The aim of all disaster mental-health management, including
any type of debriefing, should be the humane, competent, and
compassionate care of all affected. The goal should be to prevent
adverse health outcomes and to enhance the well-being of
individuals and communities. In particular, it is vital to use
all appropriate endeavors to prevent the development of chronic
and disabling problems such as PTSD, depression, alcohol abuse,
and relationship difficulties. Debriefings are a type of
intervention that are sometimes used following a disaster or
other traumatic event.
Different types of debriefing
Operational debriefing is a routine and formal part of an organizational response to a disaster. Mental-health workers
acknowledge it as an appropriate practice that may help
survivors acquire an overall sense of meaning and a degree of
closure.
Psychological or stress debriefing refers to a variety
of practices for which there is little supportive empirical
evidence. It is strongly suggested that psychological
debriefing is not an appropriate mental-health intervention.
Critical Incident Stress Debriefing (CISD) is a
formalized, structured method whereby a group of rescue and
response workers reviews the stressful experience of a
disaster. CISD was developed to assist first responders such as fire
and police personnel; it was not meant for the survivors of a
disaster or their relatives. CISD was never intended as a
substitute for therapy. It was designed to be delivered in a
group format and meant to be incorporated into a larger,
multi-component crisis intervention system labeled
Critical Incident Stress Management (CISM). CISM includes the following
components: pre-crisis intervention; disaster or large-scale
demobilization and informational briefings (town meetings);
staff advisement; defusing; CISD; one-on-one crisis counseling
or support; family crisis intervention and organizational
consultation; follow-up and referral mechanisms for assessment
and treatment, if necessary.
Currently, many mental-health workers consider some form of
stress debriefing the standard of care following both natural
(earthquakes) and human-caused (workplace shootings, bombings)
stressful events. Indeed, the National Center for PTSD's Disaster
Mental Health Guidebook (which is currently being revised)
contains information on how to conduct debriefings. However,
recent research indicates that
psychological debriefing is not always an appropriate
mental-health intervention. Available evidence shows that, in
some instances, it may increase traumatic stress or complicate
recovery. Psychological debriefing is also inappropriate for
acutely bereaved individuals. While operational debriefing is
nearly always helpful (it involves clarifying events and
providing education about normal responses and coping
mechanisms), care must be taken before delivering more
emotionally focused interventions.
A recent review of eight debriefing studies, all of which met
rigorous criteria for being well-controlled, revealed no evidence
that debriefing reduces the risk of PTSD, depression, or anxiety;
nor were there any reductions in psychiatric symptoms across
studies. Additionally, in two studies, one of which included
long-term follow-up, some negative effects of CISD-type
debriefings were reported relating to PTSD and other
trauma-related symptoms
1. Therefore, debriefings as currently employed may be useful for low
magnitude stress exposure and symptoms or for emergency care
providers. However, the best studies suggest that for individuals
with more severe exposure to trauma, and for those who are
experiencing more severe reactions such as PTSD, debriefing is
ineffective and possibly harmful.
The question of why debriefing may produce negative results
has been considered and hypotheses have been formulated. One
theory connects negative outcomes with heightened arousal in the
early posttrauma phase and in long-term psychopathology
2,
3. Because verbalization
of the trauma in debriefing is limited, habituation to evoked
distress does not occur. The result may be an increase rather
than a decrease in arousal. Any such increased distress caused by
debriefing may be difficult to detect in a group setting. Thus,
attempting to use debriefing to override dissociation and
avoidance in the immediate posttrauma phase may be detrimental to
some individuals, particularly those experiencing heightened
arousal. Another consideration is that the boundary between
debriefing and therapy is sometimes blurred (e.g., challenging
thoughts), which may increase distress in some individuals
3. Finally, those facilitating the debriefing sessions
frequently are unable to adequately assess individuals in the
group setting. They may erroneously conclude that a one-time
intervention is sufficient to prevent further symptomatology.
Practice guidelines on debriefing formulated by the
International Society for
Traumatic Stress Studies conclude there is little evidence
that debriefing prevents psychopathology. The guidelines do
recognize that debriefing is often well received and that it may
help (1) facilitate the screening of those at risk, (2)
disseminate education and referral information, and (3) improve
organizational morale. However, the practice guidelines
specify that if debriefing is employed, it should:
Be conducted by experienced, well-trained
practitioners
Not be mandatory
Utilize some clinical assessment of potential
participants
Be accompanied by clear and objective evaluation
procedures
The guidelines state that while it is premature to conclude
that debriefing should be discontinued altogether, "more complex
interventions for those individuals at highest risk may be the
best way to prevent the development of PTSD following
trauma."
References
1.
Rose, S.,
Bisson, J., & Weseley, S. (2001). Psychological debriefing
for preventing Posttraumatic Stress Disorder (PTSD). The Cochrane
Library, Issue 3: Update Software Ltd.