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Thoughts on psychological debriefings: a noted authority on psychological debriefings cautions against "throwing the debriefing baby out with the reactionary bath water" in the debate over post-traumatic stress disorder.

In the past several years, debate over the efficacy of psychological debriefings has intensified. While controversy and examination often generate useful discussion, the recent trashing of debriefings as a viable service seems a bit reactionary (if not downright unjustified) and is founded on inadequate and poorly designed research.

Part of the problem is that somewhere along the line, someone apparently said or inferred that debriefings prevent post-traumatic stress disorder (PTSD). That is certainly a naive notion. Most mental health professionals understand that if an individual experiences an incident or process that results in a bona fide diagnosis of PTSD, a single intervention of any type will not suffice to manage the disorder. A multi-modal approach of talk therapy in combination with medication and other interventions, such as eye movement desensitization and reprocessing (EMDR), hypnosis, cognitive behavioral therapy, exercise, and support groups, usually is required to deal with the disorder over an extended period of time.

Some "experts" have even made the remarkable assertion that debriefings may, in fact, cause PTSD. According to an article in Crisis Management Quarterly, "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." (1)

There is little question that a debriefing must comprise more than "re-hashing and re-telling upsetting events" or it will be of limited benefit. Nonetheless, more and more organizations are dismissing debriefings based on faulty studies and naive misconceptions. For example, the American Red Cross and the American Psychological Association 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." (2)

An equally valid hypothesis may be that since debriefings are voluntary, only those who are truly upset about an incident will decide to attend a debriefing, and these individuals may be so traumatized they will develop PTSD even if they do not attend an intervention. Moreover, some people may recognize the symptoms of PTSD as a result of attending a debriefing and then decide to avail 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.

Some studies refer to the Cochrane Library and position it as the benchmark analysis in the field. (3) The Cochrane Library looked at studies of individuals from many different facilities who received crisis interventions that bore "little resemblance" to psychological debriefings and that sometimes were used in "situations where major stress reactions are not expected." (4) The interventions were provided by a diverse group of practitioners without the benefit of a specific model.

Comparing the Cochrane Library to debriefings is an "apples to oranges" proposition. As the British Psychological Society noted, "There are serious flaws in many of the studies that evaluate debriefings. Several fail to define debriefing or describe the protocol used or the training of the debriefers." (5) Again, minus a valid research design, we should hesitate to decimate an intervention that, at the least, has a fair amount of anecdotal support.

PSYCHOLOGICAL AGENDAS

Another possible reason for the controversy over debriefings is that some mental health professionals prescribe a rather rigid intervention structure. While having a theoretical framework or intervention model is important, it is impossible to take a one-size-fits-all approach to psychological debriefings. I have always felt, for example, that a critical incident stress debriefing (CISD) is designed strictly for police, fire, and emergency medical and mental health personnel who are in the forefront of crisis, trauma, and disaster response or who deal directly with the victims of such incidents. These individuals are trained to respond to critical incidents as a team.

When a tragedy befalls a regular workplace, it is not a critical incident nor is it appropriate to provide a CISD. Rather, this is trauma in the workplace, with far more dramatic impacts on those involved because--

* The "first responders" are co-workers with little to no formal training in trauma response and no warning that the trauma was about to occur;

* The trauma involves a person or persons with whom the responders may have had a personal relationship;

* After the trauma occurs, the responders and victims must go back to work and, thus, revisit the scene; and

* The responders and victims have not developed the emotional defense structure that professional crisis care providers have developed over many years of performing their job.

One cannot compare services delivered to crisis care professionals with those delivered to workplace trauma victims. Thus, the possibility of a more dramatic psychological impact, a higher incidence of PTSD, and a need for more robust intervention should be expected and understood. (6)

On many occasions I am called to provide services after an employee died outside the workplace, meaning his/her co-workers did not witness or experience the death. These are not CISDs, nor are they workplace trauma debriefings; they are meetings to talk about the death of (worker name) and are equally applicable to suicides, tragic deaths, and cases where someone succumbs to a long-term illness.

The psychological agendas of participants in debriefings and meetings will differ according to the type of incident. For this reason, facilitators need to orient the discussion to meet the specific characteristics of the situation and the demographics of the participants. For example, when not working with paramilitary organizations (such as police officers, firefighters, and medical specialists), I eschew the term "debriefing" and instead describe an intervention in layperson's terms, such as "meeting," "discussion," "talk," etc. Certainly, the term "CISD" should not apply to any intervention performed in response to a downsizing or layoff, relocation, removal of a chief executive, or other administrative crisis.

Finally, I have discovered that most police, fire, and hospital professionals already understand debriefings, but in the aftermath of a workplace trauma, many workers will come to a debriefing/meeting with little or no true understanding of what is about to happen. To help bring everyone up to speed and mitigate some of the inconsistency in communication about the meeting, I draft a statement and fax or e-mail it to the workplace liaison so it can be incorporated into the "invitation" to potential participants. I also provide handouts for participants to take with them that pertain to the situation, be it a trauma in the workplace, suicide at home, layoff, etc.

These materials indicate that the meeting/ debriefing is only one of many techniques or services designed to help if reactions to the incident persist.

NOT A YARDSTICK

Another reason some question the efficacy of debriefings is that people who participate in them may continue reacting to a critical incident or trauma for several weeks or months. Administrative personnel in particular may ask themselves, "How come people are still upset? They had a debriefing, didn't they?" Those of us who conduct debriefings and meetings must be careful not to collude with this lack of understanding. In addition to conducting a debriefing, we must provide good consultation to the workplace and help management appreciate that employees might require more than a single meeting.

We also must stop using Sept. 11, 2001, as the yardstick by which to measure the efficacy of interventions. The events of that day were so "over the top" of our experience that to draw any inference regarding psychological services is simply speculation. Certainly it is understandable that for an event of that magnitude, a single debriefing may serve as little more than a well-intentioned "spit in the bucket."

The question, however, is not whether a debriefing is sufficient, but what other services should be made available. The goal of trauma support is to have a "toolbox" that is both wide and deep (and utilized by experienced practitioners). An initial debriefing may serve to facilitate access to further services for those in need.

Now let's talk about training. As a psychologist for more than 25 years and a practitioner of psychological debriefings for more than 17, I believe that working with groups of people who have experienced a major trauma should be considered an expertise that requires, at a minimum, training, experience, consultation, and staying current with the literature. A one- or two-day workshop is a good start, but it is not sufficient for people who are serious about becoming or remaining proficient in this field. And while the peer support model may be sufficient for emergency personnel, I do not recommend that they provide critical incident or trauma services in other types of employment settings.

In sum, many issues--the type of incident, demographics of the victims, demographics of the participants, training and supervision of facilitators, documentation, management consultation, and post-debriefing follow-ups--must be taken into account when providing critical incident or trauma services. A well-founded research design that takes into account controlling incident demographics, utilization of a specific model, the random assignment of participants to treatment and non-treatment groups, pre-morbid history, the personal variables of the participants, the 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 laboratory, any research that measures the benefits 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

For a comprehensive review of the literature on the wide range of issues related to psychological debriefings, I strongly recommend "Psychological Debriefing" by the British Psychological Society (www.bps.org.uk/ documents/Rep12.pdf).

(1) Tennyson, A. 2003. "When Doing the Right Thing Might Be Wrong." Crisis Management Quarterly, V (32): Summer.

(2) Ibid.

(3) Wessely, S., S. Rose, and J. Bisson. 1998. "A systemic review of brief psychological interventions (debriefing) for treatment of immediate trauma related symptoms and the prevention of post-traumatic stress disorder." The Cochrane Library (4).

(4) "Psychological Debriefing." 2002. British Psychological Society.

(5) Ibid.

(6) Lewis, G. 1994. "Critical Incident Stress and Trauma in the Workplace." In Accelerated Development, Philadelphia, Penn: Taylor Francis.

Gerald Lewis is the director of Compass, which provides employee assistance programs, management consultation, organizational development, and employee training and education. He is an international consultant to government agencies, treatment facilities, schools, and private businesses and provides litigation consultation and expert testimony on workplace issues. He can be reached by calling (508) 872-6228 or by e-mail at glewis@geraldlewis.com.
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Title Annotation:Employee Assistance Programs
Author:Lewis, Gerald
Publication:The Journal of Employee Assistance
Geographic Code:1USA
Date:Jan 1, 2004
Words:1766
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