Critical Incident Stress Management (CISM) dominates treatment for Acute Stress in the United States. Most people haven’t heard the evidence against it due to decades of biased research. Meanwhile, CISM’s founders have backed for-profit companies that certify clinicians in trauma treatment, showing their priorities have always been financial.
CISM is a structured peer-support intervention created by Dr. Jeffrey Mitchell in which trauma survivors are motivated to engage in group or individual interviews shortly after the incident. Dr. Mitchell’s challenge was twofold: prove that his model for peer support is superior to non-clinical peer support interventions, and prove that it improves outcomes for clients.
Objectively, he’s failed at both, (Forneris, 2013, Van emerik 2002, Mayou 2000, Bisson 1997, National Institute of Mental Health 2002, Litz 2002). The reasons for this are fairly obvious to anyone who’s worked with trauma. One problem with sticking all survivors into debriefing groups is that not everyone is equally at risk for PTSD, (Litz 2002). Recent research shows that putting people through debriefing does not decrease stigma around mental health, (Anderson 2020) which is another long-defended myth about the benefits of CISM.
If you look into the clinical literature you can see the battle that was fought over CISM between the mid-90’s and early 2000’s.
Some of the harshest quotes from this period include:“Talking to a stranger, whom one has never met before and will not meet again, may impede the normal processes of recovery that utilise one’s own social networks,” (Wesseley and Deahl, 2003,) “It is unrealistic to expect a brief interaction, like CISD, to have a significant impact on posttraumatic adjustment, (Bryant and Harvey 2000), and from a Cochrane Review, no less: “Compulsory debriefing of victims of trauma should cease,” (Rose, 2002).
After 2002, the United States Department of Defense and the American Red Cross stopped using CISM for debriefings. The current guidelines for PTSD and Acute Stress Disorder from the Department of Veteran’s Affairs and Department of Defense cite research that CISD does not reduce PTSD, (VA, 2023).
Researchers have thoroughly debunked any claims that CISM prevents PTSD, (Anderson 2020, Litz 2002, Maglione 2022, Mayou 2000, National Institute of Mental Health 2002, Rose 1999, Rose 2002, Sijbrandij 2006, Tuckey 2014, Van Emmerik 2002). A recent study exonerated several potentially harmful therapies but not CISM, concluding it’s: “Ineffective at best, and appreciably harmful at worst,” (Williams 2021).
Researchers say CISM’s mechanism of action is catharsis (Bryant and Harvey, 2000), or the theory that traumatic stress is relieved after making the unconscious elements conscious. CISD claims it’s not therapy (Mitchell, 2010) and it’s goal is: “Identification of individuals who may need additional support or a referral for psychotherapy,” (Mitchell, 2010), which sounds like assessment.
Yet the model encourages catharsis with questions like: “What is the very worst thing about this event for you personally?” (Mitchell, 2010). Clinical literature explicitly cautions against this kind of emotional activation soon after a traumatic event, (Sijbrandij 2006).
Dr. Mitchell advises: “Absolutely avoid asking how people feel,” (Mitchell, 2010). I’m guessing this language is a legal formality to avoid infringing into the scope of practice of licensed counselors, which in the United States includes discussions of emotions or mental health disorders. This way CISM can be marketed to anyone, increasing it’s customer base.
Often debriefings are facilitated by senior “peers.” The same person leading the debriefing also holds decision-making authority over the career paths of it’s attendees, so attendees have an incentive to conceal their symptoms. CISD coping skills include advising clients against self-destructive behavior and encouraging them to return to work, (Mitchell, 2010). Eventually they will naturally recover or repress their symptoms enough that it seems like they’ve recovered.
I checked, and most pro-CISM articles published on the database PubMed within the last ten years were written by current ICISF members, awardees, or authors associated with the ICISF (Andrews, 2022, DeFraia, 2013, Harrison, 2017, Muller-Leonhart, 2014, Newmeyer, 2014, Price, 2022, Priebe, 2013). (I’ll save you some fact checking: Dr. George Everly is the founding editor of The International Journal of Emergency Mental Health and Human Resilience). There is almost nothing impartial being published about CISM.
The International Critical Incident Stress Foundation (ICISF), which is the organization that oversees CISM, had revenue for the fiscal year 2021 of over $2.4 million, (Department of the treasury, 2021) $2 million of which was net through, “education and training.” The money for these trainings often comes from underfunded departments in rural America. According to the same tax report, over $1.1 million went to salaries and benefits of the ICISF
Both EMDR and CISM claim to work on every population and every age group. Mitchell’s CISD manual has instructions for group child debriefings for as young as age 6 (Mitchell, 2010) and there are EMDR models adapted to children as young as 18 months old, (Shapiro, 2001). If you believe them, CISM and EMDR are true panaceas. The models’ marketing was similar so I looked into collaboration between Everly, Mitchell, and Francine Shapiro, EMDR’s founder.
Everly and Shapiro are on the board of scientific and professional advisors for a company called the American Association of Experts in Traumatic Stress (AAETS). If you pay $375 and fill out a form on their website, you can add “D.A.A.E.T.S” (Diplomate of the American Academy of Traumatic Stress) after your name. They will also issue you a diplomate with the National Center for Crisis Management, an organization with no website whose social media redirects to AAETS.
This is not the only organization like this. On the Association of Traumatic Stress Specialists (ATSS) website you can find a sponsor, fill out an application, pay $250, and receive a credential. Mitchell holds one of these certifications.
Both the AAETS and the ATSS are affiliated with the Green Cross Academy of Traumatology (GCAT), which allegedly trains “traumatologists” to deploy to war zones and disaster areas. This title was borrowed from the medical term for a type of surgeon and is not recognized by any licensing board in the United States to describe mental health clinicians.
GCAT claims their trainings are approved by FEMA (Federal Emergency Management Association), but I checked and FEMA has never heard of them (W. Scott, Personal Communication, July 12, 2023). On the “about” page of their website is a picture of someone standing in front of a bulletin board that says “fire information” as though the organization has deployed there. Closer reading revealed that members pay to learn from aid workers, they do not ‘deploy’ anywhere.
According to Dr. Charles Figley’s website (Figley, n.d.), the Green Cross was founded by himself and “other leaders in the field of traumatology (especially Frank Ochberg, Bessel van der Kolk, and Gorge[sic] Everly),” (Figley, n.d.) I am not sure if Shapiro was involved with the Green Cross Organization, beyond EMDR being a suggested training course. Van Der Kolk and Figley have written supporting the efficacy of EMDR (Figley 2000, van der kolk, 2007), which would potentially be a conflict of interest if they were all financially benefiting from these organizations at the same time.
To understand acute stress I turned to Theophrastus, who lived in a war-centric society in 4th century BC Greece. He created a list of archetypal characters, including ‘the coward.’ Instead of running into battle with everyone else, the coward pretends that he’s lost his sword. He finds a wounded comrade to take care of and manages to miss the rest of the battle. “Spattered with blood from the other’s wound he meets the troops returning from battle and announces, with the look of one who has risked his life, ‘I have saved one of our men,’” (Campbell, 2013).
The ICISF has monetized cowardice, selling a bill of goods to departments desperate for a cure for PTSD. It’s part of a larger trend in the United States and the reason for thousands of self-proclaimed trauma ‘specialists.’ Everyone wants to be a hero, the one who walks into a debriefing after something terrible has happened and makes everyone feel better. But ask anyone who works with trauma: there is no one-session miracle cure for PTSD.
Money spent on CISD debriefings and trainings could be better applied to wellness programs for first responders, investment in departments, or actual therapy. We need training that’s evidence-based, not corporate-sponsored.
Anderson, G. S., Di Nota, P. M., Groll, D., & Carleton, R. N. (2020). Peer Support and Crisis-Focused Psychological Interventions Designed to Mitigate Post-Traumatic Stress Injuries among Public Safety and Frontline Healthcare Personnel: A Systematic Review. International journal of environmental research and public health, 17(20), 7645. https://doi.org/10.3390/ijerph17207645
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