Psychological Debriefing

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Over the last 20 years, it has become customary and then almost mandatory to apply early intervention after disasters and other traumatic events, in the hope of accelerating the resolution of trauma-associated symptoms. Early interventions are intuitively appealing and appear to be a response to a perceived need, but whether or not they are useful remains unclear.

The procedure of choice has become psychological debriefing, in which the subject is encouraged to talk about the trauma in narrative detail, recounting the facts and elaborating on his or her thoughts and feelings during the event. Debriefing is typically provided in a single session, within 72 hours of the trauma, in an individual or group setting. This is based on the assumption that the earlier the intervention occurs the less opportunity there is for maladaptive and disruptive cognitive and behavioral patterns to become established.

The concept of group debriefing grew out of the work of Marshall during World War II. He noticed that when a person could describe what happened to him during a very stressful experience this served not only an abreactive purpose but allowed colleagues to correct misperceptions and render social support. This appeared to reduce the likelihood of combat stress reactions and to restore the readiness to combat [33].

Debriefing has become increasingly popular as a treatment for victims of a wide range of traumatic events, from violent crime to natural disasters. In some circumstances and in certain occupations it has become mandatory. Organizations which routinely send their employees into potentially traumatizing situations are compelled to use it in order to protect the health of employees and minimize the impact of litigation seeking compensation.

Psychological debriefing is a formal type of post-traumatic care, for which several models have been developed in the past two decades. Among them, the Critical Incident Stress Debriefing (CISD), also known as the Mitchell model, is the most popular. This is a preventive method proposed by Jeffrey Mitchell to minimize adverse effects of the normal stress response [34,35]. It is one of the most widely practiced forms of early intervention in disruptive situations, promoting emotional processing, ventilation, normalization of reactions and preparation for possible future experiences. It aims to reduce pathological patterns, by focusing on the ''here and now'', during the 48-72 hours after the disruptive event, in a group meeting that lasts approximately 2 or 3 hours, led by one or two debriefers. Groups of participants are led in an active process of abreaction, sharing, and normalizing of stress reactions while participants are told that they are not ''patients''.

Mitchell describes several stages in the process of debriefing: (a) the introductory phase (introduction of the team, purpose of the meeting, confidentiality, ground rules, etc.); (b) the fact phase (reconstruction of the event in detail, in chronological order, viewed from all sides and perspectives, and by each group member); (c) the thought phase (sights, smells, other sensory impressions and thoughts about what happened; participants are asked to share what ''thoughts'' they had at key moments); (d) the reaction phase (to identify and ventilate feelings regarding self, victims or colleagues and raised by the event); (e) the symptom phase (review of symptoms and signs of distress; description of the normal stress response legitimizing participants' physical symptoms and behavioral reactions; challenging inappropriate feelings of guilt and responsibility); (f) the teaching phase (emphasizing that the feelings and stress symptoms are normal reactions to abnormal situations and that they are expected to resolve normally; teaching coping strategies to deal with possible psychological symptoms, with family, friends and work; explaining when, where and under what circumstances to get further help if necessary); (g) the reentry phase (summarize, discuss selected issues, complete and close the debriefing).

Perren-Klingler [36] identifies seven stages for debriefing: (a) introducing the procedure; (b) processing the thread connecting different aspects of the event; (c) transition to the next stage by elaborating emotions and feelings related to the event; (d) going over impressions and sensations; (e) information and normalizing of reactions; (f) separation rituals; (g) recovering contact with reality and daily routine. Herman [37] proposes a ''three-phase model'': the first aims to re-establish a sense of safety and self-control, as well as control over the environment, and to learn how to handle symptoms that put the subject at risk; the second is that for remembrance and mourning, that is, when the patient reconstructs the traumatic event through a narration where fragments of memory and emotional and physical sensations become integrated; the third is for reconnection (the patient is again connected with his/her present and future and with significant relationships and activities).

The timing of debriefing is considered of vital importance. Defenses start to work almost immediately and the individuals begin to deny and project anger. Therefore, it is commonly maintained that many groups should be debriefed as soon as possible to avoid the crystallization of such maladaptive defenses.

How effective is psychological debriefing? Is psychological debriefing a waste of time [38]? We can find numerous anecdotal reports suggesting that providing debriefing for everyone involved in a disruptive experience reduces subsequent psychopathological morbidity [39-41]. We became accustomed to using psychological debriefing with no research available as to whether it was helpful or not. Despite its popularity, this technique had been studied only sporadically over the years, and it is only in the last decade that high-quality research (i.e., high-quality clinical trials in which traumatized people were randomly assigned to be debriefed or not) has been published.

In recent years, studies have, in fact, shown that the procedure has no positive effect on post-traumatic stress symptoms. One study found no difference between victims of motor vehicle accidents who received debriefing and those who did not, 3 months after they experienced the trauma [42]. Moreover, longer-term studies have suggested that debriefing may impede the natural process of recovery: in a study of burn victims, there was no difference between those who did and did not receive the intervention 3 months later, but, at 13 months, those who had had debriefing did worse: 15% met criteria for PTSD, compared with none [43].

A Cochrane review [44] of eight randomized trials found no evidence that debriefing has any impact on psychological morbidity (in particular, no strong evidence that debriefing reduces a person's odds of developing PTSD, depression and anxiety; is safe and effective for children; or can be an effective form of group therapy). Furthermore, there is no information about debriefing for those who had psychiatric disorders prior to the trauma, because such people have been excluded from all studies. The most troubling finding came from the controlled trials with the longest follow-up (one tracked participants for 13 years), which provided evidence that some people are worse off after debriefing. The reviewers concluded that, for some people, ''debriefing may actually cause the post-traumatic stress it is intended to prevent. This may be because talking about and reliving the trauma is a further traumatic event in itself'' [44]. The reviewers also found that people most likely to develop PTSD are unlikely to be helped by a single debriefing session, and ''indeed such an intervention may be harmful'' [44]. These findings were so alarming that the reviewers recommended to stop the practice of compulsory post-trauma debriefing in people with certain occupations.

In the above review, it was hypothesized that the relatively recent changes in awareness of the psychological effects of traumas could render debriefing obsolete. Due to this awareness, ''everybody experiences a 'bit of debriefing' anyway, thus reducing the possibility of showing any effects from a formal intervention'' [44]. Concerning the apparent harmful effect of the intervention, it was postulated that debriefing may ''medicalize'' normal distress, thus increasing ''the expectancy of developing psychological symptoms in those who would otherwise not have done so'' [44].

Evidence about the ineffectiveness of debriefing has come from randomized trials which used broad definitions of the intervention. Therefore, it might be that these findings were obtained because an inappropriate form of debriefing was used. In particular, if a specific model like CISD had been used, the outcome could have been different. However, there have been no published, randomized controlled trials using such specific models. There has also been no randomized controlled trial comparing the different types of debriefing. Therefore, there is no evidence supporting the use of one type of debriefing instead of another.

Debriefing is a very popular intervention among many health and allied practitioners. Many organizations are likely to continue using it, since there is no comparable broadly acceptable early intervention with a similar low cost.

Everly and Mitchell [45] pointed out several methodological problems in research carried out up to now on debriefing. Some studies pooled the results of interventions offered by practitioners with varied levels of skills and training, and possibly using different debriefing models. Other studies involved an improper application of debriefing, using it as a freestanding intervention rather than as one component of a complete critical incident stress management (CISM) program. Apparently, similar difficulties commonly arise whenever researchers attempt to study the efficacy of psychotherapy using randomized experimental designs. The only way to get an accurate picture of the effectiveness of these interventions may be to allow a broader research approach, including the use of non-randomized designs and survey research [45].

A National Institute of Mental Health (NIMH) workshop on mass violence concluded that early intervention in the form of ventilation of events and emotions evoked by a traumatic event does not consistently reduce risk for later PTSD or related adjustment difficulties [46]. However, the same workshop concluded that early, brief, and focused psychothera-peutic intervention can reduce stress in bereaved spouses, parents, and children and that selected cognitive-behavioral approaches may help reduce incidence, duration, and severity of acute stress disorder (ASD), PTSD and depression in survivors.

CISD was never designed to be a stand-alone intervention, but, instead, a component of a broader, multi-component CISM-type intervention, that included training in being prepared for a crisis, follow-up, and referral. Therefore, debriefing should be used carefully and always as part of a broader crisis intervention program including ongoing education, social support and, when necessary, psychotherapy.

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