Friday, September 19, 2014
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The Trouble with Treating Trauma

When disaster strikes, the arrival of ``trained counselors'' is as much a part of the theater of disaster as the arrival of the emergency services. What do these counselors actually do? Usually, they perform some form of what is called ``debriefing'' or ``critical incident stress debriefing.'' But do these sessions do any good?

Debriefing is invariably a short, usually single session, an intervention that is performed with as many of those caught up in a traumatic event as possible. It involves linking examination of the traumatic incident with education about the expected emotional responses and assurances that these are normal. The hope is to reduce acute emotional distress and prevent the onset of post-trauma psychiatric disorder.

Many organizations offer debriefing as part of their response to traumatic incidents - such as police officers involved in firearm incidents, or bank staff who witness robberies. In some institutions interventions are compulsory - perhaps out of a desire to reduce psychological distress, but also from a belief this will reduce exposure to litigation.

There are many reasons why belief in the effectiveness of debriefing has become so widespread. When facing disasters, all of us feel a need to do something. The idea that talking about trauma must be better than ``repressing'' or ``bottling up'' accords with a long tradition in psychological treatment - ``better out than in.'' Many people who have been debriefed judge the experience positively.

But does it work? There is only one way to really know if any intervention does more good than harm, and that is via randomized controlled trials. The studies undertaken so far provide no evidence of any benefit through intervention.

Perhaps the process of debriefing, part of whose purpose is to warn participants of emotional reactions that might be expected to develop over weeks and months, actually increases the occurrence of these symptoms. Perhaps for some people not talking is the most appropriate response. Indeed, psychological defense mechanisms may exist precisely because it is not always ``better out than in.''

Talking to a stranger, whom one has never met before and will not meet again, may impede the normal processes of recovery that rely on one's own social networks - family, friends, priest, doctor, who may be better able to place the trauma in context. Perhaps debriefing serves merely to professionalize distress - part of the wider process nowadays by which adversity has been professionalized.

Of course, when a cherished belief is challenged, various counter claims arise - the evidence is for the wrong type of debriefing, the trials were not well done, elements of debriefing could still ``work,'' the testimonies of those who are certain it helped them cannot be discounted, and so on. This is inevitable, but it should not distract us from the main findings.

So we must reassess how we respond to trauma. There can be no doubt that those who are attempting to help people involved in disasters and trauma have noble motives, but that is not enough. It is time that those who are asked to take part in debriefing are warned that the process has the capacity to do harm as well as good. Compulsory debriefing, which is still used in some organizations, must cease forthwith.

But should we be skeptical of all ``talking treatments?'' Unlike debriefing, there is overwhelming evidence that some talking treatments, such as cognitive therapy or cognitive behavior therapy, is effective when applied to disorders such as depression, panic disorder or post-traumatic stress disorder (PTSD). What is the difference then between these talking therapies and the vogue for debriefing?

Two things. First, unlike debriefing these interventions work not on normal people who have been exposed to adversity, but on those who have a definite psychiatric disorder. Second, these are skilled interventions, delivered by practitioners with well defined and well regulated professional skills, who are either clinical psychologists or psychiatrists. They are also given over a period of time. Sadly in mental health, effective treatments are neither swift nor easily learnt.

There is also a final paradox. When disaster strikes, it is the experience of all health professionals that they are often overwhelmed with offers of help. After the shootings at Columbine high school in the US a few years ago, the school received over 3,000 offers from people willing to come and ``debrief'' the children.

But it is the mundane, non-newsworthy traumas of life that cause real harm. The old people shattered by a burglary. The wife driven to depression by her husband's infidelity. The bank manager who cannot get to work because of panic attacks. Or the teenager disabled by obsessive compulsive disorder. For them finding skilled psychological therapies and therapists is rarely easy, even though in all of these instances the evidence of effectiveness is beyond dispute.

So we should take a long, hard look at how we manage our resources. It seems better to concentrate on delivering effective treatments to the smaller number of people who really need them, and not on the larger number of people who don't.

The story of debriefing provides a salutary lesson. First, people are more resilient than we give them credit for. Second, no matter how well meaning our attempts to reduce distress and prevent psychiatric disorder, and no matter how self-evident the intervention, we still require firm proof of the benefits. Any health care intervention has the capacity to do harm as well as good, and occasionally the balance between the two will surprise us.

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