Crisis intervention

The debate about debriefing continues to rage. But despite claims that its
effectiveness is unproven it is clearly helpful in the recovery process of
people who have experienced a traumatic incident.  By John Parker

Debriefing has been around for over 20 years. Recently its usefulness following
a threatening or horrific incident has come under question. Some psychologists,
psychiatrists and others say that at best it is not proven, at worst it can
further damage traumatised people. It is right to subject any therapeutic
method to clinical trial. In the opinion of many practitioners working in the
field, however, some of the criticism of debriefing is unfair or misleading.
This article is not so much a review of current research, but a de-briefing
practitioner’s response to some of the questions posed by critics of the
approach.

A crisis intervention tool

I have used debriefing as a crisis intervention tool for many years and have
no doubt about its helpfulness to the victims of shocking events.

How do I know that it helps people? First of all, they tell me it does. The
vast majority of those who take part in debriefing later report that it has
been helpful to them. Even those studies which do not find positive outcomes
from the approach find that people like debriefing. Secondly, I can see that it
does.

I follow up most of the people I debrief, and they have usually improved.
Debriefed employees have generally returned to work and normal functioning, or
are moving towards doing so. They typically are suffering less anxiety and are
much less inclined to see themselves as foolish, guilty, weak or ill.

They are supportive of each other in the workplace. A small number of people
may require more help, to overcome a phobic reaction such as the fear of going
out or returning to work, or problems with arousal, such as difficulties in
going to sleep or being able to concentrate. These people recognise that
de-briefing has provided a useful first step in a longer process.

Critics of debriefing will say that my evidence is subjective, and not supported
by properly designed clinical trials. By this they mean there is no objective
evidence that debriefing prevents post- traumatic stress disorder or other
psychiatric conditions. If debriefing does not prevent PTSD then why engage in
it at all? When I hear these arguments against debriefing I want to ask these
critics if they would also question the value of bereavement counselling on the
grounds that it does not prevent grieving or the use of pain killers on the
grounds that they do not cure disease.

The two questions that need to be asked when considering any evaluation of
debriefing interventions are:

– What does the debriefer actually do in the session?

– What are they trying to achieve?

The first and most important duty of any health worker is to do no harm.
Therefore the first question is important because it concerns the prospect of
debriefing being harmful. The mere fact that someone has "conducted
debriefing" needs to be questioned.

Debriefing is not an exact science. How did the debriefer conduct him or
herself? Were they sensitive to the mood of the audience and can they adapt
their approach, as necessary? Can they respond to severe distress? Are they
able to cope with needs that cannot be met, such as a desire to turn back the
clock? Debriefing, like any other therapy, requires skill, training and
experience to be effective.

Group sessions

Most of the debriefings I conduct are group sessions. A properly run group
does not put people on the spot. People who are reluctant to speak are not under
the same pressure as they would be in an individual meeting, they can listen to
their colleagues while remaining silent. They will still receive the benefits
of the process as a silent participator. Quiet participants can come to
understand that their reactions are normal and similar to their colleagues.
They are able to participate in peer support, and receive advice on future
coping – without having to say a word.

Cognitive control

The model I use is cognitive, rather than cathartic one. This means that the
aim of debriefing is to help participants put meaning to what is happening to
them, rather than to encourage an emotional outpouring. It is true that
sometimes people get upset or angry in meetings. There may be a need to
ventilate feelings, and there is nothing wrong with that, providing the
debriefer is trained to contain and respond to these raw emotions – but that is
not the aim. The aim is to achieve a sense of cognitive control, rather than a
feeling of being overwhelmed.

Group debriefing is a useful way of achieving these aims. It helps those
involved in the disaster or tragedy to piece together what happened. The group
is able to share and make sense of their own and their colleagues’ reactions. A
major aspect of debriefing is the learning experience. Why do we react in the
way that we do? How much of what we do is related to our instinct to survive?

Education

In the educational part of debriefing, people are prepared for possible
future reactions. While it is not possible to predict what they will
experience, we can describe common reactions and give advice on future coping.
Those who are aware of possible reactions are in a better position to deal with
them if they occur.

Debriefing is a complicated process. It takes account of people’s reactions
in the here and now. The structure of any debriefing is adapted accordingly.
Debriefing following a suicide is different from that in the aftermath of an
assault. Survivors are different from rescue workers, or a management group.
Survivors and rescue workers may be struggling to cope with distressing imagery
which managers or the colleagues of a suicide may not. Survivors will be
hypervigilant, on guard against a potential recurrence of danger while others
may be more concerned with organisational issues or those of professional
competence.

The basic principles, outlined in the box, left, however, are always the
same.

Debriefing and PTSD

Debriefing is a powerful psychological intervention and a badly conducted
debriefing has the potential for damaging people, just as badly conducted
counselling, psychotherapy or surgery can cause harm. There have been a couple
of studies that have suggested that those undergoing debriefing are more at
risk of developing PTSD than a control group who were not debriefed. These
studies have been shown to be methodologically flawed. In one, inexperienced
practitioners were used to conduct the debriefings1. The debriefings were
administered too soon; were too short and too much was attempted in the single
session. More importantly, they were one-off meetings, with no follow-up. It is
not surprising to learn that they did more harm than good.

Debriefing is not like a pill that can be administered and the results then
scrutinised. It is not a standalone activity that can be evaluated outside of a
wider support structure for traumatised people. It is only effective as a part
of a series of measures that support people through a difficult time, and give
them the courage to carry on. More sophisticated studies have never concluded
that debriefing harms people.

My second question asks what the debriefer is trying to achieve. To be
honest, I do not know if debriefing helps prevent the onset of PTSD or acute
stress disorder. Debriefing was designed as a group process, and the majority
of debriefings that I conduct are with groups. Most of the studies that have
been reported involve one-to-one interventions. They therefore lose many of the
important therapeutic components that occur in group debriefing.

Group debriefing provides the opportunity to bring back a sense of normality
through the group members sharing their experiences as well as the promotion of
group support. There are one or two studies of group meetings. Other studies
have tended to show that debriefing has either no long-term benefits, or fairly
low level gains over time (they do report that the meetings are almost
universally well received, and do no harm)2,3. Proper clinical trials are
methodologically difficult to design. They will happen, and they need to happen
– but they haven’t happened yet.

But isn’t this missing the point? What are we trying to achieve in a
debriefing? When I sit down with a group of people who have been robbed at
knifepoint, or have experienced the suicide of a close colleague, or have
narrowly survived an air accident – I do not have avoidance of PTSD as my major
goal. I am concerned to help them with the trauma of the incident here and now.

We can do something, or we can do nothing. Some would advocate doing
nothing, waiting to see if problems arise in the future, and treating them if
they do. I think this approach is complacent and dangerous. For a start, we
have learned from the victims of disasters that the large majority of people do
not ask for help. People do not put themselves forward.

A properly organised crisis intervention approach, which is proactive, gets
to people early. Debriefing helps them to understand that their reactions are
normal. It is very good at doing this. It provides an effective assessment in
some cases, and engages individuals early in a recovery process. The
alternative may be to let unproductive defences harden.

The majority of people would recover eventually, with no intervention of any
sort, but does that mean that we should not do something that makes them feel
better sooner?

Debriefing helps people manage their reactions. Just one example: in my
experience, the biggest reason why staff go off sick after a traumatic incident
at work is because they are angry. They are often angry at their organisation
for not caring enough about them.

A crisis care system, involving defusing, debriefing and follow up provides
a way of managing that anger, and the other reactions that anger often masks.

Summary

This article is a summary of my views as a crisis care practitioner over
many years, and of hundreds of interventions following a wide range of
incidents. I do not always use a debriefing model. When I do I have often
adapted it to the specific circumstances and audience. I have used it as a
process to take people through in the belief that it will be helpful to them.

Many times I have finished a meeting with a very distressed group with that
belief in question – only to return for a follow-up meeting to hear reports of
improvements and comments such as, "I was sceptical, but it’s been very
helpful to talk about it, thanks".

Many organisations, including commercial companies, emergency services and
local and health authorities have taken up debriefing as part of their staff
support services. I know of none that have stopped using it because they have
found it ineffective.

John Parker
Trauma Response

References

1.Hobbs, Mayou, Harrison, Worlock (1996)

2. Deahl, Srinivasan, Jones, Thomas, Neblett, Jolley (2000)

3.Carlier, Voerman, Gersons (2000)

Basic principles

Cognitive making sense of what was done, thought and felt

Supportive fostering peer support, exploring other
sources of support

Educative understanding the nature and normality of post-trauma
reactions

Preparative advising on future coping

Key points

– Debriefing does not harm people –
unless someone who does not know what they are doing carries it out. Experience
and properly conducted research have repeatedly demonstrated this

– We do not yet know if debriefing is effective in reducing the
onset of PTSD and other disabling conditions. I believe that methodologically
sound clinical trials will show that it does

– Debriefing should always be carried out as part of a wider
crisis intervention programme

– The practitioner needs to be skilled, experienced and
sensitive to the specific needs of the client group, and to tailor his or her
intervention accordingly

– Whatever the long-term results, debriefing helps people
manage their reactions here and now

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