Early Intervention for Trauma: Current Status and Future
Directions
Brett Litz and Matt Gray, National Center for PTSD, Richard
Bryant, University of New South Wales, & Amy Adler, Walter Reed
Army Institute of Research
(This report is printed in
Clinical Psychology: Science and Practice and is posted with
permission.)
Abstract
Although psychological debriefing (PD) represents the most
common form of early intervention for recently traumatized people,
there is little evidence supporting its continued use with
individuals who experience severe trauma. This review identifies
the core issues in early intervention that need to be addressed in
resolving the debate over PD. It critiques the available evidence
for PD and the early provision of cognitive-behavioral therapy
(CBT). Based on available evidence, we propose that psychological
first aid is an appropriate initial intervention but that it does
not serve a therapeutic or preventive function. When feasible,
initial screening is required so that preventive interventions can
be used for those individuals who may have difficulty recovering on
their own. Evidence-based CBT approaches are indicated for people
who are at risk of developing posttraumatic psychopathology.
Guidelines for managing acutely traumatized people are suggested
and standards are proposed to direct future research that may
advance our understanding of the role of early intervention in
facilitating adaptation to trauma.
Early Intervention for Trauma: Current Status and Future
Directions
Although there are cogent humanitarian reasons to provide mental
health interventions to people soon after exposure to trauma
(Wilson, Raphael, Meldrum, Bedosky, & Sigman, 2000), there is
growing consensus that early intervention for trauma, generically
called psychological debriefing (PD), does not prevent subsequent
psychopathology (Bisson, McFarlane, & Rose, 2000; Gist &
Woodall, 2000). Further, there is some evidence that PD may
exacerbate subsequent symptoms (e.g., Bisson, Jenkins, Alexander,
& Bannister, 1997). Even though there is insufficient evidence
supporting its continued use, PD is routinely provided immediately
after exposure to potentially traumatizing events (PTE; Mitchell
& Everly, 1996; Raphael, Wilson, Meldrum, & McFarlane,
1996). This state of affairs is not surprising, considering the
prevalence of trauma, the demand for efficient management of the
extensive individual, corporate, and societal costs associated with
chronic Posttraumatic Stress Disorder (PTSD), the financial
interests of those who provide acute interventions, and the
tendency for organizations and participants to perceive PD as
useful (Deahl, Gillham, Thomas, Searle, & Srinivasan, 1994;
Hobfoll, Spielberger, Breznitz, Figley, & van der Kolk, 1991;
Raphael et al., 1996; Wilson et al., 2000).
In this context, our aim is to review the available evidence and
to address a number of core questions pertaining to early
intervention. Specifically, are there sufficient data from which to
conclude that all early interventions are counterproductive? Is the
Critical Incident Stress Debriefing (CISD) approach particularly
problematic? Are some components of PD justified? Should
psychological interventions only be provided to those who are at
risk of developing psychopathology? Our goal is to consider if it
is valid to conclude that early brief preventive interventions for
trauma are inappropriate, as recently recommended in the Cochrane
Collaboration review of the randomized controlled trials (RCT) of
one-session debriefing (Rose, Wessely, & Bisson, 1998 with a
follow-up by Rose, Bisson, & Wessely, 2001; cf. Rose &
Bisson, 1998), and to examine possible alternative approaches to
preventing chronic PTSD. By secondary prevention we mean assisting
individuals who have been exposed to trauma and have developed
acute symptoms, so as to reduce their risk for chronic PTSD.
In their Cochrane review, Rose et al. (2001) concluded that
there is no evidence for the efficacy of one-session PD provided
soon after exposure to PTE and recommended that "Compulsory
debriefing of victims of trauma should cease." It should be noted,
however, that the Cochrane reviews provide relatively
circumscribed, brief, and global recommendations for practitioners.
In contrast to the Cochrane reviews, we consider a broader
conceptual approach to early intervention, provide more detailed
methodological critiques of PD studies, and consider the evidence
for early provision of cognitive-behavioral therapy (CBT). We also
provide a more extensive set of recommendations and standards for
future research on early intervention. Finally, we provide a
summary of the risk factors for PTSD germane to early intervention
and offer practical guidelines for managing people who are recently
traumatized.
The Need for Early Intervention
Although lifetime risk for exposure to PTE is extremely high
(60%-90%, Breslau et al., 1998; Kessler, Sonnega, Bromet, Hughes,
& Nelson, 1995), the prevalence of PTSD is relatively low. For
example, approximately 8% of individuals in the National
Comorbidity Survey had PTSD at some point across the lifespan,
indexed to an event rated as "the most traumatic" (Kessler et al.,
1995). Breslau et al. also found that approximately 9% of
individuals exposed to any PTE report PTSD at some point across the
lifespan. The prevalence estimates for PTSD vary considerably, due
to differences in samples, sampling strategies, assessment methods,
and the way that a PTSD diagnosis is defined. Moreover, the
prevalence of PTSD varies across different types of PTE, with
sexual assault and exposure to violence being associated with the
highest risk for PTSD (e.g., Breslau et al., 1998). Nevertheless,
even the most conservative estimates of risk for PTSD reflect the
tremendous mental health toll associated with trauma.
Prospective studies have shown that most trauma survivors
display a range of PTSD reactions in the initial weeks after a
traumatic event, but that most of these people adapt effectively
within approximately three months. Those that fail to recover by
this time are at risk for chronic PTSD (e.g., Blanchard et al.,
1996; Riggs, Rothbaum, & Foa, 1995; Rothbaum, Foa, Riggs,
Murdock, & Walsh, 1992; Koren, Arnon, & Klein, 1999).
Further underscoring the risk for chronicity in PTSD, Kessler et
al. (1995) found that one third of people with PTSD fail to recover
after many years, in many cases after years of mental health
treatment. These findings have several implications. First, the
majority of people will be distressed after exposure to a PTE, and
assistance in coping and immediate adjustment may be indicated.
Second, a smaller proportion of individuals exposed to PTE will
have persistent problems, which require therapeutic intervention.
The following review of early intervention strategies recognizes
these fundamental patterns in trauma response and accepts the
premise that, whereas all distressed people may require, and in
theory benefit from, assistance following trauma, only a small
proportion will eventually require therapy for a pathological
response. Unfortunately, in the PD literature, little attention has
been paid to secondary prevention specifically for individuals who
are at risk for chronic PTSD.
Risk Factors for PTSD
Since exposure to PTE is a necessary but not sufficient cause of
chronic PTSD, attention has been focused on the pretraumatic,
peri-traumatic, recovery environment, and posttrauma lifespan
conditions that create risk for posttraumatic difficulties
(Halligan & Yehuda, 2000; King et al., 1999). The premise that
exposure to trauma is the exclusive risk factor for PTSD, which
underlies most PD models (e.g., Mitchell & Everly, 1996) has
resulted in intervention efforts typically failing to address the
role other risk factors may play in adjustment after exposure to
PTE. For this reason, the "one size fits all" framework of PD fails
to acknowledge the personal and social resources that, in most
cases, promote recovery (Bisson et al., 2000; Gist & Woodall,
2000). Effective management of those who suffer more than a
transient stress response to trauma would be greatly facilitated by
screening those who are at risk for chronic PTSD after exposure to
PTE. Furthermore, there is increasing recognition that because of
the complex array of vulnerability factors that contribute to the
development of posttraumatic psychopathology, single-session
interventions are unlikely to make substantive differences in
long-term adjustment (Shalev, 2000).
In the PTSD field, risk factor research is in an early stage,
conceptually and empirically. As a result, the extent to which risk
variables can be used practically in early interventions is reduced
considerably. For example, there is no distinction between
risk indicators (variables that have been found to correlate
with chronic PTSD) and
risk mechanisms (risk factors or variables that suggest
specific modes of mediation, which are less susceptible to third
variable and directionality concerns; Rutter et al., 2001). Rather,
the global term "risk factor" is typically employed and causal
mechanisms remain unspecified. Although research has revealed
several noteworthy risk indicators, few risk mechanisms have been
explicated. Once future research identifies risk mechanisms, these
variables will likely be specific targets for secondary prevention
interventions. Nevertheless, at this stage, several risk indicators
could legitimately be used to screen individuals exposed to PTE who
are more likely to suffer long-term problems.
In this section, we review two risk indicators (prior exposure
to trauma and acute stress disorder) and two potential risk
mechanisms (social support and hyper-arousal) that deserve special
attention. Younger age and female gender have been shown to be risk
indicators for chronic PTSD (e.g., Breslau et al., 1998; Kulka et
al., 1988). However, these variables alone cannot be usefully
employed to identify individuals who may uniquely benefit from
early intervention. Intelligence is another example of a risk
indicator found in the literature (e.g., Macklin et al., 1998);
however, we cannot envision a scenario in which this variable could
impact decision making about who should receive early intervention.
Of course, age, gender, and intelligence are factors that need to
be taken into account in modifying the content and process of early
interventions. We end this section by describing how resource
losses represent an important set of risk mechanisms, which, to
date, have not been sufficiently examined in early intervention
research.
Prior Trauma
It has become axiomatic that prior exposure to PTE is a risk
indicator for chronic PTSD stemming from a subsequent PTE (King et
al., 1999; Stretch, Knudson, & Durand, 1998). In particular, a
history of exposure to interpersonal violence, in childhood or
adulthood, substantially increases the risk for chronic PTSD
following exposure to any type of PTE (Bremner, Southwick, Brett,
& Fontana, 1992; Breslau et al., 1998; Green et al., 2000;
Nishith, Mechanic, & Resnick, 2000). Dougall, Herberman,
Delahanty, Inslicht, and Baum (2000) hypothesized that prior trauma
history sensitizes victims to the new stressor, thus potentiating
its impact. They argued that evaluating trauma history is essential
for improving early intervention efforts. There are no empirical
data, however, detailing the effects of prior trauma history on
response to psychosocial interventions for PTSD in general or early
interventions in particular.
Acute Stress Disorder
Prior to DSM-IV (American Psychiatric Association, 1994), severe
distress occurring in the month after a traumatic event was not
regarded as a diagnosable clinical problem. Although this prevented
the pathologizing of transient reactions, it hampered the
identification of more severely traumatized individuals who might
benefit from early interventions. To address this issue, DSM-IV
introduced the diagnosis of acute stress disorder (ASD) to describe
those acute reactions associated with an increased likelihood of
developing chronic PTSD. A diagnosis of ASD is given when an
individual experiences significantly distressing symptoms of
reexperiencing, avoidance, and increased arousal within 2 days to 4
weeks of the trauma. The DSM-IV diagnosis of ASD requires that the
victim report at least three of the following five symptoms labeled
as indicators of dissociation: numbing, reduced awareness of
surroundings, derealization, depersonalization, and dissociative
amnesia. These requirements are based on some evidence found in
previous studies that dissociative symptoms at the time of (or
shortly after) the traumatic event are predictive of the subsequent
development of chronic PTSD (Bremner et al., 1992; Marmar, Weiss,
Shchlenger, & Fairbank, 1994; Koopman, Classen, & Spiegel,
1994), Thus, the fundamental differences between PTSD and ASD
involve time elapsed since the trauma and the relative emphasis on
dissociative symptoms in the ASD diagnosis.
Several longitudinal investigations of motor vehicle accident
(MVA) survivors have documented the predictive utility of ASD in
identifying those individuals who are likely to exhibit more
enduring or persistent pathology. Harvey and Bryant (1998a)
evaluated MVA survivors within 1 month of their accident for the
presence of ASD and then reevaluated this sample 6 months later for
PTSD. At follow-up, 78% of those who met diagnostic criteria for
ASD within 1 month of their accident met diagnostic criteria for
PTSD six months later. These researchers noted that 60% of victims
who met all but the dissociative criteria for ASD also met
diagnostic criteria for PTSD at 6 months, suggesting that the ASD
emphasis on dissociative symptoms may result in significantly
distressed survivors being overlooked by clinicians. These findings
were replicated at a 2-year follow-up evaluation (Harvey &
Bryant, 1999a). The strong relationship between ASD and the
subsequent development of chronic PTSD has also been observed among
MVA victims suffering mild traumatic brain injuries (Bryant &
Harvey, 1998; Harvey & Bryant, 2000) as well as among sexual
and physical assault victims (Brewin, Andrews, Rose, & Kirk,
1999). Brewin et al. (1999) noted that the most accurate and
efficient prediction of PTSD in their sample of crime victims was
afforded by a cutoff of 3 or more symptoms of reexperiencing or
hyper-arousal after trauma. Their findings also suggest that
dissociative symptoms, while predictive of PTSD, fail to provide
incremental validity beyond the core PTSD symptoms.
Bryant and Harvey (1997) assert that there is little empirical
justification for the requirement of three dissociative symptoms to
occur for the ASD diagnosis to be given. Although early studies
documented significant associations between peri-traumatic
dissociation and PTSD, much of this research was retrospective in
nature. Evidence that recall of acute stress symptoms is influenced
by current mood indicates that symptom status at the time of
evaluation could have influenced reports of prior dissociative
symptoms (Harvey & Bryant, 2001). Accordingly, Bryant and
Harvey advocate for consistency between ASD and PTSD diagnostic
criteria because of the many individuals that fail to meet
diagnostic criteria for ASD but ultimately meet criteria for PTSD
despite the fact that their symptoms remain unchanged. In addition,
Marshall, Spitzer, and Liebowitz (1999) note that there are
numerous pretrauma and peri-trauma vulnerability factors that
predict dissociation, ASD, and subsequent PTSD equally well.
Cardiovascular reactivity, prior history of Axis I disorder, prior
history of Axis II disorder, depressive symptomatology, use of
avoidance coping strategies, trait neuroticism, and history of
prior traumatization have all been found to be significant
predictors of subsequent ASD or PTSD diagnoses (Barton, Blanchard,
& Hickling, 1996; Bryant, Harvey, Guthrie & Moulds, 2000;
Harvey & Bryant, 1998b; Harvey & Bryant, 1999b; McFarlane,
1988). Accordingly, Marshall and colleagues assert that it makes
little sense to elevate one class of vulnerability factors (i.e.,
dissociative symptoms) above all others to the status of core
diagnostic criteria. Allowing a PTSD diagnosis anytime after trauma
when criteria are met would be the most parsimonious solution. They
note that there are numerous bona fide medical conditions and
mental disorders that resolve spontaneously over time. Accordingly,
a "waiting period" of 30 days is inconsistent with general
nosological principles. Despite the controversy over the ASD
diagnosis, the evidence suggests that indexing specific reactions
several weeks after a trauma can be helpful in identifying those
who are most at risk of developing PTSD.
Social Support
An individual's recovery from trauma is facilitated by the
availability of positive social supports and the inclination to use
them to share the account of the trauma (Forbes & Roger, 1999;
Foy, Sipprelle, Rueger, & Carroll, 1984; Harvey, Orbuch,
Chwalisz, & Garwood, 1991; Keane, Scott, Chavoya, Lamparski,
& Fairbank, 1985; King, King, Fairbank, Keane, & Adams,
1998; Martin, Rosen, Durand, Knudson, & Stretch, 2000;
Pennebaker & O'Heeron, 1984). To date, early interventions have
not sufficiently taken into account the social factors in the
recovery environment that promote or hinder recovery from trauma.
In order to be maximally effective, early interventions for trauma
may need to evaluate systematically the breadth and depth of social
supports in the recovery environment and the victim's learning
history of using social supports under stressful circumstances.
Further, early intervention may need to assist the individual with
anticipating problems in using their support system. This may be
particularly important in light of the fact that the psychological
aftermath of trauma may significantly disrupt a person's capacity
to use others to cope with and manage posttraumatic symptoms and
daily demands (e.g., Riggs, Byrne, Weathers, & Litz, 1998;
Solomon, Mikulincer, & Avitzur, 1988). In addition, preexisting
conflict in significant relationships could negatively impact
recovery, particularly in those who are motivated to use others to
cope with the aftermath of severe stress (Major, Zubeck, Cooper,
& Cozzarelli, 1997). In order to regain a sense of equilibrium
and coherence, some victims may need a period of respite from
posttrauma demands, and they may initially need to be allowed to
avoid discussing their trauma (Charlton & Thompson, 1996;
Tarrier, Pilgrim, & Sommerfield, 1999). Conflict in significant
relationships may make it difficult for those individuals who need
a period of disengagement to achieve this state without
exacerbating relationship difficulties.
Hyper-arousal
High degrees of psychophysiological arousal in the acute
aftermath of trauma are known to be associated with increased risk
for chronic PTSD (Yehuda, McFarlane, & Shalev, 1998). A series
of studies by Shalev and colleagues examined cardiac activity
prospectively in individuals exposed to PTE (Shalev, Freedman,
Peri, Brandes, & Sahar, 1997). For example, Shalev, Sahar, et
al. (1998) found that in a mixed group of trauma survivors
evaluated in the emergency room, those individuals who had severe
symptoms of PTSD one week after the event had higher initial mean
heart rates (measured in the emergency room) than those who did not
develop PTSD. In addition, Shalev and colleagues found that PTSD
prevalence rates 4 months later were best predicted by heart rate
in the emergency room, after controlling for age, gender, trauma
history, and immediate psychological response to the event. This
finding has been replicated by Bryant et al. (2000).
A number of risk mechanisms have been proposed to account for
hyper-arousal's affect on risk for PTSD. Increased cardiac output
in the immediate aftermath of exposure to trauma (e.g., when
assessed in emergency rooms) is likely to be part of the
unconditioned response to the trauma, the intensity of which varies
across individuals (e.g., Orr, Meyerhoff, Edwards, & Pitman,
1998). Generally, arousal symptoms negatively impact individuals'
attempts to return to daily routines and affect rest and sleep
capacity, which further exacerbates levels of stress and arousal.
In addition, basal increases in cardiac activity can be caused by
poor coping with daily stress and anticipatory anxiety (e.g.,
McFall, Murburg, Ko, & Veith, 1990; Orr et al., 1998; Prins,
Kaloupek, & Keane, 1995). This suggests that early
interventions for trauma should target hyper-arousal by training
survivors in methods of anxiety and stress management. Although
speculative, it is plausible that systematic reductions in
hyper-arousal in the days and weeks after a trauma could accomplish
a number of goals: (1) Effective arousal management can engender a
sense of control over emotional experience at a time when there may
be considerable affective lability; (2) learning adaptive means to
manage arousal serves to reduce the risk for maladaptive behaviors
used to cope with negative affect (e.g., substance use); (3) daily
relaxation exercises promote self-care, which may restore a sense
of safety and comfort often compromised by trauma; and (4) reduced
arousal in the aftermath of exposure to trauma would serve to limit
generalization of conditioning and higher-order conditioning, which
in theory would minimize chronic conditioned emotional reactivity
and lessen motivation for avoidance behavior.
Posttraumatic Resources
A variety of personal and environmental factors create risk for
enduring posttraumatic difficulties. Hobfoll, Dunahoo, and Monnier
(1995) contend that trauma necessarily involves a loss of resources
and that loss can occur on multiple ecological levels such as
family, organization, and community. The Conservation of Resources
(COR) theory is based on the premise that people strive to obtain
and protect resources (Hobfoll, 1989). These resources can include
material goods, life conditions (e.g., marriage or occupation), or
personal resources (e.g., self-esteem or perceptions of
competency). According to COR theory, stress ensues when there is a
threatened or actual loss of resources. Traumatic events result in
inordinate stress because the losses incurred are most closely
related to one's survival, and the losses tend to be numerous and
profound. In the case of natural disasters, for instance, victims
often lose their homes, money, and social network. Hobfoll et al.
(1995) assert that early posttraumatic interventions employed by
psychologists have not been especially helpful because they attend
exclusively to psychological variables to the exclusion of other
domains of resource loss. Trauma survivors may not be in a position
to benefit from traditional psychological interventions that target
anxiety and affective symptoms when they have legitimate concerns
about physical well-being, safety, shelter, or significant
financial problems. Accordingly, resolution of these issues may be
a necessary precondition to an individual's capacity to benefit
from early interventions addressing psychological variables
following trauma.
Given the potentially deleterious impact of trauma across
multiple domains of functioning, what do victims need in the
immediate aftermath of trauma? Resnick, Acierno, Holmes, Dammeyer,
and Kilpatrick (2000) recommend that safety planning and emergency
stabilization should precede any efforts to address psychological
or emotional sequelae. In particular, crime victims may need
contact information for shelters, emergency housing, rape crisis
services, as well as services to address pressing medical and legal
issues. The presence of suicidal and homicidal ideation and
significant substance abuse should be routinely assessed following
traumatic exposure, as the risk for each of these increases
significantly after a trauma, complicating the course of ASD/PTSD
treatment (Resnick et al.). The recommendations are in accord with
Hobfall et al.'s (1995) call for psychologists to attend to
victims' resource losses in multiple domains.
The History of Debriefing
The provision of psychological debriefing originated in the
military. In World War I and World War II, soldiers were
"debriefed" by commanders immediately after a significant battle.
The expectation was that sharing personal stories about combat
would improve morale and better prepare soldiers for future combat.
Parallel to this, battlefield psychiatrists developed strategies to
address the needs of soldiers who were incapacitated by acute
combat stress (a condition labeled "battle fatigue," or "combat
stress reaction;" see Solomon and Benbenishty, 1986). Frontline
treatment in the war-zone was provided using a framework of
"proximity," "immediacy," and "expectancy." That is, soldiers were
treated near the battlefield, shortly after their problems were
identified, and with the expectation that they would return to
duty. In theory, providing treatment close to a soldier's unit was
seen as particularly important because it helped to maintain group
support and cohesion, as well as reduce stigma (see Jones &
Hales, 1987). Interventions applied on the frontline have varied
over time. However, in the modern military there is considerable
uniformity (Hall et al., 1997). Typically, clinicians promote rest,
consider pharmacological treatment to manage hyper-arousal, and
provide psycho-education about the effects of trauma. In addition,
group discussion is provided, designed to facilitate soldiers'
sharing of horrific encounters in the war-zone and to process their
emotional experience with others similarly afflicted (Shalev, 1994;
2000). In the United States military, soldiers exposed to PTE are
routinely provided front-line psychological "first-aid" in the form
of informal event-processing interventions, pastoral counseling,
and, if need be, triage to stepped-up care (McDuff & Johnson,
1992).
Critical Incident Stress Debriefing
Although the content, process, and goals of PD vary
considerably, there are many commonalities, and the CISD approach
is the most recognized and used method (Mitchell & Everly,
1996). The CISD approach stems from the crisis intervention
tradition. It is typically applied to emergency services personnel,
individuals whose work entails risk for exposure to trauma (e.g.,
law enforcement personnel, emergency medical technicians, fire
fighters, military personnel, and disaster workers such as the Red
Cross). CISD may be attractive to workers in these occupations
because of its emphasis on the PD not being "psychotherapy." That
is, CISD is presented not as a clinical intervention, but rather an
opportunity for individuals to share their common normal response
to extreme circumstances with CISD team members, at least one of
whom is highly familiar with the culture of the work system. These
factors have lead to the pervasive and routine application of CISD
in risky occupations such as the military, even in the face of
insufficient evidence for its efficacy (see Deahl et al.,
2000).
The CISD framework has been revised recently so that it is now
considered part of a more comprehensive, Critical Incident Stress
Management (CISM) program (Everly & Mitchell, 2000). The CISM
program is a series of interventions that seems as though it will
be effective. It is designed to comprehensively address the needs
of emergency services organizations and personnel. The CISM
interventions are designed to psychologically prepare or prebrief
individuals prior to dangerous work, meet the support needs of
individuals during "critical incidents" (e.g., while Red Cross
personnel are working with families who lost loved ones in a
disaster), provide CISD as well as delayed interventions, consult
with organizations and leaders, work with the families of those
directly affected by trauma, and to facilitate referrals and
follow-up interventions to address lingering stress disorders.
However, there has been no controlled empirical study of the
various components of CISM to date.
The cornerstone of CISM is CISD, which is a semistructured group
intervention with didactic and experiential components. The
overarching goals of CISD are: (a) to educate individuals about
stress reactions and ways of coping adaptively with them, (b) to
instill messages about the normality of reactions to PTE, (c) to
promote emotional processing and sharing of the event, and (d) to
provide information about, and opportunity for, further
trauma-related intervention if it is requested by the participant.
Individuals exposed to a PTE are invited, within days, to
participate in a three to four hour session in which the "incident"
is reviewed. Personnel are invited to attend a CISD regardless of
the degree of their acute symptoms or functional impairment (e.g.,
Hokanson & Wirth, 2000). The assumption of the CISD approach is
that everyone exposed to a PTE is at risk for a stress
reaction/PTSD and that everyone could benefit from an opportunity
to share their experience and learn about trauma and adaptive
coping. The model fails to incorporate epidemiological research
that has shown that not everyone is equally at risk for PTSD after
exposure to PTE. In addition, the CISD framework eschews formal
assessment of symptoms and outcomes in order to emphasize the
nonclinical nature of the intervention and to create confidence in
the confidential nature of the group. Thus, participants in a CISD
could be free from acute symptoms and have very little risk for
chronic PTSD, or individuals could be experiencing severe ASD.
According to Mitchell and Everly (1996), successful PD is
accomplished through a series of seven phases or stages. In terms
of content, many of the stages share some of the same features as
the stress management aspects of standard cognitive-behavioral
treatment packages for PTSD as well as in broad terms, exposure
therapy (e.g., Flack, Litz, & Keane, 1998). A debriefing begins
with an "introduction stage." At this time the facilitator's job is
to explain what is going to happen during the debriefing and
clarify any questions participants might have. Special emphasis is
placed on confidentiality, which may be particularly important for
individuals with a common work-system concerned about whether
shared information will affect their advancement in the
organization. The next step is called the "fact phase." During this
time, participants are asked to describe the stressor and what
happened during the event. Next, in the "thought phase," the
primary facilitator asks participants to describe their thoughts
during the incident. This phase is intended to be a vehicle to the
next phase, in which emotional reactions are shared. Focusing
initially on thoughts, rather than feelings, allows participants to
begin to talk about the events with some degree of distance to
reduce defensive coping reactions. Following this is the "reaction
phase," the focus shifts to participants' emotional responses
during the event as well as what they are currently experiencing
and the meaning they assign to these experiences. The facilitator
attempts to normalize the experience as much as possible and assist
individuals in reframing and integrating the experience into their
view of themselves and the world. In stage 5, the "symptoms phase,"
the facilitator discusses typical stress reactions and answers
questions concerning personal responses to the event. During stage
6, the "teaching phase," the debriefing team members attempt to
find out what the participants know about stress reactions and
stress management strategies and to clarify any points of
misunderstanding. Finally, in the "reentry phase," the team sums up
the debriefing and the referral process.
As can be seen in the description above, a great deal needs to
be covered in one meeting. Psychological debriefing is apparently
designed to facilitate support seeking and to prepare individuals
for the challenges of recovering over time. In the published CISD
manuals, there are explicit messages about PD being a necessary,
but by no means sufficient, intervention for severely traumatized
individuals who have lingering disturbing symptoms and problems
after a trauma (these individuals are said to require individual
follow-up treatment). Yet, the CISD literature also suggests that
PD alone is a secondary prevention intervention (e.g., Mitchell
& Everly, 1996). That is, attending a PD is enough to prevent
the formation of PTSD and other trauma-linked disorders. In this
context, the necessary and sufficient conditions for effective
early intervention are unclear. Perhaps attendance at a CISD
functions as a screening for participants who suffer severe
symptoms (e.g., acute stress disorder) or who have poor coping
resources (e.g., they are isolated) - conditions which trigger
referral for sustained intervention. If this is the case, it raises
the possibility that some individuals are unduly taxed by a CISD
and the need to screen individuals earlier in the process.
Other concerns about CISD center on how the intervention may
exacerbate distress. When CISD is provided in a group format,
attendees have varying degrees of familiarity with each other and
the group is led by a team trained in CISD. The team includes
formally trained mental health professionals as well as, in most
cases, a layperson who works in the same field, or someone familiar
with individuals affected by the PTE. Although the idea of
including peer support personnel seems sensible, this feature has
been criticized strongly because it can, in theory, create dual
relationships and may make some attendees feel unsafe, which may be
counter-therapeutic and possibly unethical (e.g., Gist &
Woodwall, 2000). Formally, the goal of including peer support
personnel in a CISD team is to enhance the team's credibility and
legitimacy in terms of particular work cultures. It is quite
possible that this feature is very important in many work contexts,
although it also seems likely that it constrains the extent to
which emotionally salient or inadvertently incriminating
experiences are shared for some.
Another concern about how CISD is implemented is that if
individuals are mandated or subtly coerced by their employers to
attend a debriefing session it raises the possibility that choice
and control are wrested from some traumatized people, which is
likely to create frustration, anger, and resentment, as well
intensify the experience of victimization. It should be noted that
the formal CISD literature emphasizes that debriefing attendance is
voluntary. However, volunteer status may be affected by work
cultures unbeknownst to CISD personnel. For example, overt and
strong support from supervisors and administrators may impact
decisions about participation (e.g., Gist & Woodall, 2000). A
related criticism of CISD is that an individual who is reluctant to
disclose personal information may feel stigmatized and pressured by
the group's expectations. In this context, sharing of personal
experiences may have harmful, rather than helpful, consequences
(Young & Gerrity, 1994).
One of the confusing issues in the execution of CISD is the
process whereby an individual (or group of individuals) is found to
be appropriate for CISD. Again, formally, CISD is designed only for
use with emergency service workers (fire fighters, rescue
personnel, emergency room personnel, police officers, etc.),
although the CISD training also describes CISD as appropriate for
witnesses to critical events and bystanders who suddenly become
helpers by virtue of their being in a particular place at a
particular time. The literature emphasizes that "direct victims" of
critical incidents, family members of those seriously injured or
killed, and those seriously injured in trying to respond to an
incident require more extensive treatment and should not attend a
CISD. These so-called "direct victims" are handled in unspecified
ways within the broader treatment framework of CISM. However, it is
unclear whether those who practice CISD apply the intervention only
to individuals secondarily exposed to trauma (Dyregrov, 1999). For
example, following the terrorist attacks on the World Trade Center,
thousands of office workers and other people directly involved in
the incident were apparently provided with variants of CISD.
One of the particularly attractive features of the CISD
framework is the special attention paid to the unique needs of
workers at risk for exposure to others' direct trauma and
suffering, targeting the intense strain and stress of emergency and
disaster relief activity. It also responds to the need for
organizations to address the needs of their workers and to maintain
cohesion and morale. A cogent example would be the Red Cross
workers responding to grief stricken and horrified family members
of victims of the terrorist attacks in New York City and at the
Pentagon on September 11, 2001. The psychological burden of such
work is considerable, and the CISD framework has provided a
systematic structure to address the emotional needs of helpers in
organizations such as the Red Cross. However, some have argued that
proponents of debriefing fail to recognize sufficiently the natural
resiliency of emergency care workers and their capacity to find
adaptive individualized and personal ways of managing their
reactions to the stressful demands of their duties (e.g., Gist
& Woodall, 2000).
In the CISD framework, the types of events that constitute
"critical incidents" warranting CISD are unclear, and it is
uncertain how, within a given occupation or work-system, "direct
victims" of trauma are actually screened. The manner in which the
formal distinction is made between primary or "direct" and
"indirect" exposure also remains uncertain. The use of an
individual's role in the traumatic context as the sole criterion
for CISD inclusion may constitute an arbitrary distinction. For
instance, emergency workers may be exposed to severe PTE "directly"
and secondarily by virtue of observing others suffer greatly.
Whether such individuals would be considered inappropriate
candidates for CISD remains unclear.
The CISD model assumes that direct or primary victims are
inappropriate for CISD because some measurable physical, cognitive,
or emotional quality of the "victim" experience makes the CISD
process insufficient or inappropriate. If that argument is to be
accepted, then operationally defining what constitutes direct
exposure becomes critical. It appears that the distinction between
a primary and a secondary victim within the CISD framework hinges
superficially on whether there is physical injury, which is
inappropriate, given the vast literature about the long-term
consequences of psychological trauma. We argue that attempts to
categorically distinguish direct (primary) and indirect (secondary)
victims will be difficult if the intervention is intended to
address psychopathological responses. If early intervention is to
afford individuals who do emotionally challenging emergency work an
opportunity to maintain group cohesion, as well as share and
receive information about adaptive coping, then focusing on
emergency workers seems an appropriate goal. On the other hand, if
the intervention is to target pathological responses to trauma,
then it does not appear justified to determine eligibility for
early intervention in terms of one's type of involvement in the
trauma. In the recent terrorist attack on the World Trade Center,
survivors who fled the building and the emergency workers who
assisted with the evacuation had much in common in terms of
exposure to life-threat, although their roles, training, and mental
preparation were different. In any case, the appropriate type of
early intervention for specific posttrauma problems, the type of
individual or group that can benefit from these interventions, and
the relevance of one's role in a trauma are empirical issues that
have yet to be resolved.
We suggest that it is more appropriate and defensible to
evaluate (when feasible logistically) anyone exposed to PTE,
regardless of work role or context, for the severity or magnitude
of their exposure and their peri-traumatic subjective emotional
experience. There are a number of good screening measures that
could assist in this effort (Litz, Miller, Ruef, & McTeague,
2002). If an assessment (when feasible) indicates that individuals
require intensive intervention, those individuals should be
provided with multisession interventions that have empirical
support. We recognize that assessment and intervention with
emergency workers requires special attention to the cultural and
organizational features of those groups. This recognition should
not be confused, however, with assumptions that psychopathological
responses are qualitatively different in these individuals.
Research on Debriefing Effectiveness
Anecdotal accounts, unpublished studies, and a few uncontrolled
peer-reviewed studies of PD suggest that it is an effective
intervention (see Everly, Flannery, & Mitchell, 2000 for a
review). However, until recently there was a dearth of randomized
controlled trials (Rose et al., 2001). It is important to note that
debriefing research is challenging for several reasons. It is
impossible to predict the occurrence of PTE that require debriefing
and thus extremely difficult to assess individuals prior to
exposure. In addition, it is difficult to conduct randomized
controlled trials; randomization has historically been considered
unethical because it would mean withholding a potentially useful
treatment from acutely distressed individuals. The concern about
withholding a useful early intervention is changing in this
research domain given recent findings of equivocal or negative
results. However, the organizational and societal chaos that follow
a major disaster, as seen in the aftermath of the September 11,
2001 calamity in the United States, hinders desirable experimental
control over outcome evaluation.
Our intention in this section is to critically appraise
peer-reviewed research that, at a minimum, randomly allocated
participants to an active single session PD or a no-intervention
control group, a criterion also used by the latest Cochrane review
of PD (Rose et al., 2001). Everly et al. (2000) recently reviewed a
number of uncontrolled studies (and in some cases nonpeer reviewed
studies), which led them to conclude that there was empirical
support for the efficacy of PD. In our opinion, none of the studies
reviewed by Everly et al. (2000) are sufficiently internally valid
to warrant this conclusion. By virtue of the fundamental problem of
a lack of random assignment, there is no sufficiently valid
evidence from uncontrolled or quasi-experimental studies of early
intervention to suggest that the intervention promoted recovery to
a greater degree than would have occurred with the passage of time.
In addition, when self-selection determines participation, there is
a possibility that individual differences (e.g., greater distress,
higher motivation) may explain inclusion in PD. This limitation is
compounded by the fact that the majority of studies reviewed by
Everly et al. (2000) failed to assess individuals prior to the
intervention; post-PD symptom ratings could reflect enduring
preexisting levels of distress. Finally, no study reviewed by
Everly et al. employed independent assessment of outcome.
We critically reviewed six peer-reviewed randomized controlled
trials, all of which were included in Rose et al.'s (2001) Cochrane
review of PD. In their review, Rose et al. (2001) included two
studies that predate the advent of formalized approaches such as
CISD and the formal diagnosis of PTSD, which we exclude because it
is not clear what the interventions entailed, and their
applicability as a test of PD is uncertain. In addition, unlike
Rose et al., we elected to exclude one study that appeared not to
entail putative exposure to PTE (i.e., miscarriage).
Most of the RCT have noteworthy positive features (see Table 1).
All studies used standard, well-accepted self-report outcome
measures, and several studies used state of the art structured
clinical interviews to evaluate PTSD, which allowed for independent
blind assessment of outcome (Bisson et al., 1997, and Rose et al.,
1999). All studies had adequate follow-up evaluation of
participants and one study reported results three years
postintervention (Mayou, Ehlers, & Hobbs, 2000). Finally, and
most importantly, random allocation of participants allowed for a
determination of whether participants who received PD improved
beyond how they would have adapted on their own with the passage of
time. In all instances the PD failed to promote change to a greater
degree relative to no intervention.
We calculated an estimate of the direction and the magnitude of
change in the severity of PTSD symptoms in five of the six studies
reviewed in Table 1 (Deahl et al., 2000 failed to provide
sufficient descriptive data to conduct this analysis). Change
scores were expressed as mean changes in standard deviation units
(SDU) from baseline to the last follow-up interval reported.
Although the group receiving PD reported less severe symptoms at
follow-up (SDU=.45), this was, on average, not different from any
of the control groups (SDU=.42). Of course, these averages obscure
individual trajectories of change, but these data are not
surprising given the normative course of adaptation to trauma, and
they underscore the need to prescreen individuals at risk for
having difficulty adapting on their own over time. We also
calculated an average effect size estimate by weighting the effect
sizes of the five individual studies by the sample sizes of that
particular study. The mean effect size for PTSD measures was -.11
(Cohen's d). This indicates that participants receiving PD had
slightly worse PTSD scores at follow-up (one-tenth a standard
deviation) than those not receiving PD (90% confidence interval
ranges from -.32 to +.10). Because the confidence interval includes
zero, and because the effect size estimate is very small, it is
premature to conclude that PD is detrimental or helpful in terms of
secondary prevention of PTSD.
Taken as a whole, the set of studies revealed similar changes in
PTSD symptoms at follow-up between the PD and control groups.
Nevertheless, two of the more methodologically rigorous studies
found that PD created a degree of PTSD symptom exacerbation over
time. Bisson et al. (1997) found that 26% of the burn victims who
were provided PD had PTSD at the 13-month follow-up interval
according to the Clinician Administered PTSD Scale (CAPS; Blake et
al., 1990), whereas only nine percent of the control group endorsed
sufficient symptoms to meet the diagnostic criteria for PTSD at
follow-up. Also, the PD group reported significantly higher anxiety
and depression symptoms on subscales of the Hospital Anxiety and
Depression Scale (HADS; Zigmond & Snaith, 1983) and Impact of
Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) at the
13-month follow-up (3-month data were not reported). However,
despite random assignment, participation in the intervention group
was confounded with several risk factors. Intervention group
participants had higher initial symptoms, more severe burn trauma,
and were more likely to report preburn histories of exposure to
PTE. Bisson et al. controlled for initial symptom levels in their
analysis, in an attempt to take into account these confounds, and
the results were unchanged. However, initial symptom level is not
necessarily a good proxy for all three of the confounding factors
or their interactions. It would have been revealing if the authors
had conducted a post-hoc multivariate analysis of the predictors of
change in symptom severity in order to examine the characteristics
of the person (including the three potentially confounding
factors), their experience of the stressor, or their experience of
the intervention that might be associated with outcome.
Hobbs et al. (1996) found that MVA victims administered PD
within two days after their accident were no different at a 4-month
follow-up interval from individuals given no intervention with
respect to the number of PTSD cases, PTSD symptom severity, and
interview ratings of intrusive thoughts or travel anxiety. A threat
to internal validity in this study was that 22% percent of the PD
group could not be followed up, in contrast to six percent of the
no-treatment controls. The follow-up group may have been
over-represented by those who fared worse from the PD. In their
three year follow-up examination of the participants from Hobbs et
al. (1996), Mayou, Ehlers, and Hobbs (2000) found that the group
that received PD had significantly worse outcome three years later.
Their overall distress and travel anxiety were worse, as were
overall levels of functioning and financial problems. Those MVA
survivors with initially high intrusion and avoidance symptoms
recovered without PD intervention but those who received the
intervention remained symptomatic. Unfortunately, only a little
over half of the participants in the first study were assessed a
second time, so it is unclear whether the follow-up sample was
biased in some undetermined way. In addition, initial differences
between the intervention and control groups prior to debriefing may
have affected the three-year outcome.
The Bisson et al. (1997) study is of note because it compared
CISD to an information-only and no-intervention condition. This
allowed for an examination of the differential impact of what could
be considered the nonactive, but perhaps sufficient, components of
CISD (empathic contact with a professional coupled with the
provision of information about trauma and its impact, etc.). There
were no differences between the three groups in rates of PTSD,
severity of PTSD, or depression at follow-up, suggesting that
providing PD to individuals exposed to PTE has no unique effect on
outcome in victims of violent crime.
Few published studies have empirically examined the use of
debriefing in the military, despite its frequent use in militaries
across a diverse range of cultures (Adler & Bartone, 1999).
Deahl et al. (2000) conducted the only RCT of soldiers provided PD
in a group format, with mixed results. At the 6-month follow-up,
Bosnia peacekeepers in the debriefed group had lower HADS scores
than those in the nondebriefed group, but the nondebriefed soldiers
reported a greater drop in IES scores from baseline. On the other
hand, alcohol abuse problems were lessened over time in the
debriefed group and not the control group. However, Deahl et al.'s
findings are difficult to interpret because of a likely floor
effect; at baseline soldiers expressed very low symptoms. In
addition, since commanding officers assigned soldiers to the study
by virtue of availability, selection bias cannot be ruled out.
All studies employed CISD, or at least stated that they followed
the basic tenets of CISD, with individuals (the Bisson et al. study
also used couples) who would be considered primary victims of
trauma in the CISD scheme (e.g., burn victims and traffic accident
survivors). However, no investigators explicated their rationale
for intervening with individuals who would be excluded from CISD
formally. It would have been preferable for investigators to
contextualize their work in light of the recommendations of CISD,
given that they are testing the efficacy of this specific approach.
In our view, it is legitimate to evaluate whether CISD could be
useful to individuals who experience severe trauma, especially
given the popularity of CISD and its application to so-called
primary victims. However, without sufficient background
justification, these studies are at risk for being dismissed as
inappropriate tests of the CISD model. Furthermore, proponents of
CISD might argue that negative findings confirm the CISD principle
that individual primary victims of trauma are inappropriate for PD
(this is the main criticism of the Cochrane review). Clearly,
controlled study of group-administered CISD to emergency services
personnel exposed secondarily to trauma is needed to test the CISD
model.
A number of studies suffered from participant selection that was
likely biased in unspecified ways. For example, only 7% of the
victims of violent crime contacted by Rose et al. (1997) consented
to participate. The self-selected group of victims who agreed to
participate may have been more willing to talk about their trauma
and may have been less avoidant overall than the average victim.
Thus, it remains an empirical question whether PD might be
effective for reluctant and avoidant victims who may agree to
participate in PD because organizations or hospitals recommend it
as part of routine practice (Shalev, 1994). Theoretically, the PD
process may facilitate change in these individuals because it
reduces avoidance by suggesting experientially that approach
behaviors (e.g., self-disclosing) can lead to favorable
outcomes.
The timing of the interventions provided was also variable. For
example, Rose et al. provided CISD, on average 21 days postincident
(range: 9-31 days), which differs considerably from the standard
practice of providing PD within days of a PTE (it also differs from
the timing of PD in other RCT). However, it could be argued that it
is more appropriate to delay PD in some contexts. For example, in
the case of the Bisson et al. (1997) study where individuals were
suffering from acute burn pain, it may have been more appropriate
to delay the PD until acute pain is managed effectively. It is also
unclear whether burn patients are appropriate for a single session
of any early intervention, given the physiological and
psychological burden of burns (Weinberg et al., 2000).
Although most of the participants who received PD reported that
they experienced it as very helpful, perceived helpfulness was not
associated with positive change in psychological status. Although
this pattern could reflect the influence of demand characteristics,
it is also possible that early professional contact may make people
feel validated about their suffering and result in positive
evaluations about PD. The nonspecific beneficial elements of
respectful listening and validation may have a positive influence,
but this has not been measured in studies of PD to date.
Several studies that revealed symptom exacerbation concluded
that PD might be inappropriate because it involves emotional
processing of a trauma prematurely and without sufficient time for
follow-up therapeutic processing (e.g., Bisson et al., 1997). This
conclusion appears premature, however, because there is a lack of
information about the extent of negative affect produced by the PD,
and there is no treatment fidelity data to evaluate the specific
content of PD interventions. Another flaw of these studies is their
failure to index the extent to which participants perceive PD as an
imposition, which could exacerbate distress. However, in one study,
it was found that those who chose to receive a PD reported higher
exposure to the stressor and more severe initial symptoms and a
greater willingness to talk about their experience than those who
opted out of PD (Fullerton, Ursano, Vance, & Wang, 2000).
Finally, some individuals may report more symptoms after PD because
the experience enhances their awareness of internal experiences and
symptoms, therefore sensitizing them to report more intense or
frequent trauma-related symptoms but perhaps not more functional
impairment (Neria & Solomon, 1999; Rose et al., 2001). Future
studies should evaluate areas of functional impairment as well as
symptomatology.
It is possible that a one-time PD is insufficient and
individuals need more sustained intervention. However, the results
of one recent study suggest that multiple debriefing sessions may
not in fact be effective. Carlier, Voerman, and Gersons (2000)
provided three debriefing sessions (at 24 hours, 1-month and
3-months postincident) to police officers in the Netherlands
exposed to trauma and found that PD had no impact. These
researchers also found that, one week postincident, debriefed
subjects reported more PTSD symptoms than nondebriefed subjects,
which is consistent with several studies (e.g., Bisson et al.,
1997). Even if PD is applied over several occasions, it may fail to
pay sufficient attention to assisting group members in preparing
for the challenges they face in the coming weeks and months.
Nevertheless, determining the optimal number of sessions and the
necessity for follow-up, in order to enhance maintenance, are
empirical questions for future research.
The timing of providing PD has not been systematically studied.
While Mitchell and Everly (1986) argue that PD is most effective
when conducted very soon after a critical incident, this empirical
question has not been explicitly tested. Several authors have
suggested that CISD may exacerbate symptoms because the trauma is
confronted too early, which is disruptive rather than healing (Gist
& Woodall, 2000; Shalev, 2000). It may be that, for some people
exposed to some types of traumas, a period of rest and relative
withdrawal is what is needed. In this context, PD may be
experienced as an imposition and may be overwhelming for some if it
is provided too early.
Conclusions
Single session PD, when applied to individuals with moderate to
severe exposure to PTE who are not prescreened for risk factors or
suitability for active intervention, is not useful in reducing PTSD
symptoms to a greater extent than would occur with the passage of
time, Although it is premature to conclude unequivocally that PD
hinders recovery from trauma (and, researchers have yet to
explicate the cause(s) of symptom exacerbation), there is
sufficient evidence that the indiscriminant use of single-session
PD with individuals is inappropriate. However, much more research
is needed to examine: (a) the optimal time frame to provide early
intervention, (b) the process of change, (c) the specific change
agents, (d) the type of postintervention behaviors that promote
recovery and maintenance of change, and (e) the optimal mode and
method of screening for various types of PTE (e.g., mass disaster
and victims of violence presenting at emergency rooms). Although we
recommend that interventions be devised to treat only those
individuals who are not likely to recover over time on their own,
more research is needed to determine which risk indicators and risk
mechanisms are optimal. In addition, researchers and clinicians
should be vigilant about the possibility that early identification
of individuals could inadvertently produce negative iatrogenic
effects (e.g., stigmatization and self-fulfilling prophecy).
The application of PD to groups of emergency services personnel
has yet to be examined with a RCT. However, the roles of the
peacekeepers who were provided group PD in the Deahl et al. (2000)
study are similar to those of emergency services personnel;
peacekeepers are typically well-trained and chiefly exposed to
others' suffering and the aftermath of violence (Litz, 1996). There
is initial evidence that PD provided for groups of individuals with
a shared background and experience and low to moderate stressor
exposure does not serve to reduce stress symptoms. On the other
hand, group PD appears to facilitate more adaptive coping (e.g.,
less use of alcohol). More research is needed to examine the
efficacy of group PD for other emergency care providers, especially
in the context of exposure to severe PTE.
Cognitive-Behavioral Therapy as Early Intervention
Recent investigations of cognitive-behavioral therapy (CBT) for
recently traumatized individuals have demonstrated promising
results in preventing the development of chronic psychopathology
following trauma. In this section, we describe in detail one pilot
study and two RCTs of multisession secondary prevention of PTSD.
Our intention is not only to critically evaluate the research
methodology but also to provide a detailed description of the
assessment and intervention strategies employed and contrast them
to the PD approach.
Foa, Hearst-Ikeda, and Perry (1995) compared the symptom course
of 10 female victims of rape or aggravated assault who received a 4
session cognitive-behavioral intervention shortly after their
assault with that of 10 assessment-only control victims. All
participants were matched on symptom severity, type and severity of
assault, demographic characteristics, and time since the assault.
This individually administered intervention consisted of educating
participants about common reactions to assault, relaxation
training, imaginal and in vivo exposure, and cognitive
restructuring. During the first session, victims were educated
about common posttraumatic reactions and they were asked to list
avoided activities and situations. The second session began by
providing victims with a rationale for exposure therapy followed by
relaxation training. The relaxation training was audio taped, and
victims were encouraged to use this tape to practice relaxation
techniques at home. Next, imaginal exposure was conducted as
victims were instructed to relive the assault by closing their
eyes, vividly imagining the event, and describing it aloud in the
present tense. This narrative was also audio taped and victims were
encouraged to use this tape to repeat imaginal exposure daily.
During the narrative, the therapist attended to maladaptive beliefs
that the victim mentioned regarding perceived incompetence and the
dangerousness of the world. The remainder of the session was
devoted to cognitive restructuring as maladaptive beliefs that
emerged during the victim's trauma narrative were challenged. In
addition to imaginal exposure homework, victims were encouraged to
begin confronting some of their avoided situations and activities.
The third session consisted of imaginal exposure and cognitive
restructuring, and once again, victims were encouraged to repeat
imaginal and in vivo exposure exercises daily on their own. Victims
were also instructed to monitor negative thoughts, feelings, and
cognitive distortions using a daily diary. The fourth and final
session again consisted of imaginal exposure to the assault
followed by cognitive restructuring.
Two months after the assault, victims receiving CBT reported
experiencing significantly fewer symptoms of PTSD than did
assessment control participants. At a 5.5-month follow-up
assessment, participants in the treatment condition reported
significantly fewer symptoms of depression, although there were no
differences between groups with respect to PTSD symptoms. Effect
size analyses indicated that the difference in PTSD scores between
the two groups at the 5.5-month follow-up was relatively large, but
because of the small sample size, the lack of a statistically
significant difference likely resulted from low statistical power.
Moreover, the control group in this investigation experienced
significant symptom remission that also may have contributed to the
lack of a statistically significant difference in PTSD symptoms at
the 5.5-month follow-up. Nevertheless, the large reductions in PTSD
symptoms at posttreatment coupled with significantly reduced
depressive symptomatology at the 5.5-month follow-up suggests that
additional study of CBT in secondary prevention interventions for
trauma is indicated.
Bryant, Harvey, Dang, Sackville, and Basten (1998) also report a
successful CBT program for recently traumatized individuals. This
intervention specifically targeted individuals with ASD, and
accordingly their study provided a more direct test of the efficacy
of brief CBT in preventing PTSD. Moreover, because control
participants received supportive counseling, it was possible to
evaluate the extent to which treatment promoted improvement above
and beyond that resulting from nonspecific therapeutic factors.
Participants were survivors of motor vehicle accidents or
industrial accidents who were randomly assigned to either CBT or
supportive counseling. Both interventions consisted of five
1.5-hour weekly individual therapy sessions. Similar to the Foa et
al. (1995) intervention, CBT included education about common
posttraumatic reactions, relaxation training, imaginal exposure to
the traumatic event, graded in vivo exposure, and cognitive
restructuring. Each of the last 4 sessions included 40 minutes of
imaginal exposure, and participants were encouraged to engage in
imaginal exposure daily between treatment sessions. By contrast,
the supportive counseling condition included trauma education and
more general problem-solving training in the context of an
unconditionally supportive relationship.
At posttreatment and at 6-month follow-up, significantly fewer
participants in the cognitive-behavioral treatment group met
diagnostic criteria for PTSD compared to supportive counseling
control participants. Similarly, those in the cognitive-behavioral
treatment group reported significantly fewer symptoms of PTSD at
posttreatment and 6-month follow-up, and significantly fewer
symptoms of depression at the 6-month follow-up, than did
participants in the supportive counseling condition.
In a subsequent study that dismantled the components of CBT,
Bryant and colleagues randomly allocated 45 civilian trauma
survivors with ASD to five sessions of either (a) CBT (prolonged
exposure, cognitive therapy, anxiety management), (b) prolonged
exposure combined with cognitive therapy, or (c) supportive
counseling (Bryant, Sackville, Dang, Moulds, & Guthrie, 1999).
This study found that, at a six-month follow-up, PTSD was observed
in approximately 20% of both active treatment groups compared to
67% of those receiving supportive counseling.
The brief cognitive-behavioral interventions described by Foa et
al. (1995) and Bryant et al. (1998, 1999) represent encouraging
attempts to prevent the development of chronic posttraumatic
pathology in recent trauma victims. These interventions share many
features with psychological debriefing. For example, they both
include an education component designed to inform trauma victims
about common posttraumatic reactions and sequelae, and both attempt
to teach coping skills for managing symptoms of stress and
anxiety.
Given the similarity between psychological debriefing and
cognitive behavioral interventions, what may account for the
apparent differences in treatment efficacy? Perhaps the most
prominent reason that CBT appears to be more efficacious is the
greater emphasis on repeated imaginal reliving of the traumatic
event and graded in vivo exposure of avoided trauma-reminiscent
situations. In their review of the psychological debriefing
literature, Bisson et al. (2000) suggest that one-session intense
exposure to trauma memories that characterizes most debriefing
approaches might be counter-therapeutic because it may heighten
arousal and distress without allowing sufficient time for
extinction or resolution of intensely negative posttraumatic
affect. The results of the cognitive-behavioral interventions
described above would seem to refute the notion that early exposure
per se is counter-therapeutic. Rather, the hasty and
incomplete exposure to trauma memories that typifies traditional
psychological debriefing approaches may be potentially harmful.
The CBT approaches of Foa et al. (1995) and Bryant et al. (1998,
1999) also included considerable attention to cognitive
restructuring. There is considerable evidence that acute
pathological trauma responses are characterized by catastrophic
cognitive styles (Smith & Bryant, 2000; Warda & Bryant,
1998). There is increasing evidence from treatment studies of PTSD
that cognitive restructuring is effective in reducing symptoms
(Tarrier et al., 1999). The inclusion of cognitive restructuring
over repeated sessions in the early provision of CBT is an
important difference between current PD approaches and structured
CBT.