Evidence-Based Reviews

Crisis debriefing: What helps, and what might not

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Good intentions are admirable, but providing effective treatment contributes more.


 

References

Debriefing interventions have sprung from the understandable desire to reduce—if not eliminate—victims’ suffering after traumatic loss. Unfortunately, no compelling evidence has shown that an intervention given within a few days of a traumatic event can prevent significant psychological distress.

Evidence does suggest, however, that components of psychological debriefing discussed here may help you provide effective “first aid” to trauma victims and identify persons at risk for chronic psychological problems.

Complicated grief reactions

Death of a family member or close friend is among life’s most painful loses. When death occurs unexpectedly—as from violence, accident, natural disaster, or suicide—survivors’ emotional and psychological response can be pronounced.

Most survivors report great distress immediately after trauma or traumatic loss, but only an estimated 9% develop chronic psychopathology,1 such as complicated grief (Table 1).2,3 If the death was violent, surviving loved ones may experience complicated grief and posttraumatic stress disorder (PTSD)4 (Table 2).

Complicated grief is associated with considerable morbidity and risk of physical illness.5 PTSD develops in approximately one-third of cases involving sudden, unexpected death of a close friend or relative1 and can result in comorbid—but distinguishable—reactions to the loss (Box).6

Evidence-based secondary and tertiary intervention protocols have been developed for PTSD,7 but no practice guideline exists for treating or preventing complicated grief. Few controlled trials have been done.8

Table 1

Clinical features of complicated grief

  • Constant longing, yearning, or pining for the lost person
  • On edge or jumpy
  • Trouble accepting the loss
  • Difficulty trusting others
  • Anger or bitterness about the loss
  • Uneasiness about moving on with life
  • Emotionally numb
  • Trouble feeling connected to others
  • Feeling as if there is no future or that the future holds no meaning without the lost person
Source: Reference 3
Table 2

Clinical features of posttraumatic stress disorder

  • Exposure to traumatic event characterized by actual or threatened death or serious injury OR threat to physical integrity of self or others
  • Peritraumatic response must be characterized by intense fear, helplessness, or horror
  • Re-experiencing symptoms (1 or more), such as intrusive distressing memories or nightmares
  • Avoidance and numbing symptoms (3 or more), such as avoidance of trauma-reminiscent cues, contexts, or conversations
  • Hyperarousal symptoms (2 or more), such as concentration difficulties, exaggerated startle response
  • Duration: Symptoms must be present for at least 1 full month after the trauma and must be of sufficient severity to compromise functioning
Source: DSM-IV-TR
Early interventions. After traumatic events, the early interventions routinely offered by mental health professionals are forms of psychological debriefing—specifically critical incident stress debriefing (CISD). CISD is a variant of debriefing developed by Mitchell et al, whereas psychological debriefing can take a variety of forms. However, all forms of debriefing (CISD or otherwise) typically consist of four components:
  • educating individuals about stress reactions and how to cope with them
  • instilling messages that stress reactions are normal
  • helping affected persons process and share their emotions
  • providing information about and opportunity for further intervention, if needed.
Typically, individuals exposed to potentially traumatic events are invited, within days, to participate in a 3- to 4-hour session in which the incident is reviewed. Participants are asked to describe the stressor, provide a factual account of the event, then describe their thoughts during the incident. Emotional reactions to the event also are shared, and the facilitator normalizes these reactions.

Box

How complicated grief differs from posttraumatic stress disorder

Traumatic loss. Although complicated grief (CG) and posttraumatic stress disorder (PTSD) can both develop following the loss of a loved one from a traumatic event, CG also can develop after expected deaths from natural causes. PTSD is exceedingly uncommon if a loved one’s death did not result from homicide, suicide, or accident, whereas CG can occur when the loss was not particularly violent or sudden.

Avoidance vs preoccupation. The fundamental difference between CG (Table 1) and PTSD (Table 2) symptoms is the degree that survivors avoid cues and contexts that remind them of their loss.

Those with PTSD go to great lengths to avoid thinking about the traumatic event and actively avoid situations that may remind them of it. This avoidance, paradoxically, exacerbates intrusive memories, as trying not to think about something increases the frequency of those thoughts.

Individuals with CG do not avoid reminders of the deceased. Quite the opposite, they seek out reminders (such as photos or recordings) and find solace in them. Reminders may contribute to their ongoing rumination or preoccupation, in which they retreat into memories of the deceased rather than engage in present life.

Hyperarousal symptoms that are required for PTSD diagnosis are largely absent in CG. Even when persons with CG experience arousal, it is not akin to scanning the environment for danger or threat, as is typical with PTSD. Persons with CG have a pronounced negative affect and bereavement-related depression, rather than an exaggerated startle response or heightened physiologic reactivity.

Source: Reference 3

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