Monday, 16 January 2012

Is it time to resurrect post-trauma psychological debriefing for emergency responders and aid workers?

You've probably seen on the news, after a disaster, the announcement that trained counsellors will be on hand as a matter of routine. Or you used to. In fact, the practice of offering routine post-trauma psychological debriefing (Critical Incident Stress Debriefing - CISD - to give it its original, formal title) is all but dead and buried. It's hard to say who exactly executed the fatal blow.

NICE - the trusted, independent UK body that provides health advice - is a chief culprit. Based on seven randomly controlled trials (RCTs) comparing psychological debriefing against control groups, NICE recommended in 2005 that brief, single-session interventions not be routinely offered to individuals who have experienced a traumatic event. In 2006, another likely culprit, the Cochrane Collaboration, (widely respected for its meta-analyses of published studies) identified 15 relevant RCTs and made a similar recommendation.

Psychiatrist Simon Wesseley, based at the Institute of Psychiatry in London, went further and must also be a chief suspect. In a debate held at the Royal Institution in 2006, he proposed psychological debriefing after trauma as the "worst ever idea on the mind", based on the fact that it's ineffectual and possibly harmful. "It's a bad idea and a bad intervention," he said.

I must confess that I too may have played a part, however minor, in the demise of post-trauma counselling. In my Psychologist magazine article When Therapy Causes Harm, I highlighted Critical Incident Stress Debriefing as among the therapies identified by Emory University psychology professor Scott Lilienfeld as potentially harmful and that should be avoided. In my book The Rough Guide to Psychology, I used the possible harm caused by post-trauma psychological debriefing as an example of a counter-intuitive finding in psychology.

Now a team of therapists and trauma consultants, Debbie Hawker, John Durkin and David Hawker, who've worked extensively with NGOs, aid workers and emergency responders, have called for post-trauma debriefing to be resurrected for these specific client groups. In a scholarly plea, they've argued that the damning conclusions formed by NICE, Cochrane, Wesseley and others were premature and too narrowly interpreted (NICE acknowledges that their guidance may not apply to debriefing of emergency workers or group debriefing). Hawker and co claim that there are many who would welcome the return of post-trauma debriefing: "As mental health professionals active in the military, emergency service and humanitarian fields, we are aware that the personnel we work with often request debriefing, and speak of its benefit for them". Yet the debriefing is usually not available: "Professionals ... are afraid of being accused of professional misconduct if they offer psychological debriefing ...".

Hawker and co point out that of the 15 RCTs identified by the NICE and Cochrane reviews, three found a positive effect of debriefing, nine found no effect and only two found a harmful effect. These two studies, they explain, were seriously flawed. The patients who received debriefing were more severely injured than the controls; they received debriefing too soon, before they were ready; the debriefing was too brief (it averaged 44 minutes, whereas experts say it should last at least two hours, with at least one follow up); and the debriefers were inadequately trained (a research assistant delivered the debriefing in one study; the other negative outcome study said the debriefers had received half a day's training).

In effect, Hawker et al say, these trials were more like "inefficacy trials" - exploring what happens when an intervention is delivered badly to the wrong people. As it was originally conceived, they explain, post-trauma psychological debriefing was meant to be part of:
"a package for emergency workers who'd experienced critical incident stress as part of their work. It was specifically designed for selected psychologically resilient personnel who are trained to cope with expected pressure during their routine work in stressful situations. These are teams of people who have trained together and been briefed together before working together."
Post-incident debriefing was also meant to be delivered by a mental health worker and a peer debriefer, both of whom should have experience of the emergency services they're working with, thus lending the debriefers all-important credibility.

Debriefing is popular with emergency workers and aid workers, Hawker and co say, because many of them see it as their only chance to talk about their experiences. It allows them to do so as a matter of routine, without the stigma of therapy, which they sometimes fear could be detrimental to their careers. Given this need, perhaps it's no surprise that post-trauma psychological debriefing is surfacing under new names like "powerful event group support" and "trauma risk management".

"We have been told that the case against debriefing is proven and the debate is closed," Hawker, Durkin and Hawker conclude. "We disagree ... We predict that appropriate psychological debriefing will be shown to have benefits for secondary victims of trauma who have been briefed together and who have worked together through traumatic events. Research into these uses of debriefing should be encouraged and supported."

_________________________________ ResearchBlogging.org


Hawker, D., Durkin, J., and Hawker, D. (2011). To debrief or not to debrief our heroes: that is the question. Clinical Psychology and Psychotherapy, 18 (6), 453-463 DOI: 10.1002/cpp.730



Post written by Christian Jarrett for the BPS Research Digest.

17 comments:

  1. Anonymous10:50 am

    As an aid worker who experienced long-term severely traumatic events, I can confirm that the psychological debriefing I was given was far too short and conducted by someone who didn't appear particularly interested in what they were doing. It also took about 18 months for me to fully digest the experience, and it was only after this delay that all of the emotional response came tumbling out. Pyschological wellfare of aid workers is of paramount importance - we ask them to do terrible jobs in often very difficult circumstances. My feeling is that psychological debriefing on return from mission (2 hours minimum) is important, but it HAS to be done properly, with empathy and with real engagement. Otherwise it is worse than useless, and can be damaging. I certainly felt that my experiences were brushed aside, and the debriefer was more interested in his next coffee break.

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    1. Debbie Hawker12:06 pm

      As one of the authors of the paper, I can only say that I'm sorry you were treated in such a disrespectful, unhelpful manner. I agree with your comments that if debriefing is offered, it must be done properly. This is why we are working to improve care for aid workers, as too many have had experiences similar to those you describe.

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  2. Anonymous12:55 pm

    It's not time to bring it back, or just to critique the review: it's time for an updated review on this critically important subject.

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  3. I think there's an important distinction in the paper which is not made entirely clear in the post: the authors are not arguing for the benefit of post-disaster 'critical incident stress debriefing' for everyone, just aid workers.

    I think we have more than sufficient evidence to avoid 'debriefing' after disasters for the general population. Consequently, it is now being specifically not recommended by everyone from the World Health Organisation to the National Center for Child Traumatic Stress.

    However, I'm not sure the authors' argument for the utility of debriefing for aid workers is convincing either.

    They spend a lot of time highlighting the problems in two trials in meta-analyses that reported a harmful effect of debriefing but don't tackle the other trials which showed the intervention to be ineffective. Deploying ineffectual interventions is not to be recommended either.

    But the two harmful trials they critique are not on aid workers and neither are the meta-analyses in which they appear. Meanwhile, comparative trials specifically on aid workers also show harmful effects of debriefing...

    http://dx.doi.org/10.1348/000711200160327
    http://dx.doi.org/10.1080/10811440290057639
    http://dx.doi.org/10.1002/(SICI)1099-1700(199807)14:3<143::AID-SMI770>3.0.CO;2-S

    or report no effect:

    http://www.ncbi.nlm.nih.gov/pubmed/10473306

    The authors make that point that much of the 'debriefing' studied in the literature does not strictly adhere to the original Mitchell and Everly approach which is a valid criticism. Probably for this reason the World Health Organisation define debriefing as "as promoting ventilation by asking a person to
    briefly but systematically recount their perceptions, thoughts and emotional reactions during a recent stressful event" in their guidelines 'Psychological first aid: Guide for field workers'.

    Nevertheless, supporters of debriefing need to show that the strict intervention has a beneficial effect while similar forms of discussing the event have no effect or are harmful. As even the trials of orthodox debriefing show, at best, no effect, there is still no convincing evidence that critical incident stress debriefing is a useful intervention and the evidence for risk remains.

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    1. D Hawker12:56 pm

      Thank you for such a considered and informed response. I understand that you work for MSF, and I wonder what support you recommend in place of debriefing? I am always keen to learn from others.

      To respond to a few of your points:
      1. Many of the studies in the NICE and COCHRANE reviews which found debriefing to have no effect suffer from similar problems to the 2 studies which we highlighted (intervention being too short etc). As our main focus is on the debriefing of selected, trained emergency responders/ aid workers, we did not go in to details of all the methodological problems with the RCTs on people for whom CISD was never designed.
      2. You mention some studies of police officers and firefighters. (You also list Rose's study of victims of crime - which is one of the NICE studies but not on aid workers).
      The police and fire fighter studies you mention were not RCTs. They are interesting but fail to mention important details about the timing and duration of debriefing etc. The Carlier et al (1998) study found one significant result out of multiple analyses and the authors acknowledge the possibility of Type 1 error. The data were obtained retrospectively. In the Carlier et al (2000) study the main comparison was between debriefed officers and officers who declined debriefing, often as they did not perceive the event as shocking (i.e. it was not a trauma to them) - so the comparison is limited. 'Debriefings' took place 24 hours after the trauma (which is too soon), and again after 1 and 3 months. Intervention averaged 41 minutes, 17 minutes and 16 minutes - which is not an adequate length of debriefing. Follow-up data were restrospective, and there were difficulties with matching the groups.

      There have been many other studies of CISD among firefighters, police officers etc with various results. Reviews indicate that on thoe whole debriefing has been shown to be more effective with emergency workers than with primary victims of trauma. But there is a lack of high quality research using interventions of sufficient duration etc. We agree with your point that there is a need to demonstrate whether debriefing is beneficial for aid workers. In the paper we mention some related research with military groups. One reason for our paper is to encourage further research on this.

      As we mention, benefits are not limited to reduced risk of PTSD. There are many benefits (such as increased morale) which have not been reported in the RCTs.

      In the meantime, we continue to also use other appropriate (and proven) psychological measures to support aid workers (throughout their whole experience, from selection, placement, preparation, on-field support through to re-entry).

      Thank you for discussing this with us. We value your comments.

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    2. David Hawker1:50 pm

      As third author, I would like to add some further comments on Vaughan's stimulating critique.

      There is a limit to what can be covered in a single article. Our paper took over a decade to get into print and faced extraordinary challenges along the way. We chose to focus on two trials in detail because of their disproportionate influence on the debate.

      You are right to take up our point that the two harmful trials (like the meta-analyses) were not on aid workers. The frustrating thing it is those trials are nevertheless used to deny them effective debriefing. Too many are still offered either no debriefing, or inadequate debriefing as described by the anonymous aid worker above.

      We would not argue that Mitchell-Everley debriefing is the only effective model. Rather, we would expect that similar methods would be similarly effective. What we would disupte is the notion that a brief discussion of a traumatic event is as good as a long one.

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  4. hi Vaughan - thanks for your comments.

    You said: "I think there's an important distinction in the paper which is not made entirely clear in the post: the authors are not arguing for the benefit of post-disaster 'critical incident stress debriefing' for everyone, just aid workers."

    Thanks for highlighting that distinction. I've made a couple of tweaks to the post and to the title, to make that distinction clearer in my blog post.

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  5. The timing looks to be crucial too - debriefing/counselling close to the event reduces forgetting. I doubt it would be useful to promote better retention of potentially traumatic events.

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    1. D Hawker7:16 pm

      That's right. We would not recommend debriefing in the first 24 hours after the event or while trauma is ongoing.

      Delete
  6. In my opinion it is a valuable preventative measure. Even if it isn't necessary for the majority of aid workers it can serve as a good evaluation tool to determine if someone requires more attention and counseling. Far too often we deny people preventative measures due to economic circumstances, but it only leads to bigger and costlier problems down the road. Compassion immediately often makes sense financially too.

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  7. I am training to be an integrative psychotherapist and currently am completing my EMDR training working with veterans. I hope to use this and other techniques to work with aid workers but am finding if difficult to source any information on recruitment.
    Can anyone help?

    Many thanks

    Kat

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  8. Anonymous12:39 pm

    Hello, I am newly responsible for a group of volunteer debriefers suporting a Fire and Rescue Service. I do not have a clinical background but have been trained in our adopted process (based on Mitchell). Up until recently we have had an occupational health Dr who has completely supported our process, but recently we got a new doctor. I think he has been reading the Cochrane Report and NICE recommendations as he is questioning the process in particular concerns about calling the process 'debriefing' he thinks it should probably be called 'defusion' instead his belief being that a debrief has some negative connotations in that it implies a psychological debrief has taken place, which he believes has been largely discredited as a process. I have shared this article and I truly believe it to be part of a suite of support for our staff. I would very much like to read the further paper. To debrief or not to debrief our heros that is the question, but I am not part of any clinical body, can you help me to find where I might get it. What I really want to do is put to bed his concerns. Thank you

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    1. Hi, if you click on the "authors" tab here: http://onlinelibrary.wiley.com/doi/10.1002/cpp.730/abstract

      you will see a contact email address for the authors. I suggest you contact them and request a copy of their paper.

      Delete
    2. sorry, to be clear, the tab is marked "author information"

      Delete
    3. Anonymous10:26 am

      Sorry - I have only just seen your message. To contact the authors, email doctors_hawker@yahoo.co.uk

      Delete
  9. Anonymous1:34 pm

    Thank you for your replies. I have taken direction and am looking forward to their reply.

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  10. Anonymous10:48 am

    Hello - I've been asked to investigate options for a team of legal professionals who frequently work on harrowing cases. I appreciate that their needs will be very different, as they don't witness the trauma first hand. They generally investigate a case over several months, have to review graphic evidence, take witness statements and will have continued contact with witnesses. They have requested access to drop-in counselling sessions run by an external expert. Does anyone have any advice as to how I could proceed? Thank you.

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