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26 August 2011

Too much too soon

Can the good intentions and passion to help people soon after a traumatic event do more harm than good?

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 The terror and tragedy of violence and natural disaster can have a devastating psychological impact on survivors. In response to such events, trauma debriefing has been advocated as a way of supporting survivors.

In many cases, the rapid mobilisation of counsellors to assist with the psychological response to a disaster is done with a great sense of urgency, in the belief that immediate intervention (within 72 hours) could prevent the development of post-traumatic stress disorder (PTSD).

While hundreds of counsellors volunteer their services, the provision of debriefing services has become a multi-million dollar industry in countries such as America. For example, after the World Trade Centre terrorist attacks, thousands of “debriefers” attended the area, advocating and offering debriefing services.

But can the good intentions and passion to help following a trauma carry with it paradoxical effects?

Potential for harm

Contrary to popular belief, research over the past few years has indicated that immediate trauma debriefing, termed "critical incident stress debriefing" (CISD), is highly disputed and may even do more harm than good.

“There are still so many misconceptions about the use of trauma debriefing in the aftermath of trauma,” says Prof Soraya Seedat, psychiatrist and co-director at the MRC Unit on Anxiety Disorders.

According to Seedat, there is growing body of research (studies of single-session debriefing) indicating that this approach may not be effective in preventing PTSD, i.e. that survivors of a life-threatening traumatic event who have been given this intervention show no significant improvement in PTSD symptoms when they are followed up months later.

Australian researchers Grant Devilly and Peter Cotton warned in a meta-analysis in 2002 that claims that CISD can mitigate long-term pathology are not proven and that this intervention system may, in fact, result in paradoxical outcomes.

Seedat says that there has subsequently been more evidence to suggest that debriefing may be associated with a worse outcome when compared to a control group (i.e. those who do not receive the debriefing and receive no intervention at all).

There are several guidelines that echo this view - for example the UK’s National Institute for Health and Clinical Excellence for the treatment of PTSD states that “the systematic provision of brief, single-session debriefing focusing on the traumatic incident should not be routine practice”.

The US Department of Veterans Affairs and Department of Defense guidelines also support this view, as do Australian guidelines for the treatment of PTSD, among others.

The Japanese example

Dr David Berceli, a trauma expert who has worked with trauma survivors all over the world, agrees that premature trauma intervention may be harmful. He warns that while some people need to talk immediately afterwards, others can’t because it recharges and retraumatises them and it therefore makes matters worse.

Soon after a traumatic event such as the 2011 Tôhoku Japan earthquake and tsunami, people were attending to basic needs such as food and shelter. They were still in a state of shock and not fully present. Even weeks after the disaster in Japan, people still feared danger and no one felt completely safe. Thousands of evacuees are still living in school gymnasiums and other public buildings and many still continue to search for loved ones.

“Common symptoms people experience in such a state are inability to sleep, anxiety, feeling unsettled, waiting for disaster to occur again, a sense of impending doom, and being on alert constantly. People also typically feel a sense of rage at the universe, which is aimed at the government and insurance companies.

“Rage gets displaced onto social structures because there is nothing else to vent it towards. This explains why there is often a rise in domestic violence four to five years following a traumatic event,” says Berceli.

Some relief workers in Japan reported that many Japanese have thus far chosen not to make use of trauma counselling services. The reasons for this may be partly due to stigma around mental illness and seeking help. It might also be because of the timing of intervention.

“Intervention offered may have been too early because everything is still too raw, too dangerous, and the trauma is not over yet. The Japanese – a quiet, family-orientated nation – are typically introverts who need time to reflect. Intervention which encourages people to talk may be experienced as too intrusive and overly-stimulating.

Berceli did extensive work in Haiti, four to five months after the disaster there. He was only able to do constructive work once people had makeshift houses and had started to reorganise their lives. Only then were people ready for neurological shifts to occur, because a place of safety could be ensured.

How the Japanese might be responding to trauma

 Much has been reported about the calm and ordered way in which the Japanese have dealt with had happened, and still continues to happen, to them.

Berceli, who worked in Japan for two years, says that a culture which appears calm on the outside is indicative of a regimented society, and of great social consciousness: “You can’t misbehave because it will reflect poorly on your family. You need to find some way of expressing your fear and trauma which isn’t viewed socially. People find hidden ways of expression. Substance abuse and domestic violence are common, but kept very quiet; people will commit suicide before they would commit murder. People still have the same natural human responses but express them in a way that isn’t offensive or obvious to society. There is a great fear of bringing shame to the family or being ostracised.”

Berceli predicts that once a sense of equilibrium is reached, people will put all energy back into rebuilding the country, as they did after the world war, becoming industrious to the point of driving themselves. Alcohol abuse is expected to rise, as is insomnia, and individuals becoming excessively compulsive around activities such as cleaning. This is all a reflection of the high charge of anger, hurt and betrayal. Protest against the government for the nucleur disaster may intensify (protest is socially acceptable because there will be widespread support and agreement in the society).

Matrix for intervention

Dr Neil McGibbon, Health24's Teen Expert is a Clinical Psychologist who worked with trauma survivors in Northern Ireland and at the Traumatic Stress Service in South West London.

"There is a very real danger of deskilling and pathologising people if professionals rush in with trauma debriefing.  We have levels of resilience that are sometimes put to the test by traumatic events, and it is crucial that time is given to allow for an individual’s natural self-healing capacities.  This is not about leaving someone to suffer; it is about monitoring the situation and a person’s symptoms over time," says McGibbon. 

"Normalising their responses in the early stages can help strengthen someone’s recovery rather than them being disempowered by others intervening.  Only if the symptoms persist and someone’s mental state is deteriorating, is it necessary for professional intervention.  Watch and wait is indeed an approach I support."

According to Israeli psychologist Dr Irwin Mansdorf, who did extensive research on psychological interventions for terror, the acute effect of trauma is mitigated over time and not all reactions to trauma will result in long-term clinical damage.

As a result, not all who experience trauma will actually require any formal psychological treatment.

He urges people to be very careful in prescribing psychological treatment intervention at all and outlines the following conservative matrix of major approaches in dealing with terror-related reactions:

  • Minor - no symptoms: allow natural recovery, limit to education and/or social support to foster individual coping, no formal intervention
  • Moderate symptoms: foster resilience and individual coping by providing psychological tools; avoid mandatory or intrusive emotional debriefing
  • Severe: formal psychological and medical intervention

(Ilse Pauw, Health24, April  2011)

Sources

Pers Comm (March 2011) Prof Soraya Seedat, MRC Unit for Anxiety Disorders.

Pers Comm (March 2011) Dr David Berceli, Trauma Releasing Exercises.

Pers Comm (July 2011) Dr Neil McGibbon, Health24's Teen Expert

Devilly, G. and Cotton, P. (July 2003) Psychological Debriefing and the Workplace: Defining a Concept, Controversies and Guidelines for Intervention, Australian Psychologists, Volume 38, 2.

Mansdorf, I. J. (November 2008) Psychological interventions following terrorist attacks, British Medical Bulletin, 88: 7-22.

Related links

PTSD

A new form of trauma treatment

 

 
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