What Can We Learn From The Criticism of CISM Vaughn Donaldson, Dist. Chief Midland Fire Dept. Midland, TX

What Can We Learn From What Can We Learn From The Criticism of CISMThe Criticism of CISM

Vaughn Donaldson, Dist. ChiefVaughn Donaldson, Dist. Chief

Midland Fire Dept.Midland Fire Dept.

Midland, TXMidland, TX

The Rest Of The StoryThe Rest Of The Story

ByByVaughn Donaldson, Dist. ChiefVaughn Donaldson, Dist. Chief

Midland Fire Dept.Midland Fire Dept.Midland, TX Midland, TX

The Bad StuffThe Bad Stuff

IneffectiveIneffective No evidence that it worksNo evidence that it works Does nothing at allDoes nothing at all Prevents healingPrevents healing

Really Bad StuffReally Bad Stuff

Makes people worseMakes people worse Causes PTSDCauses PTSD Not only does it not work….it hurtsNot only does it not work….it hurts

The Unexamined Life Is The Unexamined Life Is Not Worth LivingNot Worth Living

SocratesSocrates

The StudiesThe Studies Harris - firefightersHarris - firefighters Mcnab – air ambulanceMcnab – air ambulance Deahl – body recovery soldiersDeahl – body recovery soldiers Bisson – burn victimsBisson – burn victims Hobbs – mvc victimsHobbs – mvc victims Rose – victims of violent crimeRose – victims of violent crime Carlier – police officersCarlier – police officers Amir – terrorist attack on Israeli womenAmir – terrorist attack on Israeli women Hytten - firefightersHytten - firefighters Litz – lit. reviewLitz – lit. review

They Call It “Quality They Call It “Quality Science”Science”

Title: Mental health of trauma exposed Title: Mental health of trauma exposed firefighters and critical incident firefighters and critical incident stress debriefingstress debriefing

Type: SurveyType: SurveyJournal: Journal: Journal of Loss and TraumaJournal of Loss and Trauma

2002, 223 – 2382002, 223 – 238Authors: Harris, Baloglu, and StacksAuthors: Harris, Baloglu, and Stacks

They Call It “Quality They Call It “Quality Science”Science” 852 met selection criteria for the study.852 met selection criteria for the study.

Of these, 264 had attended CISD sessions Of these, 264 had attended CISD sessions following the Mitchell model.following the Mitchell model.

396 non-debriefed firefighters were randomly 396 non-debriefed firefighters were randomly selected by computer as the comparison groupselected by computer as the comparison group

Conclusion: “Within this model, we find no Conclusion: “Within this model, we find no evidence of a significant direct contribution of evidence of a significant direct contribution of debriefing to coping skills or traumatic stress debriefing to coping skills or traumatic stress reactions.”reactions.”

““No relationship was found between debriefing No relationship was found between debriefing and PTSD.”and PTSD.”

Harris - The Rest of the Harris - The Rest of the StoryStory

The findings emphasize the need for The findings emphasize the need for further research on CISD, stress exposure, further research on CISD, stress exposure, and dispositional variables in firefighters. and dispositional variables in firefighters.

The nature and quality of debriefings The nature and quality of debriefings attended by the firefighters in FEMA attended by the firefighters in FEMA Region VI were no doubt diverse.Region VI were no doubt diverse.

Firefighters with more general and Firefighters with more general and pervasive mental health difficulties may pervasive mental health difficulties may seek, and fact benefit from, CISD. seek, and fact benefit from, CISD.

Harris – The Rest of the Harris – The Rest of the StoryStory

On the other hand seeking treatment for On the other hand seeking treatment for personal mental health issues in the personal mental health issues in the context of one’s coworkers and workplace context of one’s coworkers and workplace may not be in the best interests of those may not be in the best interests of those so affected.so affected.

Pre-employment mental health screening Pre-employment mental health screening and appropriate selection criteria…..could and appropriate selection criteria…..could be argued to represent a bona fide be argued to represent a bona fide occupational requirement. occupational requirement.


Ethical issues of dual roles, Ethical issues of dual roles, confidentiality, provision of confidentiality, provision of unnecessary services, competence unnecessary services, competence and beneficiance to those affected and beneficiance to those affected require serious consideration in require serious consideration in policymaking regarding the provision policymaking regarding the provision of mental health services on a of mental health services on a mandatory basis mandatory basis

Harris - The Rest of the Harris - The Rest of the StoryStory

Our results are recommended to provide Our results are recommended to provide caution for future research and policy caution for future research and policy decisions regarding CISD. decisions regarding CISD.

Clinical wisdom might suggest that there Clinical wisdom might suggest that there is inherent value in the provision of is inherent value in the provision of support and psychosocial instruction support and psychosocial instruction during the post-exposure period, and during the post-exposure period, and empirical evidence from this study does empirical evidence from this study does not contradict that notion. not contradict that notion.


• Study was done 6 months after the Study was done 6 months after the critical incidentcritical incident

• CISD participants has less negative CISD participants has less negative affect at 6 monthsaffect at 6 months

• CISD participants had more positive CISD participants had more positive beliefs and positive affect at 6 beliefs and positive affect at 6 monthsmonths

They Call It “They Call It “Quality Science”Quality Science”

Title: Title: Critical incident stress Critical incident stress intervention after loss of an air intervention after loss of an air ambulance: two-year follow-up.ambulance: two-year follow-up.

Type: Type: Non-randomized controlled trialNon-randomized controlled trial JournalJournal: : Prehospital Disaster Prehospital Disaster

MedicineMedicine1999;14(1):8-121999;14(1):8-12 Authors: Authors: Macnab, Russel, Lowe, Macnab, Russel, Lowe,

GagnonGagnon


Air ambulance accident in British Air ambulance accident in British Columbia killed 5.Columbia killed 5.

Directly involved paramedics, Directly involved paramedics, physicians, and nurses received CISM. physicians, and nurses received CISM. (defusing, debriefing, follow-up).(defusing, debriefing, follow-up).

CISD provided by CISM -trained CISD provided by CISM -trained chaplain assisted by BCAS CISM team.chaplain assisted by BCAS CISM team.

Control group derived from non-Control group derived from non-involved peers.involved peers.


Standard psychological measures Standard psychological measures used.used.

Debriefed group had more stress Debriefed group had more stress symptoms at 1 week.symptoms at 1 week.

CISD did not appear to reduce the CISD did not appear to reduce the severity of stress symptoms.severity of stress symptoms.

People with pre-existing stress People with pre-existing stress management routines appeared to management routines appeared to have less symptoms at 6 months.have less symptoms at 6 months.

Mcnab – The Rest of the StoryMcnab – The Rest of the Story Air ambulance fails to arrive to evacuate Air ambulance fails to arrive to evacuate

a patient in early morning hoursa patient in early morning hours Unknown if it crashedUnknown if it crashed Information sharing session initiated at Information sharing session initiated at

hospital by cism teamhospital by cism team Defusing done @ 1400 hours and @ Defusing done @ 1400 hours and @

1730 hours1730 hours

Mcnab - The Rest of the Mcnab - The Rest of the StoryStory

Next day – spousal debriefing sessionNext day – spousal debriefing session 2 days later another CISD for all at 2 days later another CISD for all at

hosp. who wanted ithosp. who wanted it Fate of crew still unknownFate of crew still unknown 5 days after the event the wreckage 5 days after the event the wreckage

was found and only 2 bodies was found and only 2 bodies recoveredrecovered


The hospital stress management The hospital stress management team, particularly those unfamiliar team, particularly those unfamiliar with the working environment of the with the working environment of the transport team, were not seen to be transport team, were not seen to be as helpful or comforting during CISD as helpful or comforting during CISD as did those from the Ambulance as did those from the Ambulance Service.Service.


Particularly resentment occurred Particularly resentment occurred when team members felt there was when team members felt there was impulsive and unusual interest in impulsive and unusual interest in their welfare, with the assumption of their welfare, with the assumption of inappropriate intimacy and inappropriate intimacy and familiarity with the realities of their familiarity with the realities of their work environment.work environment.


TitleTitle: Psychological sequelae : Psychological sequelae following the Gulf War: Factors following the Gulf War: Factors associated with subsequent morbidity associated with subsequent morbidity and the effectiveness of PD.and the effectiveness of PD.

TypeType: Non-randomized CT: Non-randomized CT JournalJournal: : Brit J Psych, Brit J Psych, 165 (1994)165 (1994) Authors: DeahlAuthors: Deahl et al et al


Evaluated 62 soldiers in the British Army Evaluated 62 soldiers in the British Army AWGS.AWGS.

69% received PD.69% received PD. Conclusion: “These findings show that a Conclusion: “These findings show that a

psychological debriefing following a series of psychological debriefing following a series of traumatic events or experiences does not traumatic events or experiences does not appear to reduce subsequent psychiatric appear to reduce subsequent psychiatric morbidity and highlights the need for further morbidity and highlights the need for further research in military and civilian settings.”research in military and civilian settings.”

Deahl - The Rest of the Deahl - The Rest of the StoryStory

Less alcohol use in debriefed groupLess alcohol use in debriefed group Not a RCTNot a RCT Low symptoms of distress in both Low symptoms of distress in both

groups from the outset, but debriefed groups from the outset, but debriefed group started out with much lower group started out with much lower symptoms of distress, although it symptoms of distress, although it didn’t get much lower didn’t get much lower

Single session debriefingSingle session debriefing

Deahl - The Rest of the Deahl - The Rest of the StoryStory

Debriefing not rigorously standardized Debriefing not rigorously standardized in content or timingin content or timing

Highlights the need for studies to Highlights the need for studies to investigate the whether there is a role investigate the whether there is a role for screening those recruited into for screening those recruited into “high-risk” professions“high-risk” professions

Despite our findings we remain Despite our findings we remain committed to the principle of debriefingcommitted to the principle of debriefing


TitleTitle: Randomised controlled trial of : Randomised controlled trial of psychological debriefing for victims psychological debriefing for victims of acute burn trauma.of acute burn trauma.

TypeType:RCT:RCT JournalJournal: : Brit J Psych, Brit J Psych, 171 (1997)171 (1997) AuthorsAuthors:Bisson, Jenkins, Alexander, :Bisson, Jenkins, Alexander,

BannisterBannister


132 adult burn victims entered into study132 adult burn victims entered into study Randomly assigned to a group that received PD Randomly assigned to a group that received PD

or a control group that did not.or a control group that did not. They were subsequently evaluated by an They were subsequently evaluated by an

assessor blind to PD status at 3 & 13 months.assessor blind to PD status at 3 & 13 months. Conclusion: 26% of the PD group had PTSD at 13 Conclusion: 26% of the PD group had PTSD at 13

months compared to 9% of the control groupmonths compared to 9% of the control group ““This study seriously questions the wisdom of This study seriously questions the wisdom of

advocating one-off interventions post-trauma advocating one-off interventions post-trauma and should stimulate research into more and should stimulate research into more effective initiatives.”effective initiatives.”


““The excess number in the PD group was The excess number in the PD group was due to absence of block randomization and due to absence of block randomization and termination of recruitment when preliminary termination of recruitment when preliminary analysis of the data revealed possible analysis of the data revealed possible adverse consequences for the intervention adverse consequences for the intervention group.”group.”

““The PDs adhered to the structure first The PDs adhered to the structure first described by Mitchell (1983) adapted for described by Mitchell (1983) adapted for use with either an individual or a couple. use with either an individual or a couple. The facilitator proceeded through a seven-The facilitator proceeded through a seven-phase semi-structured approach.”phase semi-structured approach.”

Bisson - The Rest of the Bisson - The Rest of the StoryStory

Debriefed group scored higher on Debriefed group scored higher on whether other people were involved in the whether other people were involved in the accidentaccident

Debriefed group had more serious injuriesDebriefed group had more serious injuries Debriefed group also had higher initial Debriefed group also had higher initial

scores on psychopathologyscores on psychopathology Shorter period of time between the burn Shorter period of time between the burn

trauma and debriefing sessiontrauma and debriefing session

Bisson - The Rest of the Bisson - The Rest of the StoryStory

Debriefed group had more financial Debriefed group had more financial difficultiesdifficulties

Some sessions were as short as 40 Some sessions were as short as 40 minutesminutes

Bisson describes debriefing as Bisson describes debriefing as “intense imaginal exposure to a “intense imaginal exposure to a traumatic incident”traumatic incident”


TitleTitle: A randomised controlled trial of : A randomised controlled trial of PD for victims of road traffic accidents.PD for victims of road traffic accidents.

TypeType: RCT: RCT JournalJournal: : Brit Med J Brit Med J ; 313 (1996); 313 (1996) AuthorsAuthors: Hobbs, Mayou, Harrison, : Hobbs, Mayou, Harrison,

WorlockWorlock


106 victims of MVCs were randomly assigned 106 victims of MVCs were randomly assigned to a PD group or a control group.to a PD group or a control group.

PD was completed within 24-48 hours. (PD was completed within 24-48 hours. (in most in most cases)cases)

Conclusions: “Psychiatric morbidity was Conclusions: “Psychiatric morbidity was substantial 4 months after injury, with no substantial 4 months after injury, with no evidence that debriefing had helped—and, evidence that debriefing had helped—and, indeed, indications that it might have been indeed, indications that it might have been disadvantageous.”disadvantageous.”


Proponents of CISM often discount this Proponents of CISM often discount this study because the debriefed group study because the debriefed group was more severely injured.was more severely injured.

But the authors report PTSD was no But the authors report PTSD was no different between the groups.different between the groups.

CISD is supposed to mitigate PTSD CISD is supposed to mitigate PTSD symptoms, not physical injuries.symptoms, not physical injuries.

Hobbs - The Rest of the Hobbs - The Rest of the StoryStory

Debriefed group had worse injuriesDebriefed group had worse injuries 1 hr debriefing1 hr debriefing Debriefed group had longer hospital Debriefed group had longer hospital

staystay Individual interventionIndividual intervention The training and experience of his The training and experience of his

debriefers is unknowndebriefers is unknown


TitleTitle: A randomised controlled trial : A randomised controlled trial of individual debriefing for victims of of individual debriefing for victims of violent crime.violent crime.

TypeType:RCT:RCT JournalJournal: : Psych MedPsych Med; 29 (1999); 29 (1999) AuthorsAuthors:Rose, Brewin, Andrews, Kirk:Rose, Brewin, Andrews, Kirk


2,161 victims of violent crime were contacted, 2,161 victims of violent crime were contacted, 243 replied, 157 selected for study and randomly 243 replied, 157 selected for study and randomly assigned to one of three groups: assigned to one of three groups: 1. Assessment only, 1. Assessment only, 2. Education, 2. Education, 3. Education & PD (based loosely on Mitchell’s model).3. Education & PD (based loosely on Mitchell’s model).

Conclusions: “No evidence was found to support Conclusions: “No evidence was found to support the efficacy of brief one-session interventions for the efficacy of brief one-session interventions for preventing post-traumatic symptoms in individual preventing post-traumatic symptoms in individual victims of violent crime.”victims of violent crime.”

Rose – The Rest of the StoryRose – The Rest of the Story

Loosely based on Mitchell’s ModelLoosely based on Mitchell’s Model Participants were prompted with specific Participants were prompted with specific

questions designed to elicit facts, questions designed to elicit facts, cognitions and were encouraged to cognitions and were encouraged to express negative emotions such as fear, express negative emotions such as fear, guilt or shame which in normal guilt or shame which in normal circumstances might have remained circumstances might have remained hiddenhidden

Debriefings lasted 1 hourDebriefings lasted 1 hour

Rose – The Rest of the StoryRose – The Rest of the Story It is important to clarify that our study It is important to clarify that our study

does not speak to the efficacy of group does not speak to the efficacy of group debriefing.debriefing.

The sample contained substantial The sample contained substantial subgroups with high levels of previous subgroups with high levels of previous psychopathology, and of previous psychopathology, and of previous assaults in childhood.assaults in childhood.

It is possible that individual one-session It is possible that individual one-session debriefings are insufficient to bring about debriefings are insufficient to bring about changes among those with previous changes among those with previous psych or trauma historypsych or trauma history


TitleTitle: The influence of occupational : The influence of occupational debriefing on post-traumatic stress debriefing on post-traumatic stress symptomatology in traumatized symptomatology in traumatized police officers.police officers.

TypeType: Non-randomized CT: Non-randomized CT JournalJournal: : Br J Med PsychBr J Med Psych; 73 (2000); 73 (2000) AuthorsAuthors: Carlier, Voerman, Gersons: Carlier, Voerman, Gersons


A sample of 243 traumatized police A sample of 243 traumatized police officers were divided into three groups: officers were divided into three groups: 1. Debriefed officers (86), 1. Debriefed officers (86), 2. Non-debriefed-internal (82) 2. Non-debriefed-internal (82) 3. Non-debriefed-external (75)3. Non-debriefed-external (75)

Three group successive debriefing Three group successive debriefing sessions (24 hours, 1 month, and 3 sessions (24 hours, 1 month, and 3 months post-trauma).months post-trauma).

Debriefings followed Mitchell’s (1983) Debriefings followed Mitchell’s (1983) model.model.

They Call It “Quality They Call It “Quality Science”Science” Conclusions: “No differences in Conclusions: “No differences in

psychological morbidity were found psychological morbidity were found between the groups at pre-test, 24 hours, between the groups at pre-test, 24 hours, and 6 months post-trauma. One week and 6 months post-trauma. One week post-trauma, debriefed subjects exhibited post-trauma, debriefed subjects exhibited more post-traumatic stress disorder more post-traumatic stress disorder symptomatology than non-debriefed symptomatology than non-debriefed subjects.”subjects.”

““High levels of satisfaction with debriefing High levels of satisfaction with debriefing were not reflected in positive outcomes.”were not reflected in positive outcomes.”

Carlier – The Rest of the Carlier – The Rest of the StoryStory

Debriefing adapted for use with Debriefing adapted for use with individual trauma victimsindividual trauma victims

First debriefing lasted avg. 41.4 First debriefing lasted avg. 41.4 minutesminutes

Second lasted 17.4Second lasted 17.4 Third lasted 15.9 minutesThird lasted 15.9 minutes

Carlier - The Rest of the Carlier - The Rest of the StoryStory

Internal control group declined the Internal control group declined the offer for debriefing because they did offer for debriefing because they did not perceive the event as shocking or not perceive the event as shocking or had no time for a debriefing interviewhad no time for a debriefing interview

As we focused on individual As we focused on individual debriefing, the results may not be debriefing, the results may not be directly comparable with data on directly comparable with data on group or couple debriefinggroup or couple debriefing


TitleTitle: Debriefing with brief group : Debriefing with brief group psychotherapy in a homogenous group of psychotherapy in a homogenous group of non-injured victims of a terrorist attack: a non-injured victims of a terrorist attack: a prospective study.prospective study.

TypeType: Prospective non-controlled: Prospective non-controlled JournalJournal: : Acta Psych Scand; Acta Psych Scand; 98 (1998)98 (1998) AuthorsAuthors: Amir, Weil, Kaplan, Tocker, : Amir, Weil, Kaplan, Tocker,

WitztumWitztum


15 non-injured women exposed to a terrorist 15 non-injured women exposed to a terrorist bombing in Israel while on a day care bus trip.bombing in Israel while on a day care bus trip.

All women participated in a group debriefing 2 All women participated in a group debriefing 2 days after the attack followed by 6 group days after the attack followed by 6 group psychotherapy sessions.psychotherapy sessions.

Conclusion: “The results of the present study Conclusion: “The results of the present study show that the psychological intervention did not show that the psychological intervention did not bring substantial relief of the suffering of bring substantial relief of the suffering of terrorist attack victims in this study.”terrorist attack victims in this study.”

Amir – The Rest of the StoryAmir – The Rest of the Story

It is possible that debriefings and early It is possible that debriefings and early interventions focus on irrelevant issues.interventions focus on irrelevant issues.

The IES showed a significant decrease The IES showed a significant decrease in intensity.in intensity.

These women were day care workers in These women were day care workers in an area an hour away from their home an area an hour away from their home in an area with much political unrest in an area with much political unrest and continuous terrorist attacks on and continuous terrorist attacks on civilians.civilians.


TitleTitle: Fire fighter: A study of stress : Fire fighter: A study of stress and copingand coping

TypeType: Non-randomized, controlled: Non-randomized, controlled JournalJournal: : Acta Psych Scand; Acta Psych Scand; 355 355

(1989)(1989) AuthorsAuthors: Hytten & Hassle: Hytten & Hassle


58 non-professional firefighters participated in a 58 non-professional firefighters participated in a major 12-story hotel fire where 14 guests lost their major 12-story hotel fire where 14 guests lost their lives.lives.

39 men participated in PD39 men participated in PD Conclusion: “Those who took part in formal Conclusion: “Those who took part in formal

debriefing claimed that it had helped them. debriefing claimed that it had helped them. Nevertheless, there was no significant difference on Nevertheless, there was no significant difference on the IES between those who received formal the IES between those who received formal debriefing versus those who only talked with their debriefing versus those who only talked with their colleagues in more informal settings.”colleagues in more informal settings.”

Hytten - The Rest of the Hytten - The Rest of the StoryStory

Of the 39 who participated – 2/3 Of the 39 who participated – 2/3 claimed the effort had been claimed the effort had been professionally useful and felt their professionally useful and felt their self confidence had increasedself confidence had increased

Also mentioned as positive aspects of Also mentioned as positive aspects of the debriefing experience wasthe debriefing experience wasEnhanced group cohesionEnhanced group cohesion

Hytten - The Rest of the Hytten - The Rest of the StoryStory

More knowledge about people’s More knowledge about people’s responsesresponses

And a different priority of valuesAnd a different priority of values Never defines debriefingNever defines debriefing ““We do not know enough about how We do not know enough about how

debriefing help is brought about, an debriefing help is brought about, an how it should be arranged to become how it should be arranged to become most effective.”most effective.”


TitleTitle: Early interventions for trauma: : Early interventions for trauma: Current status and future directionsCurrent status and future directions

TypeType: Collective Review: Collective Review JournalJournal: : Clin Pscyh Sci Prac; Clin Pscyh Sci Prac; 9(2002)9(2002) AuthorsAuthors: Litz, Gray, Bryant, Adler: Litz, Gray, Bryant, Adler


Collective review of all current Collective review of all current literature pertaining to PD/CISD/CISM.literature pertaining to PD/CISD/CISM.

Conclusions: “Based on available Conclusions: “Based on available evidence, we propose that evidence, we propose that psychological first aid is an psychological first aid is an appropriate initial intervention, but it appropriate initial intervention, but it does not serve a therapeutic or does not serve a therapeutic or preventative function.”preventative function.”

Litz – The Rest of the StoryLitz – The Rest of the Story

It appears that there is sufficient It appears that there is sufficient empirical evidence to recommend empirical evidence to recommend that PD not be provided to that PD not be provided to individuals immediately after trauma.individuals immediately after trauma.

In our opinion, one session, one-on-In our opinion, one session, one-on-one meetings between trauma one meetings between trauma survivors and professionals are survivors and professionals are appropriate if they ….appropriate if they ….


A. assess the need for sustained A. assess the need for sustained treatmenttreatment

B. provide psychological first aidB. provide psychological first aid C. provide education about trauma C. provide education about trauma

and treatment resourcesand treatment resources


Since PD is fully accepted as Since PD is fully accepted as standard practice for emergency standard practice for emergency personnel and well-received by personnel and well-received by groups and organizations, it is hard groups and organizations, it is hard to find fault in it’s application in to find fault in it’s application in disasters.disasters.


Formal debriefing may serve to Formal debriefing may serve to maintain morale and cohesion….feel maintain morale and cohesion….feel validated, empowered,…and that the validated, empowered,…and that the group based approach contributes to group based approach contributes to better functioning in the work better functioning in the work environment after a high stress environment after a high stress incident. incident.

What Can We Learn From The What Can We Learn From The Criticism of CISM?Criticism of CISM?

What Can We Learn?What Can We Learn?

Meet BASIC needs first and foremostMeet BASIC needs first and foremost

Follow accepted standards – don’t start Follow accepted standards – don’t start doing CISDs before you even know doing CISDs before you even know what happenedwhat happened

Use EXTREME caution in mandating Use EXTREME caution in mandating attendance at interventionsattendance at interventions

Pre-incident education, Pre-incident education,


Pre-employment screening needs to Pre-employment screening needs to be mandatory in high stress be mandatory in high stress professionsprofessions

CISM is not a one shot dealCISM is not a one shot deal

Stop probing and trying to turn Stop probing and trying to turn group crisis intervention into group group crisis intervention into group therapy!!!therapy!!!

Don’t use crisis intervention to treat Don’t use crisis intervention to treat psychopathogy psychopathogy


Match peers for the Match peers for the profession….duh!profession….duh!

We need unbiased research into We need unbiased research into CISMCISM

What we’re doing is working………What we’re doing is working………when we follow the “Standard of when we follow the “Standard of Care”Care”

Overwhelmingly, the recipients of Overwhelmingly, the recipients of our services appreciate what we’re our services appreciate what we’re doing, and find the process helps doing, and find the process helps them recover traumatic events.them recover traumatic events.

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What Can We Learn From The Criticism of CISM Vaughn Donaldson, Dist. Chief Midland Fire Dept. Midland, TX