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Editorial |
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Editorial |
Justin Kenardy, PhD, School of Psychology, University of Queensland, Brisbane, Queensland 4072, Australia. Email: kenardy@psy.uq.edu.au
There have been many anecdotal reports of the effectiveness of stress debriefing but only a
handful of recent systematic evaluations of the effectiveness or efficacy of stress debriefing.
There is evidence from uncontrolled studies that indicates that debriefing is a positive
experience (eg Robinson & Mitchell, 1993). However Jean Griffiths and Rod Watts (Griffiths
& Watts,
1992) conducted research following the Kempsey and Grafton Bus Crashes that indicated that
debriefed victims actually had high levels of distress. Sandy Mc Farlane (McFarlane, 1988) found
that while debriefing helped reduce acute post-trauma stress following the Ash Wednesday Fires,
it also predicted increased delayed stress. Also Martin Deahl and colleagues (Deahl, Gillham,
Thomas, Searle, & Srinivansan, 1994) in Britain found no differences in traumatic stress
symptoms between debriefed and non-debriefed Gulf War soldiers. These findings have been
replicated substantively in later studies (Bisson, Jenkins, Alexander, & Bannister, 1997; Hobbs,
Mayou, Harrison & Worlock, 1996; Hobbs & Adshead, 1997; Hytten & Hasle, 1989; Kenardy
et al., 1996; Lee, Slade, & Lygo, 1986).
So when it became apparent from the data collected after the Newcastle Earthquake that
questions concerning the effectiveness of psychological debriefing could be answered we
proceeded to do so. It might be worthwhile describing the Newcastle Earthquake Study first
though. When the Newcastle Earthquake hit in 1989 Vaughan Carr from the University of
Newcastle Department of Psychiatry decided to set up a study of the prospective impact of this
large scale trauma on the community (Carr, Lewin, Webster & Kenardy, 1997.) What resulted
was a prospective longitudinal study of 1,089 inhabitants of Newcastle assessed four times over
two years. As part of that study it was decided to specifically assess a subsample of professional
and volunteer disaster workers. As with the larger study 196 helpers were followed up at six-monthly intervals over the next two years. Serendipitiously questions about psychological
debriefing were included in the questions and scales administered so we could directly compare
the 65 debriefed versus 133 non-debriefed helpers. What we found surprised us. While debriefing
was generally reported as helpful, there was no relationship to rate of recovery found, and in fact
we did find a slight trend for reduced rate of recovery amongst debriefed helpers. Furthermore
we found no relationship between the reported degree of helpfulness of debriefing and the actual
outcome in terms of symptoms of post-trauma and other psychological distress.
Whilst our study was not intended as an evaluation of debriefing and failed to randomise helpers
to either a debriefed or no debriefing condition (a necessary requirement to avoid the
confounding effects of self-selection) we did try to control for factors that might have influenced
that self-selection process such as degree of exposure to danger and self-reported distress.
However since the study was not designed to evaluate it cannot be concluded that Stress
Debriefing is ineffective. However, we were concerned. And while it should not be concluded
that we cease using Psychological Debriefing we should be very vigilant of possible negative
effects and of any discrepancy between perceived helpfulness and actual outcomes. Finally we
cannot conclude that the apparent lack of impact of Psychological Debriefing lies in how it was
applied because first it must first be shown that Stress Debriefing can to be effective and we just
don't know this yet.
For us this finding highlighted how little we do know about Psychological Debriefing. As yet we
still do not know how useful Psychological Debriefing is. In particular we do not know whether
information giving is productive. In terms of that information, we do not know when it is best
given, how and by whom. For example does information need to be presented by a debriefer or
would handouts be sufficient. We also do not know what information is useful to whom. For
example some information may trigger in some individuals a heightened sense of distress. We
do not know the impact of self disclosure. There is a commonly held view that self-disclosure
of traumatic experience is desirable. However what we do not know is if and when it is not.
Debriefing may be useful as functioning as a time to screen for those who may be likely to go
on to develop ongoing problems, yet I suggest that we still do not know what to look for. We
do not have a clear notion yet of what are the "early warning signs" and how they are best
detected.
There is a need for researchers and practitioners to examine the parameters effecting debriefing.
There has been much said about who should provide the debriefing. The need in the debrief for
understanding the trauma from the participants' point of view would support the notion of peers
as debriefers. Peers may be more likely than "outsiders" to comprehend operational and
organisational factors as well as the particular social circumstances of the participants.
On the other hand if the debriefing is to be considered part of an overall debriefing management
process whose boundaries stretch beyond the actual debriefing, then it could be argued that
someone detached from the organisation my be more appropriate in order to prevent possible
conflicts of interest. The professional qualifications of such a person may be generic (eg
counsellor) or specific (eg mental health professional, clinical psychologist, clinical social
worker).
How is debriefing to be provided? There are a number of debriefing "methods" (eg Red Cross,
Mitchell, Dyregrov) with their own protocols. Given the heterogeneity it is not possible to clearly
determine the adequacy of one over the other. In fact, there is an ongoing development of
debriefing. Newer "hybrid" protocols emerge from older ones without evaluation of either.
Protocols are assumed to be useful and appropriate and therefore maintained, or they are changed
on the basis of clinical rather than empirical evidence. One example is the decisions that guide
most appropriate time for provision of debriefing. There is a commonly held point of view that
debriefing should be held as close in time and space to the actual trauma. A time of 72 hours has
been identified as the most desirable upper limit. How was the decided? On what evidence?
Clearly there is a need to examine the impact of information provision and emotional disclosure
at varying times after trauma.
Finally, psychological debriefing may need to clarify its purpose. If it is indeed to be a
preventative intervention then that should guide associated activities such as identification of "at
risk" participants, follow-up and evaluation. If on the other hand its purpose is to "bond"
participants that would lead to a very different set of desirable outcomes.
The great attraction of debriefing is that it has excellent face validity in the eyes of practitioners
and many members of the public. It is a response to the psychological distress experienced
following a trauma. However there may be some who see psychological debriefing as a way to
divest themselves of ongoing responsibility for those who may have continuing problems
subsequent to the trauma. Perhaps the most problematic issue is the precription of psychological
debriefing following traumas. If there were unequivocal evidence that debriefing contributes to
the recovery of an individual this position might be defensible. But at present the literature
provides no support for this position (Wessely, Rose, & Bisson, 1997.)
The following issue of the Australasian Journal of Disaster and Traumatic Stress is devoted to
the vexed issue of psychological debriefing. Each of the contributors to this issue have provided
a considered, and at times challenging, perspective on the problem. I would urge readers to keep
an open mind to the issues raised. An article outlining the CISD/CISM position was invited and
submitted, but a decision to withdraw it was made by the author(s) following the peer review
process.
Carr, V.J., Lewin, T.J., Webster, R.A., & Kenardy, J. (1997) A
synthesis of the findings from the Quake Impact Study: A two-year
investigation of the psychosocial sequelae of the 1989 Newcastle
Earthquake. International Journal of Social Psychiatry and
Psychiatric Epidemiology,32,123-136.
Deahl, M.P., Gillham, A.B., Thomas, J. , Searle, M.M., &
Srinivasan, M. (1994). Psychological sequelae following the Gulf
war: factors associated with subsequent morbidity and the
effectiveness of psychological debriefing. British Journal of
Psychiatry, 265, 60-65.
Griffiths, J. & Watts, T. (1992). The Kempsey and Grafton bus
crashes: The aftermath. Lismore, NSW: Instructional design
Solutions, University of New England
Hobbs, M., & Adshead, G. (1997). Preventative psychological
intervention for road crash victims. In Mitchell, M., (Ed.) The
aftermath of road accidents: Psychological, Social and Legal
Perspectives. London, Routledge.
Hobbs, M., Mayou, R., Harrison, B. & Worlock, P. (1996). A
randomised controlled trial of psychological debriefing for
victims of road traffic accidents. British Medical Journal. 313,
1438-1439.
Hytten, K., & Hasle, A. (1989). Firefighters: A study of stress
and coping. Acta Psychiatrica Scandinavica 80(Suppl. 355) 50-55.
Kenardy,J.A., Webster, R.A., Lewin, T.J., Carr, V.J., Hazell,
P.L. & Carter, G.L. (1996). Stress debriefing and patterns of
recovery following a natural disaster. Journal of Traumatic
Stress, 9, 1, 37-49.
Lee, C., Slade, P., & Lygo, V. (1986). The influence of
psychological debriefing on emotional adaptation in women
following early miscarriage: A preliminary study. British
Journal of Medical Psychology, 69, 47-58.
McFarlane, A.C. (1988). The longitudinal course of posttraumatic
morbidity: The range of outcomes and their predictors. The
Journal of Nervous and Mental Disease, 176, 1, 30-39.
Robinson, R. & Mitchell, J.T. (1993). Evaluation of
psychological debriefing. Journal of Traumatic Stress, 6: 367-82.
Wessely, S., Rose, S., & Bisson, J. (1997) A systematic review of brief psychological interventions ("debriefing") for the treatment of immediate trauma related symptoms and the prevention of post traumatic stress disorder. Manuscript submitted for publication.
