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."

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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.

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