Early Intervention for Trauma: Current Status and Future Directions
A National Center for PTSD Fact Sheet
by Brett Litz and Matt Gray, National Center for PTSD, Richard Bryant,
University of New South Wales, & Amy Adler, Walter Reed Army Institute of
Research
This report is currently in press at Clinical Psychology: Science and
Practice and is posted with permission.
Abstract
Although psychological debriefing (PD) represents the most common form of
early intervention for recently traumatized people, there is little evidence
supporting its continued use with individuals who experience severe trauma.
This review identifies the core issues in early intervention that need to be
addressed in resolving the debate over PD. It critiques the available evidence
for PD and the early provision of cognitive-behavioral therapy (CBT). Based on
available evidence, we propose that psychological first aid is an appropriate
initial intervention but that it does not serve a therapeutic or preventive
function. When feasible, initial screening is required so that preventive
interventions can be used for those individuals who may have difficulty
recovering on their own. Evidence-based CBT approaches are indicated for people
who are at risk of developing posttraumatic psychopathology. Guidelines for
managing acutely traumatized people are suggested and standards are proposed to
direct future research that may advance our understanding of the role of early
intervention in facilitating adaptation to trauma.
Early Intervention for Trauma: Current Status and Future Directions
Although there are cogent humanitarian reasons to provide mental health
interventions to people soon after exposure to trauma (Wilson, Raphael,
Meldrum, Bedosky, & Sigman, 2000), there is growing consensus that early
intervention for trauma, generically called psychological debriefing (PD), does
not prevent subsequent psychopathology (Bisson, McFarlane, & Rose, 2000;
Gist & Woodall, 2000). Further, there is some evidence that PD may
exacerbate subsequent symptoms (e.g., Bisson, Jenkins, Alexander, &
Bannister, 1997). Even though there is insufficient evidence supporting its
continued use, PD is routinely provided immediately after exposure to
potentially traumatizing events (PTE; Mitchell & Everly, 1996; Raphael,
Wilson, Meldrum, & McFarlane, 1996). This state of affairs is not
surprising, considering the prevalence of trauma, the demand for efficient
management of the extensive individual, corporate, and societal costs
associated with chronic Posttraumatic Stress Disorder (PTSD), the financial
interests of those who provide acute interventions, and the tendency for
organizations and participants to perceive PD as useful (Deahl, Gillham,
Thomas, Searle, & Srinivasan, 1994; Hobfoll, Spielberger, Breznitz, Figley,
& van der Kolk, 1991; Raphael et al., 1996; Wilson et al., 2000).
In this context, our aim is to review the available evidence and to address
a number of core questions pertaining to early intervention. Specifically, are there
sufficient data from which to conclude that all early interventions are
counterproductive? Is the Critical Incident Stress Debriefing (CISD) approach
particularly problematic? Are some components of PD justified? Should
psychological interventions only be provided to those who are at risk of
developing psychopathology? Our goal is to consider if it is valid to conclude
that early brief preventive interventions for trauma are inappropriate, as
recently recommended in the Cochrane Collaboration review of the randomized
controlled trials (RCT) of one-session debriefing (Rose, Wessely, & Bisson,
1998 with a follow-up by Rose, Bisson, & Wessely, 2001; cf. Rose &
Bisson, 1998), and to examine possible alternative approaches to preventing
chronic PTSD. By secondary prevention we mean assisting individuals who have
been exposed to trauma and have developed acute symptoms, so as to reduce their
risk for chronic PTSD.
In their Cochrane review, Rose et al. (2001) concluded that there is no
evidence for the efficacy of one-session PD provided soon after exposure to PTE
and recommended that "Compulsory debriefing of victims of trauma should
cease." It should be noted, however, that the Cochrane reviews provide
relatively circumscribed, brief, and global recommendations for practitioners.
In contrast to the Cochrane reviews, we consider a broader conceptual approach
to early intervention, provide more detailed methodological critiques of PD
studies, and consider the evidence for early provision of cognitive-behavioral therapy
(CBT). We also provide a more extensive set of recommendations and standards
for future research on early intervention. Finally, we provide a summary of the
risk factors for PTSD germane to early intervention and offer practical
guidelines for managing people who are recently traumatized.
The Need for Early Intervention
Although lifetime risk for exposure to PTE is extremely high (60%-90%,
Breslau et al., 1998; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995),
the prevalence of PTSD is relatively low. For example, approximately 8% of
individuals in the National Comorbidity Survey had PTSD at some point across
the lifespan, indexed to an event rated as "the most traumatic"
(Kessler et al., 1995). Breslau et al. also found that approximately 9% of individuals
exposed to any PTE report PTSD at some point across the lifespan. The
prevalence estimates for PTSD vary considerably, due to differences in samples,
sampling strategies, assessment methods, and the way that a PTSD diagnosis is
defined. Moreover, the prevalence of PTSD varies across different types of PTE,
with sexual assault and exposure to violence being associated with the highest
risk for PTSD (e.g., Breslau et al., 1998). Nevertheless, even the most
conservative estimates of risk for PTSD reflect the tremendous mental health
toll associated with trauma.
Prospective studies have shown that most trauma survivors display a range of
PTSD reactions in the initial weeks after a traumatic event, but that most of
these people adapt effectively within approximately three months. Those that
fail to recover by this time are at risk for chronic PTSD (e.g., Blanchard et
al., 1996; Riggs, Rothbaum, & Foa, 1995; Rothbaum, Foa, Riggs, Murdock,
& Walsh, 1992; Koren, Arnon, & Klein, 1999). Further underscoring the
risk for chronicity in PTSD, Kessler et al. (1995) found that one third of
people with PTSD fail to recover after many years, in many cases after years of
mental health treatment. These findings have several implications. First, the
majority of people will be distressed after exposure to a PTE, and assistance
in coping and immediate adjustment may be indicated. Second, a smaller
proportion of individuals exposed to PTE will have persistent problems, which
require therapeutic intervention. The following review of early intervention
strategies recognizes these fundamental patterns in trauma response and accepts
the premise that, whereas all distressed people may require, and in theory
benefit from, assistance following trauma, only a small proportion will eventually
require therapy for a pathological response. Unfortunately, in the PD
literature, little attention has been paid to secondary prevention specifically
for individuals who are at risk for chronic PTSD.
Risk Factors for PTSD
Since exposure to PTE is a necessary but not sufficient cause of chronic
PTSD, attention has been focused on the pretraumatic, peri-traumatic, recovery
environment, and posttrauma lifespan conditions that create risk for
posttraumatic difficulties (Halligan & Yehuda, 2000; King et al., 1999).
The premise that exposure to trauma is the exclusive risk factor for PTSD,
which underlies most PD models (e.g., Mitchell & Everly, 1996) has resulted
in intervention efforts typically failing to address the role other risk
factors may play in adjustment after exposure to PTE. For this reason, the
"one size fits all" framework of PD fails to acknowledge the personal
and social resources that, in most cases, promote recovery (Bisson et al.,
2000; Gist & Woodall, 2000). Effective management of those who suffer more
than a transient stress response to trauma would be greatly facilitated by
screening those who are at risk for chronic PTSD after exposure to PTE.
Furthermore, there is increasing recognition that because of the complex array
of vulnerability factors that contribute to the development of posttraumatic
psychopathology, single-session interventions are unlikely to make substantive
differences in long-term adjustment (Shalev, 2000).
In the PTSD field, risk factor research is in an early stage, conceptually
and empirically. As a result, the extent to which risk variables can be used
practically in early interventions is reduced considerably. For example, there
is no distinction between risk indicators (variables that have been
found to correlate with chronic PTSD) and risk mechanisms (risk factors
or variables that suggest specific modes of mediation, which are less
susceptible to third variable and directionality concerns; Rutter et al.,
2001). Rather, the global term "risk factor" is typically employed
and causal mechanisms remain unspecified. Although research has revealed
several noteworthy risk indicators, few risk mechanisms have been explicated.
Once future research identifies risk mechanisms, these variables will likely be
specific targets for secondary prevention interventions. Nevertheless, at this
stage, several risk indicators could legitimately be used to screen individuals
exposed to PTE who are more likely to suffer long-term problems.
In this section, we review two risk indicators (prior exposure to trauma and
acute stress disorder) and two potential risk mechanisms (social support and
hyper-arousal) that deserve special attention. Younger age and female gender
have been shown to be risk indicators for chronic PTSD (e.g., Breslau et al.,
1998; Kulka et al., 1988). However, these variables alone cannot be usefully
employed to identify individuals who may uniquely benefit from early
intervention. Intelligence is another example of a risk indicator found in the
literature (e.g., Macklin et al., 1998); however, we cannot envision a scenario
in which this variable could impact decision making about who should receive
early intervention. Of course, age, gender, and intelligence are factors that
need to be taken into account in modifying the content and process of early
interventions. We end this section by describing how resource losses represent
an important set of risk mechanisms, which, to date, have not been sufficiently
examined in early intervention research.
Prior Trauma
It has become axiomatic that prior exposure to PTE is a risk indicator for
chronic PTSD stemming from a subsequent PTE (King et al., 1999; Stretch,
Knudson, & Durand, 1998). In particular, a history of exposure to
interpersonal violence, in childhood or adulthood, substantially increases the
risk for chronic PTSD following exposure to any type of PTE (Bremner,
Southwick, Brett, & Fontana, 1992; Breslau et al., 1998; Green et al.,
2000; Nishith, Mechanic, & Resnick, 2000). Dougall, Herberman, Delahanty,
Inslicht, and Baum (2000) hypothesized that prior trauma history sensitizes
victims to the new stressor, thus potentiating its impact. They argued that
evaluating trauma history is essential for improving early intervention
efforts. There are no empirical data, however, detailing the effects of prior
trauma history on response to psychosocial interventions for PTSD in general or
early interventions in particular.
Acute Stress Disorder
Prior to DSM-IV (American Psychiatric Association, 1994), severe distress
occurring in the month after a traumatic event was not regarded as a
diagnosable clinical problem. Although this prevented the pathologizing of
transient reactions, it hampered the identification of more severely
traumatized individuals who might benefit from early interventions. To address
this issue, DSM-IV introduced the diagnosis of acute stress disorder (ASD) to
describe those acute reactions associated with an increased likelihood of
developing chronic PTSD. A diagnosis of ASD is given when an individual experiences
significantly distressing symptoms of reexperiencing, avoidance, and increased
arousal within 2 days to 4 weeks of the trauma. The DSM-IV diagnosis of ASD
requires that the victim report at least three of the following five symptoms
labeled as indicators of dissociation: numbing, reduced awareness of
surroundings, derealization, depersonalization, and dissociative amnesia. These
requirements are based on some evidence found in previous studies that
dissociative symptoms at the time of (or shortly after) the traumatic event are
predictive of the subsequent development of chronic PTSD (Bremner et al., 1992;
Marmar, Weiss, Shchlenger, & Fairbank, 1994; Koopman, Classen, &
Spiegel, 1994), Thus, the fundamental differences between PTSD and ASD involve
time elapsed since the trauma and the relative emphasis on dissociative
symptoms in the ASD diagnosis.
Several longitudinal investigations of motor vehicle accident (MVA)
survivors have documented the predictive utility of ASD in identifying those
individuals who are likely to exhibit more enduring or persistent pathology.
Harvey and Bryant (1998a) evaluated MVA survivors within 1 month of their
accident for the presence of ASD and then reevaluated this sample 6 months
later for PTSD. At follow-up, 78% of those who met diagnostic criteria for ASD
within 1 month of their accident met diagnostic criteria for PTSD six months
later. These researchers noted that 60% of victims who met all but the
dissociative criteria for ASD also met diagnostic criteria for PTSD at 6
months, suggesting that the ASD emphasis on dissociative symptoms may result in
significantly distressed survivors being overlooked by clinicians. These
findings were replicated at a 2-year follow-up evaluation (Harvey & Bryant,
1999a). The strong relationship between ASD and the subsequent development of
chronic PTSD has also been observed among MVA victims suffering mild traumatic
brain injuries (Bryant & Harvey, 1998; Harvey & Bryant, 2000) as well
as among sexual and physical assault victims (Brewin, Andrews, Rose, &
Kirk, 1999). Brewin et al. (1999) noted that the most accurate and efficient
prediction of PTSD in their sample of crime victims was afforded by a cutoff of
3 or more symptoms of reexperiencing or hyper-arousal after trauma. Their findings
also suggest that dissociative symptoms, while predictive of PTSD, fail to
provide incremental validity beyond the core PTSD symptoms.
Bryant and Harvey (1997) assert that there is little empirical justification
for the requirement of three dissociative symptoms to occur for the ASD
diagnosis to be given. Although early studies documented significant
associations between peri-traumatic dissociation and PTSD, much of this
research was retrospective in nature. Evidence that recall of acute stress
symptoms is influenced by current mood indicates that symptom status at the
time of evaluation could have influenced reports of prior dissociative symptoms
(Harvey & Bryant, 2001). Accordingly, Bryant and Harvey advocate for
consistency between ASD and PTSD diagnostic criteria because of the many
individuals that fail to meet diagnostic criteria for ASD but ultimately meet
criteria for PTSD despite the fact that their symptoms remain unchanged. In
addition, Marshall, Spitzer, and Liebowitz (1999) note that there are numerous
pretrauma and peri-trauma vulnerability factors that predict dissociation, ASD,
and subsequent PTSD equally well. Cardiovascular reactivity, prior history of
Axis I disorder, prior history of Axis II disorder, depressive symptomatology,
use of avoidance coping strategies, trait neuroticism, and history of prior
traumatization have all been found to be significant predictors of subsequent
ASD or PTSD diagnoses (Barton, Blanchard, & Hickling, 1996; Bryant, Harvey,
Guthrie & Moulds, 2000; Harvey & Bryant, 1998b; Harvey & Bryant,
1999b; McFarlane, 1988). Accordingly, Marshall and colleagues assert that it
makes little sense to elevate one class of vulnerability factors (i.e.,
dissociative symptoms) above all others to the status of core diagnostic criteria.
Allowing a PTSD diagnosis anytime after trauma when criteria are met would be
the most parsimonious solution. They note that there are numerous bona fide
medical conditions and mental disorders that resolve spontaneously over time.
Accordingly, a "waiting period" of 30 days is inconsistent with
general nosological principles. Despite the controversy over the ASD diagnosis,
the evidence suggests that indexing specific reactions several weeks after a
trauma can be helpful in identifying those who are most at risk of developing
PTSD.
Social Support
An individual's recovery from trauma is facilitated by the availability of
positive social supports and the inclination to use them to share the account
of the trauma (Forbes & Roger, 1999; Foy, Sipprelle, Rueger, & Carroll,
1984; Harvey, Orbuch, Chwalisz, & Garwood, 1991; Keane, Scott, Chavoya,
Lamparski, & Fairbank, 1985; King, King, Fairbank, Keane, & Adams,
1998; Martin, Rosen, Durand, Knudson, & Stretch, 2000; Pennebaker &
O'Heeron, 1984). To date, early interventions have not sufficiently taken into
account the social factors in the recovery environment that promote or hinder
recovery from trauma. In order to be maximally effective, early interventions
for trauma may need to evaluate systematically the breadth and depth of social
supports in the recovery environment and the victim's learning history of using
social supports under stressful circumstances. Further, early intervention may
need to assist the individual with anticipating problems in using their support
system. This may be particularly important in light of the fact that the
psychological aftermath of trauma may significantly disrupt a person's capacity
to use others to cope with and manage posttraumatic symptoms and daily demands
(e.g., Riggs, Byrne, Weathers, & Litz, 1998; Solomon, Mikulincer, &
Avitzur, 1988). In addition, preexisting conflict in significant relationships
could negatively impact recovery, particularly in those who are motivated to
use others to cope with the aftermath of severe stress (Major, Zubeck, Cooper,
& Cozzarelli, 1997). In order to regain a sense of equilibrium and
coherence, some victims may need a period of respite from posttrauma demands,
and they may initially need to be allowed to avoid discussing their trauma (Charlton
& Thompson, 1996; Tarrier, Pilgrim, & Sommerfield, 1999). Conflict in
significant relationships may make it difficult for those individuals who need
a period of disengagement to achieve this state without exacerbating
relationship difficulties.
Hyper-arousal
High degrees of psychophysiological arousal in the acute aftermath of trauma
are known to be associated with increased risk for chronic PTSD (Yehuda,
McFarlane, & Shalev, 1998). A series of studies by Shalev and colleagues
examined cardiac activity prospectively in individuals exposed to PTE (Shalev,
Freedman, Peri, Brandes, & Sahar, 1997). For example, Shalev, Sahar, et al.
(1998) found that in a mixed group of trauma survivors evaluated in the
emergency room, those individuals who had severe symptoms of PTSD one week
after the event had higher initial mean heart rates (measured in the emergency
room) than those who did not develop PTSD. In addition, Shalev and colleagues
found that PTSD prevalence rates 4 months later were best predicted by heart
rate in the emergency room, after controlling for age, gender, trauma history,
and immediate psychological response to the event. This finding has been
replicated by Bryant et al. (2000).
A number of risk mechanisms have been proposed to account for hyper-arousal's
affect on risk for PTSD. Increased cardiac output in the immediate aftermath of
exposure to trauma (e.g., when assessed in emergency rooms) is likely to be
part of the unconditioned response to the trauma, the intensity of which varies
across individuals (e.g., Orr, Meyerhoff, Edwards, & Pitman, 1998).
Generally, arousal symptoms negatively impact individuals' attempts to return
to daily routines and affect rest and sleep capacity, which further exacerbates
levels of stress and arousal. In addition, basal increases in cardiac activity
can be caused by poor coping with daily stress and anticipatory anxiety (e.g.,
McFall, Murburg, Ko, & Veith, 1990; Orr et al., 1998; Prins, Kaloupek,
& Keane, 1995). This suggests that early interventions for trauma should
target hyper-arousal by training survivors in methods of anxiety and stress
management. Although speculative, it is plausible that systematic reductions in
hyper-arousal in the days and weeks after a trauma could accomplish a number of
goals: (1) Effective arousal management can engender a sense of control over
emotional experience at a time when there may be considerable affective
lability; (2) learning adaptive means to manage arousal serves to reduce the
risk for maladaptive behaviors used to cope with negative affect (e.g.,
substance use); (3) daily relaxation exercises promote self-care, which may
restore a sense of safety and comfort often compromised by trauma; and (4)
reduced arousal in the aftermath of exposure to trauma would serve to limit
generalization of conditioning and higher-order conditioning, which in theory
would minimize chronic conditioned emotional reactivity and lessen motivation
for avoidance behavior.
Posttraumatic Resources
A variety of personal and environmental factors create risk for enduring
posttraumatic difficulties. Hobfoll, Dunahoo, and Monnier (1995) contend that
trauma necessarily involves a loss of resources and that loss can occur on
multiple ecological levels such as family, organization, and community. The Conservation
of Resources (COR) theory is based on the premise that people strive to obtain
and protect resources (Hobfoll, 1989). These resources can include material
goods, life conditions (e.g., marriage or occupation), or personal resources
(e.g., self-esteem or perceptions of competency). According to COR theory,
stress ensues when there is a threatened or actual loss of resources. Traumatic
events result in inordinate stress because the losses incurred are most closely
related to one's survival, and the losses tend to be numerous and profound. In
the case of natural disasters, for instance, victims often lose their homes,
money, and social network. Hobfoll et al. (1995) assert that early
posttraumatic interventions employed by psychologists have not been especially
helpful because they attend exclusively to psychological variables to the
exclusion of other domains of resource loss. Trauma survivors may not be in a
position to benefit from traditional psychological interventions that target
anxiety and affective symptoms when they have legitimate concerns about
physical well-being, safety, shelter, or significant financial problems.
Accordingly, resolution of these issues may be a necessary precondition to an
individual's capacity to benefit from early interventions addressing
psychological variables following trauma.
Given the potentially deleterious impact of trauma across multiple domains
of functioning, what do victims need in the immediate aftermath of trauma?
Resnick, Acierno, Holmes, Dammeyer, and Kilpatrick (2000) recommend that safety
planning and emergency stabilization should precede any efforts to address
psychological or emotional sequelae. In particular, crime victims may need
contact information for shelters, emergency housing, rape crisis services, as
well as services to address pressing medical and legal issues. The presence of
suicidal and homicidal ideation and significant substance abuse should be
routinely assessed following traumatic exposure, as the risk for each of these
increases significantly after a trauma, complicating the course of ASD/PTSD
treatment (Resnick et al.). The recommendations are in accord with Hobfall et
al.'s (1995) call for psychologists to attend to victims' resource losses in
multiple domains.
The History of Debriefing
The provision of psychological debriefing originated in the military. In
World War I and World War II, soldiers were "debriefed" by commanders
immediately after a significant battle. The expectation was that sharing
personal stories about combat would improve morale and better prepare soldiers
for future combat. Parallel to this, battlefield psychiatrists developed
strategies to address the needs of soldiers who were incapacitated by acute
combat stress (a condition labeled "battle fatigue," or "combat stress
reaction;" see Solomon and Benbenishty, 1986). Frontline treatment in the
war-zone was provided using a framework of "proximity,"
"immediacy," and "expectancy." That is, soldiers were
treated near the battlefield, shortly after their problems were identified, and
with the expectation that they would return to duty. In theory, providing
treatment close to a soldier's unit was seen as particularly important because
it helped to maintain group support and cohesion, as well as reduce stigma (see
Jones & Hales, 1987). Interventions applied on the frontline have varied
over time. However, in the modern military there is considerable uniformity
(Hall et al., 1997). Typically, clinicians promote rest, consider
pharmacological treatment to manage hyper-arousal, and provide psycho-education
about the effects of trauma. In addition, group discussion is provided,
designed to facilitate soldiers' sharing of horrific encounters in the war-zone
and to process their emotional experience with others similarly afflicted
(Shalev, 1994; 2000). In the United States military, soldiers exposed to PTE
are routinely provided front-line psychological "first-aid" in the
form of informal event-processing interventions, pastoral counseling, and, if
need be, triage to stepped-up care (McDuff & Johnson, 1992).
Critical Incident Stress Debriefing
Although the content, process, and goals of PD vary considerably, there are
many commonalities, and the CISD approach is the most recognized and used
method (Mitchell & Everly, 1996). The CISD approach stems from the crisis
intervention tradition. It is typically applied to emergency services
personnel, individuals whose work entails risk for exposure to trauma (e.g.,
law enforcement personnel, emergency medical technicians, fire fighters, military
personnel, and disaster workers such as the Red Cross). CISD may be attractive
to workers in these occupations because of its emphasis on the PD not being
"psychotherapy." That is, CISD is presented not as a clinical
intervention, but rather an opportunity for individuals to share their common
normal response to extreme circumstances with CISD team members, at least one
of whom is highly familiar with the culture of the work system. These factors
have lead to the pervasive and routine application of CISD in risky occupations
such as the military, even in the face of insufficient evidence for its
efficacy (see Deahl et al., 2000).
The CISD framework has been revised recently so that it is now considered
part of a more comprehensive, Critical Incident Stress Management (CISM)
program (Everly & Mitchell, 2000). The CISM program is a series of
interventions that seems as though it will be effective. It is designed to
comprehensively address the needs of emergency services organizations and
personnel. The CISM interventions are designed to psychologically prepare or
prebrief individuals prior to dangerous work, meet the support needs of
individuals during "critical incidents" (e.g., while Red Cross
personnel are working with families who lost loved ones in a disaster), provide
CISD as well as delayed interventions, consult with organizations and leaders,
work with the families of those directly affected by trauma, and to facilitate
referrals and follow-up interventions to address lingering stress disorders. However,
there has been no controlled empirical study of the various components of CISM
to date.
The cornerstone of CISM is CISD, which is a semistructured group
intervention with didactic and experiential components. The overarching goals
of CISD are: (a) to educate individuals about stress reactions and ways of
coping adaptively with them, (b) to instill messages about the normality of
reactions to PTE, (c) to promote emotional processing and sharing of the event,
and (d) to provide information about, and opportunity for, further
trauma-related intervention if it is requested by the participant. Individuals
exposed to a PTE are invited, within days, to participate in a three to four
hour session in which the "incident" is reviewed. Personnel are
invited to attend a CISD regardless of the degree of their acute symptoms or
functional impairment (e.g., Hokanson & Wirth, 2000). The assumption of the
CISD approach is that everyone exposed to a PTE is at risk for a stress
reaction/PTSD and that everyone could benefit from an opportunity to share
their experience and learn about trauma and adaptive coping. The model fails to
incorporate epidemiological research that has shown that not everyone is
equally at risk for PTSD after exposure to PTE. In addition, the CISD framework
eschews formal assessment of symptoms and outcomes in order to emphasize the
nonclinical nature of the intervention and to create confidence in the
confidential nature of the group. Thus, participants in a CISD could be free
from acute symptoms and have very little risk for chronic PTSD, or individuals
could be experiencing severe ASD.
According to Mitchell and Everly (1996), successful PD is accomplished
through a series of seven phases or stages. In terms of content, many of the stages
share some of the same features as the stress management aspects of standard
cognitive-behavioral treatment packages for PTSD as well as in broad terms,
exposure therapy (e.g., Flack, Litz, & Keane, 1998). A debriefing begins
with an "introduction stage." At this time the facilitator's job is
to explain what is going to happen during the debriefing and clarify any
questions participants might have. Special emphasis is placed on
confidentiality, which may be particularly important for individuals with a
common work-system concerned about whether shared information will affect their
advancement in the organization. The next step is called the "fact
phase." During this time, participants are asked to describe the stressor
and what happened during the event. Next, in the "thought phase," the
primary facilitator asks participants to describe their thoughts during the
incident. This phase is intended to be a vehicle to the next phase, in which
emotional reactions are shared. Focusing initially on thoughts, rather than
feelings, allows participants to begin to talk about the events with some
degree of distance to reduce defensive coping reactions. Following this is the
"reaction phase," the focus shifts to participants' emotional
responses during the event as well as what they are currently experiencing and
the meaning they assign to these experiences. The facilitator attempts to
normalize the experience as much as possible and assist individuals in
reframing and integrating the experience into their view of themselves and the
world. In stage 5, the "symptoms phase," the facilitator discusses
typical stress reactions and answers questions concerning personal responses to
the event. During stage 6, the "teaching phase," the debriefing team
members attempt to find out what the participants know about stress reactions
and stress management strategies and to clarify any points of misunderstanding.
Finally, in the "reentry phase," the team sums up the debriefing and
the referral process.
As can be seen in the description above, a great deal needs to be covered in
one meeting. Psychological debriefing is apparently designed to facilitate
support seeking and to prepare individuals for the challenges of recovering
over time. In the published CISD manuals, there are explicit messages about PD
being a necessary, but by no means sufficient, intervention for severely
traumatized individuals who have lingering disturbing symptoms and problems
after a trauma (these individuals are said to require individual follow-up
treatment). Yet, the CISD literature also suggests that PD alone is a secondary
prevention intervention (e.g., Mitchell & Everly, 1996). That is, attending
a PD is enough to prevent the formation of PTSD and other trauma-linked
disorders. In this context, the necessary and sufficient conditions for
effective early intervention are unclear. Perhaps attendance at a CISD
functions as a screening for participants who suffer severe symptoms (e.g.,
acute stress disorder) or who have poor coping resources (e.g., they are isolated)
- conditions which trigger referral for sustained intervention. If this is the
case, it raises the possibility that some individuals are unduly taxed by a
CISD and the need to screen individuals earlier in the process.
Other concerns about CISD center on how the intervention may exacerbate
distress. When CISD is provided in a group format, attendees have varying
degrees of familiarity with each other and the group is led by a team trained
in CISD. The team includes formally trained mental health professionals as well
as, in most cases, a layperson who works in the same field, or someone familiar
with individuals affected by the PTE. Although the idea of including peer
support personnel seems sensible, this feature has been criticized strongly
because it can, in theory, create dual relationships and may make some
attendees feel unsafe, which may be counter-therapeutic and possibly unethical
(e.g., Gist & Woodwall, 2000). Formally, the goal of including peer support
personnel in a CISD team is to enhance the team's credibility and legitimacy in
terms of particular work cultures. It is quite possible that this feature is
very important in many work contexts, although it also seems likely that it
constrains the extent to which emotionally salient or inadvertently
incriminating experiences are shared for some.
Another concern about how CISD is implemented is that if individuals are
mandated or subtly coerced by their employers to attend a debriefing session it
raises the possibility that choice and control are wrested from some
traumatized people, which is likely to create frustration, anger, and
resentment, as well intensify the experience of victimization. It should be
noted that the formal CISD literature emphasizes that debriefing attendance is
voluntary. However, volunteer status may be affected by work cultures
unbeknownst to CISD personnel. For example, overt and strong support from
supervisors and administrators may impact decisions about participation (e.g.,
Gist & Woodall, 2000). A related criticism of CISD is that an individual
who is reluctant to disclose personal information may feel stigmatized and
pressured by the group's expectations. In this context, sharing of personal
experiences may have harmful, rather than helpful, consequences (Young & Gerrity,
1994).
One of the confusing issues in the execution of CISD is the process whereby
an individual (or group of individuals) is found to be appropriate for CISD.
Again, formally, CISD is designed only for use with emergency service workers
(fire fighters, rescue personnel, emergency room personnel, police officers,
etc.), although the CISD training also describes CISD as appropriate for
witnesses to critical events and bystanders who suddenly become helpers by
virtue of their being in a particular place at a particular time. The
literature emphasizes that "direct victims" of critical incidents,
family members of those seriously injured or killed, and those seriously
injured in trying to respond to an incident require more extensive treatment
and should not attend a CISD. These so-called "direct victims" are
handled in unspecified ways within the broader treatment framework of CISM.
However, it is unclear whether those who practice CISD apply the intervention
only to individuals secondarily exposed to trauma (Dyregrov, 1999). For
example, following the terrorist attacks on the World Trade Center, thousands
of office workers and other people directly involved in the incident were
apparently provided with variants of CISD.
One of the particularly attractive features of the CISD framework is the
special attention paid to the unique needs of workers at risk for exposure to
others' direct trauma and suffering, targeting the intense strain and stress of
emergency and disaster relief activity. It also responds to the need for
organizations to address the needs of their workers and to maintain cohesion
and morale. A cogent example would be the Red Cross workers responding to grief
stricken and horrified family members of victims of the terrorist attacks in
New York City and at the Pentagon on September 11, 2001. The psychological
burden of such work is considerable, and the CISD framework has provided a
systematic structure to address the emotional needs of helpers in organizations
such as the Red Cross. However, some have argued that proponents of debriefing
fail to recognize sufficiently the natural resiliency of emergency care workers
and their capacity to find adaptive individualized and personal ways of
managing their reactions to the stressful demands of their duties (e.g., Gist
& Woodall, 2000).
In the CISD framework, the types of events that constitute "critical
incidents" warranting CISD are unclear, and it is uncertain how, within a
given occupation or work-system, "direct victims" of trauma are
actually screened. The manner in which the formal distinction is made between
primary or "direct" and "indirect" exposure also remains
uncertain. The use of an individual's role in the traumatic context as the sole
criterion for CISD inclusion may constitute an arbitrary distinction. For
instance, emergency workers may be exposed to severe PTE "directly"
and secondarily by virtue of observing others suffer greatly. Whether such
individuals would be considered inappropriate candidates for CISD remains unclear.
The CISD model assumes that direct or primary victims are inappropriate for
CISD because some measurable physical, cognitive, or emotional quality of the
"victim" experience makes the CISD process insufficient or
inappropriate. If that argument is to be accepted, then operationally defining
what constitutes direct exposure becomes critical. It appears that the
distinction between a primary and a secondary victim within the CISD framework
hinges superficially on whether there is physical injury, which is inappropriate,
given the vast literature about the long-term consequences of psychological
trauma. We argue that attempts to categorically distinguish direct (primary)
and indirect (secondary) victims will be difficult if the intervention is
intended to address psychopathological responses. If early intervention is to
afford individuals who do emotionally challenging emergency work an opportunity
to maintain group cohesion, as well as share and receive information about
adaptive coping, then focusing on emergency workers seems an appropriate goal.
On the other hand, if the intervention is to target pathological responses to
trauma, then it does not appear justified to determine eligibility for early
intervention in terms of one's type of involvement in the trauma. In the recent
terrorist attack on the World Trade Center, survivors who fled the building and
the emergency workers who assisted with the evacuation had much in common in
terms of exposure to life-threat, although their roles, training, and mental
preparation were different. In any case, the appropriate type of early
intervention for specific posttrauma problems, the type of individual or group
that can benefit from these interventions, and the relevance of one's role in a
trauma are empirical issues that have yet to be resolved.
We suggest that it is more appropriate and defensible to evaluate (when
feasible logistically) anyone exposed to PTE, regardless of work role or
context, for the severity or magnitude of their exposure and their
peri-traumatic subjective emotional experience. There are a number of good
screening measures that could assist in this effort (Litz, Miller, Ruef, &
McTeague, 2002). If an assessment (when feasible) indicates that individuals
require intensive intervention, those individuals should be provided with
multisession interventions that have empirical support. We recognize that
assessment and intervention with emergency workers requires special attention
to the cultural and organizational features of those groups. This recognition should
not be confused, however, with assumptions that psychopathological responses
are qualitatively different in these individuals.
Research on Debriefing Effectiveness
Anecdotal accounts, unpublished studies, and a few uncontrolled
peer-reviewed studies of PD suggest that it is an effective intervention (see
Everly, Flannery, & Mitchell, 2000 for a review). However, until recently
there was a dearth of randomized controlled trials (Rose et al., 2001). It is
important to note that debriefing research is challenging for several reasons.
It is impossible to predict the occurrence of PTE that require debriefing and
thus extremely difficult to assess individuals prior to exposure. In addition,
it is difficult to conduct randomized controlled trials; randomization has
historically been considered unethical because it would mean withholding a
potentially useful treatment from acutely distressed individuals. The concern
about withholding a useful early intervention is changing in this research
domain given recent findings of equivocal or negative results. However, the
organizational and societal chaos that follow a major disaster, as seen in the
aftermath of the September 11, 2001 calamity in the United States, hinders
desirable experimental control over outcome evaluation.
Our intention in this section is to critically appraise peer-reviewed
research that, at a minimum, randomly allocated participants to an active
single session PD or a no-intervention control group, a criterion also used by
the latest Cochrane review of PD (Rose et al., 2001). Everly et al. (2000)
recently reviewed a number of uncontrolled studies (and in some cases nonpeer
reviewed studies), which led them to conclude that there was empirical support
for the efficacy of PD. In our opinion, none of the studies reviewed by Everly
et al. (2000) are sufficiently internally valid to warrant this conclusion. By
virtue of the fundamental problem of a lack of random assignment, there is no
sufficiently valid evidence from uncontrolled or quasi-experimental studies of
early intervention to suggest that the intervention promoted recovery to a
greater degree than would have occurred with the passage of time. In addition,
when self-selection determines participation, there is a possibility that
individual differences (e.g., greater distress, higher motivation) may explain
inclusion in PD. This limitation is compounded by the fact that the majority of
studies reviewed by Everly et al. (2000) failed to assess individuals prior to
the intervention; post-PD symptom ratings could reflect enduring preexisting
levels of distress. Finally, no study reviewed by Everly et al. employed
independent assessment of outcome.
We critically reviewed six peer-reviewed randomized controlled trials, all
of which were included in Rose et al.'s (2001) Cochrane review of PD. In their
review, Rose et al. (2001) included two studies that predate the advent of
formalized approaches such as CISD and the formal diagnosis of PTSD, which we
exclude because it is not clear what the interventions entailed, and their
applicability as a test of PD is uncertain. In addition, unlike Rose et al., we
elected to exclude one study that appeared not to entail putative exposure to
PTE (i.e., miscarriage).
Most of the RCT have noteworthy positive features (see Table 1). All studies
used standard, well-accepted self-report outcome measures, and several studies
used state of the art structured clinical interviews to evaluate PTSD, which
allowed for independent blind assessment of outcome (Bisson et al., 1997, and
Rose et al., 1999). All studies had adequate follow-up evaluation of
participants and one study reported results three years postintervention
(Mayou, Ehlers, & Hobbs, 2000). Finally, and most importantly, random
allocation of participants allowed for a determination of whether participants
who received PD improved beyond how they would have adapted on their own with
the passage of time. In all instances the PD failed to promote change to a
greater degree relative to no intervention.
We calculated an estimate of the direction and the magnitude of change in
the severity of PTSD symptoms in five of the six studies reviewed in Table 1
(Deahl et al., 2000 failed to provide sufficient descriptive data to conduct
this analysis). Change scores were expressed as mean changes in standard
deviation units (SDU) from baseline to the last follow-up interval reported.
Although the group receiving PD reported less severe symptoms at follow-up
(SDU=.45), this was, on average, not different from any of the control groups (SDU=.42).
Of course, these averages obscure individual trajectories of change, but these
data are not surprising given the normative course of adaptation to trauma, and
they underscore the need to prescreen individuals at risk for having difficulty
adapting on their own over time. We also calculated an average effect size
estimate by weighting the effect sizes of the five individual studies by the
sample sizes of that particular study. The mean effect size for PTSD measures
was -.11 (Cohen's d). This indicates that participants receiving PD had
slightly worse PTSD scores at follow-up (one-tenth a standard deviation) than
those not receiving PD (90% confidence interval ranges from -.32 to +.10).
Because the confidence interval includes zero, and because the effect size
estimate is very small, it is premature to conclude that PD is detrimental or
helpful in terms of secondary prevention of PTSD.
Taken as a whole, the set of studies revealed similar changes in PTSD
symptoms at follow-up between the PD and control groups. Nevertheless, two of
the more methodologically rigorous studies found that PD created a degree of
PTSD symptom exacerbation over time. Bisson et al. (1997) found that 26% of the
burn victims who were provided PD had PTSD at the 13-month follow-up interval
according to the Clinician Administered PTSD Scale (CAPS; Blake et al., 1990),
whereas only nine percent of the control group endorsed sufficient symptoms to
meet the diagnostic criteria for PTSD at follow-up. Also, the PD group reported
significantly higher anxiety and depression symptoms on subscales of the
Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) and
Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) at the
13-month follow-up (3-month data were not reported). However, despite random
assignment, participation in the intervention group was confounded with several
risk factors. Intervention group participants had higher initial symptoms, more
severe burn trauma, and were more likely to report preburn histories of
exposure to PTE. Bisson et al. controlled for initial symptom levels in their
analysis, in an attempt to take into account these confounds, and the results
were unchanged. However, initial symptom level is not necessarily a good proxy
for all three of the confounding factors or their interactions. It would have
been revealing if the authors had conducted a post-hoc multivariate analysis of
the predictors of change in symptom severity in order to examine the
characteristics of the person (including the three potentially confounding
factors), their experience of the stressor, or their experience of the
intervention that might be associated with outcome.
Hobbs et al. (1996) found that MVA victims administered PD within two days
after their accident were no different at a 4-month follow-up interval from
individuals given no intervention with respect to the number of PTSD cases,
PTSD symptom severity, and interview ratings of intrusive thoughts or travel
anxiety. A threat to internal validity in this study was that 22% percent of
the PD group could not be followed up, in contrast to six percent of the
no-treatment controls. The follow-up group may have been over-represented by
those who fared worse from the PD. In their three year follow-up examination of
the participants from Hobbs et al. (1996), Mayou, Ehlers, and Hobbs (2000)
found that the group that received PD had significantly worse outcome three
years later. Their overall distress and travel anxiety were worse, as were
overall levels of functioning and financial problems. Those MVA survivors with
initially high intrusion and avoidance symptoms recovered without PD
intervention but those who received the intervention remained symptomatic.
Unfortunately, only a little over half of the participants in the first study
were assessed a second time, so it is unclear whether the follow-up sample was
biased in some undetermined way. In addition, initial differences between the
intervention and control groups prior to debriefing may have affected the
three-year outcome.
The Bisson et al. (1997) study is of note because it compared CISD to an
information-only and no-intervention condition. This allowed for an examination
of the differential impact of what could be considered the nonactive, but
perhaps sufficient, components of CISD (empathic contact with a professional
coupled with the provision of information about trauma and its impact, etc.).
There were no differences between the three groups in rates of PTSD, severity
of PTSD, or depression at follow-up, suggesting that providing PD to
individuals exposed to PTE has no unique effect on outcome in victims of
violent crime.
Few published studies have empirically examined the use of debriefing in the
military, despite its frequent use in militaries across a diverse range of
cultures (Adler & Bartone, 1999). Deahl et al. (2000) conducted the only
RCT of soldiers provided PD in a group format, with mixed results. At the
6-month follow-up, Bosnia peacekeepers in the debriefed group had lower HADS
scores than those in the nondebriefed group, but the nondebriefed soldiers
reported a greater drop in IES scores from baseline. On the other hand, alcohol
abuse problems were lessened over time in the debriefed group and not the
control group. However, Deahl et al.'s findings are difficult to interpret
because of a likely floor effect; at baseline soldiers expressed very low
symptoms. In addition, since commanding officers assigned soldiers to the study
by virtue of availability, selection bias cannot be ruled out.
All studies employed CISD, or at least stated that they followed the basic
tenets of CISD, with individuals (the Bisson et al. study also used couples)
who would be considered primary victims of trauma in the CISD scheme (e.g.,
burn victims and traffic accident survivors). However, no investigators
explicated their rationale for intervening with individuals who would be
excluded from CISD formally. It would have been preferable for investigators to
contextualize their work in light of the recommendations of CISD, given that
they are testing the efficacy of this specific approach. In our view, it is
legitimate to evaluate whether CISD could be useful to individuals who
experience severe trauma, especially given the popularity of CISD and its
application to so-called primary victims. However, without sufficient
background justification, these studies are at risk for being dismissed as
inappropriate tests of the CISD model. Furthermore, proponents of CISD might
argue that negative findings confirm the CISD principle that individual primary
victims of trauma are inappropriate for PD (this is the main criticism of the
Cochrane review). Clearly, controlled study of group-administered CISD to
emergency services personnel exposed secondarily to trauma is needed to test
the CISD model.
A number of studies suffered from participant selection that was likely
biased in unspecified ways. For example, only 7% of the victims of violent
crime contacted by Rose et al. (1997) consented to participate. The
self-selected group of victims who agreed to participate may have been more
willing to talk about their trauma and may have been less avoidant overall than
the average victim. Thus, it remains an empirical question whether PD might be
effective for reluctant and avoidant victims who may agree to participate in PD
because organizations or hospitals recommend it as part of routine practice
(Shalev, 1994). Theoretically, the PD process may facilitate change in these
individuals because it reduces avoidance by suggesting experientially that approach
behaviors (e.g., self-disclosing) can lead to favorable outcomes.
The timing of the interventions provided was also variable. For example,
Rose et al. provided CISD, on average 21 days postincident (range: 9-31 days),
which differs considerably from the standard practice of providing PD within
days of a PTE (it also differs from the timing of PD in other RCT). However, it
could be argued that it is more appropriate to delay PD in some contexts. For
example, in the case of the Bisson et al. (1997) study where individuals were
suffering from acute burn pain, it may have been more appropriate to delay the
PD until acute pain is managed effectively. It is also unclear whether burn
patients are appropriate for a single session of any early intervention, given
the physiological and psychological burden of burns (Weinberg et al., 2000).
Although most of the participants who received PD reported that they
experienced it as very helpful, perceived helpfulness was not associated with
positive change in psychological status. Although this pattern could reflect
the influence of demand characteristics, it is also possible that early
professional contact may make people feel validated about their suffering and
result in positive evaluations about PD. The nonspecific beneficial elements of
respectful listening and validation may have a positive influence, but this has
not been measured in studies of PD to date.
Several studies that revealed symptom exacerbation concluded that PD might
be inappropriate because it involves emotional processing of a trauma
prematurely and without sufficient time for follow-up therapeutic processing
(e.g., Bisson et al., 1997). This conclusion appears premature, however,
because there is a lack of information about the extent of negative affect
produced by the PD, and there is no treatment fidelity data to evaluate the
specific content of PD interventions. Another flaw of these studies is their
failure to index the extent to which participants perceive PD as an imposition,
which could exacerbate distress. However, in one study, it was found that those
who chose to receive a PD reported higher exposure to the stressor and more
severe initial symptoms and a greater willingness to talk about their
experience than those who opted out of PD (Fullerton, Ursano, Vance, &
Wang, 2000). Finally, some individuals may report more symptoms after PD
because the experience enhances their awareness of internal experiences and
symptoms, therefore sensitizing them to report more intense or frequent trauma-related
symptoms but perhaps not more functional impairment (Neria & Solomon, 1999;
Rose et al., 2001). Future studies should evaluate areas of functional
impairment as well as symptomatology.
It is possible that a one-time PD is insufficient and individuals need more
sustained intervention. However, the results of one recent study suggest that
multiple debriefing sessions may not in fact be effective. Carlier, Voerman,
and Gersons (2000) provided three debriefing sessions (at 24 hours, 1-month and
3-months postincident) to police officers in the Netherlands exposed to trauma
and found that PD had no impact. These researchers also found that, one week
postincident, debriefed subjects reported more PTSD symptoms than nondebriefed
subjects, which is consistent with several studies (e.g., Bisson et al., 1997).
Even if PD is applied over several occasions, it may fail to pay sufficient
attention to assisting group members in preparing for the challenges they face
in the coming weeks and months. Nevertheless, determining the optimal number of
sessions and the necessity for follow-up, in order to enhance maintenance, are
empirical questions for future research.
The timing of providing PD has not been systematically studied. While
Mitchell and Everly (1986) argue that PD is most effective when conducted very
soon after a critical incident, this empirical question has not been explicitly
tested. Several authors have suggested that CISD may exacerbate symptoms
because the trauma is confronted too early, which is disruptive rather than
healing (Gist & Woodall, 2000; Shalev, 2000). It may be that, for some
people exposed to some types of traumas, a period of rest and relative
withdrawal is what is needed. In this context, PD may be experienced as an
imposition and may be overwhelming for some if it is provided too early.
Conclusions
Single session PD, when applied to individuals with moderate to severe
exposure to PTE who are not prescreened for risk factors or suitability for
active intervention, is not useful in reducing PTSD symptoms to a greater
extent than would occur with the passage of time, Although it is premature to
conclude unequivocally that PD hinders recovery from trauma (and, researchers
have yet to explicate the cause(s) of symptom exacerbation), there is sufficient
evidence that the indiscriminant use of single-session PD with individuals is
inappropriate. However, much more research is needed to examine: (a) the
optimal time frame to provide early intervention, (b) the process of change,
(c) the specific change agents, (d) the type of postintervention behaviors that
promote recovery and maintenance of change, and (e) the optimal mode and method
of screening for various types of PTE (e.g., mass disaster and victims of
violence presenting at emergency rooms). Although we recommend that
interventions be devised to treat only those individuals who are not likely to
recover over time on their own, more research is needed to determine which risk
indicators and risk mechanisms are optimal. In addition, researchers and clinicians
should be vigilant about the possibility that early identification of
individuals could inadvertently produce negative iatrogenic effects (e.g.,
stigmatization and self-fulfilling prophecy).
The application of PD to groups of emergency services personnel has yet to
be examined with a RCT. However, the roles of the peacekeepers who were
provided group PD in the Deahl et al. (2000) study are similar to those of
emergency services personnel; peacekeepers are typically well-trained and
chiefly exposed to others' suffering and the aftermath of violence (Litz,
1996). There is initial evidence that PD provided for groups of individuals
with a shared background and experience and low to moderate stressor exposure
does not serve to reduce stress symptoms. On the other hand, group PD appears
to facilitate more adaptive coping (e.g., less use of alcohol). More research
is needed to examine the efficacy of group PD for other emergency care
providers, especially in the context of exposure to severe PTE.
Cognitive-Behavioral Therapy as Early Intervention
Recent investigations of cognitive-behavioral therapy (CBT) for recently
traumatized individuals have demonstrated promising results in preventing the
development of chronic psychopathology following trauma. In this section, we
describe in detail one pilot study and two RCTs of multisession secondary
prevention of PTSD. Our intention is not only to critically evaluate the
research methodology but also to provide a detailed description of the
assessment and intervention strategies employed and contrast them to the PD
approach.
Foa, Hearst-Ikeda, and Perry (1995) compared the symptom course of 10 female
victims of rape or aggravated assault who received a 4 session
cognitive-behavioral intervention shortly after their assault with that of 10
assessment-only control victims. All participants were matched on symptom
severity, type and severity of assault, demographic characteristics, and time
since the assault. This individually administered intervention consisted of
educating participants about common reactions to assault, relaxation training,
imaginal and in vivo exposure, and cognitive restructuring. During the first
session, victims were educated about common posttraumatic reactions and they
were asked to list avoided activities and situations. The second session began
by providing victims with a rationale for exposure therapy followed by
relaxation training. The relaxation training was audio taped, and victims were
encouraged to use this tape to practice relaxation techniques at home. Next,
imaginal exposure was conducted as victims were instructed to relive the
assault by closing their eyes, vividly imagining the event, and describing it
aloud in the present tense. This narrative was also audio taped and victims
were encouraged to use this tape to repeat imaginal exposure daily. During the
narrative, the therapist attended to maladaptive beliefs that the victim
mentioned regarding perceived incompetence and the dangerousness of the world.
The remainder of the session was devoted to cognitive restructuring as
maladaptive beliefs that emerged during the victim's trauma narrative were
challenged. In addition to imaginal exposure homework, victims were encouraged
to begin confronting some of their avoided situations and activities. The third
session consisted of imaginal exposure and cognitive restructuring, and once
again, victims were encouraged to repeat imaginal and in vivo exposure
exercises daily on their own. Victims were also instructed to monitor negative
thoughts, feelings, and cognitive distortions using a daily diary. The fourth
and final session again consisted of imaginal exposure to the assault followed
by cognitive restructuring.
Two months after the assault, victims receiving CBT reported experiencing
significantly fewer symptoms of PTSD than did assessment control participants.
At a 5.5-month follow-up assessment, participants in the treatment condition
reported significantly fewer symptoms of depression, although there were no
differences between groups with respect to PTSD symptoms. Effect size analyses
indicated that the difference in PTSD scores between the two groups at the
5.5-month follow-up was relatively large, but because of the small sample size,
the lack of a statistically significant difference likely resulted from low
statistical power. Moreover, the control group in this investigation
experienced significant symptom remission that also may have contributed to the
lack of a statistically significant difference in PTSD symptoms at the 5.5-month
follow-up. Nevertheless, the large reductions in PTSD symptoms at posttreatment
coupled with significantly reduced depressive symptomatology at the 5.5-month
follow-up suggests that additional study of CBT in secondary prevention
interventions for trauma is indicated.
Bryant, Harvey, Dang, Sackville, and Basten (1998) also report a successful
CBT program for recently traumatized individuals. This intervention
specifically targeted individuals with ASD, and accordingly their study
provided a more direct test of the efficacy of brief CBT in preventing PTSD.
Moreover, because control participants received supportive counseling, it was
possible to evaluate the extent to which treatment promoted improvement above
and beyond that resulting from nonspecific therapeutic factors. Participants
were survivors of motor vehicle accidents or industrial accidents who were
randomly assigned to either CBT or supportive counseling. Both interventions
consisted of five 1.5-hour weekly individual therapy sessions. Similar to the
Foa et al. (1995) intervention, CBT included education about common
posttraumatic reactions, relaxation training, imaginal exposure to the
traumatic event, graded in vivo exposure, and cognitive restructuring. Each of
the last 4 sessions included 40 minutes of imaginal exposure, and participants
were encouraged to engage in imaginal exposure daily between treatment
sessions. By contrast, the supportive counseling condition included trauma
education and more general problem-solving training in the context of an
unconditionally supportive relationship.
At posttreatment and at 6-month follow-up, significantly fewer participants
in the cognitive-behavioral treatment group met diagnostic criteria for PTSD
compared to supportive counseling control participants. Similarly, those in the
cognitive-behavioral treatment group reported significantly fewer symptoms of
PTSD at posttreatment and 6-month follow-up, and significantly fewer symptoms
of depression at the 6-month follow-up, than did participants in the supportive
counseling condition.
In a subsequent study that dismantled the components of CBT, Bryant and
colleagues randomly allocated 45 civilian trauma survivors with ASD to five
sessions of either (a) CBT (prolonged exposure, cognitive therapy, anxiety management),
(b) prolonged exposure combined with cognitive therapy, or (c) supportive
counseling (Bryant, Sackville, Dang, Moulds, & Guthrie, 1999). This study
found that, at a six-month follow-up, PTSD was observed in approximately 20% of
both active treatment groups compared to 67% of those receiving supportive
counseling.
The brief cognitive-behavioral interventions described by Foa et al. (1995)
and Bryant et al. (1998, 1999) represent encouraging attempts to prevent the
development of chronic posttraumatic pathology in recent trauma victims. These
interventions share many features with psychological debriefing. For example,
they both include an education component designed to inform trauma victims
about common posttraumatic reactions and sequelae, and both attempt to teach
coping skills for managing symptoms of stress and anxiety.
Given the similarity between psychological debriefing and cognitive
behavioral interventions, what may account for the apparent differences in
treatment efficacy? Perhaps the most prominent reason that CBT appears to be
more efficacious is the greater emphasis on repeated imaginal reliving of the
traumatic event and graded in vivo exposure of avoided trauma-reminiscent
situations. In their review of the psychological debriefing literature, Bisson
et al. (2000) suggest that one-session intense exposure to trauma memories that
characterizes most debriefing approaches might be counter-therapeutic because
it may heighten arousal and distress without allowing sufficient time for extinction
or resolution of intensely negative posttraumatic affect. The results of the
cognitive-behavioral interventions described above would seem to refute the
notion that early exposure per se is counter-therapeutic. Rather, the
hasty and incomplete exposure to trauma memories that typifies traditional
psychological debriefing approaches may be potentially harmful.
The CBT approaches of Foa et al. (1995) and Bryant et al. (1998, 1999) also
included considerable attention to cognitive restructuring. There is considerable
evidence that acute pathological trauma responses are characterized by catastrophic
cognitive styles (Smith & Bryant, 2000; Warda & Bryant, 1998). There
is increasing evidence from treatment studies of PTSD that cognitive restructuring
is effective in reducing symptoms (Tarrier et al., 1999). The inclusion of cognitive
restructuring over repeated sessions in the early provision of CBT is an important
difference between current PD approaches and structured CBT.
Related Fact Sheets
Acute Stress
Disorder
Explains briefly what ASD is, how common it is, who is at risk, how it differs
from PTSD, and effective treatments
Cognitive-Behavioral
Therapy
Answers questions about the effectiveness of Cognitive-Behavioral Therapy as
a technique for early intervention
Critical
Incident Stress Debriefing
Discussion of CISD: a facilitator-led group process conducted soon after a
traumatic event with individuals under stress from trauma exposure
Phases
of disasters
A fact sheet detailing the phases of a disaster: the impact phase, immediate
postdisaster phase, recoil and rescue phase, and recovery phase
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