The current status of psychological debriefing

It may do more harm than good

Papers p 1043

Despite the widespread use of psychological debriefing, serious concerns have been raised about its effectiveness and potential to do harm. ^{1 2} Psychological debriefing is broadly defined as a set of procedures including counselling and the giving of information aimed at preventing psychological morbidity and aiding recovery after a traumatic event. In 1995 Raphael and colleagues emphasised that there was an urgent need for reliable evidence from randomised controlled trials on the impact and worth of debriefing.³ Unfortunately, the news has not been good for debriefing.

Debriefing is generally applied within the first few days after a traumatic event, lasts one to three hours, and usually includes procedures that encourage and normalise emotional expression. Debriefing can also be more narrowly defined in terms of the procedures used, the information provided and the target population. One example of this type of debriefing is known as critical incident stress debriefing.4

A recent Cochrane review of eight randomised trials found no evidence that debriefing had any impact on psychological morbidity.5 The authors recommended that compulsory debriefing should cease. This was in part based on evidence that poorer outcomes were sometimes associated with debriefing. In this week's BMJ, the large randomised trial of debriefing after childbirth by Small et al (p 1043) provides yet more evidence that debriefing is ineffective.6 This study also provides further evidence that negative outcomes may be associated with debriefing.

Evidence about the ineffectiveness of debriefing has come from randomised trials that have used broad definitions of debriefing; thus, it might be that these findings have arisen because an inappropriate form of debriefing was used. It has been argued that if a more prescribed form, such as critical incident stress debriefing or its descendant, critical incident stress management, were used the outcomes would be different. However, there have been no published, randomised controlled trials using these prescribed approaches. There has also been no randomised controlled trial comparing the different types of debriefing. Therefore, until there is evidence there is no support for using one type of debriefing over any other.

Debriefing is a “grassroots” intervention that is popular among many health and allied practitioners. Some of them are likely to continue to advocate its use in spite of the lack of empirical support for it. Organisations such as banks and hospitals are likely to continue using it since there is no comparable broadly acceptable early intervention that is comparatively low cost. The continued use of debriefing might not matter (other than to taxpayers and shareholders) if studies had found that psychological debriefing had no effect or a positive effect on recovery. But this is may not be the case. Distress after trauma typically reduces over time, stabilising at levels that are proportional to the initial traumatic event.7 For debriefing to be worthwhile it should at least accelerate the downward trajectory of distress. What should concern practitioners, organisations, and researchers is that not only does the evidence indicate that this is not happening, but it also indicates that debriefing may prolong the process of recovery.

Why should this happen? Research shows that certain factors probably have an impact on the recovery process, such as the perception that a trauma was life threatening, the person's premorbid psychiatric state, and the presence of serious ongoing stressors. 7 8 Other factors may also affect recovery—for example, people's expectations of their responses and reactions. Thus, it has been suggested that debriefing “medicalises” normal distress by generating in an individual the expectation of a pathological response.5 Personality and coping style may also interact with debriefing and affect recovery. However, this relation is likely to be complex. For example, a tendency to avoid rather than confront emotionally distressing experiences is associated with poorer outcomes after trauma, suggesting that people with this tendency will need help in confronting or discussing the trauma. However, an exposure that is too brief, such as in debriefing, may exacerbate, rather than ameliorate, distress.5

These are still hypotheses without supporting evidence. But since they bear directly on how an early psychological intervention after a trauma might proceed they are worthy of attention. There is little evidence to support current debriefing practices, and little is known about why debriefing might adversely affect recovery. There does, however, continue to be a great need for an early intervention that is demonstrably effective after a trauma.