealed 20 papers of specific CISM programs or multiple
interventions programs that are CISM-like in nature. These papers are reviewed and the strengths and
weaknesses of the literature as a whole are presented; implications are discussed.
D 2003 Elsevier Ltd. All rights reserved.

Keywords: Crisis intervention; Critical incident stress management; Debriefing; Emergency services

1. Introduction

In the evolution of cost-effective, clinically efficacious crisis intervention approaches,

critical incident stress management (CISM; Everly & Mitchell, 1999) represents a departure
from earlier univariate crisis intervention models as facilities and organizations learn the
importance of having several available crisis intervention resources to address the complex-

* Corresponding author. Department of Psychology/6B, Worcester State Hospital, 305 Belmont Street,
Worcester, MA 01604, USA. Tel.: +1-508-368-3517; fax: +1-508-363-1512.

1359-1789/03/$ see front matter D 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S1359-1789(03)00030-2
320 R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329

ities of todays events. CISM (Everly & Mitchell, 1999) is an integrated, comprehensive,
multicomponent crisis intervention approach that spans preincident training through acute
care to relevant postincident response. CISM is designed to mitigate the acute psychological
distress associated with critical incidents and to mitigate, and possibly prevent, the onset of
posttraumatic stress disorder (PTSD).
Preincident training refers to improving the cognitive and behavioral responses of at-risk
populations so that they have a clear understanding of possible adverse outcomes and an up-
to-date working knowledge of relevant risk management strategies. Acute care services refer
to a range of individual, group, family, or organizational crisis interventions that may be
needed in the aftermath of any particular critical incident. Postincident response refers to the
provision of services needed for individual, organizational, or community recovery. It may
include resources, such as legal and financial aid, or referrals to private therapists who
specialized in treating victims of psychological trauma. The multicomponent nature of CISM
is emerging as an international standard of care and has been utilized by organizations as
diverse as the Airline Pilots Association, the United States Coast Guard, the National Guard,
the Bureau of Alcohol Tobacco and Firearms, the Hong Kong Hospital Authority, the Armed
Services of Singapore, the Australian Navy, the Federal Bureau of Investigation, as well as
numerous hospitals and universities throughout the world. The first published review of the
CISM literature (Everly, Flannery, & Mitchell, 2000) covered publications through 1997, and
included findings on individual crisis intervention procedures, single-factor psychological
group debriefings, and early reports of CISM approaches to assist the reader in understanding
the historical roots and evolution of CISM programs (Everly et al., 2000; Everly & Mitchell,
1999). This second review focuses exclusively on CISM approaches from 1998 through June
2002. The search for relevant manuscripts included abstracting PubMed and the Psycho-
logical Abstracts with key words, such as crisis intervention, CISM, emergency services, and
the like. This search yielded 20 papers that utilized CISM approaches and included case
studies, programmatic evaluations, and controlled research efforts. At times, papers in these
last two categories overlapped. In these cases, papers were categorized by what appeared to
be the authors (or authors) primary emphasis. This compilation may not be fully
representative, however, as many facilities and organizations may be utilizing multicompo-
nent CISM interventions intuitively, but not labeling them as such.

2. Review of the CISM literature, 19982002

2.1. Case studies

As can be seen in Table 1, three (Clifford, 1999; Hassling, 2000; Mitchell, Schiller, Eyler,
& Everly, 1999) of the 20 publications were traditional case studies. (Empty cells in the table
indicate that a particular study did not report information for that domain.)
The first CISM case study (Clifford, 1999) involved the New South Wales fire brigades
response to the Thredbo snow landslide of 1997. CISM interventions included preincident
training on interagency cooperation during natural disasters; acute care interventions
 R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329 321

including individual, family, and group services; and postincident follow-up phone calls and
educational letters for the 120 firefighters and officers who responded. The stages of this
CISM operation are outlined in detail, but no data on the psychological response of
participants are presented.
The 1989 Coldenham, New York, tornado disaster that resulted in death and serious injury
to several children in a collapsed elementary school lunchroom is the subject of the second
case study (Mitchell et al., 1999). Eighteen firefighters were provided acute care services.
These included individual and group crisis interventions as well as postincident responses of
stress management and of individual referrals for counseling for firefighters. Many fire-
fighters reported fewer and less severe PTSD sysmptomatology on psychometric tests and
five firefighters on sick leave were able to return to active duty.
The final case study focused on emergency service personnels response to the Goteborg
dance hall fire of 1998 in which 63 adolescents died (Hassling, 2000). Services were provided
to victim survivors, family survivors, and emergency services personnel. Preincident training
included training in emergency services routines, peer support, family support, drug abuse,
and general counseling techniques. Acute care services consisted of both individual and
group interventions. Postincident follow-up included educating the young in schools about
fire safety and providing days away for the emergency personnel for self-care, relaxation and
review of the event and procedures. No formal outcome data are reported. However, protocols
for improved CISM services are presented.

2.2. Programmatic evaluations

Twelve of the 20 CISM papers were programmatic evaluations (Boomsma, Dassen,

Dingemans, & van der Heuvel, 1999; Corcoran, Stephenson, Perreyman, & Allen, 2001;
Flannery, Corrigan, Tierney, & Walker, 2001; Flannery, Lizotte, Laudani, Staffieri, & Walker,
2001; Flannery, Schuler, Farley, & Walker, 2002; Flannery, Stevens, Juliano, & Walker, 2002;
Flannery, Stone, Rego, & Walker, 2001; Poijula, Dyregov, Wahlberg, & Jokelainer, 2001;
Poijula, Wahlberg, & Dyregov, 2001; Relsch, Schlatter, & Tschacher, 1999; Rotheram-Borus,
Piacentini, Cantwell, Belin, & Song, 2000; Rudolph, Lakin, Oslund, & Larson, 1998) (see
Table 1).
Rudolph et al. (1998) compared the efficacy of a community behavioral support and a
crisis response team with the services of traditional institutional care for persons with mental
retardation in Minnesota. The specialized services program included preincident training in
the areas of functional behavioral analysis, care provider training, and increased staffing.
Acute care interventions consisted of individual at-home counseling and short-term, inpatient,
crisis placement services. Postincident follow-up by quarterly phone contracts for 1 year
completed the program. In effect, this was a CISM program, and the authors provide a variety
of outcome empirical data to demonstrate the special programs enhanced quality of care and
appreciable dollar-cost savings, when compared to traditional care.
The Northern Center for Health Care Research in the Netherlands (Boomsma et al., 1999)
compared the effectiveness of crisis-oriented versus long-term psychiatric home care
interventions from an analysis of several quality management categories in nursing care
 322
Table 1
Summary overview of CISM studies: 1998 2002
Study Research Duration Settings Type of subjects N CISM Measurable outcomes

R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329
design of study interventions
Case studies
Clifford (1999) Case study 5 Months Natural disaster Firefighters 16 Pre/Acute/Post No data reported
Mitchell et al. (1999) Case study 6 Months Natural disaster Firefighters 18 Acute/Post Fewer PTSD
symptoms, firefighters
return to active duty
Hassling (2000) Case study 2 Weeks Man-made Emergency services Pre/Acute/Post No data reported
disaster personnel

Program evaluations
Rudolph et al. (1998) Retrospective 21 Months Mental Persons with mental 76 Pre/Acute/Post Enhanced
posttesting retardation retardation cost-effective clinical
care
Boomsma et al. Retrospective Community Persons with serious 159 Acute care Crisis care enhanced
(1999) posttesting residential mental illness self-esteem and
housing emotional well-being,
long-term enhanced
community living
skills
Relsch et al. (1999) Pre-/Posttesting 6 Months University Primarily Suicidal 51 Acute care Decreases in
Psychiatric Patients Depression Phobic
Inpatient Service Anxiety, and Social
Fear
Rotheram-Borus et al. Pre-/Posttesting 18 Months Psychiatric Suicidal female 140 Pre/Acute Reductions in
(2000) emergency room adolescents depression scores,
enhanced treatment
compliance
Flannery, Schuler, Retrospective 10 Years Public sector Persons with serious 1033 Preincident Assailants likely
et al. (2002) analysis health care system mental illness older males with
schizophrenia:
younger, male/
females with
personality disorders
Flannery, Corrigan, Retrospective 10 Years Public sector Persons with serious 1033 Preincident Most active time
et al. (2001) analysis health care system mental illness periods on inpatient
wards and community
residences

R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329
Flannery, Stevens, Retrospective 6 Years Public sector Persons with serious 706 Preincident Past violence,
et al. (2002) analysis health care system mental illness personal victimization,
and substance use
disorder increase risk
Flannery et al. (2000) Retrospective 10 Years Public sector Staff victims 1033 Acute care Less experienced,
analysis health care system less trained at
increased risk
Flannery, Lizotte, Retrospective 6 Years Public sector Staff victims 706 Acute care Female staff at risk
et al. (2001) analysis health care system from both male and
female patients in
community housing
Corcoran et al. Retrospective 2 Years Policing Police officers 219 Acute care 79% found
(2001) analysis intervention of
assistance onsite
Poijula, Dyregov, Posttesting 6 Months Public high school Students 1205 Acute care Less depression
et al. (2001)
Poijula, Wahlberg Posttesting 4 Years Public high school Students 1205 Acute care Less suicide
et al. (2001)

Controlled research studies

Amir et al. (1998) Pre-/Posttesting 6 months Jewish settlement Female preschool 15 Acute care Less intense IES
teachers scores
Flannery et al. (1999) Single-case design 1-1/2 Years Public sector Staff victims 1 Postincident Decline in facility
health care system assault rate
Flannery et al. (2000) Single-case design 1 Year Public sector Staff victims 34 and 25 Postincident Decline in assault rate
health care system in one of two facilities
Deahl et al. (2000) Randomized 1 Month Military base Soldiers 106 Pre/Acute Reducing in alcohol
control study use
Richards (2001) Nonrandomized 12 Months Bank branches Bank tellers 524 Pre/Acute/Post Lower trauma
control study morbidity

323
324 R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329

plans. The crisis-oriented initiative proved what would be considered acute care CISM
services and included short-term stabilization, medication management, coping enhancement,
and activity therapy. The long-term program also emphasized medication management and
coping enhancement, but focused on the longer term issues of managing problems in daily
living and in stressful life events. Statistical trends indicated the crisis program provided
enhanced self-esteem and emotional well being, whereas the long-term program increased
skills necessary for eventual community placement. The importance of multiple interventions
in both programs was noted.
Relsch et al. (1999) evaluated the effectiveness of a crisis intervention unit in Switzerland.
Fifty-one patients, many of whom were suicidal, received a multiple, CISM-like series of
acute care interventions. These included 14 hours of various group therapies and 2 hours of
both individual and milieu therapy within a 3-week period. Their two-step approach of acute
care crisis services for the immediate precipitant and postincident referral for longer term
therapy resulted in measured pre/post outcomes of decreased depression, phobic anxiety, and
social fear.
A second crisis intervention program for suicidal individuals was conducted with
adolescent females in New York (Rotheram-Borus et al., 2000). One hundred forty
adolescents received either standard emergency room (ER) care that included psychiatric
evaluation and referrals for long-term therapy, or specialized ER care that included
preincident training for staff, acute care services for individuals and families that included
psychiatric evaluation for the patient family education or suicide, a crisis intervention session,
and postincident referrals for long-term therapy. The specialized ER care initiative, which was
essentially a CISM program, resulted in lower depression scores and increased attendance at
subsequent follow-up therapy sessions.
Flannery, Schuler, et al. (2002) conducted five studies of a specific CISM program for
health care staff who were assaulted by patients in Massachusetts. Known as the Assaulted
Staff Action Program (ASAP), it provides preincident training in strategies for nonviolent
self-defense, alternatives to restraint and seclusion, and identifying the characteristics of
patients at high risk to be assaultive. ASAP provides acute care services that include
individual, family, and group crisis interventions and short-term, ongoing support groups.
ASAP also provides postincident referrals to trauma specialists, when indicated, and risk
management procedures as noted below. Utilizing the ASAP report form that tracks the
characteristics of patient assailants and staff victims, Flannery et al. carried out a series of
program evaluations that span a 10-year period. This multicomponent CISM program
resulted in three preincident studies to identify high-risk patients (Flannery, Corrigan, et
al., 2001; Flannery, Schuler, et al., 2002; Flannery, Stevens, et al., 2002). The full 10-year
analysis of all assailants revealed that there were two groups of high-risk patients: older, male
patients with schizophrenia and younger, male/female patients with personality disorders
(Flannery, Schuler, et al., 2002). An analysis of the time and risk for patient assaults
identified active meal times on inpatient wards and bedtime routines in community
residential settings as periods with increased frequency of assaults (Flannery, Corrigan, et
al., 2001). A third analysis of the clinical variables of history of violence, personal
victimization, and substance use disorder (Flannery, Stevens, et al., 2002) revealed that
 R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329 325

patients with all three variables were at substantial increased risk for subsequent assaultive
behavior toward staff.
Acute care ASAP studies for the same 10-year period revealed that the less experienced,
less formally trained employees were at increased risk to be victimized (Flannery, Stone, et
al., 2001), especially female staff in community residences. A second analysis of assaults by
gender (Flannery, Lizotte, et al., 2001) found male patients assaulted male staff in inpatient
and community settings. Furthermore, female patients attacked female staff in inpatient and
community settings. However, female staff in community settings were at increased risk from
both male and female patients. Postincident response is reported in the next section.
An additional CISM-like, crisis intervention programmatic evaluation was conducted by
Corcoran et al. (2001) in Virginia. This study evaluated a multicomponent, policesocial
work crisis team that included preincident training for team social work members. This
training included an overview of family dynamics and violence intervention methods. The
program also offered acute care crisis interventions onsite for individuals and families and a
range of legal postincident interventions, including legal referrals, victim rights advocacy, and
social work in shelters for battered women. The majority of police officers found this program
to be of assistance onsite during domestic violence calls.
The two remaining programmatic interventions were evaluations of a CISM crisis
intervention approach for adolescents in Finnish schools where fellow classmates had
committed suicide (Poijula, Dyregov, et al., 2001; Poijula, Wahlberg, et al., 2001). The
intervention included an initial classroom group intervention to explain the facts of the
suicides to offer an opportunity for grieving, and to provide emotional stabilization. However,
not all schools availed themselves of this CISM set of interventions. Psychometric assessment
indicated that students experienced less grief when CISM was early and adequate (Poijula,
Dyregov, et al., 2001) and that suicidal contagion was recorded in the one school where
CISM was not provided (Poijula, Wahlberg, et al., 2001).

2.3. Controlled research studies

This section of the review lists the five studies in Table 1 that have included more formal
research methodology and differing levels of experimental control (Amir, Weil, Kaplan,
Tocker, & Witztum, 1998; Deahl, Scrinivasan, Jones, Neblett, & Jolly, 2000, Flannery, Penk,
& Corrigan, 1999; Flannery, Anderson, Marks, & Uzoma, 2000; Richards, 2001).
Amir et al. (1998) conducted a prospective study on 15 Israeli, noninjured, female victims
of a terrorist attack. Amir et al.s CISM acute care initiative included one brief abreactive
group meeting followed by six weekly debriefing meetings and one debriefing meeting with
the victims husbands. Psychometric evaluation indicated that victims with higher scores on
the Impact of Events (IES) Scale and the SCL-90 (Amir et al., 1998) initially had onset PTSD
6 months after the attack (27%). The IES showed a significant reduction in intensity for all
subjects, but the CISM intervention did not appear to bring substantial relief to the victims.
Flannery and his colleagues conducted two studies measuring the levels of assaultive
behavior pre- and postfielding an ASAP team (Flannery et al., 2000; Flannery et al., 1999).
These two studies in Massachusetts utilized the ASAP CISM model noted earlier and focused
326 R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329

on postincident response. Utilizing a single case design in each of four facilities, statistically
significant reductions in facility-wide levels of assaultiveness were noted for a community
mental health center and an intermediate/extended-care facility. No significant reductions
were noted in a second community mental health setting. The study of a community
residential housing ASAP team was judged to be not a true test because of structural issues
associated with managed care initiatives.
Deahl et al. (2000) conducted a randomized controlled study to reduce the psychological
sequelae associated with armed conflict in returning British soldiers. Prior to deployment, all
subjects had been given exposure to a preincident operational stress training package and a
randomly selected group also received acute care postoperational group debriefing. The
group, which received both CISM-like interventions, had substantially lower scores on a
measure of substance use disorder.
The final study in this series was a prospective field trial of a stand-alone group
intervention versus a multicomponent CISM approach (Richards, 2001). In this study, British
bank tellers who were robbed received the companys first human resource intervention,
traditional, stand-alone group psychological debriefing. Tellers who were robbed 16 months
later received the companys expanded CISM program. This second program included
preincident training in stress inoculation, acute care services of group psychological debrief-
ing, and postincident response that included one-hour, individual follow-up sessions for
symptom management one month after each robbery. Measures included the IES and other
measures of PTSD and general health (Richards, 2001). While there were no initial
differences between the two groups, follow-up several months later revealed lower trauma
morbidity for those in the CISM program. The two groups in this study represent company
practices at different points in time rather than a true randomized controlled study with a no-
intervention control group.

3. Discussion

The types of critical incidents listed in Table 1 (Amir et al., 1998; Boomsma et al., 1999;
Clifford, 1999; Corcoran et al., 2001; Deahl et al., 2000; Flannery et al., 2000; Flannery,
Corrigan, et al., 2001; Flannery, Lizotte, et al., 2001; Flannery et al., 1999; Flannery, Schuler,
et al., 2002; Flannery, Stevens, et al., 2002; Flannery, Stone, et al., 2001; Hassling, 2000;
Mitchell et al., 1999; Poijula, Dyregov, et al., 2001; Poijula, Wahlberg, et al., 2001; Relsch et
al., 1999; Richards, 2001; Rotheram-Borus et al., 2000; Rudolph et al., 1998) reflect
significant human suffering and suggest that CISM approaches (Everly & Mitchell, 1999)
may represent one effective way to address the adverse psychological distress that may result
from such events. Although CISM interventions are sometimes thought to be only relevant to
the needs of emergency services personnel (Litz, Gray, & Adler, 2002), these CISM studies
document their efficacy with a variety of victims groups worldwide with significant outcome
domains such as improved safety, enhanced care, sustained productivity, and dollar cost
efficiencies. Most of these studies reported significant helpful outcomes; three (Amir et al.,
1998; Deahl et al., 2000; Flannery et al., 2000) reported mixed findings, and none reported
 R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329 327

harmful outcomes. This second review with its 20 papers reflects a 60% increase in CISM
studies in the 5 years since the first review (Everly et al., 2000), which noted eight papers at
that time. This may suggest that clinicians and researchers in the field of crisis intervention,
either consciously or intuitively, are beginning to understand the need for multicomponent
CISM interventions (Everly & Mitchell, 1999).
Although some progress has been made in clearly operationally defining CISM inter-
ventions and in the increased utilization of psychometric measures, many of the methodo-
logical concerns in the original review remain (Everly et al., 2000). These include the need
for standardized operational definitions of traumatic events, improved and standardized valid
and reliable outcome measures, and interventions procedures that are standardized in format
and fielded by counselors formally trained in these procedures.
To date, initial CISM studies have essentially addressed treating and evaluating outcomes
in victim groups immediately impacted by some form of critical incident and there remains
the need for rigorously controlled experimental studies. The nature of how these experimental
studies should be conducted is currently being debated within the field. Some authors (e.g.,
Litz et al., 2002) believe that research on crisis intervention procedures should adhere to the
basic scientific standard of the true randomized controlled study. Others (Seligman, 1995)
have suggested that the nature of critical incidents requires the development of nonrandom-
ized experimental designs. Seligman (1995) believes that efficacy studies omit many of the
crucial elements that characterize field interventions, such as the level of competence of the
service provider, the real-time self-correcting nature of the intervention, the complex
precipitating stressors, and the issue of timing of research in true chaotic conditions. He
proposes that the effects of randomization may be addressed through the measurement of
potential sources of systematic error, large sample sizes from diverse subject pools, and meta-
analytic approaches.
In addition, the ethical issue of withholding treatment from people in need is often an
important consideration in crisis intervention research. For example, the ASAP program
(Flannery, Schuler, et al., 2002) for assisting assaulted staff is often associated with
substantial declines in assaultive behavior facility-wide (Everly et al., 2000; Flannery et
al., 1999, 2000). These studies have employed single-case and multiple-baseline designs to
evaluate these research outcomes because it was considered unethical to withhold this
treatment intervention from any interested facility. If future single-case or multiple-baseline
studies failed to replicate the declines in rates of assault after ASAP is fielded or if some
facility refused ASAP for other considerations, then a true randomized controlled study could
be conducted. Similar controlled studies might also be fielded in school or correctional
settings where violence is to be reasonably expected unlike natural or man-made disasters,
which are usually not foreseeable.
A recent review of early intervention in trauma (Litz et al., 2002) has noted that victims of
PTSD from prior critical events are at increased risk to develop intense reactions to
subsequent traumatic incidents. These authors suggested that victims in any critical incident
be screened for posttrauma histories and be referred for evaluation and extended care as
needed. This excellent idea would again be difficult to implement immediately onsite where
normal routines and resources are severely impacted and where safety needs must be
328 R.B. Flannery Jr., G.S. Everly Jr. / Aggression and Violent Behavior 9 (2004) 319329

addressed first. However, one possible solution might lie in having a prescreened and trained
group of licensed clinicians who would volunteer to screen all victims after the immediate
crisis has subsided.
Although disaster, violence, and other forms of critical incidents are a painful component
of life, these events do present thoughtful clinicians and researchers with important
opportunities for developing scientifically sound, event-adapted CISM approaches to assist
in relieving unnecessary suffering.

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