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Dissecting the controversy about early psychological response to disasters and trauma

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Right now in Oklahoma, first responders and volunteers are pulling out the stops to mobilize all the help they can, including psychological support. They’ll be able to rely on people’s great reserves of generosity and resilience.

Devastating tornadoes have a lot in common with other major traumas, like life-threatening accidents, the Boston bombing and the Newtown shooting – especially the emotional distress they leave in their aftermath. As predictable and common as that distress is, though, early psychological response after trauma is still surprisingly controversial. It’s the center of a heated scientific debate that stewed and bubbled through the ‘90s and then boiled over.

It began when a technique from the battlefield crossed over to civilian life. Soldiers traditionally debrief to share information and learn from missions and incidents. Psychological debriefing evolved along with military psychiatry: instead of only discussing what happened, groups discussed feelings and coping too.

Psychological debriefing then spread to civilian first responders. Like soldiers, trauma was in the line of normal duty for them. They needed to be prepared and to cope with the stress, and debriefing was part of normality.

Then psychological debriefing spread out to victims of trauma, too. And on to experiences like childbirth.

Some people expected that professional care could prevent post-traumatic stress disorder (PTSD) and other psychological harm. But in the search for an affordable and efficient intervention that could be offered to everyone, it was often a single session.

Somewhere along the way, the belief had spread that it was always better to get your emotions out than bottle things up. Debriefing fit right in with that belief. Offering professional care to people in crisis also meets the need people are feeling when they see heart-wrenching scenes in Oklahoma now: to do something immediately to help relieve intense distress.

By the ‘90s psychological first responders had become as much a part of immediate disaster response as medical care and blankets. A police psychologist was already on the scene within half an hour of the first shots at Columbine High School in 1999, for example.

People who got debriefing often said it had helped – and people who were debriefed were coping well or recovering from deep distress. But then, most people will cope and recover after trauma, even without particular help. Robust randomized controlled trials were needed to be sure if debriefing was genuinely helping, and if it was the best way to respond.

Just as we worry about saying the wrong thing and further distressing someone in crisis, professionals can make things worse for people too. And maybe everyone doesn’t benefit from dwelling on the trauma in the immediate aftermath of a crisis.

A few trials of single session debriefing were done in the ‘90s. The people weren’t traumatized in the line of duty. They had suffered traumas like burns, road accidents or crimes. Or they had been debriefed around childbirth. And when discouraging results came in, controversy erupted.

What followed was a researcher version of “he said, she said." That’s notoriously hard to sort out. In the ideal world, instead of just arguing about the merits or weaknesses of this or that study, all the important studies would be found and analyzed in a good systematic review. That would sort out conflicting trials and everyone would be happy.

But in this instance the same “he said, she said" problem emerged with reviews, too, after one concluded debriefing was at best ineffective and might cause PTSD.

Some stopped debriefing or recommended against it. Others continued, either believing that the results did not apply to their system – or they were just not convinced by the review. Others modified their approach or developed new techniques.

So why has this research and the conclusion about possible harm been so controversial? Is it just because people shot the messenger when they didn’t like the message?

Even though systematic reviews are the best scientific option we’ve got, they still involve a lot of judgment calls. Researchers make quite legitimate decisions about precise questions differently, and that can lead to a different set of studies being analyzed. They can weigh the quality and value of individual studies differently. It’s a bit like several teams playing football at once, but the players can be on more than one team and the teams are playing by different rules. It gets complicated.

Reviewers from the US Agency for Healthcare Research and Quality (AHRQ) recently concluded that some form of early intervention by a trained professional may turn out to be important in the short-term and prevent some serious mental health problems. But basically, the quality of the evidence is just too low to be sure about a lot. Which is a recipe for ongoing controversy.

You can read some more detail about the technical differences in these reviews here. While several factors play a role in different review conclusions, the conclusion about harm depended mostly on a single trial that had extensive weaknesses. Without more solid evidence, we really just can’t know for sure.

While counseling for everyone exposed to a trauma splits the disaster community’s opinions, there’s more agreement that people with symptoms of PTSD could benefit from early therapy. And many others need support. But that leaves professionals to struggle with the question, where exactly is the line between psychological support and counseling?

Interviewed after the Aurora theater shooting, a counselor summed up their role this way: “Most people are resilient. Our job in disaster response is to help them find their resilience." I hope the trials are under way to help them do it well.

If you’re looking for information for support after trauma, psychological first aid is one of the newer techniques. There are resources from the VA National Center for PTSD here, including Handouts for Survivors.

Image: by Author, under Creative Commons CC-BY-SA licence.

The views expressed are those of the author and are not necessarily those of Scientific American.

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