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  Key Issues in the Use of Psychological Debriefing Models

(© Baranowsky, 2002)

  1. What do we hope to accomplish with Psychological Debriefing (PD) Methods and other methods of early intervention (i.e., Critical Incident Stress Debriefing CISD)?

    • PD originated in the military, where soldiers were “debriefed” following significant battles by commanders in WWI and II. 
    • The perception was that PD improved morale and prepared soldiers for future battles. 
    • War-zone “proximity”, “immediacy” and “expectancy” were recognized risk factors.
    • Group support and cohesion and a reduction of stigma were seen as the primary benefits of PD.
    • CISD was originally developed for use by emergency and/or disaster services personnel following exposure to work-related traumatic events.
    • It was not developed as a form of psychotherapy.
    • CISD has been an approach to share normal responses to extreme events.
    • More recently CISD has undergone a revision to include a more comprehensive approach.  This approach was called Critical Incident Stress Management (CISM)
    • CISM is designed to prepare personnel prior to exposure to events of an extreme nature and debrief following exposure to critical incidents.  It is also includes Psychoeducation, promote emotional processing, early identification of those at risk, referral for further intervention and follow-up components.
  2. What does the PD research seem to suggest?

    • Psychological Debriefing (CISM/D) is the most commonly utilized early intervention approach currently.
    • Psychological Debriefing (PD) may result in symptom exacerbation
    • PD does not “prevent” psychopathology
    • PD methods fail to recognize that the majority of those exposed to trauma recover independently. 
    • It may be necessary to offer prior screening for PD to prevent further harm through the use of PD for those unable to tolerate this approach.
    • Dual relationships exist in some PD teams.  This may mean that the PD may leave a participant feeling more vulnerable because they have revealed their feelings in front of a peer, coworker or supervisor.
    • Mandated PD may create anger, frustration, fear and resentment.
    • Coercion to disclose may increase feelings of vulnerability, shame, and grief.
    • According to CISD literature direct victims, family members of those injured, killed, those injured in response yet these individuals are often directed to attend PDs.
    • Those directly impacted have not necessarily been adequately prepared as emergency workers.  Nor do they necessarily have access to referral or further intervention options.  Thus PD may open a door to a room with no floor.
    • Bisson et al. (1997) study compared CISD to information-only and no-intervention controls.  There were no differences in the three groups with regard to PTSD rates, PTSD symptom severity or depression at follow-up.  So it may be that education, assessment and referral would offer a better approach.
    • Most PD participants report finding the experience help and validating even if they did not achieve an improvement in their post-trauma symptoms.
  3. What Problems do we see with PD Research?

    • Participants selected for treatment and control had different degrees of exposure to trauma.  More extreme exposure in treatment group would likely result in differences in outcome.
    • Most research does not consider other benefits (i.e., reduction in substance use for coping, general subjective feelings of well-being, degree to which the individual feels “recovered” from the event).
    • Research outcome studies where treatment group follow-ups had many dropouts.  Those that dropped out may simply have felt better and not wanted to be bothered with treatment related follow-ups.
    • Not all research uses the same treatment approach (i.e., CISD/M) yet there is a notion that PD is PD regardless of the approach.
    • Primary victims of trauma are not good candidates for PD yet many of the studies focus on primary survivors.
    • Other selection biases were identified in this research literature such as self-selection where those most severely traumatized elected to be part of PD groups whereas those who recovered well chose not to participate in groups.
    • Intervention timing varied across studies and many studies failed to follow the standard protocol of PD within several days following event.
    • Symptom magnification may be a result of further awareness of symptoms through Psychoeducation and discussions that occur during debriefing.
  4. What are the alternatives to current Debriefing Methods?

    • NCPTSD suggests the use of the term Psychological First Aid
    • Evidence-based CBT approaches for those at risk of developing maladaptive post-trauma responses.
    • Provision of guidelines for screening and prevention.
    • Discontinue “compulsory” debriefing of trauma survivors.
    • Know risk factors for development of post-trauma responses (i.e., prior trauma exposure and prior diagnosis of acute stress disorder greater vulnerability to PTSD, greater physiological reactivity – rapid heart rate, other stressors or recent losses, pre-existing mental health disorder).
    • Know potential risk mechanisms (i.e., social support as a buffer and lowering physiological reactivity).
    • Stabilize resource losses (Conversation of resource model, Hobfoll, 1989).  COR recognizes various types of resources such as material goods, life conditions, OR personal resources such as self-esteem or perceptions of competency.  Increases in threats to resources lead to increased stress levels even if resources are never actually lost.
    • Offer safety planning and emergency stabilization prior to emotional or psychological care (Resnick, Acierno, Holmes, Dammeyer & Kilpatrick, 2000).  Suicidal and homicidal ideation and substance abuse need to be assessed early, as this is part of safety planning.
    • Evaluate/assess those exposed to traumatic events for severity or magnitude of exposure, peri-traumatic response.  Based on results of evaluation provide Psychoeducation and/or make appropriate referrals for intervention. 
    • Do not attempt to diagnose as an early intervention.  Focus instead on screening to flag those who may need further care.
    • Provide comfort, information, support and meet practical needs.  Remain supportive and non-interventionist.  Do not provide therapy or treatment as an early intervention.
    • Provide handouts, flyers, brochures that describe symptoms that may occur, and when to seek help, where to get help.
    • Offer an alternative to CISD such as individual CBT of alternative trauma therapy.
    • Assist individuals to access indigent services. 
    • Assist individuals in connecting with their communities and utilizing existing social supports.  Alternatively help them make these connections if they do not exist currently.
  5. Above all do no harm.

    • If you are providing care, inform those you are helping of who you are, who you work for and in what capacity are you assisting them.
    • Ask for permission to assist.
    • Tell them what assistance you are qualified to offer.  Inform them what your service mandate is in this situation.
Footnotes: 

References

Bisson, J.I., Jenkins, P.L., Alexander, J., & Bannister, C. (1997). Randomized controlled trial of psychological debriefing for victims of acute burn trauma. British Journal of Psychiatry, 171, 78-81.

Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44, 513-524.

Hobfoll, S. E., Dunahoo, C. A., & Monnier, J. (1995). Conservation of resources and traumatic stress. In J. R. Freedy & S. E. Hobfoll (Eds.), Traumatic stress: From theory to practice. New York: Plenum Press.

Litz, B., Gray, M., Bryant, R., Adler, A., & Reed W. (2002). Early Intervention for Trauma: Current Status and Future Directions. NCPTSD Dept. Veterans Affairs Website.

Resnick, H., Acierno, R., Holmes, M., Dammeyer, M., & Kilpatrick, D. (2000). Emergency evaluation and intervention with female victims of rape and other violence. Journal of Clinical Psychology, 56, 1317-1333.

Ritchie, P. J. (2002). Management of Critical Incident Stress in a Military Environment. Unpublished manuscript.

van Emmerik, A., Kamphius, J. H., Hulsbosch, A. M., & Emmerik, P. (2002). Single Session Debriefing after Psychological Trauma. The Lancet, (vol. 360).