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.

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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.

24. Bryant RA, Harvey AG, Dang S, et al. Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol 1998;66(5):862-6.

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26. National Institute of Mental Health. Mental health and mass violence: evidence-based early psychological intervention for victims/survivors of mass violence. A workshop to reach consensus on best practices. NIH publication No. 02-5138. Washington, DC: U.S. Government Printing Office; 2002:13. Available at: www.nimh.nih.gov/healthinformation/massviolence_intervention.cfm. Accessed August 24, 2006.

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29. Shear K, Frank E, Houck PR, Reynolds CF, 3rd. Treatment of complicated grief: a randomized controlled trial. JAMA 2005;293(21):2601-8.

immediate emotional and informational support
psychoeducational materials that describe common sequelae of trauma
information about how and where to get help, if desired.

Table 3

Recommended components of ‘psychological first aid’

Protect survivors from further harm Reduce psychological arousal Mobilize support for those who are most distressed Keep families together and facilitate reunions of loved ones Provide information and foster communication and education Use effective risk communication techniques
Source: National Institute of Mental Health, reference 15

Included is information about the potential benefits of discussing reactions to the loss with trusted friends, family members, or significant others when victims feel comfortable doing so.

Screening for risk factors. When victims seek your professional support or services immediately after a traumatic event, screen for risk factors for complicated grief, PTSD, or other chronic difficulties. Complicated grief is a relatively new diagnosis, and research on its risk factors is preliminary. The literature suggests, however, that risk factors may include:

childhood abuse and neglect
childhood separation anxiety
loss of a child
excessive interpersonal dependency or insecure attachment styles.⁶

To assess for PTSD risk, ask about history of exposure to other traumatic events, pretraumatic psychological difficulties (especially anxiety disorders), inadequate social supports, and exposure to grotesque aspects of the current trauma (such as seeing mutilated or dismembered bodies).²⁷

In the weeks and months after the traumatic event, we recommend screening the most distressed victims for risk of developing chronic psychopathology. The National Center for PTSD offers self-report measures appropriate for various populations (such as children or adults) and trauma contexts (such as combat) (see Related resources). The Inventory of Complicated Grief²⁸ is useful for screening for CG.

Empirically informed CBT. Provide brief cognitive behavioral interventions only for persons at risk and only after sufficient time has passed to allow you to differentiate between normal grief and abnormal responses. Early interventions that have shown promising outcomes typically have been delivered approximately 2 weeks after the traumatic exposure.^24,25

Brief, multi-session CBT given several days to a few weeks after the trauma has been associated with improved posttraumatic adjustment.^24,25 Interventions that appear to be most promising for patients who meet criteria for CG combine:

psychoeducation
exposure therapy for those having difficulty grasping the reality of their loss
and behavioral activation techniques.²⁹

Unlike most PTSD interventions, those for bereavement-related distress have been used several weeks (rather than days) after the patient’s loss.

Focus psychoeducation on how maladaptive strategies (such as avoiding trauma cues) can prolong trauma-related distress. Structure early interventions to encourage home-based exercises (such as exposure). These may reduce victims’ reliance on maladaptive strategies, accelerate therapeutic effects, and promote the generalization of treatment gains.^24-25

Related resources

Litz BT (ed). Early intervention for trauma and traumatic loss. New York: Guilford Press; 2004.
National Center for PTSD:
Shear K, Frank E, Houck PR, Reynolds CF 3rd. Treatment of complicated grief: a randomized controlled trial. JAMA 2005;293(21):2601-8.

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.