MeSH  Options  History

This review should be cited as: Suzanna Rose, Jonathan Bisson, Simon Wessely. Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane Review). In: The Cochrane Library, Issue 3, 2001. Oxford: Update Software.

A substantive amendment to this systematic review was last made on 02 May 2001. Cochrane reviews are regularly checked and updated if necessary.

Background: Over approximately the last last fifteen years early psychological interventions such as psychological 'debriefing' have been increasingly used to treat psychological trauma. While these intervention have become popular and their use spread to several settings - efficacy had largely not been tested emprically. In 1997 a systmatic review of single session psychological "debriefing" was undertaken and this subsequently became a protocol and Cochrane Review published in 1998 (Issue2). This update forms the first substantive update of the original review.

Objectives: To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder.

Search strategy: Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health,SOCIOFILE, CINAHL, PSYCINFO, PSYNDEX, SIGLE, LILACS, CCTR, CINAHL, NRR, Hand search of Journal of Traumatic Stress. Contact with leading researchers.

Selection criteria: The inclusion criteria for all randomized studies was that they should focus on persons recently (one month or less) exposed to a traumatic event, should consist of a single session only, and that the intervention involve some form of emotional processing/ventilation by encouraging recollection/reworking of the traumatic event accompanied by normalisation of emotional reaction to the event.

Data collection and analysis: 11 trials fulfilled the inclusion criteria. Quality was generally poor. Data from two trials could not be synthesised.
Two trials involved the use of the intervention in an obstetric setting.

Main results: Single session individual debriefing did not reduce psychological distress nor prevent the onset of post traumatic stress disorder (PTSD). Those who received the intervention showed no significant short term (3-5 months) in the risk of PTSD (odds ratio 1.22 (95% ci 0.60 to 2.46 )). At one year one trial reported that there was a significantly increased risk of PTSD in those receiving debriefing (odds ratio 2.88 (1.11 to 7.53))odds ratio 95%).

There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety.

Reviewers' conclusions: There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease.

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Background

Debriefing is a psychological treatment intended to reduce the psychological morbidity that arises after exposure to trauma (Hodgkinson & Stewart, cited in Rose, 1997). Its origins can be traced to efforts to maintain group morale and reduce psychiatric distress amongst soldiers immediately after combat. It became prominent in the 1980s when the principles were transferred to civilian life.

Debriefing involves promoting some form of emotional processing/catharsis or ventilation by encouraging recollection/ventilation/reworking of the traumatic event. Mitchell, 1983 and Dyregov, 1989 have operationalised it in seven stages:

1. Introduction
2. The facts
3. Thoughts and impressions
4. Emotional Reactions
5. Normalisation
6. Planning for the future
7. Disengagement

Curtis (1995) suggests an eight stage approach:
1. Identification
2. Labelling
3. Articulation
4. Expression
5. Externalization
6. Ventilation
7. Validation
8. Acceptance

Another variation, known as Multiple Stressor Debriefing (Armstrong et al., 1991) has a similar model, but with more emphasis on discussion of previous experience of trauma and coping. It will be seen that the critical elements that unite these approaches are those of identifying emotional responses, encouraging their expression and legitimizing them ("it's normal, it's to be expected").

Debriefing has been used in a considerable range of circumstances. The literature contains accounts of debriefing of police officers involved in shooting incidents, sailors after maritime collisions, Red Cross personnel, adolescents who have been secluded during psychiatric admissions, medical students whose patients have died, families whose children are undergoing bone marrow transplants, any rescue workers involved in any natural disaster, soldiers assigned to grave registration duties, drivers of trains who have witnessed people jumping under their trains, jurors involved in disturbing murder trials, burns victims, road traffic accident victims, rape victims, medical or paramedical staff involved in failed resuscitations, patients who have recovered from testicular cancer, nurses involved in cancer care, children involved in any accident, casualty staff after traumatic incidents, workers who have experienced or witnessed an industrial injury, or who have colleagues who have been injured, Air Force personnel on bases where fatal accidents have occurred, children in schools where traumatic incidents have taken place (either on or off site), and no doubt many other situations.

There is no doubt that debriefing is now routinely offered in a number of settings internationally, including the victims of mass disasters, or individuals involved in traumatic incidents in the workplace. Debriefing is usually offered on a voluntary basis, but there are instances, such as debriefing of bank employees in both the UK and Australia, or in some UK police forces, who are victims of trauma, when it can be compulsory. This is in order to reduce the threat of litigation concerning the development of post traumatic stress disorder (PTSD) . The assumption of such policies is naturally that debriefing can prevent the onset of PTSD.

Debriefing has two principal intentions. The first is to reduce the psychological distress that is found after traumatic incidents. The second, related, intention is to prevent the development of psychiatric disorder, usually PTSD.

The effectiveness of debriefing in achieving either of these aims remains unknown. Exponents of debriefing draw attention to its popularity, and claim that it is meeting important needs (example, Robinson & Mitchell, 1995). Others are more cautious. Recent reviews ( Shalev, 1994; Raphael et al , 1995;Raphael et al, 1996; Rose 1997, Rick et al. 1998) drew attention to the lack of randomised controlled trials. This is an update of a previous systematic review published in this format.

Objectives

Criteria for considering studies for this review

Types of studies

Types of participants

Types of intervention

Interventions were restricted to a single session only.

Excluded:
1. Crisis intervention services for psychiatric patients and/or their families
2. Debriefing of research participants, such as psychology students recruited for studies involving deception
3. Perinatal grief support/bereavement counselling
4. Treatment of PTSD
5. N=1 and cross over designs will not be included at present
6. Interventions aimed at children

Types of outcome measures

B: Measurement.
a) Traumatic stress symptoms:
Impact of Event Scale (IES). This has been widely used in this context, and formed the main measure for this review. It can be understood as a measure of how much a person is bothered by unpleasant memories of the trauma.
Traumatic Neurosis Symptoms (not included in analysis)
Clinician Administered PTSD Scale (not included in analysis)

b) General psychological morbidity.
Hospital Anxiety and Depression Scale (HADS),
Brief Symptom Inventory (BSI) (not included in analysis)
Langer 22 Item Scale of psychiatric symptoms (not included in analysis)

c) Depression:
Hospital Anxiety and Depression Scale - Depression Subscale (HAD-D)
Beck Depression Inventory (BDI).
Edinburgh Postnatal Depression Scale (not included in analysis)

d) Anxiety:
Hospital Anxiety and Depression Scale- Anxiety Subscale (HAD-A);
Spielberger State/Trait Anxiety.
Gottschalk and Gleiser content analysis of anxiety (not included in analysis)
Viney and Westbrook cognitive anxiety (not included in analysis)

C: Duration of follow up.
Studies recorded outcomes from between one month to 3 years. One study recorded only the immediate effect of intervention (Bunn). In the analysis an a priori decision was made to measure outcome within one month, between two and five months, between six and twelve months, and longer than twelve months.

Search strategy for identification of studies

See: Collaborative Review Group search strategy

ELECTRONIC SEARCH STRATEGY
1. All references to debrief*, critical incident (no qualifiers), crisis intervention in all databases
2. Cochrane Medline optimal RCT search strategy was combined with key words "explode rape" in MeSH ( trauma, traumatic stress, road accident, victim).
3. Cochrane Medline optimal RCT search strategy was combined with PTSD, post-traumatic, stress-prevention (although trials of the management of PTSD are excluded).
4. Embase Cochrane optimal RCT search strategy was combined with psychological debriefing, stress debriefing, crisis, crisis intervention, early psychological intervention, preventive, psychological, intervention, preventive psychological intervention
5. PsychLit, Embase, Sociofile (1974-1995), Biosis Previews (1985-1996), Occupational Safety and Health (1973-1996), PASCAL (1973-1996) for debriefing, stress debriefing, psychological debriefing, crisis intervention, early psychological intervention, preventive psychological intervention
6. CDSR Register of Trials was searched with key words psychological debriefing; stress debriefing; crisis; crisis intervention; early, psychological intervention; preventive, psychological, intervention; preventive psychological intervention
7. For this update a new CCDANCTR search was performed. The search strategy used was; debrief* or 'critical incident' or crisis-intervention or 'crisis intervention or rape or trauma or 'traumatic stress' or 'road accident' or victim of PTSD or post-traumatic or stress-prevention or crisis or 'early psychological intervention' or 'preventive psychological intervention'.
Databases searched and date: CCTR Issue 2, 2000 April 00; CINAHL Update code 20000201-Feb-00; EMBASE Update code 0018 Jun-00;
LILACS Nov. 1999 Nov-99; MEDLINE Update code 2000073 Jul-00; NRR Issue 2, 1999 1999; PSYCINFO Update code 20000401 June-00;
PSYNDEX OCT. 1999 Oct-99; SIGLE 1999 1999.
8. Citation searches on located trials
9. Abstract search of Proceedings of the International Congress on Traumatic Stress
10. Citation search on Impact of Events Scale (Horowitz, 1979)

CONTACTS
1. Contact with key individuals (Alexander, Bolton, Deahl, Dyregov, Kenardy, Malt, Marks, McFarlane, Mitchell, Turner, Watson,Yule).

HAND SEARCH
Journal of Traumatic Stress (all years)
Journal of the Emergency Medical Services (all years)
Journal of Human Stress (all years)
Mass Emergencies and Disasters (all years)

Methods of the review

Quality Assessment:
This was carried out using three methods. First the traditional approach as described in the Cochrane Handbook, which considers method of randomisaton, allocation concealment and intention to treat. The second was the scale devised by Churchill (1996) for the assessment of quality in trials of psychiatric interventions The third was a scale derived from Kenardy & Carr, 1996 giving proposed quality standards for trials of psychological debriefing. Neither of the two last mentioned approaches have been validated as yet.

Data Management:
The analysis maintained the study groups according to the original randomization procedure. In one study (Stevens/Adshead) 12 patients were lost to follow up in which there was no information about allocation - it was assumed these were equally divided between cases and controls.

Data from the Bunn trial was not entered into the meta analysis because of its subjective nature, the absence of means and standard deviations, and the period of follow up (minutes after the intervention).

Subsequent issues of this review will consider the impact of different assumptions on those lost to follow up, but because overall loss to follow-up in the various studies was not significantly influenced by treatment condition, these assumptions will not alter the overall pattern of results.

Data synthesis

1. For categorical (binary) outcomes, which were the presence of PTSD, depression or anxiety caseness, the Peto method for computing the pooled odds ratio was used.

2. The principal continuous measure used in all the modern trials was the Impact of Events Scale (IES) (Horowitz, 1979). This is the most used measure of the impact of trauma in current research work. However, there are problems with using this data in a meta analysis, since in all the studies the variance in the IES scores (Armstrong et al,1991)is considerable. For all studies except the Lee trial the standard deviation of the results, when multiplied by 1.645, was considerably greater than the mean of the given outcome. At present we are unable to perform a formal meta analysis for continuous data. Check other studies for wide variation of the IES.

Description of studies

Patient selection. (see "Characteristics of included trials" table).
Overall the study populations are reasonably comparable apart from the three studies involving childbirth or miscarriage - Small et al. (2000); Lavender et al.; Lee, 1996. Most involve those admitted to hospital following trauma (Bisson, 1997, Dolan et al. in press), Hobbs, 1996 , Bordrow, 1979, Stevens/Adshead) or attending casualty (Conlon, 1999). Rose, 1999 recruited subjects via the local police and medical services. Most studies show an excess of males, reflecting the epidemiology of trauma, although interestingly this was not the case with Dolan et al. (in press) where there was a predominance of females. One trial was of a different population - Bunn studied the relatives of victims, who might be considered "second level" victims.

Cultural setting:
United Kingdom (7 studies); Ireland (1 study); Australia (3 studies)

Sample size:
The number of patients randomised in the trials ranged from 30 to 908

Description of Study Design.
All trials were described as 'randomized'. Lee, 1996 used alternate number allocated by the nurse recruiting the subjects, and thus was quasi randomised.

Time interval:
All were single session interventions. Most took place shortly after the event (within 24 hrs-Stevens/Adshead; within 48 hs-Hobbs, 1996; Lavender et al. Small et al. (2000) - within 1 week -Bordrow, 1979; within 2 weeks -Lee, 1996, Bisson, 1997, Conlon 1998, Dolan et al.in press within 1 month - Rose, 1999). The time period for Bunn was unclear, but was probably one day.

REASONS FOR EXCLUDING STUDIES.
These included non randomised design (Carlier, Deahl 1994, Deahl 2000, Foa, 1995, Hytten, 1989, Kenardy, 1996, Robinson, 1993: Matthews, 1998; Amir, 1998), not satisfying criteria for debriefing (Doctor, 1994; Polak , 1975, Viney, 1985); more than a single session intervention (Andre, 1997; Bisson (in press);Brom, 1993; Doctor, 1994); treatment started too late (Brom, 1993)

Methodological quality

All three reviewers assessed the methodological quality of each trial

Quality Assessment 1:
The first rating of quality used the methods described in Cochrane Collaboration Handbook.
Category A (adequate) is where the report describes allocation of treatment by any of the following procedures: (i) some form of centralised randomised scheme, such as having to provide details of an enrolled participant to an office by phone to receive the treatment group allocation; (ii) some form of randomisation scheme controlled by a pharmacy; (iii) numbered or coded containers (iv) an on-site or coded computer system(v) if assignment envelopes were used, the report should at least specify that they were sequentially numbered, sealed, opaque envelopes.
Category B (intermediate) is where the report describes allocation of treatment by: (i) use of a "list" of "table" to allocate assignments;
(ii) use of "envelopes" or "sealed envelopes"; (iii) stating the study as "randomised" without further detail.
Category C (inadequate) is where the report describes allocation of treatment by: (i) alternation; (ii) reference to case record numbers, dates of birth, day of week etc (iii) any allocation procedure that is entirely transparent before assignment.

Four trials (Bisson, 1997, Lavender et al. Rose 1999; Small et al. (2000) had adequate allocation concealment (computer generated random numbers/opening consequtively numbered sealed opaque envelopes/centralised telephone randomisation); 2 had intermediate (Stevens/Adshead; opaque envelopes) Dolan et al. (in press; sealed envelope method) for the rest allocation concealment was either unsatisfactory or unclear.

Quality Assessment 2:
Each reviewer also rated the studies using the quality ratings devised by Churchill (1996) for studies of psychiatric interventions,
where the maximum score is 37. Differences were resolved by discussion. Ratings are made on objectives of trial; sample size, length of follow up, power, randomisation, standardisation of treatment, blinding, source of population, recruitment procedures, exclusion criteria, demographic descriptions, blinded assessments, reasons for withdrawal, outcomes measures, intention to treat, presentation of results, type of data presented, statistical analysis and control of baseline differences.

The scores per trial were as follows:
Rose et al. 27
Small et al. 24
Bisson, 1997 : 23
Conlon : 21
Mayou et al. 20
(follow up of Hobbs, 1996)
Dolan et al. 16
Lavender et al. 16
Hobbs, 1996 : 15
Lee, 1996 : 14
Bordrow, 1979: 11
Stevens/Adshead : 10
Bunn, 1979 : 8

Quality Assessment 3:
Finally, a quality measure developed specifically for studies of debriefing was used ( Kenardy & Carr, 1996). This suggests that specific quality criteria include:

a) clear definition of the population to receive the intervention
*nature and extent of the exposure
* time since exposure
* premorbid vulnerability characteristics
* age, gender, other relevant demographic characteristics

b) delineation of appropriate goals of the debriefing. Possibilities include
* imparting information as to the nature of stress responses and their "normalisation"
* imparting information regarding what criteria indicate a need for specialist assistance and where to get it
* developing a sense of belonging with those of "shared" experience
* prevention of PTSD symptoms/signs or other symptoms/signs of relapse
* relief of PTSD/other symptoms/signs
* prevention or improvements in levels of disability linked to the stressor (eg absenteeism, family difficulties etc)
* perceived helpfulness

c) randomisation

d) use of both self report and objective assessments, the latter performed by a rater blind to debriefing condition, to obtain baseline measures of the phenomena which constitute the goals of the debriefing, employing instruments of demonstrable reliability and validity

e) thorough description of the debriefing procedures, ensuring that:
* they are compatible with the specified goals of the debriefing
* personnel conducting the debriefing are adequately trained in the procedure
* quality-control measures adequate to ensure that the debriefing is delivered (in a manual)
* the amount of exposure to debriefing is constant and delivered over a constant period
f) obtain outcome measures at times post debriefing that are regarded as appropriate given the nature of the target problems and the nature of the intervention, again using a combination of self-report and objective measurement by a rater blind to debriefing condition.

We developed a quantitative version of the variables suggested by Kenardy. Maximum scores were 26. Disagreements were resolved by discussion (sw and jb). The ratings were:

Bisson, 1997 : 22
Rose: 19
Dolan et al. 18
Conlon: 15
Lee, 1996 14
Hobbs, 1996 13
Stevens/Adshead: 13
Bordrow, 1979: 11
Small et al. 11
Lavender et al. 10
Bunn, 1979 8

The differences between the general Churchill and the specific Kenardy scales reflect that fact that the Churchill scale emphasises general methodological issues relevant to all clinical trials, with a particular emphasis towards pharmacological trials, albeit relevant to psychiatry. The Kenardy scale gives more weight to specific issues concerning debriefing, and in particular the content of debriefing.

The studies were then ranked in quality order. One obstetric study (Small et al. 2000) scored highly on the Churchill scale
because of its robust methodology but scored lower on the Kenardy scale because of lack of consistency on the debriefing intervention. Indeed the content of the 'patient led' debriefing described in the two obstetric papers (Lavender et al. Small et al.) makes comparison with the other studies problematic.

The general pattern of results was similar to the earlier review, with the Bisson, 1997 and Rose trials scoring highly, Dolan et al., Conlon, Lee, 1996 and Hobbs, 1996 intermediate, and the others low. The Stevens/Adshead trial was rated slightly differently using the two schemes. It was decided to use the Kenardy ratings for the final ranking since this was specifically devised for trials of debriefing. The final rankings were therefore Bisson, 1997 placed 1st, followed by Rose (1999) as 2nd, Dolan et al. (in press) as third, Conlon (1999) as 4th, Lee, 1996 as 5th, Hobbs, 1996 as 6th, Stevens/Adsheadwas rated 7th, Bordrow, 1979 and Small et al. as joint 8th, Lavender et al. as 9th and Bunn, 1979 last.

Overall, methodological quality of the included studies was variable. This was partly due to incomplete data recording. Most gave reasonable information on a priori objectives, and source of sample. Only Rose (1999) gave information on allocation concealment, but this was obtained from the authors for the Bisson, 1997 , Stevens/Adshead (1997) and Lee, 1996 trials. Information on numbers/reasons for withdrawal was given in six trials. One study used a true intention to treat (ITT) analysis (Mayou et al. 2000, follow-up on Hobbs 1996)) . Bordrow, 1979 gives no details of follow up - it appears that this was complete, but it is not clear. Bunn, 1979 does have an intention to treat analysis, but as there is no follow up after the single session of treatment, this is not a intention to treat analysis in a meaningful sense. Only Bisson and Conlon included an assessor blind to intervention. Stevens (1997) excluded individuals who displayed "undue distress" during the intervention, which may have introduced significant bias, whilst Hobbs (1997) did the opposite by excluding those without any psychological symptoms, thus also introducing bias.

Results

• List of comparisons
  

Post traumatic stress disorder:
Four studies used a categorical diagnostic category for PTSD - these include the highest quality and largest studies. Two suggest an adverse effect of intervention. In the study with the longest follow up there is a significant adverse effect of treatment (OR 2.9, 95% CI 1.1-7.5). Pooling four studies gives no evidence of a beneficial short term effect at around 3 months (OR 1.1, 95% CI 0.6-2.5). The pooled long term effect (around 12 months) from two studies is 2.0 (95% ci 0.9-4.5).

Trauma Related Symptoms: The single most cited instrument is the Impact of Events (IES) scale. This is used in all the modern studies, apart from the obstetric ones. It is reported in all studies as a continuous outcome measure, except in the Stevens/Adshead trial where it is not given by treatment group. In all studies the variance for the IES is considerable, with only one (Lee, 1996) in which the mean is more than 1.6 times the standardised deviation. Thus only Lee (1996) has at present been entered into the data synthesis.

The study of Lee, 1996 shows a non significant effect at four months post intervention (OR -2.9, 95% CI -12.2 to 6.5). That of Bisson, 1997 showed a mean difference of 4.15 units on the IES between treated and controls, the treated group having worse scores, although again the confidence limits (-11.6 to 3.3) included the possibility of a positive effect of treatment.

Bisson, 1997 reported a very marked adverse effect at the longest follow up (13 months), with a ten point adverse difference (95% ci 3.3-16.4) in IES score between treated and non treated groups.

Depression and Anxiety:
One study reports dichotomous data for depression and anxiety (Lee, 1996). At four months debriefing showed no effect on the prevalence of anxiety (pooled odds ratio 1.1, 95% ci 0.4-2.9) or depression (pooled odds ratio 0.6, 95% ci 0.1-3.6). These confidence limits are very wide, and include the possibility of both a positive and negative effect of treatment.

Evidence of heterogeneity.
The overall pattern of results does suggest heterogeneity, in that the two earliest trials (Bordrow, 1979 and Bunn, 1979) appear to come from a different population as do the two obstetric studies (Lavender and Walkinshaw 1998; Small et al. 2000). However, on methodological grounds none of the four have been included in the main comparisons. Data from the Bordrow, 1979 trial has only been used for the comparison of brief versus extended debriefing. That from the Brom, 1993 trial cannot be entered into the meta analysis because of the nature of the measures.

Because of the lack of a full data synthesis, and the question of heterogeneity, the following paragraph lists the treatment effects for the IES for the six trials that used that measure and provided interpretable data, as well as a summary of the remaining five trials. This allows the reader to make a direct assessment of all six trials utlising the IES.
Bisson, 1997ConlonHobbs, 1996Lee, 1996RoseBunn, 1979Bordrow, 1979

Discussion

In contrast the six modern studies use a similar intervention. Five of the six have similar subjects (in terms of their trauma) and all come from similar cultural settings (United Kingdom & Ireland). The results show no evidence of heterogeneity, and it is reasonable to assume come from the same population.

The possible exception is the study of Lee, 1996, which was discrepant in that the IES scores were substantially higher than in the other studies. This study was of women recovering from spontaneous miscarriages. Miscarriages are associated with temporary high psychological morbidity (Friedman , 1989).

The two obstetric studies (Lavender and Walkinshaw 1998; Small et al. 2000) come from a different population again and even within that two different birth populations. The Lavender study included only normal cephalic births while the Small study only included operative deliveries. There were further population differences in that the Lavender study contained a high proportion of single mothers e.g. of the sample 68 were single compared with 43 who were married. Additionally, in this study there was an extremely high level of psychomorbidity in the control group with half displaying worrying high anxiety and over half high depression scores ( >11) on the HADS. A further issue of clinical heterogeneity is the comparison of childbirth (whether normal or otherwise) to other arguably more life-threatening traumatic experiences. The authors would welcome comments as to the continued inclusion of this clinical group. There are also issues of statistical heterogeneity in these studies in that the measures used were the HADS or the EPDS and the study objectives were to reduce on the onset of postnatal depression rather than PTSD.

2. Quantitative findings
There is no evidence that debriefing reduces the risk of developing PTSD. At no time does any study suggest a significant reduction in IES in those receiving the intervention. On the other hand, the trials with the longest follow up (Hobbs et al. 1996;Bisson, 1997) both reported adverse effects. Results from the 3 year follow-up of the Hobbs et al. study (1996) showed that follow-up participants (n=61) had been more severely injured at outset although there was no significant differences in terms of overall demographics and initial emotional response to the accident. The intervention group at 3 years had a significantly worse outcome of those with high original IES scores >24 t(14) =2.56, p .23). There was no difference at 3 year follow-up of those with low initial IES scores. Results indicated that the negative effects of the intervention on patients with high initial IES scores were already present at 4 months post intervention and this was maintained at follow-up. This study shows that those at most risk of developing PTSD and other poor psychological outcomes are unlikely to be helped by a single PD session and indeed such an intervention may be harmful. However, although attrition was broadly similar between the control and treatment group it was high and conclusion from this study should therefore be limited. Bisson 1997 measured out come at 13 months This is based on a single trial only in which the data shows considerable variance. There was also differential loss to follow-up between the treated and control groups. If those who were improved were less likely to remain in contact, then this may have introduced bias. Thus the exact magnitude of the adverse effect is open to question. However, in the only 2 long-term studies discovered to date it appears that, so far debriefing appears to have increased long term traumatic distress.

In one study (Lavender and Walkinshaw 1998) there is evidence that psychological debriefing significantly reduced depression or anxiety (in terms of the HADS scores). Follow-up for this study was at 3 weeks with a highly significant reduction in the HADS anxiety score - odds ratio 13.5, 95% ci. 4.1-56.9 and HADS depression score odds ratio - 8.5, 95% ci. 2.8-30.9. However, as mentioned earlier this is in many ways an atypical group in terms questioning the traumatic nature of a normal birth and the psychosocial background of this sample. However, it may also be the case that given the patient led nature of this type of debriefing (which did not contain a 'forced' reexposure to the effect) was of benefit to these women in terms of dramatically reducing their HADS scoring at 3 weeks. However, in the Small et al. obstetric study of PD following operative birth a similar format of debriefing appeared to have been used to that in the Lavender and Walkinshaw study but with no overall effect in reducing depression score at 6 months although in Small et al. study the depression rate was elicited by use of the EPDS only.

Again in Lee, 1996 there is no evidence of PD significantly reducing depression and anxiety . Although the confidence limits are wide, and include the possible of both a positive and negative effect of treatment, the interpretation of no effect is supported by the individual results of the other studies which only report continuos data, and which also give no support for an effect of intervention on either depression or anxiety.

Comparison with other data sources.
Some may be continued to be surprised by the lack of evidence of the efficacy of debriefing, given there are many positive uncontrolled studies of the efficacy of debriefing. However, the possibility that early psychological intervention for the victims of trauma might be ineffective has also been suggested in the literature prior to this review or its update. Non randomised studies of debriefing also exist that suggest a negative effect (ex Carlier et al, ), but are outside the scope of this review. Another related area is psychological intervention in schools following the suicide of a classmate, known as postvention. No randomised trials exist - the most recent assessment also noted a negative impact (Callahan, 1996).

Crisis intervention has been excluded from this review. Crisis intervention predates the development of psychological debriefing, but is a strong influence upon it. The closest to modern formulations of debriefing appears to be the "person centered cathartic approaches" used by Polak and colleagues. A short term study showed no effect of intervention (Polak et al, 1975), whilst the 18 month outcome indicated an adverse effect on bereavement (Williams & Polak, 1979).

Why might treatment have failed?
1. Were the interventions too short? This would not explain why treatment appeared to have an adverse effect on the IES scores, unless one postulates that the intervention lead to an increase in psychological distress by virtue of re exposure to the traumatic event, but without allowing time for habituation to occur. This "secondary trauma" argument will be discussed further. On the other hand, four studies that used more than a single session (Foa, 1995, Andre, 1997and Bryant 1998a, Bisson et al. in press) do report a beneficial effect of CBT treatment. A more suitable strategy may be to target vulnerable individuals and give them more intensive interventions such as highlighted by Foa, 1995, Andre, 1997,Bryant 1998a, and Bisson et al. in press. It appears that there is an important role in acute stress disorder predicting the later onset of chronic PTSD Bryant 1998a;Bryant 1998b; Brewin at al. 1999; Bisson et al, in press.

2. Was follow up too short? It is possible that longer follow up might have revealed more benefits to the treated group, but in the 2 longest trials (, Hobbs et al. 1996;Bisson, 1997) differences between treated group and controls were widening over time.

3. The vagaries of randomisation and/or inadequate allocation concealment meant that the treated group in the Bisson, 1997 trial had significantly more initial trauma (as assessed by % burn and subjective life threat), whilst the treated group in the Hobbs, 1996 trial also showed a higher mean injury score. On the other hand, adjustment for initial distress made no difference to the results of the burns unit study (Bisson, 1997). When analysis of co variance using the presence and absence of debriefing and initial distress was performed, initial distress was a far stronger predictor of poor outcome than the presence or absence of debriefing.

4. Was the timing of the intervention wrong? The two studies reporting an adverse outcome for debriefing both gave the intervention close to the trauma, whilst in the study of women experiencing miscarriages Lee, 1996 study of miscarriages, in which there was no benefit nor ill effects of treatment, gave their intervention two weeks after the event. It may be that more time is needed to allow physical recovery from the trauma before embarking on a psychological intervention but in Rose et. al. 1999 the mean time of the intervention was 21 days and again that study had a neutral impact.

5. Has the wider culture changed rendering debriefing unnecessary? There can be little doubting that awareness of the possible adverse psychological effects of trauma has altered over the years, at least in Western cultures. The randomised trials cited in this review are all relatively recent. It is therefore possible that the general themes underlying debriefing are now part of the accepted culture - hence there is sufficient general awareness of "psychological first aid", ether by the person themselves or their family and friends, that everybody experiences a "bit of debriefing" anyway, thus reducing the possibility of showing any effects from a formal intervention.

6. Why might treatment have an adverse effect?
There are a number of possible reasons why debriefing might be associated with an adverse effect in some. Some might find it difficult to accept any adverse effect of treatment. However, it is a general finding that any effective treatment, even psychological treatments, must always carry a risk of adverse effects in some - the question at issue is always the balance of risk and effects. In has been argued that debriefing may carry benefits in terms of the management of traumatic incidents rather than mitigating trauma symptoms and it has been suggested (Rick & Briner 2000) that organisations need to think carefully about the objectives of continuing to use debriefing without very clear and realistic aims and understanding the need to properly evaluate outcomes.

There are also some reasons why debriefing might have a specific adverse effect in some. There is the possibility of "secondary traumatisation". Debriefing involves intense imaginal exposure to a traumatic incident within a short time of the event. It is possible that in some individuals this serves as a further trauma, exacerbating their symptoms without assisting in emotional processing. Exposure therapy, as practiced for the treatment of established PTSD, may lead to an initial mild excerbation of symptomatology as distressing images are recollected. The principles of exposure therapy suggest that such distress lessens as habituation occurs over time. However, in a single intervention as reviewed here, such habituation may not occur unless the recipient engages in further self directed exposure. Another possible adverse reaction to PD could be hypothesised in those with a sense of shame as a reaction to the traumatic event. While there is no direct evidence that shame is implicated in the in the onset or course of PTSD there is some evidence that it is of predictive importance (Andrews et al., 2000). It can however be hypothesised that those with a sense of shame might be more likely to experience some exacerbation of distressing symptoms when undertaking a verbal exposure to the event, particularly when the shame and/or the underlying reasons remain undisclosed. It would appear that aspects of shame in relation to the traumatic event can range from the relatively straightforward shame of modifiable behaviour e.g.such as suffering incontinence of urine/faeces on impact to the more complex characterlogical self blame (Janoff-Bulman 1979, Gold 1986). It could therefore be argued that undertaking interventions such as PD with those who are suffering from shame based reactions is contraindicated but it is difficult to see how a shame based reaction could be elicited without a skilled, attuned and sensitive therapist. It may however, indicate that a 'safer' way of handling early psychological interventions is to elicit a client led narrative without insisting on a clinician led re-exposure to the event. Clearly, more research is needed in this area.

Another explanation is that debriefing may 'medicalise' normal distress. It may also increase the expectancy of developing psychological symptoms in those who would otherwise not have done so. No matter how great the trauma, it is a constant finding of the traumatic stress literature that not everyone develops psychological distress, and it is usually only a minority who progress to formal long term psychiatric disorder. Debriefing, by increasing awareness of psychological distress, may paradoxically induce that distress in those who would otherwise not have developed it.

Debriefing also assumes that there is a uniform, and to a certain extent predictable, pattern of reactions to trauma. At the heart of the treatment is the concept that discussing the trauma is therapeutic, and that attempting to deny it is not. This is based on a time honoured tradition of psychological thought. However, it does not follow that this is true in every case. Recalling the event may be a 'secondary trauma' - attempting to forget/distance oneself may be an adaptive response. Intervention may interfere with adaptive defence mechanisms.

A further problem is that debriefing, by definition, focuses on the single trauma. However, even if all the victims of a disaster were exposed to a uniform event, they are certainly not uniform in any other respect. Focusing attention on the single traumatic event may divert attention away from other important psychosocial, non traumatic, factors that differ between victims.

Reviewers' conclusions

Implications for practice

2. We are unable to comment on the use of group debriefing, nor the use of debriefing after mass traumas. We are also unable to make recommendations about the use of debriefing in children.

3. It appears appropriate to continue to focus resources on identifying and treating those with recognisable psychiatric disorders arising after trauma, such as acute stress disorder, depression and PTSD. Emphasis should increasingly be placed on the early detection of those at risk of developing psychopatholgy and early interventions should be aimed at this group. Follow-up assessment should increasingly viewed as important and the use of screen and treat programmes should be developed.

4.In terms of using the principles of evidence based practice where psychosocial interventions are used, even when (especially when) associated with clear need, high face validity and client satisfaction these should not be regarded as a substitute for evidence.

Implications for research

2. Since the last issue of this review three further trials and a follow-up have been reported, but there remains a continuing need for more randomised studies. Three areas are a particular priority. First, the efficacy of debriefing in emergency workers. Second, the efficacy of group, as opposed to individual, debriefing. Third, the efficacy of debriefing after mass disasters/traumas, although it is accepted that such studies will be difficult to undertake. Currently the reviewers are not aware of the evidence base surrounding debriefing in children.

3. There is a need towards working to develop predictive questionnaires with differing populations to highlight those 'at risk' (e.g. Brewin et al., 1999).

4. At present the reviewers are aware of one further RCT in progress, UK based: Nottingham trial of debriefing road accident victims (Regel, Duggan).

5. There are now four published trials of longer interventions (Foa, 1995, Andre, 1997, Bryant 1998a, Bisson et al, in press). It would now seem appropriate to commence a new review evaluating these longer intervention programmes. Such a review has recently been registered. Preliminary information suggests that delivering more formalised interventions over a longer period of time and aimed at those with overt distress may be worthwhile.

Implications for practice and research
1. The results of this review contrast with the evidence for the effectiveness of psychological treatments in the management of several psychiatric disorders. Treatments that are effective in those with established disorder cannot be assumed to be effective in prevention, and the possibility of adverse effects must be remembered.

Acknowledgements

Potential conflict of interest

References

References to studies included in this review

Bisson, 1997 (published and unpublished data)

* Bisson J, Jenkins P, Alexander J, Bannister C. Randomised controlled trial of psychological debriefing for victims of acute burn trauma. Br J Psychiatry 1997;171:78-81.

Bordrow, 1979 (published data only)

Bordrow S, Porritt D. An experimental evaluation of crisis intervention. Social Science and Medicine 1979;13:251-256.

Bunn, 1979 (published data only)

Bunn B, Clarke A. Crisis intervention: an experimental study of the effects of a brief period of counselling on the anxiety of relatives of seriously injuried or ill hospital patients. British Journal of Medical Psychology 1979;52:191-195.

Conlon (published and unpublished data)

* Conlon L, Fahy T, Conroy R. PTSD in ambulant RTA victims: prevalence, predictors and a randomised controlled trial of psychological debriefing in prophylaxis. Journal of Pschosomatic Research 1999;46(1):37-44.

Dolan et al. (unpublished data only)

Dolan L, Bowyer D, Freeman C and Little K. Critical Incident Stress Debriefing After Trauma: is it Effective?.

Hobbs, 1996 (published and unpublished data)

Mayou RA, Ehlers A, Hobbs M; Hobbs M, Mayou R, Harrison B, Worlock P. A three year follow-up of a ramdomised controlled trial of psychological debriefing for road traffic accident victims; A randomised controllled trial of psychological debriefing for victims of road traffic accidents. British Journal of Psychiatry; British Medical Journal 2000; 1996;176: 313:589-593; 1438-1439.

Lavender et al. (published data only)

* Lavender T, Walkinshaw S.A. Can Midwives Reduce Postpartume Psychological Morbidity? A Randomized Trial. Birth 1998;25(4):215-219.

Lee, 1996 (published and unpublished data)

Lee C, Slade P, Lygo V. The influence of psychological debriefing on emotional adaptation in women following early miscarriage: a preliminary study. British Journal of Medical Psychology 1996;69:47-58.

Rose (published data only)

* Rose S, Brewin CR, Andrews B, Kirk. A randomized controlled trial of individual psychological debriefing for victims of violent crime. Psychological Medicine 1999;29:793-799.

Small et al. (published data only)

* Small R, Lumley J, Donohue L, Potter A, Walderstrom U. Midwife-led debriefing to reduce maternal depression following operative birth: a randomised controlled trial. In: British Medical Journal. Vol. 321. 2000:1043-1047.

Stevens/Adshead (published and unpublished data)

Hobbs G, Adshead G. Preventive psychological intervention for road crash victims. In: Mitchell M (ed). The Aftermath of Road Accidents: Psychological, Social and Legal Perspectives. :Psychological, Social and Legal Perspectives. London, Routledge, 1997, 159-171.

Amir

Amir M, Weil G, Kapin Z, Tocker T, Witztum E. Debriefing with brief group psychotherapy in a homogenous group on non-injured victims of a terrorist attack: a prospectve study. Psych Scanda 1998;1009:237-242.

Andre, 1997

Andre C, Lelord F, Legeron P, Reignier A, Delattre A. Etude controlee sur l'efficacite a 6 mois d'une prise en charge precoce de 132 conducteurs d'authobus victimes d'agression. L'encephale 1997;23:65-71.

Brom, 1993

Andre C, Lelord F, Legeron P, Reignier A, Delattre A. . Etude controlee sur l'efficacite a 6 mois d'une prise en charge precoce de 132 conducteurs d'authobus victimes d'agression. :65-71.

Brom D, Kleber R, Horman M. Victims of traffic accidents: incidence and prevention of post traumatic stress disorder. :131-140.

Chemtob C, Tomas S, Law W, Cremniter D. Postdisaster Psychosocial Intervention: A Field Study of the Impact of Debriefing on Psychological Distress. :415-417.

Bryant

Bryant R, Harvey A, Dang S, Sackville T, Basten C. Treatment of acute stress disorder: a comparison of cognitive behavior therapy and supportive counselling. Journal of Consulting and Clinical Psychology 1998;66:862-866.

Bryant R, Harvey A, Dang S, Sackville T. Assessing Acute Stress Disorder: Psychometric Properties of a Structured Clinical Interview. Psychological Assessment 1998;10(3):215-220.

Carlier

[Effectiveness of psychological debriefing: a controlled study of traumatised police officers] [Computer program]. Carlier I, Lamberts R, Van Uchelen A, Gersons B,.

Chemtob, 1997

Deahl

Deahl M, Scrinivasan M, Jones N, Thomas J, Neblett C, Jolly A. Preventing psychological trauma in soldiers: The role of operational stress training and psychological debriefing. British Journal of Medical Psychology 2000;73:77-85.

Deahl 1994

Deahl MP, Earnshaw NM, Jones N. Psychiatry and war. Learning lessons from the former Yugoslavia. Br J Psychiatry 1994;164:441-2.

Deahl MP, Gillham AB, Thomas J, Searle MM, Srinivasan M. Psychological sequelae following the Gulf War. Factors associated with subsequent morbidity and the effectiveness of psychological debriefing. Br J Psychiatry 1994;165:60-5.

Doctor, 1994

Doctor R, Curtis D, Isaacs G. Psychiatric morbidity in policeman and the effect of brief psychotherapeutic intervention: a pilot study. Stress Medicine 1994;10:151-157.

Foa, 1995

Foa E, Ikeda D, Perry K. Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. :948-955.

Hytten, 1989

Hytten K, Hasle A. Fire fighters: a study of stress and coping. Acta Psychiatrica Scanda 1989 ; 80 (suppl 355):a study of stress and coping. Acta Psychiatrica Scanda 1989 ; 80 (suppl 355); 50-55.

Kenardy, 1996

Kenardy J, Webster R, Lewin T, Carr V, Hazell P, Carter G. Stress debriefing and patterns of recovery following a natural disaster. J Traumatic Stress 1996;9:37-49.

Matthews

Matthew, L. Effect of staff debriefing on posttraumatic stress symptoms after assaults by community housing residents. :207-212.

McFarlane 1988

McFarlane AC. The aetiology of post-traumatic stress disorders following a natural disaster. Br J Psychiatry 1988;152:116-21.

McFarlane AC. Relationship between psychiatric impairment and a natural disaster: the role of distress. Psychol Med 1988;18:129-39.

Polak , 1975

Polak P, Egan D, Vandebergh R, Williams W. Prevention in mental health: a controlled study. American Journal of Psychiatry 1975;132:146-149 Williams V, Polak R. Follow up research in primary prevention. Journal of Clinical Psychology 1979;35:35-45.

Robinson, 1993

Robinson R, Mitchell J. Evaluation of psychological debriefings. J Traumatic Stress 1993;6:367-382.

Saari, 1996

Saari S, Lindeman M, Verkasalo M, Prytz H. The Estonia Disasrer: A Description of the Crisis Intervention in Finland. :135-139.

Tadmor, 1987

Tadmor C. , Brandes J, Hofman J, Preventive intervention for a Caesarian Birth population. Br J Preventive Psychology 1987;3:343-364.

Viney, 1985

Viney L, Clarke A, Bunn T, Benjamin Y. An evaluation of three crisis intervention programmes for general hospital patients. British Journal of Medical Psychology. 1985;58:75-86 Viney L, Clarke A, Bunn T, Benjamin Y. Effects of crisis intervention counselling. J Counselling Psychology, 1985;32:29-39.

Andrews et al. 2000

Andrews A, Brewin C, Rose S, Kirk M. Predicting PTSD Symptoms in Victims of Violent Crime: The Role of Shame, Anger and Childhood Abuse. Journal of Abnormal Psychology 2000;109:69-73.

Armstrong et al,1991

Armstrong K, O'Callahan W, Marmar C. Debriefing Red Cross Disaster Personnel: the Multiple Stressor Debriefing Model. :581-593.

Armstrong et al.

Armstrong B, O'Callahan W, Marmar C. Debriefing Red Cross Personnel: The Multiple Stressor Debriefing Model. Journal of Traumatic Stress 1991;4(4):581-593.

Bisson 1994

Bisson JI, Deahl MP. Psychological debriefing and prevention of post-traumatic stress. More research is needed [editorial]. Br J Psychiatry 1994;165(6):717-20.

Bisson et al. (in pr

Bisson J, Shepherd J, Joy D, Probert R. Randomised Controlled Trial of a Brief Psychological Intervention to Prevent Post Traumatic Stress Disorder.

Brandon, 1996

Brandon, S. Psychological debriefing. Br J Psychiatry 1996;168:878.

Brewin et al. 1999

Brewin C, Andrews B, Rose S, Kirk M. Acute Stress Disorder and Posttraumatic Stress Disorder in Vcitms of Violent Crime. American Journal of Psychiatry 1999;156(3):360-366.

Bryant 1998a

Bryant R, Harvey A, Dang S, Sackville T, Basten C. Treatment of acute stress disorder: a comparison of cognitive behavior therapy and supportive counselling. Journal of Consulting and Clinical Psychology 1998;66:862-866.

Bryant et al, 1998b

Bryant R, Harvey A, Dang S, Sackville T. Assessing Acute Stress Disorder: Psychometric Properties of a Structured Clinical Interview. Psychological Assessment 1998;10(3):215-220.

Callahan, 1996

Callahan, J. Negative effects of a school suicide postvention program- a case example. Crisis 1996;17:108-115.

Churchill

A systematic review and meta analysis of the effects of pharmacotherapy and psychotherapy for the treatment of depression in primary care. MSc Thesis, London School of Hygiene and Tropical Medicine.

Deahl et al.

Deahl M, Scrinivasan M, Jones N, Thomas J, Neblett C, Jolly A. Preventing Psychological Trauma in Soldiers: The Role of Operational Stress Training and Psychological Debriefing.

Dyregov, 1989

Dyregov, A. Caring for helpers in disaster situations: Psychological debriefing. Disaster Management 1989;2:25-30.

Foa et al. 1995

Foa E, Heart-Ikeda D, Perry K (1995). Evaluation of a brief cognitive-behavioural program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology 1995;63(6):948-955.

Friedman , 1989

Friedman T, Gath D. The psychiatric consequences of spontaneous abortion. :810-813.

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Gold E. Long-term Effects of Sexual Victimisation in Childhood: An Attributional Approach. Journal of Consulting and Clinical Psychologist 1986;54:471-475.

Horowitz, 1979

Horowitz M, Wilner N, Alvarez W. Impact of events scale: a measure of subjective distress. Psychom Med 1979;41:209-218.

Janoff-Bulman, 1992

Janoff-Bulman R. NY The Free Press. 1992.

Kenardy & Carr, 1996

Kenardy J, Carr V. Imbalance in the debriefing debate: what we don't know far outweights what we do. :what we don't know far outweights what we do. Bulletin of the Australian Psychological Society, Feb 1996, 4-6.

Kessler, 1993

Kessler R, Somnnega A, Bromet E, Nelson C. Post-traumatic stress disorder in the National Comorbidity Survey. :Institute for Social Research, 1993.

Mayou et al, 1993

Mayou R, Bryant B, Duthie R. Psychiatric consequences of road traffic accidents. British Medical Journal 1993;307:647-651.

McFarlane 1987

McFarlane AC, Policansky SK, Irwin C. A longitudinal study of the psychological morbidity in children due to a natural disaster. Psychol Med 1987;17(3):727-38.

Mitchell, 1983

Mitchell, J. When disaster strikes.... the critical incident stress debriefing procedure. Journal of Emergency Medical Services 1983;8:36-39.

Raphael et al, 1996

Raphael B, Meldrum L, McFarlane A. Does debriefing after psychological trauma work? :1479-1480.

Raphael et al, 1996a

Raphael, B. Wilson, J., Meldrum, L, Mcfarlane, A. Acute Preventive Interventions. In: Traumatic Stress: The effects of Overwhelming Experience on Mind, Body and Society. Eds Van der Kolk, B., McFarland, A., Weisath, L. :The effects of Overwhelming Experience on Mind, Body and Society. Eds Van der Kolk, B., McFarland, A., Weisath, L. Guildford Press, New York, 1996.

Raphael, 1986

Raphael, B. When Disaster Strikes: A Handbook for Caring Professionals. :A Handbook for Caring Professionals. London, Hutchinson.

Rick & Briner 2000

Rick J, Briner R. Trauma Management vs. Stress Debriefing: What should Responsible Organisations do? In: Available from Insitute of Employment Studies, www.employment-studies.co.uk. 2000.

Rick and Briner 2000

Rick et al., 1998

Rick J, Perryman S, Young K, Guppy A, Hillage J. Workplace Trauma and Its Management - Review of the Literature. The Institute of Employment Studies, UK. 1998.

Robinson & Mitchell

Robinson R & Mitchell J. Getting some balance back into the debriefing debate. Bulletin of the Australian Psychological Society October 1995;5-10.

Rose, 97

Rose, S. Psychological debriefing: history and methods. Counselling - Journal of the British Association of Counselling 1997;8(1):48-51.

Shalev, 1994

Shalev, A. Debriefing following traumatic exposure. In: Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. eds Ursano, R., McCaughey, B., Fullerton, C. :The Structure of Human Chaos. eds Ursano, R., McCaughey, B., Fullerton, C. Cambridge University Press, 1994.

Cover sheet

Sources of support

Extramural sources of support to the review

• NHS Management Executive and Berkshire Healthcare NHS Trust (SR) UK
  

Intramural sources of support to the review

• King's College School of Medicine Strategy Fund (Trials Register) SW UK
  

Synopsis

Comments and criticisms

Cochrane Commentary/Justin kenardy 8/00

Contributors to comment

Since the available evidence of randomised trials of debriefing has been based on procedures that fall into the broad definition of debriefing, it might be that the results arise from the application of an inadequate form of debriefing. Thus it has been argued that if a more prescribed form, such as CISD or its descendant Critical Incident Stress Management (CISM), were used the outcomes would be different. However, to my knowledge, there has been no published RCT employing such prescribed approaches. Certainly, there has been no direct comparison of types of debriefing intervention using RCT methodology. Therefore until this evidence is forthcoming there is no support for one type of debriefing approach over any other.

Debriefing is a "grassroots" type of intervention that has face validity and popular support amongst many health and allied practitioners. I believe that some practitioners are likely to continue to advocate its use in spite of the lack of empirical support for it. Furthermore some organisations are likely to maintain its use since there is no other comparable intervention to serve the purpose of a broadly acceptable early intervention at relatively low cost. This may not be as important an issue (other than to taxpayers and shareholders) if the studies to date were to have found that psychological debriefing had at least no impact on the recovery process. However it would seem that this is not the case. Work by our group indicates that within a community sample post-trauma response is generally one of recovery over time (aside from anniversary effects) stabilizing at levels commensurate with initial exposure1. For debriefing to be worthwhile it should at least alter the downward trajectory of distress such that the process is accelerated over time. What should be of concern to practitioners, organisations and researchers is that not only does the evidence indicate that this is not happening, but that there continues to be indications of a deceleration of recovery associated with debriefing.

Why should this be happening? From the literature there are certain factors that probably impact on that recovery process, such as perceived severity of the trauma in terms of life-threat and significant loss, pre-morbid psychiatric disorder, and significant ongoing stressors1, 2. These are likely to be indicators, in those individuals who have experienced a trauma, for direction to significantly more care than would be available within a debriefing. The challenge is to develop workable and valid methods of detecting such individuals. Other factors may also effect recovery, for example expectations concerning one's responses and reactions. Thus it has been suggested that debriefing "medicalises" normal distress3 by generating in an individual an expectation of pathological responding. Early response to psychological trauma may need to balance minimal intervention with information that helps individuals to self-refer. Personality and coping style may also interact with the process of debriefing and thus affect recovery. However this relationship is likely to be complex. For example avoidance coping style (tendency to avoid rather than confront emotionally distressing experiences) is associated with poorer outcomes following trauma1, suggesting that such individuals should be carefully assisted in undergoing exposure to elements of the trauma without associated avoidance. However these individuals may be very reluctant to engage in an exposure-based program. These issues are still hypotheses without substantive evidence. But since they bear directly on how an early psychological intervention following a trauma might proceed they are worthy of attention. There is little known about why debriefing might adversely affect recovery, but this information is crucial for the development of an effective early intervention following trauma.

Justin Kenardy, Associate Professor in Clinical Psychology
School of Psychology, University of Queensland, Brisbane Q 4072 Australia.

References

1. Carr VJ, Lewin TJ, Webster RA, Kenardy JA. A synthesis of the findings from the Quake Impact Study: A two-year investigation of the psychosocial sequelae of the 1989 Newcastle Earthquake. International Journal of Social Psychiatry and Psychiatric Epidemiology. 1997; 32:123-136.

2. MacFarlane AC. The longitudinal course of posttraumatic morbidity: the range of outcomes and their predictors. Journal of Nervous and Mental Disease. 1988; 176:30-39.

3. Wessely S, Rose S. Bisson J. A systematic review of brief psychological interventions ("debriefing") for the treatment of immediate trauma-related symptoms and the prevention of post traumatic stress disorder (Cochrane Review). In The Cochrane Library, Issue 4 1999. Oxford: Update Software.

Psychological Debriefing: Controversy and Challenge

Extracted from JANZPsych. Paper in press

Martin Deahl OSt.J. TD. MA. M.Phil. MB BS. FRCPsych.

Consultant and Senior Lecturer in Psychological Medicine,
St. Bartholomew's and Royal London School of Medicine and Dentistry, Queen Mary and Westfield College, University of London.

01 September 2000

Outcome research into the effectiveness of acute interventions such as debriefing raises important questions about the ethics as well as the status of conventional RCT methodology as the imprimatur of Evidence Based Medicine (EBM). RCTs have become the dominant paradigm of treatment outcome studies to the virtual exclusion of observational or case studies. CISD was designed for groups of emergency service workers following traumatic events. Conducting a methodologically rigorous RCT of group debriefing would be extremely difficult given that group trauma generally only occurs in unpredictable and often chaotic circumstances such as war or disaster. In emergency situations such as these the operational imperative is paramount and investigators must do the best they can with the available material under difficult and at times extremely fraught circumstances. Irrespective of whether or not debriefing reduces long-term morbidity many individuals find it subjectively helpful at the time (1). Under these circumstances can it therefore be ethically justifiable to employ "non-intervention" controls denying individuals short-term support whatever the long-term outcome? In conflict, following disaster or accident, naturalistic studies, often conducted opportunistically remain useful and have considerable heuristic value despite methodological shortcomings particularly relating to sample selection and randomisation to different treatment conditions. Applying the stringent criteria demanded by the arbiters of EBM such as the Cochrane library to trials of preventive interventions means that much useful work might go unpublished. Clinicians might well lament that in attempting to satisfy such rigorous methodological criteria RCTs have become so divorced from clinical reality that their findings become meaningless. It is noteworthy that even in the most robust RCTs subjects are seldom selected from epidemiological samples. Researchers may be forgiven for forsaking such methodologically challenging research entirely in favour of more biologically oriented research where variables can be more easily controlled, confounding factors minimised and publishable outcomes virtually guaranteed. RCTs are not the sine qua non of EBM and debriefing studies which challenges their hegemony and lend credibility to observational studies has important implications for the ways in which the quality and value of research evidence is assessed both in social psychiatry and empirical science in general.

1.Bisson JI and Deahl MP. Psychological debriefing and preventing post traumatic stress. British Journal of Psychiatry 1994; 165: 717-720.

Keywords

Tables & Graphs

• MetaView graphs
  The figures and graphs in Cochrane Reviews display the Peto Odds Ratio and the Weighted Mean Difference by default. These are not always the methods used by reviewers when combining data in their review. You should check the text of the review for a description of the statistical methods used.
• List of comparisons
• Table of included studies
• Table of excluded studies
• Table of ongoing studies

List of comparisons

01.02.00 PTSD

01.03.00 PTSD (short term)

01.04.00 PTSD (long term)

01.05.00 Impact of Events Scales (IES - non skewed data: high score = worse outcome)

01.06.00 Impact of Events Scales (IES - skewed data: high score = worse)

01.07.00 Depression

01.08.00 Depression (caseness)

01.09.00 Travel anxiety

01.10.00 Anxiety (caseness)

01.11.00 General Anxiety

01.12.00 All psychiatric morbidity

Tables of other data

Additional tables

Table of included studies

Table of excluded studies

Table of ongoing studies