Australian Psychologist, March 2004; 39(1): 24 28

COMMENT AND DEBATE

A response to the Devilly and Cotton article, Psychological Debrieng

and the Workplace . . .

J. T. MITCHELL

International Critical Incident Stress Foundation and University of Maryland, USA

Abstract
This response to the Devilly and Cotton article on psychological debrieng expresses concern that the authors have
misrepresented important factual information regarding psychological debrieng. Of particular concern is the intermingling
of the terms debrieng, psychological debrieng, Critical Incident Stress Debrieng (CISD), and Critical Incident
Stress Management (CISM) as if they were synonymous. Great concern is articulated in this response that Devilly and Cotton
have included unsubstantiated and unscientic rhetoric within what should be a scientic article. Efforts are made to
counterbalance the distortions of the Devilly and Cotton article by presenting accurate information regarding the eld of
Critical Incident Stress Management (CISM) and its specic small group intervention, Critical Incident Stress Debrieng
(CISD).

Psychological Debrieng and the Workplace: De-
ning a Concept, Controversies and Guidelines for
Intervention appeared in Australian Psychologist,
38(2), 144 150. The article is replete with inaccura-
cies, misinterpretations and distortions. Further-
more, it gives the impression that both peer and
editorial review processes were inadequate.
The most prominent of the many glaring errors in
the article is the treatment of a specic, structured,
7-step, small group crisis intervention process called
the Critical Incident Stress Debrieng (CISD) as if it
were one and the same as a comprehensive,
systematic and multi-component program called
Critical Incident Stress Management (CISM).
The CISM program includes many tactics and
techniques, but it is not limited to:
. crisis assessment services and strategic plan-
ning programs
. family support services
. individual, peer-provided crisis intervention
services
. pre-crisis education programs
. large group crisis interventions
. the provision of food and uids to work crews
. rotation and resting of work crews
. advice to command staff and supervisors
. small group crisis interventions
. follow up services and referral services
. post-crisis education
. and many other services.
The authors demonstrate a drastic lack of familiarity
with the literature in the eld of CISM. There is a
substantial body of CISM literature not referred to
by the authors. Even a cursory reading of these many
publications would certainly have claried the
denitions in the CISM eld and most likely would
have eliminated the need for this confusing and
inaccurate article.
The conclusion that a specic, 7-step group
crisis intervention tool is equivalent to an entire
multifaceted program dees logic and reason.
Likewise, equating a broad spectrum of different
crisis intervention tools and psychological counsel-
ling techniques, as if they were one and the same,
is not only imprecise, it is clinically and academi-
cally illegitimate.
Crisis intervention is a support service, not
psychotherapy or a substitute for psychotherapy. It
is an opportunity for assessment to see if people need
additional services including referrals for therapy
such as cognitive-behavioral therapy. Comparing
supportive psychological rst aid with psychother-
apy is a misguided endeavour which creates further
confusion. Therapy does not substitute for crisis

Correspondence: Jeffrey T. Mitchell, PhD, 3290 Pine Orchard Lane, Suite 106, Ellicott City, MD 21042, USA. E-mail: jmitch@umbc.edu
ISSN 0005-0067 print # The Australian Psychological Society Ltd
DOI: 10.1080/00050060410001660290
 A response to Psychological Debrieng and the Workplace. . .
intervention. Likewise, crisis intervention does not
substitute for psychotherapy.
On page 145 there is a colossal misrepresentation
of the facts. Devilly and Cotton say, More recently,
and with evidence against the use of CISD becoming
more and more convincing, Everly and Mitchell
(1999) proposed that CISD has been superceded by
Critical Incident Stress Management (CISM). The
statement is very far from the truth.
In 1983 I wrote the rst article ever written on
Critical Incident Stress Debrieng (When Disaster
Strikes . . . The Critical Incident Stress Debrieng
Process, Journal of Emergency Medical Services,
13(11), 36 39). I stated then, There are many
methods to deal with a stress response syndrome
(p. 37). The following items were listed as part of a
comprehensive systematic and multi-component
program:
. . . . strenuous physical exercise . . .
. . . . special relaxation programs . . .
. . . . individual or group meetings . . .
. . . . assessment by the facilitator of the intensity
of the stress response in the workers . . .
. . . . support and reassurance from the facilitator
...
. . . . information is provided . . .
. . . . a plan of further action may be designed . . .
. . . . referrals, if necessary, are made . . .
. The initial defusing . . .
. The Formal CISD . . .
. . . . Follow-up . . .. (pp. 37 38)
Keep in mind that in the When Disaster Strikes
. . . article the concepts were new, the thought
processes were new and the wording may not have
been perfect. A core of systematic interventions was
present, however, and the specic CISD group
process (then known at the formal CISD) was
not thought of as a stand alone intervention.
As in any eld of human endeavour, imperfect
initial efforts go through renements and elabora-
tions over time. More clearly dened systems and
specic procedures emerge. This dynamic growth
certainly occurred in the CISM eld.
Shortly after the rst article was published, it was
recognised that CISD was being used as an
umbrella term to cover the entire eld as well as a
label for a specic group crisis intervention process.
The dual use of the term CISD was confusing.
The error was corrected in numerous publications
subsequent to the 1983 article. For example, the rst
issue of Life Net, the ofcial publication of the
International Critical Incident Stress Foundation,
referred to Critical Incident Stress Management
Teams (1990, pp. 1 2). In the same issue, the use
of the term Critical Incident Stress Management
25
(CISM) teams was encouraged in an article entitled
CISM vs. CISD (p. 5). Subsequent issues of Life
Net contained articles that suggested a clarication
and proper utilisation of the terms Critical Incident
Stress Management (CISM) for the eld and Critical
Incident Stress Debrieng (CISD), previously
known as the formal CISD, for the specic group
process. In 1998 the following quote appeared on the
International Critical Incident Stress Foundations
website and in several of its training workbooks:
Admittedly, some of the confusion surrounding
this point was engendered by virtue of the fact that
in the earlier expositions, the term CISD was used
to denote the generic and overarching umbrella
program/system, while the term formal CISD
was used to denote the specic 7-phase group
discussion process. The term CISM was later used
to replace the generic CISD and serve as the
overarching umbrella program/system . . . (Everly
& Mitchell, 1997)
Again in 2001 the correction was made:
Originally, Mitchell (1983) used the term Critical
Incident Stress Debrieng, or CISD, as an
overarching label to refer to a strategic multi-
componential approach to crisis intervention . . .
As can be imagined, the authors use of the term
CISD to denote both the entire strategic
approach to crisis intervention and the formal
6-phase small group discussion process that was
part of it, led to signicant confusion, which
persists even today. In a direct effort to undo the
confusion created by the dual usage of the term
CISD and, more importantly, by the inferred,
but erroneous, tacit endorsement of CISD (the
small group discussion) as a standalone crisis
intervention, the use of the term Critical Incident
Stress Debrieng as the label for the cumulative
strategic crisis intervention system was aban-
doned in favor of the term Critical Incident
Stress Management. (Everly, Flannery, Eyler, &
Mitchell, 2001)
Let me be perfectly clear, the change in terminology
described in the paragraphs above had nothing to do
with Devilly and Cottons suggestion that mount-
ing evidence against the use of CISD caused the
change. In fact, we still have unequivocal condence
in the group CISD process when it is properly
applied according to acceptable standards of practice
and by people who have been properly trained in
applying the model. Their perception of the reason
for the change is, therefore, grossly mistaken.
On page 147 of their article, the authors make
reference to an Australian legal case (Howell v. the
26 J. T. Mitchell
State Rail Authority of New South Wales, 1997) and
then state . . . the ICISF recently used this decision
as further evidence for the use of CISD. This is a
blatant misrepresentation of the facts. ICISF did not and
would not use such a case to support the utilisation of
the group crisis intervention process known as
CISD. First of all, ICISF is not a source of legal
guidance. Second, ICISF is not knowledgeable
about the case and would not choose to use it in
recommending any kind of service. Third, the case
was about an individual and ICISF would never
recommend that a CISD be provided to an
individual because the CISD is a group process. In
any case, my personal opinion on the little I know of
that particular legal case is that the CISD would, by
commonly accepted standards of practice, have been
the wrong intervention to apply.
It is troubling to see a disregard for studies that
evaluate CISM and present positive results just
because those studies do not refer to the brand
name of CISM. Such is the case when the authors
discuss Dr Raymond Flannerys studies. The
authors say that his work is not about CISM because
he calls his program the Assaulted Staff Action
Program (ASAP). One does not have to look very
far to see the misinformation that those authors are
distributing. On the back cover of Dr Flannerys
1998 book, The Assaulted Staff Action Program:
Coping with the Psychological Aftermath of Violence,
he states ASAP is a Critical Incident Stress
Management approach that includes individual crisis
counseling, group debriengs, an employee victims
support group, employee victim family outreach, and
professional referrals, when needed. On page 37 of
his book, Flannery states:
It was clear to me that no one intervention, no
matter how effective in its own right, could
address the differing needs of the employee
victims in this facility. These differing situations
suggested the need for a CISM approach (Everly
& Mitchell, 1997), and led to my developing the
Assaulted Staff Action Program (ASAP). (Flannery,
1998, p. 37)
Flannery denes his Assaulted Staff Action Program as
. . . a voluntary, system-wide, peer help, CISM
crisis intervention program for employee victims of
patient assault (1999, pp. 103 108).
Furthermore, Devilly and Cotton say that Dr
Flannery used the wrong dependent variable and
that he only reports on violence reduction which is
not a goal of CISM. They simply skip the other
ndings that Dr Flannery reports. Those ndings
demonstrate the effectiveness of his ASAP program
which he clearly states is a CISM program. Take a
look at what Dr Flannery actually says:
ASAP, the most widely researched program of its
kind in the world, is associated with providing
needed support to employee victims and with
sharp reductions in the frequency of violence in
many of the facilities, where it is elded. ASAP
programs pay for themselves by means of sus-
tained productivity, less medical and legal expense
and reduced human suffering.
Again, this quote is on the back cover of his ASAP
book. A reading of his actual articles will reveal
greater details on the ndings this eminent Harvard
researcher and clinician has discovered which clearly
demonstrate that CISM, even if called by another
name, is a successful crisis intervention program.
The point about misinterpretation of Flannerys
work has been made. However, I have found no less
than eight other articles in peer reviewed journals in
which he carefully denes CISM and then directly
links CISM and his ASAP program (Flannery,
2001). Again Devilly and Cotton have demonstrated
a signicant lack of familiarity with the literature in
the CISM eld.
The authors cannot legitimately state that CISD
is possibly noxious as they do in the rst paragraph
of their article (p. 144). The studies they use to
support this comment never actually evaluated
CISD processes that were provided by properly
trained personnel who adhered to acceptable stan-
dards of care. In fact, there has never been a negative
outcome study of the actual CISD when properly
trained personnel adhered to the commonly ac-
cepted standards of practice that are used by 700
CISM teams in 28 countries around the world.
The majority of criticisms against debrieng have
been levelled at a process called single session
debrieng which in no way resembles the specic
group crisis intervention process of CISD. This is so
even in light of the fact that some of studies
evaluating the single session debrieng erroneously
use the term CISD. The studies were not
measuring the same things. Yet the authors glibly
intermingle the terms throughout the article as if
they were one and the same. ICISF has never
recommended the single session debriengs. They
are considered a clear violation of the standards of
CISM practice. It should be noted that no other
organisation which provides crisis services has ever
recommended the single session debriengs. That
includes the International Red Cross, the American
Red Cross, the National Organisation of Victim
Assistance, the American Academy of Experts in
Traumatic Stress, the Salvation Army or the
Association of Traumatic Stress Specialists. When
primary victims are receiving truncated, poorly
designed and badly executed services that call
themselves debriengs, psychological debrief-
 A response to Psychological Debrieng and the Workplace. . .
ings, or CISD, but do not follow the standards of
care in the CISM eld, it is of no surprise that they
would generate negative outcomes. But the authors
cannot, with legitimacy, say that those studies are
evaluating the same things as a study on the specic
group crisis process of CISD.
As a point of fact, the negative outcome studies
represent a hodgepodge of different types of inter-
ventions which do not equate to the actual CISD but
which loosely use the terminology CISD. Each of
those studies is seriously awed. Such a prejudicial
statement about CISD being possibly noxious so
early on in an article without substantiating evidence
implies an author bias. It is suggested that the
readers of this response review the Crisis Interven-
tion and CISM Research Summary which appears
on the International Critical Incident Stress Foun-
dation website (http://www.icisf.org). That article
outlines both sides of the controversy and counter-
acts the unsubstantiated comments of the authors of
the article under discussion here.
On page 144 Devilly and Cotton state that
psychological debrieng is rst resort when disas-
ters strike. The only people who would resort rst
to debrieng after a disaster are those who are
untrained and apparently unaware that many other
things need to be done before a debrieng is
provided. Debriengs are not recommended for
several weeks or longer after a disaster. The reader
should be aware that disaster response is only a tiny
percentage of the activity of a CISM team. Most of
the Devilly and Cotton argument against CISM
seems to be focused on disaster response. At least
that is the most sensational (and erroneous) material
they bring out in their article.
In proportion to stress management education,
individual peer support, family support, defusings,
referrals, planning, protocol development, consulta-
tion with administration and supervisor staff, and
responses to daily small scale emergencies, the
number of times that CISM services are used at a
disaster is rather small.
Likewise, the number of small group, 7-phase
CISD processes actually utilised by any CISM team
is minute. The proportion of one-on-one peer
support services to CISDs is about 1000 to 1. We
have witnessed among the many CISM teams a
decline in the number of CISDs when stress
education, defusing services and one-on-one crisis
intervention services are pursued by CISM teams.
Much of that work is provided by trained para-
professionals called peer support personnel.
I would question whether administrations of
emergency services organisations are willing to
substitute expensive therapy programs run exclu-
sively by mental health professionals when trained
peer support personnel have been very successful
27
running these programs for nearly 30 years. My
personal experience and that of the nearly 7000
members of the International Critical Incident Stress
Foundation which includes over 2500 mental health
professionals, is that peer support personnel are
absolutely vital to the success of a CISM program
and mental health professionals are usually kept at an
arms length from the operations personnel even
when they are known and trusted people who have
provided valuable services in the past.
The following items are of further concern within
the Devilly and Cotton article:
. Paragraph number 2 on page 144 is sensational
but not backed up by the actual numbers. The
term multimillion dollar industry is very
questionable. ICISF coordinates over 700
CISM teams and they almost all offer their
services free of charge and largely on a by
request basis. The average call out for a team
is less than once a month. No fees are charged
for services provided to emergency services
personnel. So where is the multimillion dollar
industry?
. Reports about the World Trade Center that
thousands of debriefers attended the area,
advocating and offering debrieng services
(p. 144) are greatly exaggerated. First, who
were they? Did they come in under some
ofcial body designated to provide disaster
support services or by themselves? If the came
in by themselves, then why would Devilly and
Cotton attempt to lay the blame for this
abnormal and inappropriate response in the
CISM camp? Second, what did they offer?
Third what is the denition of a debrieng?
It seems that many unauthorised people may
have offered a plethora of good and bad
services. But these people were not functioning
under auspices of a CISM team or any ofcial
disaster response organisation such as the Red
Cross and the eld of CISM should not be
blamed for their poor behavior.
. At the request of the New York Police Depart-
ment, ICISF coordinated a response of 1500
CISM trained police ofcers, police psycholo-
gists and police chaplains. It took over a year
and a half to cycle these people through New
York. They went in 7 to 12 at a time,
depending on specic local needs and they
stayed for a 7-day commitment. Critical
Incident Stress Debriengs (specic, 7-stage,
group process provided by a trained team of
personnel and following well publicised stan-
dards of practice) were rarely held. They were
only provided when homogeneous groups with
roughly equal exposure to specic traumatic
28 J. T. Mitchell
events were nished with their long term
disaster assignments. For some that was
months after the event. The greatest emphasis
in New York was on individual crisis interven-
tion support. Does this organised, appropriate,
free of charge, and requested level of support
need to be painted with the same brush that
Devilly and Cotton use to condemn the
thousands who descended like an army of
trauma tourists on New York City? Profes- misinformation about crisis intervention and the
sional articles should, in my opinion, stick to
veriable facts and not degenerate into name
calling and fantastic, but unsubstantiated
rhetoric.
. On page 145 the authors state that two of the
authors of some of the studies in one of the
meta-analyses are directors of the Interna-
tional Critical Incident Stress Foundation.
That is not the truth. Dr. Everly and I are not
the directors of ICISF. Please, lets everyone
stick to the facts. The innuendo, of course, is
that the authors of the meta-analyses cannot be
trusted because they developed the program. It
disregards their professional credentials and
status and their actual qualications to evalu-
ate material with which they are most familiar.
That is a rather bizarre position to hold and it
smacks of an ad hominem argument.
. Toward the end of the article they describe a
program that offers many of the same types of
services that a CISM program offers. I must
ask Why is their program any more accep-
table than a program that has been functioning
well for nearly 30 years? It appears inap-
propriate to criticise one program only to offer
a similar program with the exception that theirs
is based in psychotherapy and mental health
professional control instead of crisis interven-
tion with peer support personnel in control. If
the Devilly and Cotton are recommending a
therapy program, such as cognitive-behavioral
therapy, that is just ne. It would appear to me
that they would make better progress by
extolling the benets of their program without
trying to diminish the value of another
program. Should their program not stand on
its own without attacking another?
Scientic articles should serve to clear up confusion
and misunderstandings. The Devilly and Cotton
article, unfortunately, only adds to the cacophony of
eld of Critical Incident Stress Management.
References
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the workplace: Dening a concept, controversies and guide-
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Everly, G.S., Jr., & Mitchell, J.T. (1999). Critical incident stress
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to crisis intervention: Critical incident stress management.
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