WSJ:  September 12, 2003:  Is Trauma Debriefing Worse Than Letting Victims Heal Naturally?

Is Trauma Debriefing Worse Than Letting Victims Heal Naturally?

The executive was in a meeting in one of the Twin Towers when the first plane hit. Of the 30 people with him, he and only six others staggered out alive that morning. Crushed by the enormity of the tragedy, the man told his trauma counselor that it was all he could do to try to understand why he had lived while others died. Yet he had to cope with a great deal more.

Like thousands of other victims of Sept. 11, the executive underwent psychological debriefing, a catch-all term for sessions in which a counselor encourages a group of 10 to 20 trauma survivors or disaster workers to share, in a supportive environment, what they experienced, felt and thought. Debriefing, say proponents, can prevent long-term psychological problems such as post-traumatic stress disorder. The disaster industry that emerged in the 1990s has vigorously promoted psychological debriefing, training more than 40,000 people a year in it. Members of the U.S. military undergo stress debriefing before deploying home from Iraq.

For the executive who survived the 2001 terrorist attacks, though, hearing other victims describe what they saw and suffered that day was too much. When one described seeing a body part roll down a sidewalk, he had to flee the session.

For weeks afterward he suffered flashbacks and nightmares, finally seeking help from Crisis Management International, an Atlanta-based company that, at the behest of 204 corporate clients, had sent hundreds of counselors to New York within days of Sept. 11. "The group debriefing had led him right into what he couldn't get rid of in the first place: the memories and images of 9/11," says CEO Bruce Blythe.

WTC TENANTS: AFTER THE FALL   See a September 2002 special report1 from the Online Journal for a look at how former World Trade Center tenants -- including some business owners mentioned in this article -- worked to rebuild their businesses after the terrorist attacks.

In science, anecdotes are not data. But stories like this executive's are igniting a firestorm of controversy in psychology. After scrutinizing dozens of studies of psychological debriefing, a panel of eminent researchers assembled by the American Psychological Society -- Richard McNally of Harvard University in Cambridge, Mass.; Richard Bryant of the University of New South Wales in Sydney and Anke Ehlers of King's College London -- has reached a clear conclusion.

"Contrary to a widely held belief, pushing people to talk about their feelings and thoughts very soon after a trauma may not be beneficial," they write in a paper to be published in November in the journal Psychological Science in the Public Interest (available at www.psychologicalscience.org/pspi²). "Although psychological debriefing is widely used throughout the world to prevent PTSD, there is no convincing evidence that it does so. ... For scientific and ethical reasons, professionals should cease compulsory debriefing of trauma-exposed people."

Most survivors who have undergone psychological debriefing call it helpful. But objectively comparing the outcomes of people who did and didn't undergo debriefing -- survivors of car accidents, police officers exposed to trauma and disaster workers -- tells a different story. Debriefing has no effect on rates of PTSD.

A 2001 analysis, for example, examined peer-reviewed studies that randomly assigned trauma survivors to receive "critical-incident stress debriefing," a commonly used protocol, or not. (Randomized controls let you separate the effects of debriefing from natural recovery.) The conclusion: There is no evidence that debriefing helps prevent PTSD in trauma survivors, partly because most recover naturally.

More worrisome, debriefing may impede natural recovery. When police officers who worked a plane crash underwent debriefing, they had significantly more PTSD symptoms 18 months later than officers who weren't debriefed. By forcing survivors to relive horrific memories, says Prof. McNally, "debriefing may consolidate emotional memories more intensely, when what you need is to shut down for a while. As one earthquake survivor in Turkey said, 'It was as if the debriefers opened me up as in surgery and didn't stitch me back up.' "

Jeffrey Mitchell, an associate professor at the University of Maryland, Baltimore County, who devised critical-incident stress debriefing, dismisses the negative studies. Many include debriefings conducted by poorly trained or minimally experienced counselors, he says, or done too soon after the trauma. Moreover, "this was never designed as a stand-alone. Crisis intervention includes much more than debriefing."

In fact, at least one debriefing study found a benefit. In 1999, scientists reported that 42 emergency medical personnel who underwent debriefing after working the 1992 Los Angeles riots reported significantly fewer PTSD symptoms than did 23 nondebriefed workers. Other pro-debriefing studies, however, are problematic. Some failed to include a no-treatment group to serve as a control. In others, the follow-up period for assessing "lasting" psychological damage was woefully short.

Businesses aren't waiting for academics to resolve the debate. Concerned about the potential harm of debriefing, says Mr. Blythe, CMI has abandoned it. The company's Web site now warns prospective clients that the science behind debriefing is so iffy, and the suggestions of harm so troubling, that requiring employees to undergo debriefing could invite lawsuits.

• You can e-mail me at sciencejournal@wsj.com³.
 

Updated September 12, 2003