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Abstract
The question of the effectiveness of psychological debriefing has stimulated considerable debate. Evidence is contradictory. While evidence for its effectiveness is apparent when evaluation is conducted shortly after intervention takes place, it becomes less likely as the time interval between debriefing and intervention increases. This paper adopts an organisational psychological approach to ask what might happen during this interval to influence effectiveness. It explores the theoretical nature of work-related traumatic stress reactivity and the context within which reactions occur and recovery takes place. Cognitive, social and organisational influences on response are identified and used to tentatively offer explanations for the differential effectiveness of debriefing observed in evaluation studies. General conclusions regarding the implications for intervention effectiveness and design are discussed.
This study will explore the implications of the post-event social and organisational
environment for recovery. In the above evaluation studies, evidence for the
effectiveness of debriefing was often forthcoming when evaluation was conducted
shortly after the intervention was provided, but less likely as the time interval
between the precipitating event and the evaluation increased. This paper raises
questions about what might happen during this interval to influence recovery. It will
do so by exploring the theoretical nature of work-related traumatic stress reactions
and the context within which reactions occur and recovery takes place.
The starting point for the present review is some recent work exploring the nature
of the traumatic stress construct (Smith, Paton, Ramsay, & Akande, in prep).
Instruments used to assess traumatic stress, as is true for any psychological
construct, are used on the assumption that there is a degree of stability in the
psychological constructs they seek to assess. In the present context it is assumed
that the underlying construct 'traumatic stress' is robust and homogenous and
manifests itself in the same way in all those affected. This assumption provides a
consistent platform for intervention planning, design, administration and evaluation
(Paton & Smith, 1996). Smith et al., (in prep), reporting the results of a structural
re-assessment of Impact of Event Scale (IES) data obtained from over 1600 subjects
drawn from several populations who had experienced traumatic incidents while
performing their professional duties, suggest that this assumption may not be
justified.
Their structural re-analysis revealed that, at least with respect to the core diagnostic
indicators of traumatic stress reactions, intrusion and avoidance, professional status,
organisational membership and nationality influence the nature of work-related
traumatic stress reactions. The extent to which the responses of each group were
structurally different is evident in figure 1. Smith et al's. ( in prep) study reveals
that work-related traumatic stress reactions cannot be attributed solely to exposure
to a specific traumatic incident. Rather traumatic stress reactions reflect causal
influences emanating from the interaction between a traumatic event and factors that
reflect national origin, and organisational and professional membership. This
conclusion supports the argument that the physical, interpersonal and performance
context of work interact with the demands of the traumatic experience to alter the
character and intensity of the traumatic experience (Dunning, 1994). A prominent
role for organisational factors in stimulating the nature of traumatic stress reactivity
suggests that intervention procedures should be designed to manage the
consequences of a specific traumatic incident and the organisational and
professional context within which it occurs. This observation also implies that
evaluation should take place over time and against a backdrop defined by the work
environment.
A more prominent aetiological role for organisational factors in the development of
post-trauma reactions raises an issue that relates less to the question of debriefing
effectiveness and more to the manner in which a focus on a given intervention can
preclude or hinder the exploration of traumatic stress from other perspectives.
Psychological debriefing is often described as a preventative intervention. The term
'prevention', as used in this context, refers to the goal of minimising reactivity
after an individual has been exposed to a traumatic event. This approach tends to
encourage the view that traumatic stress reactions are an inevitable consequence of
exposure to particular kinds of events (Dunning, 1995). A focus on the post-event
management of individual reactivity has diverted attention from exploring personal,
group and organisational factors that could serve to promote adaptation and
minimise impact. Acknowledging that professional and organisational status
influences the nature of traumatic stress reactivity and recovery makes it easier to
appreciate the potential for strategies that can be used to prevent or minimise
reactions prior to exposure as well as managing reactions following involvement.
This issue will be particularly pertinent for professions whose members face
exposure to traumatic incidents repeatedly throughout their careers (Dunning, 1990;
Lundin & Bodegard, 1993; Paton, 1994). It suggests that appropriate interventions
such as organisational change, job re-design, training, and managerial development
have a role to play in the management of work-related traumatic stress.
Figure 1: Differences between groups defined by their location in a two dimensional space by derived subject weights. Adapted from Smith et al (in prep).
As a starting point, one approach involves drawing upon existing theoretical and
practical literatures that illuminate the relationship between people, organisations
and psychological well-being. The organisational aspects are particularly relevant
when dealing with work-related psychological trauma because the work
environment defines the context within which the traumatic experience occurred and
within which recovery will take place. Robinson and Mitchell (1995) argue that one
of the primary goals of debriefing is to restore people to normal functioning within
their routine environment as soon as possible. For work-related populations, the
therapeutic implications of returning to work have been acknowledged (Dunning,
1994; Paton, 1997). Achieving this goal requires that interventions are designed to
facilitate a survivors' ability to manage subsequent environmental demands.
Determining whether this goal is met can only be accomplished by evaluating the
effectiveness of an intervention after people have returned to the workplace. While
Robinson and Mitchell (1995) were correct in arguing that exposure to intervening
events and demands complicates the process of evaluating the effectiveness of a
debriefing per se, following individuals over time provides valuable insights into the
nature of the interaction between recovery resources and the recovery (work)
environment. It is thus important that evaluation be conducted at several points
during the post-event period. The need for normative and pre-event data, and
appropriate methodological approaches, is also indicated by this shift to a more
longitudinal approach (Paton & Smith, 1996; Robinson & Mitchell, 1995).
In addition to developing an understanding of how the environment affects recovery
per se, we also need to explore the manner in which support or recovery
interventions interact with environmental variables to determine the nature and rate
of recovery. Insights into why debriefing may work in some cases but not others,
and why it may exacerbate psychological morbidity in some, may be gained in the
process.
An appropriate starting point is to examine the personal, cognitive, social
psychological and organisational variables that could influence post-trauma
reactivity and recovery. A more prominent role for organisational and professional
variables in the aetiology of work-related traumatic stress than has previously been
acknowledged means intervention can also be conducted at the level of
organisational analysis and re-design. Isolating organisational determinants of
traumatic stress reactivity will furnish information that can serve as a basis for
designing salutogenic working environments. In reality, there will be considerable
overlap between these levels of analysis.
From the point of view of preventing or minimising reactivity, several strategies
could be envisaged. Alexander and Wells (1991), Deahl, et al. (1994), Friedman,
Framer & Shearer (1988), Lyons (1991), McCammon (1996), Paton, Ramsay, and
Sinclair (1992) and Tehrani (1995) discuss data suggesting that screening represents
a useful means of identifying high risk individuals. Screening could be used to pre-
select those at risk (and so prevent their involvement) or, post-event, to identify
high risk employees and prioritise them for support and monitoring. The latter is
likely to be the most feasible strategy in most circumstances. Indeed, this function
has been identified as an alternative to the standard use of debriefing (Orner, 1997).
However, additional work is necessary to clarify the potential use of vulnerability
data in this context (Green & Solomon, 1995; Lyons, 1991; Paton & Smith, 1996;
Scotti, et al., 1995).
Individual differences in vulnerability have other implications for intervention
design and administration. As yet there is no clear understanding of how
vulnerability status influences reactivity nor how it might affect response to support
interventions. Certainly cultural/ethnic factors will be influential in this context and
may render group interventions less appropriate for the members of some cultures
(e.g., because it is inconsistent with cultural grieving traditions and practices). The
increasingly multi-cultural nature of those in employment makes this an important
issue for future investigation. Dispositional factors may also affect utilisation of
formal and informal sources of social support (Scotti et al., 1995), rendering
debriefing less effective for individuals whose dispositional attributes limit support
usage. Risk status can be influenced in other ways. For example, although involved
in the same event, the unique nature of individual experience can expose
participants in a group process to diverse additional insights, some of which may be
helpful and some of which may not. Considerable care must be exercised to ensure
that exposure to the traumatic recollections of others does not trigger secondary
traumatisation.
Exploring individual differences in vulnerability to traumatic reactivity can provide
insights into why debriefing may work for some individuals but not for others. It is
pertinent to ask whether a group intervention, conducted over a period of a few
hours, affords sufficient opportunity to explore differences in vulnerability and
accommodate it within the group process. Assuming similarity on the grounds of
shared involvement in a given event may be inappropriate until the relationship
between vulnerability and reactivity and between vulnerability and intervention
effectiveness has been established. Considerable personal knowledge of those
involved would be required and this information would be difficult, if not
impossible to obtain, in the time frame prior to a debriefing being conducted or
during the process itself. Nor, in general, would it be available from organisational
sources.
For some groups (e.g., emergency services and law enforcement) differences in the
expectations they have about their work and the meaning systems underlying
occupational choice will influence reactivity (Carlier, in press). The relevance of
this issue is highlighted by the finding that responding to 'traumatic' events can,
under certain circumstances, be perceived as professionally rewarding (Alexander &
Wells, 1991; Andersen, Christensen, & Petersen, 1991; Hartsough & Myers, 1985;
Moran & Colless, 1995; Raphael, 1986). More objective appraisal of individual
outcome, and researching the factors contributing to positive outcomes, could
inform selection and training processes, contribute to the development of
organisational response strategies, and facilitate the evolution of more representative
models of traumatic reactivity. Moreover, failure to accommodate this possibility
within intervention processes may counter the beneficial effects of their experience,
increasing their risk status over time (Dunning, 1995; McKenzie, 1996).
Several cognitive factors can be implicated as determinants of traumatic stress
reactivity. Schema theory has recently been used as a means of conceptualising the
dynamics of trauma impact (Janoff-Bulman, 1989, 1992; Paton, 1994). For example,
differences between individuals with respect to their ability to accommodate the
atypical physical and emotional demands associated with traumatic experiences will
affect vulnerability and the effectiveness of recovery or support interventions
(Alexander & Wells, 1991; Paton, 1994).
A further issue that is pertinent to high risk groups, but which may not be readily
accommodated by recovery interventions, concerns the implications of repeat
exposure to potentially traumatic incidents. Within high risk groups (e.g., law
enforcement, emergency services) multiple traumatic or high risk experiences can
result in behavioural addiction (Gilmartin, 1986; Grigsby, 1991; Solursh, 1988,
1989; Paton & Violanti, 1997). Wilson (1980) coined the term "action junkies" to
describe how some officers become addicted to the experience of violence,
excitement and trauma and cannot function effectively without it. When this mind-
set is established, difficulty in rationally accepting and reviewing traumatic
experiences may make it more difficult for those affected in this way to engage in
appropriate recovery behaviours (Kolb, 1993). While participation in debriefing
could assist recovery under these circumstances, it is possible that the difficulty that
trauma addicted individuals have in reviewing their experiences (Kolb, 1993) may
lessen its usefulness. Additionally, hypersensitivity, an increased likelihood of their
perceiving environmental stimuli as threatening (Gilmartin, 1986), and a tendency to
focus on the traumatic and physiologically arousing aspects of the experience (van
der Kolk, 1997) may increase risk status within a group setting. More research is
needed into the implications of chronic traumatic exposure and its implications for
well-being and intervention design.
Another facet of this culture that is relevant here involves the perceived need for
control (Short, 1979). Control beliefs may be undermined by involvement in any
help-seeking process (Eränen & Liebkind, 1993; Everstine & Everstine, 1993) and
threaten self-esteem (Coyne, Ellard & Smith, 1990; Gilbert & Silvera, 1996).
Similarly, attributions about event causality and blame can influence the utilisation
of support resources (Joseph, Yule, Williams & Andrews, 1993). Attributional
processes also influence perceptions of professional self-worth (Duckworth, 1986;
MacLeod & Paton, in press; Paton, 1994) which may, in turn, affect reactivity and
the effectiveness of recovery processes.
The impact of traumatic experiences on social identity processes may also
complicate the recovery process. Shalev (1994) argued that participating in
debriefing can result in the formation of a collective identity, increasing problems
with respect to relationships with colleagues and making it more difficult for
individuals to process their personal losses. Patterns of reactivity and recovery can
also be affected by the manner in which response outcomes interact with
professional identity (Hartsough & Myers, 1985; Shalev, 1994).
Recovery is also complicated by differences in the salience of support needs and
providers over time. For example, informational support may be viewed as intrusive
if provided by significant others but not if offered by professionals, while the
opposite holds for emotional support (Shin, Lehmann, & Wong, 1984; Thoits,
1986). Over time, recovery may be more effectively facilitated by providing
understanding during the early stages and assistance with reintegration in routine
activities at a later stage (Shin et al., 1984). Effective recovery management will
thus require the integration of formal (e.g., debriefing) activities with those of
colleagues, managers and organisational systems if the potential of formal event-
related intervention is to be fully realised. The potential influence of organisational
variables (staff and systems) described in these studies reiterates the need to
consider the organisational environment in a discussion of work-related trauma.
Those fulfilling managerial or command roles are ideally placed to facilitate
adaptation and re-integration in those affected by traumatic events (Alexander &
Wells, 1991; Smith, 1985). However, an autocratic management style may limit
supervisory willingness or capability to fulfil this aspect of their recovery role
(Violanti, 1996 a, b). A lack of supervisory understanding of the reality of traumatic
stress reactions increases the likelihood of their responding to subordinates with
contempt, blaming them for what happened, or minimising the significance of their
reactions and feelings (Dunning, 1994).
Clearly the analysis and development of structural characteristics, policies and
procedures, and managerial attitudes and capabilities has a role to play within the
trauma management process (Dunning, 1994; Paton, 1997; Powell, 1991). In
addition to their more direct role as mediators of reactivity, organisational factors
will influence the reintegration process and the monitoring of staff reactions.
Organisational systems and practices (e.g., training) affect meaning systems and, as
such, represent strategies which can be implemented to moderate traumatic stress
reactions, influence recovery rates and the effectiveness of recovery interventions
(Alexander & Wells, 1991; Paton, 1994). In the longer term, organisational analyses
can contribute to organisational development programmes by providing information
that can be used to promote and sustain appropriate management-staff relationships,
a supportive organisational climate, and effective response and recovery systems.
The organisational environment, and its relationship to reactivity and recovery, thus
represents an area where further research is required to identify salient variables and
processes and to define the manner of their influence.
Resources designed to assist recovery should be made available over a prolonged
period. Moreover, support needs may change in a qualitative manner as survivors
work through their reactions in the context of a dynamic recovery environment.
Intervention development must accommodate the interaction between the survivor,
their experience, and the social-organisational context within which recovery takes
place. Support resources should thus be capable of ensuring support availability in a
contingent manner over the course of the recovery period. The provision of an
isolated intervention is likely to be less effective than previously anticipated.
While the issues discussed above have been implicated as determinants of trauma
reactivity and as influencing the quality of recovery, more systematic research is
required to clarify the nature of these relationships and their implications for the
effectiveness of recovery interventions. Because several of these reflect conditions
pertaining within an organisation, and which develop over time, a need for
organisational level intervention, both with respect to the reduction of problems and
the management of reactions, is also indicated.
More research into the nature of the longer term recovery process is required, as is
investigation of the relationship between support needs, support providers, and the
nature and content of support interventions. A need to develop support resources in
a manner that facilitates self-help and that sustains or promotes positive perceptions
of the experience is also suggested by the literature.
The important issue here is developing a realistic and comprehensive understanding
of work-related trauma reactivity and recovery processes. As this knowledge is
accumulated organisations and interventions can evolve in a manner capable of
minimising the development of reactions and assisting recovery and adaptation to
diverse demands within complex and dynamic operational and recovery
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