Evidence-Based Reviews

Crisis debriefing: What helps, and what might not

Current Psychiatry. 2006 October;5(10):17-29

References

1. Breslau N, Kessler RC, Chilcoat HD, et al. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 1998;55(7):626-32.

2. Latham AE, Prigerson HG. Suicidality and bereavement: complicated grief as psychiatric disorder presenting greatest risk for suicidality. Suicide Life Threat Behav 2004;34(4):350-62.

3. Gray MJ, Prigerson HG, Litz BT. Conceptual and definitional issues in complicated grief. In: Litz BT (ed). Early intervention for trauma and traumatic loss. New York: Guilford Press; 2004:65-84.

4. Neria Y, Litz BT. Bereavement by traumatic means: the complex synergy of trauma and grief. Journal of Loss and Trauma 2004;9(1):73-87.

5. Silverman GK, Jacobs SC, Kasl SV, et al. Quality of life impairments associated with diagnostic criteria for traumatic grief. Psychol Med 2000;30(4):857-62.

6. Lichtenthal WG, Cruess DG, Prigerson HG. A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clin Psychol Rev 2004;24(6):637-62.

7. American Psychiatric Association. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry 2004;161(11 suppl):3-31.

8. Schut H, Stroebe MS, van den Bout J, Terheggen M. The efficacy of bereavement interventions: Determining who benefits. In: Stroebe MS, Hansson RO, Stroebe W, Schut H (eds). Handbook of bereavement research: consequences, coping, and care. Washington, DC: American Psychological Association; 2001:705-37.

9. Litz BT, Gray MJ. Early intervention for trauma in adults: a framework for first aid and secondary prevention. In: Litz BT (ed). Early intervention for trauma and traumatic loss. New York: Guilford Press; 2004:87-111.

10. Litz BT, Gray MJ. Early intervention for mass violence: What is the evidence? What should be done? Cognit Behav Pract 2002;9(4):266-72.

11. Webb NB. Groups for children traumatically bereaved by the attacks of September 11, 2001. Int J Group Psychother 2005;55(3):355-74.

12. Lee C, Slade P, Lygo V. The influence of psychological debriefing on emotional adaptation in women following early miscarriage: a preliminary study. Br J Med Psychol 1996;69(1):47-58.

13. Robinson R, Mitchell J. Getting some balance back into the debriefing debate. Bull Aust Psychol Soc 1995;17:5-10.

14. Jenkins S. Social support and debriefing efficacy among emergency medical workers after a mass shooting incident. J Soc Behav Personality 1996;11:477-92.

15. Everly GS, Flannery RB, Mitchell JT. Critical incident stress management (CISM): A review of the literature. Aggression Violent Behav 2000;5(1):23-40.

16. Litz B, Gray M, Bryant R, Adler A. Early intervention for trauma: Current status and future directions. Clin Psychol Sci Pract 2002;9(2):112-34.

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

18. Conlon L, Fahy T, Conroy R. PTSD in ambulant RTA victims: A randomized controlled trial of debriefing. J Psychosom Res 1999;46:37-44.

19. Deahl M, Srinivasan M, Jones N, et al. Preventing psychological trauma in soldiers: the role of operational stress training and psychological debriefing. Br J Med Psychol 2000;73:77-85.

20. Hobbs M, Mayou R, Harrison B, Warlock P. A randomized trial of psychological debriefing for victims of road traffic accidents. BMJ 1996;313:1438-9.

21. Mayou R, Ehlers A, Hobbs M. Psychological debriefing for road traffic accident victims: three-year follow-up of a randomized controlled trial. Br J Psychiatry 2000;176:589-93.

22. Rose S, Brewin C, Andrews B, Kirk M. A randomized controlled trial of individual psychological debriefing for victims of violent crime. Psychol Med 1999;29:793-9.

23. Schut H, Stroebe MS, van den Bout J, Terheggen M. The efficacy of bereavement interventions: determining who benefits. In: Stroebe MS, Hansson RO, Stroebe W, Schut H (eds). Handbook of bereavement research: Consequences, coping, and care. Washington, DC: American Psychological Association; 2001:705-37.

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Does debriefing work?

Debriefing is designed not to address the intense but transient emotional reactions that can be expected immediately following traumatic loss but to prevent protracted, incapacitating distress. For an early intervention to be considered effective, it must be associated with greater or more expedient symptom recovery compared with natural remission. Controlled clinical trials are necessary to determine if this is the case.⁹

Control groups are essential when studying treatment outcomes of early crisis interventions. Simply documenting improvement among treated individuals is insufficient because substantial symptom remission is the norm and chronic psychopathology is comparatively rare. Thus, early interventions studies should at least:

include a treatment group and a no-treatment or wait-list control condition
randomly assign participants to avoid selfselection biases.

The debriefing literature is difficult to interpret because studies often are unclear about what intervention has been used (CISD or otherwise).

Debriefing for traumatic loss. Debriefing-based interventions have been used after mass violence and other large-scale traumatic events that may trigger complicated grief reactions.¹⁰ Most studies have not evaluated the impact of debriefing on complicated grief specifically but have focused on PTSD, anxiety, and depression. Typical published accounts of debriefing-based interventions for grief responses¹¹ have been anecdotal, qualitative, and uncontrolled.

One rare controlled study of debriefing¹² was designed to target emotional difficulties in women following early miscarriage. The one-half of participants who were debriefed 2 weeks after miscarriage perceived debriefing to be helpful. Despite significant improvement in early intrusion and avoidance scores, however, the women who were debriefed showed no greater improvement after 4 months than did a nondebriefed control group. The investigators concluded that debriefing did not influence post-loss adaptation.

A wider search. In the absence of randomized, controlled trials (RCTs) of debriefing-based interventions for traumatic loss, we turn to the larger debriefing literature. Nearly all debriefing studies have focused on PTSD symptoms rather than grief responses.

A number of peer-reviewed studies suggest that psychological debriefing is an effective intervention. These studies^13,14 are characterized by dramatic symptom reductions following the intervention. Unfortunately, nearly all lack a control group, and the few that were controlled¹⁴ were not randomized. Studies reviewed by Everly et al¹⁵ also contain fundamental flaws, such as lack of random assignment, failure to assess individuals prior to the intervention, and lack of control groups.

None of the few RCTs of psychological debriefing conducted in traumatized populations show that it accelerates recovery in treated persons compared with nontreated controls.¹⁶ All of the studies^17-22 included untreated control conditions, and participants were randomly assigned. Without exception, debriefed participants did not show superior improvement, and in two studies they showed worse outcomes than did untreated controls.^17,21

Focused interventions

To provide optimal care to our patients, we must base our decisions on rigorous empirical study. In the case of debriefing, available well-controlled trials lead us to conclude that debriefings are inert.

To be clear, we are not philosophically opposed to early intervention for traumatic loss. We believe researchers must continue to develop and study interventions that can stave off chronic pathology among those at risk after traumatic loss.

Thus, clinicians and researchers face the same imperative: to accurately and efficiently identify persons at risk. Indiscriminately debriefing all persons who experience traumatic loss—without regard to risk—is not the most judicial use of clinical resources. Nor is it likely to advance our understanding of risk factors and resiliency in loss or of treatment efficacy.

Grief literature indicates that broadly applying interventions to anyone who has experienced loss does not help and may in fact exacerbate grief symptoms. Focused interventions for persons most at risk for complicated grief are more effective.²³

Practice recommendations

Given the limited evidence, the recommendations that follow are preliminary and based on the few early interventions for trauma that have produced superior outcomes compared with untreated controls.^24,25 In general, these interventions used:

cognitive-behavioral techniques (education, promotion of adaptive coping strategies)
exposure exercises for survivors who were using maladaptive avoidant coping strategies
homework to reinforce therapeutic activities initiated in session.

Most importantly, these interventions were conducted specifically with trauma survivors who were at risk for chronic psychopathology, rather than with anyone exposed to trauma or traumatic loss. Also, these interventions usually were not given within hours or days of the trauma but several weeks later. Because most persons exposed to trauma are anxious, sad, grief-stricken, or otherwise upset, immediate attempts to identify those at risk for protracted difficulties will likely be futile.

‘Psychological first aid.’ Although immediate formal treatment is not recommended, a National Institute of Mental Health consensus conference²⁶ recommended offering trauma victims “psychological first aid” (Table 3) when feasible. Psychological first aid is not intended to prevent chronic psychopathology but to provide: