Critical Incident Stress Debriefing

The print version of the LA Times in late July ran a story with the headline “Go Ahead, Hold It In.” (The headline on the web version is a little less pithy.) Apparently new research suggests that emotional expression after a traumatic event is not as helpful as once thought:

“In the immediate aftermath of a collective trauma, it’s perfectly healthy to not want to express your thoughts and feelings,” [University of Buffalo Psychologist Mark Seery] says.

In fact, it can do more harm than good. Some people have periods of what psychologists call “healthy denial.” Like Scarlet O’Hara, they cope by promising themselves to think about it tomorrow. Being pushed to give voice to their worst reactions too soon could embed the worst of it in memory and cause them to dwell on the tragedy. And if they can’t or won’t talk, urging them to act against their instincts could make them think that something is wrong with them.

In the aftermath of major traumas like the September 11 terrorist attacks, shootings at Virginia Tech, or natural disasters, counselors and therapists are often brought in by the hundreds. They provide what is called Critical Incident Stress Debriefing, a process in which victims or family members, usually in a group setting, are encouraged to express their emotions and talk about their experiences around the event.

The LA Times puts it politely in saying such work “has gotten ahead of the evidence on the best course of mental healthcare after a disaster.” Unfortunately, we’ve known this for some time, and the CISD business is booming.

This 2003 research summary in Psychological Science in the Public Interest summed up what we knew five years ago:

Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing.

Two years later, in 2005, we had this summary of the state of CISD research:

The National Institute for Mental Health (NIMH), in conjunction with the Departments of Justice, Defense, Health and Human Services, Veterans Affairs and the American Red Cross, held a consensus conference on the mental health response to victims and survivors of mass violence. The researchers did not recommend CISM/CISD.

Finally, a 2006 article in the Review of General Psychology found that debriefing sessions accomplished nothing, good or bad, for those who participated in them.

Certainly, the method has its defenders. There’s a lively and mostly well-written defense of the field, dissecting many of the research findings (pro and con) about CISD here. You may want to skip to the end, where they discuss and attempt to refute the negative research, and address the issue of possible harm.

All of this is not an attempt to diminish the importance of having mental health services available after a disaster. Some individuals experience very real difficulties in coping and can be helped. And localized systems can easily become overwhelmed. But a massive influx of counselors and therapists after a disaster, acting as though therapy is somehow a necessity for all involved, is probably not helpful.

Getting back to the science, the whole debate on CISD reminds me a lot of the research-and-usage arc of the Drug Abuse Resistance Education (DARE) program in the 1980s and 1990s. DARE continued to be used for many years even after research had overwhelmingly declared it ineffective. Part of the reason for the continued use was that communities wanted to feel like they were doing something to combat adolescent drug use, even when they had clear evidence that their efforts were unproductive. (The fallback argument for DARE proponents, of course, begins with “If we helped even one child…” This argument ignores the studies that found DARE exposure actually increased later drug use among some groups.)

Similarly, here, we as therapists want to feel like we can be helpful in the wake of a tragic or traumatic event. Those who employ, contract with, or call upon debriefers similarly want to feel like they are doing something good. But until we devise and validate a better way to offer services in the wake of a crisis, we may be better off to stand a bit farther to the sidelines, and simply say, we’re here if you need us.

References:

Bledsoe, B. (2005). Trying to reason with hurricane season. Available online at http://www.jems.com/columnists/bledsoe/articles/15303/ .

McNally RJ, Bryant RA, & Ehlers A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest. 4(2), 45-79.