The Immediate Aftermath of Trauma and the Dangers of Psychological Debriefing
Not too long ago, I received a call from a woman looking for services for her sister, who had witnessed her husband die in an automobile accident. She had called me because I specialize in treatment of trauma and posttraumatic stress disorder (PTSD). From our brief interaction, the woman commented that the most helpful thing I told her was not to worry too much about her sister developing PTSD at this time, as any symptoms her sister might be experiencing were likely a natural consequence of what she experienced. I've since offered a more detailed description on my website of what to do when you or someone you care about has been traumatized.
Statistically, about 10-20% of people develop PTSD following trauma. Given the high incidence of trauma, PTSD remains worthy of continued focus and understanding. From a glass half-full perspective, however, it appears most people recover from trauma without developing PTSD. In the aftermath of trauma, people may exhibit PTSD-like symptoms-intrusive memories of the trauma, nightmares, hyper-vigilance, numbing-but many of these symptoms recede over time. My main point is that these natural reactions do not mean something is necessarily wrong. More important than psychotherapy in the immediate aftermath of trauma is support and access to help, which I'll discuss in greater detail below.
Unfortunately, there is an entire industry of well-meaning therapists who believe everyone needs to process trauma as soon as possible following the incident. This type of treatment is called psychological debriefing. Psychological debriefing is usually given in a group format days after treatment, and many organizations require their employees to participate following a traumatic event. Critical Incident Stress Debriefing (CISD) and Critical Incident Stress Management (CISM) are the biggest names in psychological debriefing and have been used in government agencies all over the world. Debriefing may sound like a good idea in theory; however, although people generally report liking debriefing, all unbiased experimental research suggests people do no better following debriefing than if they had received no intervention at all. I say "unbiased" because the organization behind CISD/M has its own research journal that continues to pump out articles supporting its effectiveness.
Some studies have even found that people who receive debriefing end up feeing worse than if they hadn't receive any treatment! The American Psychological Association (APA) has taken a rare critical stance against debriefing, describing it as having "no research support" and being "potential harmful." These are unusually strongly worded statements for the APA. In addition, the Cochrane Collaboration, a prestigious non-profit organization dedicated to helping people make informed decisions about healthcare, has also concluded that there is no evidence that debriefing is effective and that "compulsory debriefing of victims of trauma should cease."
This doesn't mean that therapists who offer debriefing are intentionally practicing an ineffective treatment. I'm certain most are compassionate, well-meaning individuals who simply aren't acquainted with the research on it. Unfortunately, good intentions can still have disastrous consequences. For example, Ethan Watter's book Crazy Like Us documents how, in the aftermath of the 2004 tsunami, thousands of "traumatologists" descended upon Sri Lanka and tried to do debriefing with a culture that they didn't even understand. Some concluded the Sri Lankans were "in denial" because they appeared naturally resilient to the catastrophe!
If psychological debriefing doesn't work, the question remains: what should we do when people are traumatized? This is a question that keeps debriefing in business, as many organizations feel they must do something for their employees after a traumatic event-even if only to reduce liability.
At this time, there are no supported treatments for the immediate aftereffects of trauma. Consequently, here are some general recommendations that I offer in my own practice for how to help someone immediately following trauma.
- 1. Let the person know you care about them and will be there to offer emotional and/or practical support. People who have been traumatized may feel numb or over-stimulated. They may want to withdraw from things, finding even mundane tasks such as grocery shopping overwhelming, or they may want nothing more than to engage in the basic building blocks of daily living as a way to ground themselves, to have structure, and to cope with what they've experienced. Whatever their needs, let them know you're there for them and offer your assistance while also being prepared to back off. My impression from speaking with the sister of the woman who had recently lost her husband is that this woman was fortunate to have such a supportive family.
- 2.) Consider identifying names of mental health services and therapists in the community but don't pressure the person to enter into treatment before he or she is ready. Simply let them know you have a list of resources and can help them set up an appointment if they want to take that step. That said, there are two stages through which traumatic stress can become a diagnosable condition for which there are effective treatments:
- A.) Within one month of the trauma, a person may develop what's called Acute Stress Disorder (ASD). Fortunately, there are effective treatments for ASD. These treatments are relatively brief, often between 5-9 sessions; consequently, it may be worthwhile to have some therapists lined up who know how to effectively treat ASD.
- B.) About 80% of people with Acute Stress Disorder may eventually develop PTSD. PTSD may only be diagnosed if problems persist for more than one month. (Click here for a brief description of PTSD.) If the person is still struggling, an assessment by a qualified trauma therapist may be prudent. Research support for effective PTSD treatments such as Prolonged Exposure and Cognitive Processing Therapy is even stronger than for ASD.
In summary, there are no known evidence-based treatments for trauma survivors in the immediate aftermath of trauma. Survivors may benefit from supportive counseling, but there is no evidence that psychological debriefing treatments such as Critical Incident Stress Debriefing are helpful; in fact, there is some evidence debriefing is harmful. There are, however, effective treatments for Acute Stress Disorder and PTSD In the meantime, what trauma survivors may need most in the beginning stages of their recovery are not treatment but the love and support of those around them.