Debriefing the victims: Disaster in the making?

When disaster strikes, prompt psychological care is a key part of modern emergency response plans. Yet research suggests that some common, on-the-spot crisis treatments used may actually not help much at all.

These treatments — known generally as "psychological debriefing" — are now an industry, but they were not based on solid studies. Now studies have started to come in, and none show it works, says University of Pennsylvania professor Edna Foa. "Two or three are showing that it may even impede the recovery."

Typical treatment is a single session of one-on-one or group therapy, within one to three days of the trauma. Survivors are urged to fully recount the event and their emotions, and learn about their reactions.

The idea is that this will help head off deeper psychological problems, such as post-traumatic stress disorder, for some survivors later.

Most people get through most kinds of trauma without long-term symptoms. But a substantial minority will have chronic post-traumatic stress, with an average course of seven to 10 years, says Dr. David Spiegel, professor of psychiatry and behavioral sciences at Stanford University.

So there's reason to try to prevent its development. The problem, many scientists say, is that they are unsure whether current practices achieve that.

A national disaster strategy

The issue was highlighted in the aftermath of the Sept. 11 terrorist attacks. Mental-health workers didn't have guidelines on what would best help people, says Terence Keane, director of the VA's National Center for Post-Traumatic Stress Disorder.

So last fall at an international workshop, 58 mental-health experts sought to identify which mental-health interventions work, which don't, and what remains unknown, in the wake of disaster, especially mass violence, such as school or workplace shootings, or terrorist acts.

The panel's report, released this month by the National Institute of Mental Health, recommended that scientists should develop a "national strategy" to answer those questions.

Traumas, however, aren't just collective experiences, such as natural disasters, war or a factory explosion. People can also develop severe trauma symptoms from car, train or plane crashes, for instance; physical or sexual assaults; severe burns; a sudden death of a family member; a severe illness of a child; or witnessing an assault or murder.

Speaking at a recent meeting of the American Psychological Association, Foa, a clinical psychologist, outlined some assumptions that psychologists have made that may be misleading: that all stressful experiences call for crisis intervention; that the earlier it is done, the better; and that recounting the incident is beneficial.

Efforts to debrief people right after a trauma may overwhelm them with thoughts about the tragedy, psychologist James W. Pennebaker suggested at the Chicago meeting. Pennebaker and colleagues have examined how people dealt with such collective traumas as the 1989 earthquake in San Francisco, the Gulf War, the death of Princess Diana, the bonfire collapse at Texas A&M University, and the Sept. 11 attacks.

Other criticisms: Debriefing may encourage survivors to focus on and worry too long about their symptoms; there's no follow-up or way to deal with reactions after debriefing.

Some say they aren't ready to give up on the idea of an initial intervention, but say researchers must learn a lot more about what it should be.

But more helpful, says the VA's Keane, may be "cognitive behavioral therapies," which take aim at someone's thought processes and behavior, and have been shown in some studies to help prevent post-traumatic stress disorder.

Most don't need treatment

The treatments typically involve multiple one-on-one sessions, a few weeks after the trauma. Survivors focus on things such as normal reactions to the event, relaxation exercises and coping strategies. The patients also recount the trauma and therapists try to redirect any harmful thinking (for instance, if someone believes he was responsible for the tragedy).

The report on mass violence concluded that psychologists should assume that most people will recover normally, and after two months, anyone without trauma symptoms probably doesn't need follow-up. Among those more likely to be at risk of suffering mental problems: those who already were distressed; lost a loved one or were wounded; were exposed to trauma intensely and for a long time. Children and the elderly may also be more vulnerable.