A Review of The History, Theory, and Effectiveness of Critical Incident Stress Debriefing (CISD)
Acute human suffering is hardly a novel enterprise in mortal phenomenology. For millennia humankind has inflicted one another with torture, been subject to peril, and witness to ghastly and horrific imagery (Saigh & Bremner, 1999; Tafoya & Del Vecchio, 1996; Tindall & Shi, 1996). Relatively novel; however, is the growing cross-cultural recognition of the utility of professional mental health providers in alleviating symptoms of trauma (Wilson, 2004). Research shows that many countries and many states/provinces within such countries are adopting traumatic intervention programs to address the needs of those left psychologically maligned secondary to traumatic encounters (Jacobs, Quevillon, & Stricherz, 1990; MacDonald, 2003; Mitchell, 2005).
As we rush into this era of modern philanthropy; however, the elemental question of basic needs becomes increasingly salient. That is, while we have burgeoned a literature as well as technologically advanced mechanisms to distribute and disseminate such psychological services for acute trauma victims, it is not clear whether such services are (1) soundly developed, (2) wanted by others, and (3) needed to actuate good mental health. Indeed, many have noted that traumatic reactions to acute distress are often functional, rather than dysfunctional (Bonanno, 2004). In fact it may be that the person who lacks traumatic symptoms in the face of trauma is the individual in need of intervention!
This sobering reflection sets the stage for one of psychology’s most controversial current practices, that of Critical Incident Stress Debriefing (CISD). CISD is a program developed with the intention of intervening with those exposed to trauma before allowing traumatic symptoms to fester over time (Everly & Mitchell, 2005). The basic tenet of CISD is that proper intervention reduces later onset of PTSD symptom development (Flanner & Everly, 2000). Critics of CISD claim that such a brief and rigid protocol for traumatized individuals is uncalled for, and recent evidence seems to raise doubt over the assumption that general trauma usually leads to longitudinal dysfunction (Bonnano, 2004; Devilly & Cotton; Resnick, Galea, Kilpatrick, & Vlahov, 2004; Satel & Sommers, 2005). Further, some data suggests that CISD may actually increase the rates of trauma over no treatment or other treatments (for a review see Everly & Boyle, 1999; McNally, Bryant, & Ehlers, 2003; Mitchell 2005; van Emmerik, Kamphuis, Hulsboch, & Emmelkamp, 2002).
While the literature appears to be conflicted regarding CISD, the need for psychological interventions seems to be growing rapidly, especially given the global increases in technological and terror-based warfare, potential for pandemics such as the putative “bird-flu,” as well as atypical seasonal disasters of recent years (e.g., hurricanes, typhoons, tsunami’s, etc). This paper will seek to explicate the topic of CISD with a three-tiered focus. First, the history and development of CISD will be explored. Next, a review of the basic theoretical tenets and operations involved in CISD will be described. Finally, a brief review of the outcome literature will be cited and discussed, along with suggestions for future study.
History of CISD
The formal genesis of CISD was played out in an in-vivo drama set amongst the Maryland cityscape. In the early-to-mid 1970’s a young masters-level psychology student named Jeffrey Mitchell moonlighted as a paramedic. As Mitchell responded to a particular vehicular accident, he found himself surprisingly unprepared to experience the horror of the ghastly scene. At the site, a young bride, still in her wedding dress, lay enveloped in her own blood with large pipes impaled in her body. Mitchell reportedly was unable to disconnect from the terrible images of the deceased, and spent several months trying to cope with his feelings of terror, triggers, and intrusive thoughts. Finally, in an incidental conversation with a friend, he was able to describe the experience, as well as his difficulty coping with it, finally finding respite from the unwanted symptoms. When he emerged from this conversation with a sense of closure, he surmised that debriefing post critical incidents has potential power to help those working within trauma fields to move beyond posttraumatic symptoms (Groopman, 2004).
Mitchell went on to earn a doctorate in human development in 1983, the same year in which he authored his first formal publication on CISD. He continued to publish his work both professionally as well as in the public sector, establishing the International Critical Incident Stress Foundation (ICISF), a non-profit organization dedicated to the ideals of CISD. Mitchell’s findings caught the attention of leading researchers and therapists over the next several decades, leading to a tumult of published (albeit often diametrically opposed) opinions, numerous empirical projects, and confused government consumers (Bisson, McFarlan, & Rose, 2000a; Bisson, & McFarlan, & Rose, 2000b; Cain & Ter-Bagdasarian, 2003; Campfield & Hills, 2001; Deahl, Srinivasan, Jones, Neblett, & Jolly, 2001; Devilly & Cotton, 2004; Devilly & Cotton, 2003; Everly, 2001; Everly, 2000; Everly, 1995; Everly & Boyle, 1999; Everly & Mitchell, 2005; Everly & Mitchell, 2000; Flannery & Everly, 2000; James, & Gilliand, 2001; Kinzel, 2000; Kirk & Madden, 2003; Leonard & Alison, 1999; Linton, 1995; MacDonald, 2003; McNally, et al., 2003; Miller, 2004; Mitchell, 2005; Mitchell, 2004; Robinson, 2004; Siegal & Driscoll, 1995; Smith, 2001; Tehrani, 2002; van Emmerik et al., 2002). Despite the controversy, the foundation established by Mitchell currently boasts a membership greater than thirty-thousand (Groopman, 2004).
Beyond the controversy, the theoretical and applied components of CISD have purportedly continued to evolve as well, with the emphasis of intervention being placed less on the singular therapeutic incident, and more on a multifaceted approach that involves both primary, secondary, and tertiary care (so called “Critical Incident Stress Management,” or CISM; Everly & Mitchell, 2005; Everly & Mitchell, 2000). Alternatively, critics argue that CISM and CISD are essentially different in nomenclature only for several reasons. First, while CISM is supposedly supported in the literature, the current meta-analyses used to support CISM are based largely on studies of CISD. Second, the operational definition of CISM versus CISD has not been well defined, with the multifaceted components of CISM becoming so amorphous as to elude scientific operationality and thus falsifiability (i.e., fails the Popper criteria). Finally, the perpetuators of CISM themselves seem to be somewhat at odds in terms of how they differentiate CISM from other approaches (Devilly & Cotton, 2004; Devilly & Cotton, 2003).
Given this confusion it follows that this paper should retain its’ focus on the core component of so called CISM, which is the debriefing technique more commonly referred to as CISD. The next section will explore the core theoretical framework and practical applications of CISD; ultimately leading to a brief review of the effectiveness of CISD as evidenced in the empirical literature.
Theory and Application of CISD
Before treating a traumatic reaction secondary to a critical “incident,” one must be able to reliably define a traumatic incident from a non-traumatic incident. The principle developers of CISD define a critical incident as:
a term which refers to an event which is outside the usual range of experience and challenges one’s ability to cope. The critical incident has the potential to lead to a crisis condition by overwhelming one’s usual psychological defenses and coping mechanisms (Everly & Mitchell, 2000, p.212).
Further, they define a crisis as “a response to some aversive situation, manifest or anticipated, wherein: (1) psychological homeostasis (equilibrium) is disrupted; (2) one’s usual coping mechanisms have failed to reestablish homeostasis; and (3) there is evidence of functional distress or impairment” (p.212).
Finally, Everly and Mitchell (2000) define crisis intervention as “the natural operational corollary of the conceptualization of the term crisis … crisis intervention may be thought of as an urgent and acute psychological first aid” (p.212). Further, the authors hold that such defined crisis intervention should be immediately implemented, performed in close proximity to the source of the trauma, be in line with the expectations of the recipient (i.e., the authors seem to assume that trauma recipients expect an acute problem-focused intervention), be short (one to three sessions), but simple (i.e., directive, solution focused interventions rather than dynamic, REBT based, etc).
In sum, CISD regards the purported therapeutic intervention for maladaptive reactions to an anticipated or actual aversive event, wherein potential exists to overwhelm one’s sense of control, and where it is presumed that brief, proximate, simple, solution-focused therapy may negate these potential exacerbations of distress. The implementation of such a stratagem is theoretically believed to progress the client toward four goals. First, the client becomes stable, meaning the client does not continue to escalate in problem intensity. Second, the client’s more acute signs of distress and dysfunction are mitigated, meaning their risk factors drop directly as a result of the crisis intervention. Third, the client’s independent functioning is restored; and fourth, the client is given access to a higher level of care (Everly & Mitchell, 2000; Mitchell, 2005).
Core Components of the CISD Intervention and Theoretical Mechanisms of Change
In terms of the content of CISD and mechanism of delivery itself, CISD involves a seven-stage approach to stress management. The phases in order include the introductory, fact, thought, reaction, symptom, teaching, and reentry phases. The leaders of the CISD group (i.e., the CISD “team” leaders) are to be accountable for the progression of the stages, and to keep the group on task. Each phase will be briefly described in greater detail in the next several paragraphs, based on Everly’s (1995) accounting. After this, postulated mechanisms of change will be reviewed.
In the introductory phase team members introduce themselves and describe the debriefing process. Particular attention is given to expectations, the educational/professional background of the team leaders, motivating the members to participate, and reviewing confidentiality and parameters of disclosure. As the initial phase runs its course, team leaders are to foster a directive phase of fact exploration. In other words, team leaders seek to establish in “black-and-white” who the group members are in connection to the trauma, the actual incidents they discovered/experienced, and other concrete details of the traumatic event.
Once establishing the core facts, team leaders then guide participants to mentally (i.e., not yet emotionally) react to the traumatic events. Group members discuss their thinking about the trauma, their cognitive concerns, why they think it happened, et cetera. According the authors, this then leads to an acute emotional stage, wherein respondents grieve and bemoan the horrific event. The team leaders are charged to keep the participants within an affective focus at this stage, not to go beyond emotion identification.
As the participant is able to identify the facts, thoughts, and emotions of the case, potential for symptomatic presentation of trauma is high. Therefore, the team leaders are charged to redirect such participants back to a cognitively oriented analysis of the situation. In the words of Everly (1995):
During this phase, the mental health counselor helps participants discuss, in open form, their … symptoms … It is imperative that the mental health counselor understands that the symptom phase is also a transition phase. That is, participants are guided to return to a more cognitive domain … the mental health counselor should recall that the process is one of crisis intervention and not psychotherapy, and that stabilization of patients is the primary goal. (p. 230)
Beyond symptoms, the team leaders shift the focus of the group to normalization, crisis coping, and stress management. Finally, the team leaders try to inculcate a sense of closure for the participants by reinforcing the importance of coping strategies, distributing literature, and potentially referring for more private long-term counseling.
Service delivery. The prior format is to occur within group settings, usually within 24-72 hours after the experienced trauma. Groups last between ninety minutes to three hours, depending on the size of the group, with no more than twelve participants recommended at any one time. Of note, the CISD format was also revised for specific versus mass trauma. In the mass trauma setting, the CISD stages become more cognitively oriented, with a “what did you learn to help you in the future” type of reframing approach (Everly, 1995).
Theoretical mechanisms of change. In terms of the specific factors of CISD thought to account for its’ putative therapeutic value, the CISD founders (Mitchell and Everly) discuss ten potential effects, summarized by Everly (1995). First, they hypothesize that CISD works through early intervention; that is through allowing for cognitive process prior to exacerbation of the symptoms. A second mechanism involves catharsis, the ability to ventilate and express pent-up emotions and horror. Third, the authors argue that participants are able to reconstruct the horrific memories as they reconstruct their experiences verbally with others. Fourth, the manualized structure of CISD is believed to provide a roadmap to recovery, helping participants see the end of the struggle. Related, the authors believe that the carefully charted modules provide a cognitive-affective integration that serves as a catalyst for eventual holistic recovery.
The next four mechanisms all seem to operate at the group level. The group process itself is thought to allow for group dynamics such as cohesion, modeling, hope for self, demystification, peer support, and a sense of caring, all of which is admittedly based on the work of other prominent clinicians in the field of group work (e.g., Yalom, 1995). Everly (1995) argues particularly that such peer support and modeling of care is essential amongst emergency service technicians. Finally, the authors argue that such groups are effective because they allow for screening of the most seriously impaired trauma victims, particularly those who “are highly reluctant to seek mental health services of any kind” (Mitchell, 2005, p.51).
In summary, CISD is a short-term group based format designed to de-escalate and perhaps alleviate traumatic symptoms. The designers of CISD do not tout it as psychotherapy, but do discuss it in psychotherapy terms including concepts like processing, reframing, group cohesion, and modeling. The procedure itself carries a seven stage intervention strategy which includes a largely solution focused, cognitive intervention style. Finally, the authors believe a variety of change mechanisms, including catharsis, ventilation of emotions and cognitions, and group dynamics are responsible for its’ putative therapeutic effects.
CISD has been widely accepted and implemented in various contexts, including usage with the military (MacDonald, 2003), emergency and public safety personnel (Leonard & Alison, 1999; Linton, 1995, Siegal & Driscoll, 1995), hospital medical staff (Caine, & Ter-Bagasarian, 2003; Narayanasamy & Owens, 2001), at-risk adolescents (Kirk & Madden, 2003), and mass disasters (Everly, 1995). Despite its widespread implementation; however, narrative studies have been less than flattering regarding CISD’s usefulness and value (Everly & Boyle, 1999). Further, these narratives have often been admittedly politically and/or philosophically charged, from both pro and con sides (e.g., see Devilly & Cotton, 2004; Devilly & Cotton, 2003; Mitchell, 2004; & Robinson, 2004).
McNally et al., (2003); however, appears to offer a more balanced review of the strengths and weaknesses of the CISD movement. McNally et al. note that a substantial number of studies do exist indicating some positive effects for CISD related therapies. For example they note that Wee, Mills, and Koehler (1999, as cited in McNalley et al.) found CISD to be effective for individuals exposed to primary traumas after the Los Angeles riots. In their design, 23 individuals (for idiosyncratic reasons) were not allowed to receive the mandatory CISD session after their efforts with the riot. When comparing the debriefed to the non-debriefed group, those receiving debriefing had significantly fewer PTSD symptoms. McNalley et al., go on to review more than ten other like studies all showing at least minimal improvements in PTSD related symptoms post CISD.
In contrast, they note that the utility of the studies, and their collective generalizeability is somewhat attenuated by the lack of rigid internally valid designs. For example, many of the designs assessing CISD lacked random assignment with a control group, and many deviated significantly from the protocols designed for CISD, a fact they note that the perpetuator of CISD differentially praises or denounces, in their opinions, seemingly dependent on how the results confirm or validate the intervention.
McNally et al., (2003) also reviewed the literature on studies concluding negative or no effect for CISD interventions. In particular they describe nine empirically based interventions showing that CISD has at best no effect, and at worst negative longitudinal effects on participants. They caution that all of the negative or more aversive projects regarding CISD do deviate from the explicit manualized approach to greater or lesser degrees, and that they all use individualized rather than group based procedures, which is in contradistinction of the originators group based CISD design (Everly, 1995; Mitchell, 2005; Mitchell, 2004).
Perhaps most damning is their citation of Hobbs, Mayou, Harrison, and Warlock’s (1996) work. Hobbs et al. set out to assess the impact of CISD in the aftermath of roadside trauma. It is important to note that participants received individual debriefing only, not the group debriefing, and that debriefing lasted approximately one hour, whereas Mitchell and Everly endorse approximately 90 minutes to three hours of group intervention as appropriate (Everly & Mitchell, 2005; Mitchell, 2005). Nonetheless, the intervention was given within 24 to 48 hours of the traumatic incident, and outcome assessment was held at both four months and three years post incident. Essentially, at secondary assessments, those receiving debriefing had more negative mental health symptoms than those in the assessment group only.
In summation of their narrative review, McNally et al., (2003) conclude that “Although psychological debriefing is widely used throughout the world to prevent PTSD, there is no convincing evidence that it does so … Some evidence suggests that it impedes natural recovery” (p. 72). It is important to note; however, that McNally et al. offer a qualitative review, rather than a quantitative review of the literature. Qualitative reviews have been criticized by some researchers as being inherently more vulnerable to subjectivity, subject to the confirmation bias, and thus potentially a reflection of issues most salient to the reviewers (Everly & Boyle, 1999). In light of this consideration, the next section will review two meta-analyses of CISD.
Two important meta-analyses have been performed on CISD. Of note, one meta-analysis was conducted by an independent research team, and the other by a major proponent and developer of CISD, with each leading to differing conclusions. While a comprehensive review of the empirical literature involved in each is beyond the scope of this article, the two meta-analyses will be briefly reviewed.
In 2002 van Emmerick et al. reviewed published studies on CISD, with inclusion criteria requiring the intervention be used as a stand-alone intervention, and that it be implemented within one month. Of twenty-nine potential studies to be reviewed, twenty two were excluded because the intervention was not stand-alone (i.e., participants had multiple debriefing sessions or other augmentative therapies). Of the remaining seven, five used CISD and two used comparative treatments (i.e., so called “historical debriefing” and/or general counseling approaches). Further, the authors allowed for both individual debriefing and group debriefing.
Results of the study indicated that CISD was in fact not effective in preventing or reducing either PTSD or other symptoms (i.e., symptoms as found on measures such as The Brief Symptom Inventory). Using the Cohen’s D statistic, with interpretation of weight size as follows: .2 small, .5 medium, and .8 large; the authors found a .13 effect for CISD on preventing PTSD symptoms, and a .12 effect for preventing broader symptoms. In contrast, no intervention and other intervention yielded effect sizes of .65 and .47 for PTSD and .36 and .13 for broader symptoms, respectively.
The authors (van Emmerick et al., 2002) interpret this finding to mean that not only is CISD ineffective, but perhaps it is destructive or potentially damaging for several reasons. First they speculate that CISD might interfere with intrusive and avoidant behavior that might be a natural coping mechanism of trauma. Second they theorize that CISD might not allow for normative habituation of trauma. Third, they postulate that the group based CISD interventions might expose non-traumatized persons to trauma vicariously (although this is a curious interpretation as only the individual sessions were found to have aversive effects). They speculate that if this is the reason, that it is still possible that CISD works for those not traumatized.
Everly and Boyle (1999) also conducted a meta-analyses of CISD as a stand-alone treatment. Using exclusion criteria requiring CISD be used as a stand-alone treatment, but in a group based format (i.e., they did not allow for individually based CISD), the authors identified five empirically based projects comprising a subject pool of 341 adults (interestingly none of the studies overlapped between the two meta-analyses). It should be noted that while the authors researched national databases of peer-reviewed articles, they allowed for articles from a non-peer reviewed journal, which also serves as the flagship journal on CISD (i.e., The International Journal of Emergency Mental Health), as well as an article from a book chapter published by the main company promoting CISD (i.e., The Chevron Company), to be involved in the review.
Results indicated a large effect size (Cohen’s D=.89) in terms of the effectiveness of CISD in reducing PTSD symptoms. Two of the five studies did utilize measures other than strict PTSD symptom screens, including the Symptom Checklist 90-Revised and Novaco Anger scale. The individual study yielding the highest effect size (1.37) did come from an article published in an independent, peer-reviewed journal (i.e., The American Journal of Psychiatry) which did exclusively utilize a PTSD outcome measure (i.e., the Impact of Events Scale). The authors conclude that CISD is an effective treatment, particularly when used as a group based rather than as an individually based treatment.
Perspectives on the Meta-analyses
While these differing meta-analyses seem to reflect contradicting findings regarding the use and effectiveness of CISD with regard to traumatized populations, much commentary has been written in support of each perspective. The following paragraphs will highlight several important points from this dialogue, first emphasizing the positive, then negative findings.
Positive findings. In terms of the positive findings several valid arguments have been postulated as to why some studies are in support of CISD while others are not supportive. First, Deahl et al. (2001) call attention to the narrowed outcome measurement of CISD in terms of only measuring symptoms of trauma. They indicate that CISD potentially effects the individual in numerous ways, and that true appraisal of the effectiveness of CISD should include multi-faceted measurement.
For example, they point to some of their own past work (Deahl et al., 2000, as cited in Deahl et al., 2001) to show that group based CISD reduced problematic drinking. In their design 106 servicemen returning from Bosnia who scored two standard deviations above the norm for drinking were assigned to either a single CISD group session or no treatment. At twelve month follow-up, virtually no one in either group scored significantly for PTSD on a psychometric measure, but interestingly significantly more of those in the singular CISD group dropped below clinical levels of alcohol abuse. The authors conclude that CISD may thus be effective in alleviating trauma, only such effectiveness might be masked through reporting bias or secondary masking (i.e., substance abuse and/or avoidance being higher in the no-treatment versus the CISD group). Although some projects, as previously noted, did utilize other measures of symptom distress beyond PTSD checklists, this point is well taken.
Mitchell (2005) also raises several issues regarding the mixed findings, including those of methodology, treatment fidelity, and conceptualization. Regarding methodological issues, Mitchell argues that many of the studies showing negative effects, particularly those in the randomly controlled designs, did not control for homogeneity of group, a basic staple of CISD protocol. Secondly, he contends that many of the studies did not utilize debriefing technicality, but rather had singular psychotherapy sessions or individual counseling which he argues were similar to CISD in name only. Further, he notes that virtually every study with negative findings was conducted by an uncertified CISD technician. Finally, Mitchell invokes issues of the so-called type III error, or incorrect statistical model implementation. Essentially he suggests that many of the researchers do not understand nor did they isolate effective components of CISD in their statistical models, setting up a “straw man” argument.
Negative findings. On the other hand, critics have also indicated several issues seeming to undermine the validity of the supportive findings for CISD. Foremost, Devilly and Cotton (2004) argue effectively that the main perpetuators of both the importance and validity of the CISD approach are those who stand in line to earn a monetary windfall from its implementation. They correctly note that both George Everly and Jeffrey T. Mitchell are the chief proliferators of the pro-CISD literature and that this is problematic given their leadership of the ICIFS, each earning over $100,000 a year for their ICIFS positions (p.37). Further, they note that many of the publications supporting CISD come from The International Journal of Emergency Mental Health, or chapters of books published by The Chevron Company. Devilly and Cotton note that this is problematic, as previously indicated, given that The Chevron Company is a publishing company that was explicitly established to promote CISD.
Conclusions and Future Directions
In conclusion, CISD is a growing service provision for purportedly traumatized individuals, established originally by Jeffrey T. Mitchell, and further developed by George Everly. Every year, thousands of technicians implement CISD work both in the United States and throughout the world. The theoretical tenets and thrust of CISD involves presumptions about the need for early cognitive and emotional processing to mitigate the potentially devastating effects of PTSD symptomatology. Mitchell and Everly argue that early intervention, such as that within the group based CISD design, will reduce future trauma reactions, and screen for the more severely traumatized who might then be referred for later treatment (Everly, 2001; Everly, 2000; Everly, 1995; Everly & Boyle, 1999; Everly & Mitchell, 2005; Everly & Mitchell, 2000; Mitchell 2005; Mitchell, 2004). CISD has become a passionately debated issue, with at best a confusing literature and at worst socio-political dogmatism (Devilly & Cotton, 2004; Devilly & Cotton, 2003).
While certainly monetary, legalistic, and humanistic motives in well-educated but human researchers likely contribute to the passionate tone of this debate, part of the problem in engaging the debate appears to be that the perpetuators of the CISD movement are themselves fickle and sometimes evasive in terms of their operationalization and identification of the variables of interest, as well as in their impervious differentiation of CISD versus CISM (despite numerous criticisms), which seems to buffer their abilities to make unfalsifiable statistical and academic interpretations as to the efficacy of their approach (Devilly & Cotton, 2004; Devilly & Cotton, 2003; McNally et al., 2003). On the other hand, Mitchell and Everly have both argued that those decrying CISD as ineffective have ignored their assertions that only CISD studies wherein the recommended group based design was implemented on relatively homogenous victims be followed. This is a potentially important issue as at least four of the theorized mechanisms of change purportedly involved in the intervention revolve around group factors, and that all of the negative outcome studies were composed of individual CISD designs. Further, they have argued that essentially every researcher who has shown the CISD approach to be invalid involved technicians who were not formally trained or certified in their CISD approach (McNally, et al., 2005; Mitchell, 2005; Robinson, 2004).
In conclusion, this paper started with the caveat that in mental health service provision for acute trauma, we are still unclear if such services are (1) soundly developed, (2) wanted by others, and (3) needed to actuate good mental health. With regard to CISD particularly it seems reasonable that the literature has shown that, while still potentially useful, the methodological and theoretical operants involved in the CISD intervention are not yet soundly developed. In contrast, the high consumption of and membership in the debriefing industry does seem to speak to a level of need, or want by potential consumers. Further, the very fact that PTSD exists categorically in the DSM indicates that some individuals do in fact develop maladaptive mental health symptoms indicative of trauma, thus eliciting the creation and promulgation of approaches like CISD.
Future research should thus continue to assess the value of CISD in a more dispassionate and highly scientific manner. This is particularly important as consumers of CISD themselves rate CISD as valuable and desired (McNally et al., 2003; Mitchell, 2005). Of particular import are designs where randomization with a control or comparative treatment group is employed. Further, outcome measures should incorporate a large variety of directly and indirectly related symptoms (e.g., substance abuse), and involve more pre and post measurement analysis. Finally individualized components of CISD might be analyzed (i.e., so called dismantling approaches) such that differential tenets of CISD that might be accounting for both the positive and negative effects might be identified. Until such research can be performed, consumers and providers should be cautious in terms of CISD service provision.
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