Thoughts on the Psychological Debriefing Controversy:
Let’s not throw the debriefing baby out with the reactionary bath water…

Gerald Lewis, Ph.D.

Over the past several years, there has been growing debate over the efficacy of psychological debriefings. This author addressed some of the pertinent issues in an article published in Behavioral Health Management, July 2002. (1) While controversy and examination are good and often generate useful discussion and an exercise in “lessons learned,” the recent trashing of debriefings as a viable service seems to be a bit reactionary, unjustified and founded on inadequate and poorly designed research. 

Part of the problem is that somewhere along the line, someone may have said or inferred that debriefings prevent PTSD. That is certainly a naive notion. Most mental health professionals understand that if an individual sustains an experience resulting in a bona fide diagnosis of PTSD, a single intervention of any type is not enough to manage the disorder.  Usually, a multimodal approach of talk therapy in combination with medication and other interventions such as EMDR, hypnosis, cognitive behavioral therapy, exercise, support groups, etc. is required to deal with the disorder over an extended period of time.

Some “experts” have made remarkable assertions that debriefings may, in fact, cause PTSD. As reported in the Crisis Management Quarterly, Summer 2003, “Possibly because CISDs focus on re-hashing and re-telling upsetting events, a diagnosis of PTSD could be more likely.  As a result, a negative outcome, supported by the growing body of reputable research, could provide the basis for lawsuits alleging negligence in an organization’s crisis response.”  (2) There is little question that a debriefing must be more than  “rehashing and retelling upsetting events,” or it is of limited benefit.   Yet, more and more institutions are dismissing the interventions based on faulty studies and a naïve misconception.  “The American Red Cross and the American Psychological Association have stated in a draft conclusion that post-trauma debriefings have not been shown to prevent later difficulties and may even cause problems to become entrenched or more severe over time.” An equally valid hypothesis may be that (since debriefings are voluntary) only those who were truly upset about the incident may have chosen to attend the debriefing and may have developed PTSD regardless of their participation in the debriefing.  Further, there may have been a greater number of “upset” people who went on to develop PTSD had they not attended the intervention.  Or, perhaps, some people were able to recognize the symptoms of PTSD as a result of being at the debriefing and availing themselves of further services. We will never know, because anyone who understands research design is aware of the impact of self-selection bias on statistical results. Other studies make reference to the negative findings of the Cochrane Review and hold it as the benchmark research. (4) The Cochrane Review looked at a diverse range of studies of individuals from many different facilities that “received individual crisis intervention bearing little resemblance to psychological debriefing and at times applied to situations where major stress reactions are not expected.” (5) Further these interventions were provided by a diverse group of practitioners without the benefit of a specific model. Comparing the Cochrane Review to debriefings is an “apples with oranges” proposition. The problems with the Cochrane Review are not limited to this one report.  As stated in “Psychological Debriefing” by the British Psychological Society:  “There are serious flaws in many of the studies that evaluate debriefing.  Several fail to define debriefing, describe the protocol used or the training of the debriefers.” (6) Once again… there must be a valid research design before we decimate an intervention that (at least) has a fair amount of anecdotal support. 

Another possible reason why there may be controversy about debriefings is that some prescribe a rather rigid intervention structure. While having a theoretical framework or intervention model is important, it is impossible to have a one-size-fits-all approach to psychological debriefings. As examples, this author has always felt that “CISD” applies only to those crisis care professions who are in the forefront of crisis, trauma and disaster response, or who deal directly with the victims of such incidents:  police, fire, EMTs, crisis workers, clergy, mental health, red cross, etc. It is part of their career… for which they are trained, equipped and respond as a team.   When a tragedy befalls a regular workplace, this is not a critical incident, nor does one provide a CISD.  Rather, this is  trauma in the workplace, with far more dramatic impact on those involved because:  a) it involves a co-worker with whom they may have had a personal relationship; b) the true “first responders” are coworkers; c) they have little to no formal training; d) they had no warning; e) they must go back to work and revisit the scene; f) they have not developed the “emotional calluses” or defense structure that professional crisis care providers have developed over the years of doing the job.  Therefore, one cannot compare services delivered to crisis care professionals (CISM) with those of workplace trauma victims. Thus, the possibility of a more dramatic impact, a higher incidence of PTSD and a need for more robust intervention should be expected and understood.  (7) Further, there are many occasions where this author has been called to provide services to a workplace after the death of an employee that has taken place outside of work and therefore, not witnessed/experienced by employees.  This, too, is not a CISD, nor a workplace trauma debriefing.  This is designated as meeting to talk about the death of ___.  This could apply to suicides, sudden tragic deaths, succumbing to a long term illness.  One may imagine that the psychological agendas of the participants of each type of incident would be very different. Therefore, the facilitators would need to orient the discussion to meet the specific character of the situation, as well as the demographics of the participants.  In fact, when not working with paramilitary organizations such as police, fire, hospitals, etc., this author has moved away from the term “debriefing” and instead, describes the intervention in regular layperson’s terms such as “meeting,” “discussion,” “get together to talk about the…” etc.  Certainly, the term CISD should not apply to any type of intervention around an administrative crisis such as a downsizing/layoff, relocation, removal of CEO, etc.  And finally, it is difficult to know exactly what the participants have been told about the upcoming meeting.  This author has discovered that by now, most police, fire, hospital professionals have an understanding of CISM and debriefings.  However, in a workplace trauma, many come to the debriefing/meeting with little to no true understanding of what it is about. Therefore, this may lead to a less than positive experience for some.   In order to get all on the same playing field and to mitigate some of the inconsistency in communication about the meeting, this author drafts up a statement and faxes/emails it to the workplace liaison so it can be utilized as part of the “invitation” to potential participants.  Further, there are handout materials for the participants to take with them that are pertinent to the situation, be it a trauma in the workplace, suicide at home, layoff, etc.  Most importantly, this material indicates that the debriefing is only one of many techniques or services to help if the reactions persist.

Another reason why the efficacy of debriefings may be called into question is that after a debriefing, the administrative personnel may expect that “all is well”…“people should be back on track”… Or, query a week later, “How come people are still upset? They had a debriefing, didn’t they?” When called to a workplace to provide an intervention, we must be careful not to collude with their denial or lack of understanding.  This means that, in addition to a debriefing, one must provide good consultation to the workplace and help management appreciate that their employees might require more than a single meeting.

We must stop using 911 as the yardstick by which to measure the efficacy of any interventions.  911 was “so over the top” of our experience that to draw any inference regarding psychological services is only speculation.  Certainly, it is understandable that for an event of that magnitude, a single debriefing of the police, fire, survivors, etc may serve as little more than a well intentioned “spit in the bucket.”  For many people who experience a dramatic trauma, a single intervention of any type may not be enough to mitigate their symptoms and alleviate their suffering.  However, the question is not whether the debriefing is useless, but rather what other services should be available?  The goal of trauma support is to have a “trauma toolbox” that is both wide and deep (and utilized by experienced practitioners).  Further, that as an initial proactive intervention, the debriefing may serve to facilitate the access to further services for those in need.

Let’s talk about training.  As a psychologist for more than twenty five years and doing this work for more than seventeen, this author believes that working with groups of people who have experienced a major trauma should be considered an expertise that requires training, experience, consultation, staying current with the literature, etc. A one or two day workshop is a good start, but not sufficient for people who are serious about becoming or remaining proficient in this specific field. And finally, while the “peer support” model may be sufficient for police, fire, hospital, etc. employees, it is not the recommendation that they be the ones to provide services to other types of employment settings.

There are many issues that must be taken into account such as: type of incident, demographics of the victims, demographics of the participants, training & supervision of facilitators, documentation, management consultation, post-debriefing follow-up, etc. Then, perhaps, a well founded research design that takes into account: controlling incident demographics, utilizing a specific model, random assignment of participants to treatment and non-treatment groups, pre-morbid history and personal variables of the participants, training and experience of facilitators and long term follow up with a consistent method, would provide viable data. Since humans are not mice in a lab, any qualified research that measures the benefit of mental health interventions is always fraught with some design limitations.  Therefore, one must be careful not to rely too heavily on the “latest research.”  In the words of Albert Einstein,  “Not everything that counts can be counted. Not everything that can be counted counts.” 

References 

(These references may not be in appropriate reference form)

Gerald Lewis, Ph.D. is the Director of COMPASS, providing Employee Assistance Programs, management consultation, organizational development and employee training and education.  He is an international consultant who has addressed government agencies, treatment facilities, schools and private businesses including: the U.S. Postal Service, the U.S. Army, the Federal Aviation Administration, the Bank of Montreal, the Johns Hopkins University and Medical School, the City of Phoenix, AZ, the Panama Canal Commission and the Government of Barbados.  In addition, he provides litigation consultation/expert testimony involving workplace issues. He has authored numerous articles and two books: Critical Incident Stress and Trauma in the Workplace (1994) and Workplace Hostility: Myth & Reality (co-author, 1998). Also, The At-Risk Assessment Protocol (self-published, 2001).