Escaping from the past of disaster psychology

Scientific American has a useful piece on how the immediate treatment of psychological trauma has changed since 9/11. The issue is interesting because recent progress has turned lots of psychological concepts on their head to the point where many still can’t grasp the concepts.

The article notes that at the time of the Twin Towers disaster, the standard form of treatment was Critical Incident Stress Debriefing – also known as CISD or just ‘debriefing’ – a technique where psychologists would ask survivors, usually in groups, to describe what happened and ‘process’ all the associated emotions by talking about them.

This technique is now not recommended because we know it is at best useless and probably harmful – owing to the fact that it seems to increase trauma in the long-term.

Instead, we use an approach called psychological first aid, which, instead of encouraging people to talk about all their emotions, really just focuses on making sure people feel secure and connected.

Although the article implies that 9/11 was a major turning point for our knowledge of immediate post-trauma treatment, the story is actually far more complex.

Studies had been accumulating throughout the 90s showing that ‘debriefing’ caused harm in some, although it wasn’t until around the turn of the century that two meta-analyses sealed the deal.

Unfortunately, the practice of ‘debriefing’ by aid agencies and emergency psychologists was very hard to change for a number of interesting reasons.

A lot of aid agencies don’t deal directly with the scientific literature. Sometimes, they just don’t have the expertise but often it’s because they simply have no access to it – as most of it is locked behind paywalls.

However, probably most important was that even the possibility of ‘debriefing’ having the potential to do damage was very counter-intuitive.

The treatment was based on the then-accepted foundations of psychological theory that said that emotions always need to be expressed and can do damage if not ‘processed’.

On top of this, for the first time, many clinicians had to deal with the concept that a treatment could do damage even though the patients said it was helpful and were actually and genuinely getting better.

This is so difficult to grasp that many still continue with the old and potentially damaging practices, so here’s a quick run down of why this makes sense.

The theoretical part is a hang-over from Freudian psychology. Freud believed that neuronal energy was directly related to ‘mental energy’ and so psychology could be understood in thermodynamic terms.

Particularly important in this approach is the first law of thermodynamics that says that energy cannot be created or destroyed just turned into another form. Hence Freud’s idea that emotions need to be ‘expressed’ or ‘processed’ to transform them from a pathological form to something less harmful.

We now know this isn’t a particularly reliable guide to human psychology but it still remains hugely popular so it seemed natural that after trauma, people would need to ‘release’ their ‘pent up emotions’ by talking about them lest the ‘internal pressure’ led to damage further down the line.

And from the therapists’ point of view, the patients said the intervention was helpful and were genuinely getting better, so how could it be doing harm?

In reality, the psychologists would meet with heavily traumatised people, ‘debrief’ them, and in the following weeks and months, the survivors would improve.

But this will happen if you do absolutely nothing. Directly after a disaster or similarly horrible event people will perhaps be the most traumatised they will ever be in their life, and so will naturally move towards a less intense state.

Statistically this is known as regression to the mean and it will occur even if natural recovery is slowed by a damaging treatment that extends the risk period, which is exactly what happens with ‘debriefing’.

So while the treatment was actually impeding natural recovery you would only be able to see the effect if you compare two groups. From the perspective of the psychologists who only saw the post-trauma survivors it can look as if the treatment is ‘working’ when improvement, in reality, was being interfered with.

This effect was compounded by the fact that debriefing was single session. The psychologists didn’t even get to see the evolution of the patients afterwards to help compare with other cases from their own experience.

On top of all this, after the ‘debriefing’ sessions, patients actually reported the sessions were useful even when long-term damage was confirmed, because, to put it bluntly, patients are no better than seeing the future than professionals.

In one study, 80% of patients said the intervention was “useful” despite having more symptoms of mental illness in the long-term compared to disaster victims who had no treatment. In another, more than half said ‘debriefing’ was “definitely useful” despite having twice the rate of postraumatic stress disorder (PTSD) after a year.

Debriefing involves lots of psychological ‘techniques’, so the psychologists felt they were using their best tools, while the lack of outside perspective meant it was easy to mistake instant feedback and regression to the mean for actual benefit.

It’s worth saying that the same techniques that do damage directly after trauma are the single best psychological treatment when a powerful experience leads to chronic mental health problems. Revisiting and ‘working through’ the traumatic memories is an essential part of the treatment when PTSD has developed.

So it seemed to make sense to apply similar ideas to those in the acute stage of trauma, but probably because the chance of developing PTSD is related to the duration of arousal at the time of the event, ‘going over’ the events shortly after they’ve passed probably extends the emotional impact and the long-term risks.

But while the comparative studies should have put an end to the practice, it wasn’t until the World Health Organisation specifically recommended that ‘debriefing’ not be used in response to the 2004 tsunami [pdf] that many agencies actually changed how they went about managing disaster victims.

As well as turning disaster psychology on its head, this experience has dispelled the stereotype that ‘everyone needs to talk’ after difficult events and, in response, the new approach of psychological first aid was created.

Psychological first aid is actually remarkable for the fact that it contains so little psychology, as you can see from the just released psychological first aid manual from the World Health Organisation.

You don’t need to be a mental health professional to use the techniques and they largely consist of looking after the practical needs of the person plus working toward making them feel safe and comfortable.

No processing of emotions, no ‘disaster narratives’, no fancy psychology – really just being practical, gentle and kind.

We don’t actually know if psychological first aid makes people less likely to experience trauma, as it hasn’t been directly tested, although it is based on the best available evidence to avoid harm and stabilise extreme stress.

So while 9/11 certainly focussed people’s minds on psychological trauma and its treatment (especially in the USA which is a world leader in the field) it was really just another bitter waymarker in a series of world tragedies that has shaped disaster response psychology.

So unusually for a psychologist, I’ll be hoping we’ll have the chance to do less research in this particular area and have a more peaceful coming decade.
 

Link to SciAm piece on psychology and the aftermath of 9/11.

10 Comments

  1. lklein
    Posted September 11, 2011 at 12:53 am | Permalink

    would this mean the usual military approach, back in the group after the incident they make jokes, ignore whatever is now over and just get on with whatever comes next was actually the best possible response?

  2. Daniel
    Posted September 11, 2011 at 1:58 am | Permalink

    > recent progress has turned lots of psychological concepts on their head to the point where many still can’t grasp the concepts.

    What other concepts do you consider were turned on their head?.

    If you don´t have the time to elaborate plesae post a list.

    Thanks.

  3. Jake
    Posted September 11, 2011 at 3:27 am | Permalink

    Very interesting. Thanks for the extended write-up.

  4. Vicenç
    Posted September 11, 2011 at 7:00 am | Permalink

    Thanks!

  5. james
    Posted September 11, 2011 at 2:39 pm | Permalink

    what is the history of the idea that “psychological first aid “could be” or “should be” preventive?

  6. Posted September 12, 2011 at 12:13 am | Permalink

    I wonder if this points to a wider issue with therapy in general, that self-reported progress may be generally unreliable. If that is so, then much more of modern therapy may need to be re-examined than what happens immediately after a severe trauma.

  7. JasonM
    Posted September 13, 2011 at 7:43 pm | Permalink

    Thank you for the interesting article. It was very well written.

    I realize you are a psychologist and I don’t have a PhD, but I do have to respectfully disagree with your article on a scientific level.

    You mention that the practice of debriefing was recommended to be stopped. In the public safety arena though, debriefing is a needed practice. Yes, a (relatively) normal human being may experience one or two traumatic experiences in their lives. Generalizing everyone into that category though is misleading. Public safety responders may experience ten or twenty extremely disturbing traumatic experiences throughout their career.

    In this case, debriefing can be a good thing as long as it meets two criteria. First, debriefing must NEVER be mandatory. When the practice is employed, tt should always be offered as a voluntary session. No one individual should be forced to speak if they don’t want to share. Forcing someone who doesn’t want to share to talk about their feelings can be detrimental. Second, debriefing alone is not a good idea. Public safety agencies need to have a comprehensive Critical Incident Stress Management (CISM) program in place to help responders deal with a crisis. A good CISM program has debriefing as just a single component, and in the public safety arena it can be very beneficial.

    Granted, for the general public a single debriefing after a crisis is mostly not going to do much for the person. But, for public safety responders who may have to deal with death and destruction week in and week out, debriefings as part of a larger CISM program can be extremely beneficial.

  8. lklein
    Posted September 16, 2011 at 9:23 pm | Permalink

    So what else is in the CISM that makes it so valuable? Do you have any studies comparing those who have and have not participated in the debriefing portion of the CISM?

  9. joan
    Posted September 19, 2011 at 7:54 pm | Permalink

    Debriefing is only one part of CISM. Debriefings are led by trained peers, although a mental health person attends, not always a psychologist. CISM continues to be active worldwide and specially noted by the United Nations. Having been at the World Trade Center, not with CISM, I am quite sure “nothing could fix things”. However we saw many people benefit from talking about their feelings. People are not “required to relive the event”. They do often discuss their interpretation of event and how it affects them. I suggest you might want to contact ICISF for additional information about all phases of CISM. NOVA and Red Cross were all at WTC and were helpful. Thank you for the dialogue.

  10. Posted August 29, 2013 at 6:55 am | Permalink

    If we are to take “first do no harm” seriously, the important lesson here is that in the absence of valid scientific evidence demonstrated in properly designed, replicable randomized controlled trials with active control groups, *any* therapy must be regarded as unsafe and/or ineffective. The burden of proof is to demonstrate that a therapy is safe and effective *before* trying it out on the public; to do otherwise without full disclosure of the risky experimental nature of the “treatment” is unethical. The harm that is caused is not justified by any counterbalancing validated good; anecdotal “evidence” does not cut it in the face of people getting hurt.

    http://whereistheburdenofproof.wordpress.com/


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