by Brian Thompson, Ph.D.
Recently, my state psychologist association decided to take an official stand against the use of Critical Incident Stress Debriefing (CISD). In my clinical practice, my focus is trauma and PTSD, and this seemed like a good excuse to delve more deeply into the debriefing literature. I agreed to compile a brief write-up of the CISD literature and thought I’d share it with readers of PBB. (In fact, I was surprised PBB hadn’t beaten me to it.) What follows is both an unusually clear and unequivocal verdict against CISD from a research perspective, as well as a fascinating study of spin, poor science, and misinformation.
CISD was the first and remains the most prominent of a general class of interventions called psychological debriefing (PD). PD is aimed at addressing distress and reducing the likelihood for the development of psychopathology--PTSD, in particular--in the immediate aftermath following exposure to a potentially traumatic event. CISD is a one-time, 1-3 hour intervention delivered in a group format, usually 2-14 days following the “critical incident” (Everly Jr & Mitchell, 2000). Developed by Mitchell, a former paramedic, the idea behind CISD is that through early intervention immediately following trauma exposure, debriefing can alleviate immediate distress and serve as a prophylactic against the development of more severe psychopathology over time. In theory, this sounds reasonable; consequently, it’s no surprise that organizations including the US military, the FBI, and those employing emergency service personnel have used CISD. Not only does PD offer the promise of addressing the mental health needs of employees, but it may serve as a buffer against liability by showing the organization attempted to act in the best interest of its workers.
Although PD seems like a reasonable and compassionate approach in theory, in reality, the only people who appear to find any evidence of its effectiveness are those with a vested and financial interest in the debriefing model. Not only do randomized trials indicate the ineffectiveness of PD in influencing positive mental health outcomes over time following trauma exposure, there is some evidence that people who receive PD develop more problems than those who don’t receive any intervention.
Perhaps the most damaging blow to CISD was a review by the prestigious Cochrane Collaboration, an international not-for-profit organization dedicated to making evidence-based reviews of healthcare interventions available to the public. These reviews, which tend to draw exclusively from randomized controlled trials (RCT), are periodically updated by the authors to remain current. The conclusion of the Cochrane review is pretty unequivocal: there is “no evidence that debriefing reduces the risk of developing PTSD,” nor “has any affect on any other psychological outcome” (Rose, Bisson, Churchill, & Wessely, 2002, p.10). Worse yet, the authors note that studies with the longest follow-up assessments suggest that people who engage in PD may actually experience worse distress during follow-up. As a consequence of these latter findings, Lilienfeld (2007) categorized CISD as a treatment that is “probably harmful for some individuals” (p. 58) (See PBB’s summary of this article.) Also, APA Division 12 currently describes PD for PTSD as having “no research support/treatment is potentially harmful.”
What goes unacknowledged by CISD proponents is that only 5-10% of people exposed to trauma develop PTSD; this suggest that the majority of people are resilient in the face of potentially traumatic events (Ozer, Best, Lipsey, & Weiss, 2003). As for why CISD may be harmful for some people, some suggest PD interferes with our natural ability to recover from trauma (Bootzin & Bailey, 2005; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002; Gray & Litz, 2005; Rose et al., 2002). In fairness to PD, the evidence suggesting CISD is harmful is less conclusive than the evidence that it is ineffective and therefore a waste of valuable resources (Devilly, Gist, & Cotton, 2006). For example, a recent well-conducted randomized trial did not find any evidence that CISD was helpful, but did not find any evidence that participants were any worse off either (Adler et al., 2008).
CISD proponents have answered criticisms of PD with their own reviews (Everly Jr & Mitchell, 2000; Everly, Flannery, & Mitchell, 2000). This is where the story gets interesting. CISD proponents are helped by their own journal: The International Journal of Emergency Mental Health, published by the Chevron, a company started by the International Critical Incident Stress Foundation (ICISF) for the promotion of CISD (Devilly et al., 2006; Newbold, Lohr, & Gist, 2008). Having one’s own journal is a great way to muddy the waters of professional search engines and make certain one’s own views are trumpeted to the faithful.
If I were to teach a graduate level research and design course, I think a review of a selection of the CISD literature—for and against—would make for a useful teaching tool. The literature runs the gamut from understanding the limitations of even well designed studies to misunderstanding basic research methodology. Independently evaluating the claims of both sides would make for great classroom discussions, I think.
In order to answer their critics, Everly et al. (2000) published their own review of the CISD literature, which to be fair, was not published in their own journal but in Aggression and Violent Behavior. The authors direct most of their criticisms towards the Cochrane review. One criticism had some validity at the time, but even this has been addressed by more recent research. As Everly et al. (2000) noted, Cochrane reviews rely on randomized controlled trials (RCT), the gold standard of research. At the time the Cochrane review was published and later revised, however, the only published RCT’s for PD involved debriefings that were conducted with individuals, rather than in group format as is the standard for CISD. This is a limitation of the Cochrane review; however, it also suggests the benefits of PD may be those of group interventions in general, rather than CISD in particular. Everly and colleagues try to have it both ways: they argue that the effects of CISD are above and beyond those of group effects alone but maintain that administering CISD individually may render the treatment inert. More recently, Adler et al. (2008) has since published a randomized trial of CISD in groups that found no effects, helping to close off this particular exit strategy.
In addition to criticizing the Cochrane review and individual studies that report results unfavorable to CISD, Everly and colleagues offer their own meta-analysis of five “robust empirical studies” in support of CISD. Devilly et al. (2006) dismantle this review, noting that two citations were conference presentations from a CISD-sponsored event, and one was a government document that did not report any data. Devilly and colleagues’ attempts to track down the data from Dr. Everly were unsuccessful. Of the two published studies, both were flawed (see the original article for details), and Devilly and colleagues calculated effect sizes that were lower than those found by Everly and colleagues. (I highly recommend the Devilly article, which is a great recent review.)
As criticisms of CISD mounted, its proponents begat Critical Incident Stress Management (CISM) a multi-component approach to crisis intervention, of which CISD is only one part (Everly Jr & Mitchell, 2000; Everly et al., 2000). Critics have charged that the creation of CISM was an attempt by proponents to sidestep the growing criticism of CISD (Gray & Litz, 2005; Newbold et al., 2008). The creation of CISM allows proponents to argue that because CISD is nested within the multi-component model of CISM, it cannot be studied alone (Everly Jr & Mitchell, 2000; Flannery & Everly, 2000). In CISM, they’ve created a beast too large to dismantle and study.
Astonishingly, Everly Jr and Mitchell (2000), after criticizing the Cochrane review, allow that a one-session PD is not effective by itself but is an important component of a multifaceted intervention (e.g., CISM). They further argue that CISD is “not a form of therapy per se, nor a substitute for treatment” but rather is designed to “compliment [SIC] more traditional psychotherapeutic services” (p. 220). None of these arguments adequately explain why a treatment that is ineffective, if not harmful, when used alone would add anything to a larger infrastructure. This reminds me of the breakfast cereal commercials I watched as a child. Sugary cereals were touted as “part of a well-balanced breakfast,” and were pictured with orange juice, milk, toast, eggs, bacon, etc. How a cereal that was little more than sweetened ground corn and dehydrated marshmallows—I’m looking at you, Count Chocula!—contributed to a healthy breakfast was questionable even to a child. (Not that this realization stopped me from eating them, of course!)
In addition to the debate I’ve summarized, I highly recommend reading some of the CISD/M reviews and rebuttals, as one can find some statements that are real head scratchers. Here are some examples: “To disprove the assertion that all debriefings are ineffectual, one need only find one debriefing that is effective!” (Everly Jr & Mitchell, 2000, p. 218) [uh, Type I Error?]. Everly Jr and Mitchell (2000) also claim their meta-analysis is an adequate substitute for an RCT. Everly et al. (2000) claim that RCT’s cannot be conducted with critical incidents because: 1.) “Traumatic events cannot be timed and planned in advance, and [they] require an immediate focus on assistance, not research” (p. 28); 2.) Individuals in crisis cannot give assessment measures their “full attention,” making them invalid; 3.) The greater the time between trauma, intervention, and follow-up, “the greater the possibility that additional traumatic events may influence the assessment of the original event.” (p. 29). These latter statements are particularly strange, as they are not insurmountable barriers for other trauma researchers.
Conclusion
In their review of the literature, Lohr, Hooke, Gist, and Tolin (2003) conclude, “Although the promotion of CISD continues with little diminution, the debate in the scientific community is all but over” (p. 261). The only remaining question is whether CISD is merely ineffective or both ineffective and harmful for some people. The silver lining of this literature is that it has provided pretty conclusive evidence that PD is simply not helpful for trauma survivors. Researchers may instead focus on strategies that may be helpful for people following crisis, as has been addressed by some of the authors cited in this blog post (e.g., Devilly et al., 2006; Gray & Litz, 2005; Rose et al., 2002).
For a full list of cited references, click here.
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Brian Thompson, PhD, is a licensed psychologist at the Portland Psychotherapy Clinic, Research, and Training Center, where he specializes in evidence-based treatment of trauma and PTSD. He is also the co-founder of Scientific Mindfulness, a blog focused on mindfulness research.
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