The Rush to Counsel: Lessons of Caution in the Aftermath of Disaster
Susan P. Robbins, Ph.D., LMSW-ACP
The date of September 11, 2001 has become etched indelibly into our national consciousness as the end of the illusion of safety in America. The terrorist attacks that destroyed part of the Pentagon and toppled the World Trade Centers, leaving over 3,000 people dead and countless others directly touched by this disaster have led to what Dineen (2001) has called the loss of our innocence. In addition to those who were most directly affected by the death of a family member or friend, there were many who witnessed the attacks firsthand as well as survivors who narrowly escaped death. The constant and repetitive media coverage of the attacks also brought the reality of this tragedy into the homes of millions of people across the nation, and few were left untouched by the graphic scenes of the airplane crashes and unthinkable destruction of lives and national institutions and icons.
Mental health professionals were quick to respond, offering counseling, psychological debriefing and an array of mental health services to people who were believed to need professional help to alleviate the psychological symptoms of trauma and potential post traumatic stress disorder (PTSD) as a result of the attacks. Although the intent to provide immediate psychological assistance was, no doubt, based on an honest desire to help those in distress, the rush to counsel may have unintended and negative effects according to the scientific research in this area.
Extreme reactions to a disaster are not necessarily a sign of an emotional illness or disorder and most people recover rapidly, despite initial reactions that may include shock, anger, anxiety, depression, fear, grief, emptiness, despair, nightmares, headaches, and trouble sleeping and concentrating. For most people, especially those who were functioning well before the disaster, these distressing but normal reactions to tragedy abate within a few weeks to a few months, either on their own, or with the use of natural helping networks and resources in the family and community (The Harvard Mental Health Letter, 2002; Litz, et al., 2001; Rosenfeld, 2001; Shear, et al., 2001). Some who experience disaster do develop PTSD or other serious and lasting psychiatric symptoms and there is little question that psychological counseling and other appropriate psychiatric help is indicated for those who are unable to resolve trauma of this sort without assistance.
Unfortunately, in the immediacy of the 9/11 tragedy, the distinction between those who needed professional help and those who did not was largely ignored. Under the coordination of the Red Cross and the Salvation Army emergency assistance teams, mental health professionals, the majority of whom were social workers, provided various forms of counseling and crisis intervention to thousands of people immediately following the attacks. In addition, 150 teams of counselors were dispatched to assist victims with a specific type of disaster counseling known as critical incident stress debriefing or CISD (Talan, 2001).
CISD, also known as psychological debriefing, is a one-time intervention in which people are encouraged to talk about their experiences in a structured group session. Developed in 1983 by Dr. Jeffrey T. Mitchell, a former fire fighter and paramedic, it was originally designed to reduce job related stress for emergency service personnel who responded to traumatic events. Currently world wide in its application, its use has now been extended to include victims and witnesses of disasters. It has also been included in numerous disaster counseling projects as well as the American Red Cross disaster mental health training program (Hiley-Young & Gerrity, 1994). Psychological debriefing is based on the idea that immediate processing of the tragedy will help prevent PTSD and allow people to move forward with their lives. Early intervention of this type is meant to offer people the opportunity for catharsis, a chance to verbalize the trauma, and also provide structure, group and peer support, all of which are believed to be the critical therapeutic factors necessary for recovery (Hiley-Young & Gerrity, 1994). The intervention usually consists of seven steps and after an introduction and assurance of confidentiality, the structured CISD group session helps people reconstruct the traumatic incident and discuss their individual reactions to it. It also includes a didactic discussion of the symptoms of acute trauma and grief and participants are assured that their reactions are normal and are provided with suggestions for handling signs of stress.
Tens of thousands of people have been trained in CISD (Talan, 2001) and many mental health professionals have come to believe that psychological debriefing is not only an effective intervention, but a necessary first step in assisting people who have experienced a disaster. Much of this faith, however, is based on testimonials and case studies that claim to prove the efficacy of debriefing. Others believe it is effective because people who have undergone CISD report feeling better after a debriefing session (Talan, 2001). Unfortunately, the scientific literature does not support these beliefs.
The preponderance of randomized and controlled studies now shows that psychological debriefing is not only largely ineffective but may also have long-term adverse effects on victims of trauma (Bisson, et al., 1997; Kernardy, et al., 1996; Mayou, et al., 2000; McFarlane, 1988; Raphael, et al., 1995; Raphael & Wilson, 2000). In a report known as the Cochrane Review, Wessely, et al. (1999) reviewed eight randomized trials utilizing psychological debriefing and found that it had no impact on psychological morbidity and that it was also associated with poorer outcomes in some cases. Similar results were found in a separate study by Small, et al. (2000). A more recent update to the Cochrane Review (Rose, et al. 2001), again replicated these earlier findings. This has led some researchers to conclude that, It is not an appropriate treatment for trauma victims (Mayou, et al., 2000) and that Compulsory debriefing of victims of trauma should cease (Rose at al, 2001). Even prior to these studies, the lack of scientific evidence supporting effectiveness of this intervention led Richard Geist, assistant to the chief of the Kansas City Fire Department and psychologist, to dub the debriefing movement a truly classical example of how powerful the 'Barnum effect' can become, even among folks ostensibly trained in critical empirical paradigms (1996).
Immediately following the attack on the World Trade Centers, a group of nineteen psychologists, several of them well known in the area of trauma, circulated an open letter urging their colleagues to refrain from the urge to intervene in ways that--however well-intentioned--have the potential to make matters worse. They warned that, Several independent studies now demonstrate that certain forms of postdisaster psychological debriefing (treatment techniques in which survivors are strongly suggested to discuss the details of their traumatic experience, often in groups and shortly after the disaster) are not only likely to be ineffective, but can be iatrogenic, and further urged psychologists to be of most help by supporting the community structures that people naturally call upon in times of grief and suffering. This letter was eventually published in the APA Monitor (Herbert, et al., 2001, November), titled Primum Non Nocere, or First, Do No Harm, a basic principle espoused in the Hippocratic Oath. This was picked up quickly by the mainstream media and reported in the New York Times and USA Today (Waters, 2002), creating widespread controversy outside of the usual academic journals in which issues like this are routinely debated.
Jeffrey Mitchell, quite predictably, defended CISD, citing inadequacy in the research that claimed it was ineffective. The basis of this defense had previously been published in an article written with his colleague George Everly, Jr. (Everly & Mitchell, 2000), in which they systematically criticized the randomized and controlled studies for not using the standardized debriefing process and for using individual rather than group debriefing, among other factors. They then cited multiple studies of CISD with emergency service personnel (emergency medical technicians, rescue personnel, police and healthcare providers) that showed CISD to be effective. It is important to note that none of the studies used to defend the effectiveness of CISD involved victims or witnesses of disasters.
Although additional research is needed to test Mitchell's pure group facilitated model of CISD with trauma victims, the logical conclusion that can be drawn from the current research is that there is no existing evidence that debriefing is effective for this population. Given the fact that the preponderance of studies in this area have also shown that debriefing can lead to adverse outcomes, widespread and indiscriminate use of this method for trauma victims is both risky and potentially dangerous.
In the rush to provide assistance to those who experienced the terrorist attacks of September 11th, many assumptions were made about the immediate mental health needs of the survivors and witnesses. These assumptions were based on unsupported predictions that the trauma of the attacks would necessarily produce long term negative effects for most people if they failed to receive instant professional counseling. Although social workers provided many other forms of service and counseling unrelated to psychological debriefing, some were part of the debriefing effort as well.
One of the cornerstones of sound social work practice is that intervention should be based on a thorough assessment of the problem. This is also the basis of good crisis intervention as well (Hoff, 1989; James & Gilliland, 2001). Litz, et al. (2001), have noted the importance of initial screening of trauma victims for known risk factors for PTSD, given the fact that only a minority of those who experience trauma will develop posttraumatic problems. They emphasized the need for assessment and also cautioned against routinely providing debriefing or exposure therapies to people after crisis.
Echoing, at least in part, the recommendations of Herbert, et al. (2001), they also suggested that, Early interventions for trauma should be designed to increase social support among trauma victims, as this has been found to reduce the likelihood of chronic posttraumatic psychopathology. Social workers, by the very nature of their training and chosen profession are particularly well suited to assessing available social supports and assisting people in mobilizing resources within their communities so that they can fully utilize the natural helping networks that are known to aid in enhancing post-disaster functioning.
Finally, social workers that rush to the aid of disaster victims must be well informed about normal reactions to trauma of this type so that they do not confuse predictable extreme reactions with incipient psychopathology. They must also be knowledgeable about interventions that are scientifically proven to facilitate recovery and those that have no benefit or have the potential to be detrimental. If we are to embrace the ideal of social work as truly being a helping profession, we must use caution, especially in crisis situations, and move beyond the dictum of First, do no harm to that of First foremost, and finally, do no harm.
Bisson, J., Jenkins, P., Alexander, J., & Bannister, C. (1997). Randomised controlled trial of psychological debriefing for victims of acute burn trauma. British Journal of Psychiatry, 171, 78-81
Dineen, T. (2001, Sept. 14). Losing our innocence: A continent grows up the hardest way. The Ottawa Citizen, 1
Everly, G. S. & Mitchell, J. T. (2000). The debriefing controversy and crisis intervention: A review of lexical and substantive issues. International Journal of Emergency Mental Health, 2 (4), 211-225.
Geist, R. (1996). A critical view on debriefing. http://www.trauma-pages.com/cisdgist.htm
Herbert, J.D., Lilienfeld, S., Kline, J., Montgomery, R., Lohr, J., Brandsma, L., Meadows, E., Jacobs, W. J., Goldstein, N., Gist, R., McNally, R. J., Acierno, R., Harris, M., Devilly, G.J., Bryant, R., Eisman, H.D., Kleinknecht, R., Rosen, G.M. & Foa, E. (2001, November). Letter: Primum non nocere. Monitor on Psychology 32, (10) American Psychological Association. http://www.apa.org/monitor/nov01/letters.html
Hiley-Young, B. & Gerrity, E. T. (1994). Critical incident stress debriefing (CISD): Value and limitations in disaster response. National Center of Post-Traumatic Stress Disorder Clinical Quarterly 4(2). http://www.ncptsd.org/treatment/cq/v4/n2/hiley-yo.html
Hoff, L.A. (1989). People in crisis: Understanding and helping. Redwood City, CA: Addison-Wessley.
James, R.K. & Gilliland, B.E. (2001). Crisis intervention strategies. Belmont, CA: Brooks/Cole.
Kernardy, J. A., Webster, R. A., Lewin, T. J., Carr, V. J., Hazell, P. L., & Carter, G. L. (1996). Stress debriefing and patterns of recovery following a natural disaster. Journal of Traumatic Stress, 9, 37-49.
Litz,B., Gray,M., Bryant, R. & Adler, A. (2001). Early intervention for trauma: Current status and future directions. A National Center for PTSD Fact Sheet. (Also In press for Clinical Psychology: Science and Practice). http://www.ncptsd.org/facts/disasters/fs_earlyint_disaster.html
Mayou, R. A., Ehlers, A., and Hobbs, M. (2000). Psychological debriefing for road traffic accident victims: Three-year follow-up of a randomised controlled trial. British Journal of Psychiatry, 176, 589-593.
MacFarlane, A.C. (1988). The longitudinal course of posttraumatic morbidity: the range of outcomes and their predictors. Journal of Nervous and Metnal Disease, 176, 30-39.
Raphael, B., Meldrum, L., & McFarlane, A. C. (1995). Does debriefing after psychological trauma work? Time for randomized controlled trials. British Medical Journal, 310, 1479-1480.
Raphael, B. and Wilson, J. P. (2000). Psychological debriefing: Theory, practice and evidence. New York: Cambridge University Press.
Rose, S. Bisson, J. & Wessely, S. (2001). Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane Review). The Cochrane Library, 4, Oxford, U.K.: Update Software Ltd.
Rosenfeld, L. B. (2001, Sept. 14). Children's responses to terrorism. (written especially for NASW online) http://www.socialworkers.org/terror/rosenfeld.htm
Shear, K. M., Frank, E., Foa, E., Cherry, C., Reynolds III, C. F., Bilt, J. V. and Masters, S. (2001). Traumatic grief treatment: A pilot study. American Journal of Psychiatry, 158, 1506-1508.
Small, R., Lumley, J., Donohue, L., Potter, A. & Waldenström, U. (2000). Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth. British Medical Journal, 321, 1043-1047
Talan, J. (October 2, 2001) Doubts on debriefing. Newsday.
Waters, R. (January/February, 2002). Our greatest challenge. Psychotherapy Networker, 26 (1), 52-57, 62.
The Harvard Mental Health Letter. (January, 2002). Disaster and trauma. . The Harvard Mental Health Letter. Volume 18 (7), 1-5.
Wessely, S., Rose, S., Bisson, J. (1999). 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). The Cochrane Library, 4, Oxford, U.K.: Update Software, Ltd.