Single session debriefing after psychological trauma: a meta-analysis

Summary

Background

Despite conflicting research findings and uncertain efficacy, single session debriefing is standard clinical practice after traumatic events. We aimed to assess the efficacy of this intervention in prevention of chronic symptoms of post-traumatic stress disorder and other disorders after trauma.

Methods

In a meta-analysis, we selected appropriate studies from databases (Medline Advanced, PsychINFO, and PubMed), the Journal of Traumatic Stress, and reference lists of articles and book chapters. Inclusion criteria were that single session debriefing had been done within 1 month after trauma, symptoms were assessed with widely accepted clinical outcome measures, and data from psychological assessments that had been done before (pretest data) and after (post-test data) interventions and were essential for calculation of effect sizes had been reported. We included seven studies in final analyses, in which there were five critical incident stress debriefing (CISD) interventions, three non-CISD interventions, and six no-intervention controls.

Findings

Non-CISD interventions and no intervention improved symptoms of post-traumatic stress disorder, but CISD did not improve symptoms (weighted mean effect sizes 0·65 [95% CI 0·14–1·16], 0·47 [0·28–0·66], and 0·13 [−0·29 to 0·55], respectively). CISD did not improve natural recovery from other trauma-related disorders (0·12 [−0·22 to 0·47]).

Interpretation

CISD and non-CISD interventions do not improve natural recovery from psychological trauma.

Introduction

After traumatic events such as the Sept 11 attacks, offers of emotional and practical support to victims are thought to be appropriate and caring human responses. Psychological debriefing is a formal type of post-traumatic care, for which several models have been developed in the past two decades. Everly and colleagues¹ describe three stages in the development of these models. The earliest forms of debriefing included many individually applied techniques, termed “crisis intervention approaches”. “Group psychological debriefing”² has been used to reduce immediate distress, prevent later adverse psychological sequelae including post-traumatic stress disorder, ³ and identify individuals who were at risk of development of chronic problems and who needed referral for further treatment. There are three types of group psychological debriefing: critical incident stress debriefing (CISD) also known as the Mitchell model,⁴ the Raphael model,⁵ and process debriefing.⁶

In typical CISD, within 1 week of a traumatic event, a group of victims are led through seven stages in a single 1–3 h session. Process debriefing and the Raphael model are variations on the CISD model, differing in their emphasis on structure and in certain aspects of content.² CISD was integrated in the more comprehensive critical incident stress management model (CISM).

Psychological debriefing has received increasing attention from the scientific community. A search of the PsychINFO-database for English language journal articles with the word “debriefing” in the title identified 206 hits for the 1990s, compared with 79, 47, and 11 hits in the 1980s, 1970s, and 1960s, respectively. Many interventions are offered as treatments and described as debriefing, including CISD or CISD-like interventions, interventions that share only some elements with CISD, and interventions that have very little to do with CISD in its original form. Furthermore, these interventions are delivered by professional and non-professional workers with different backgrounds, at different time-intervals (sometimes months after a traumatic event), and are assessed with different instruments.

Despite the large number of research publications on this issue, debate continues on the efficacy of single session debriefing in prevention of symptoms of chronic post-traumatic stress disorder and other negative psychological outcomes after trauma. Several narrative reviews have been published on single session debriefing.1, 2, 7 Conclusions varied from “there is no current evidence that psychological debriefing is a useful treatment for the prevention of PTSD [post-traumatic stress disorder] after traumatic incidents”⁷ to “crisis intervention procedures, group debriefings, and especially CISM approaches are effective in reducing the negative psychological aftermath of a variety of critical incidents”.¹ Thus, there is still no consensus on whether single session debriefing can contribute to the prevention of symptoms of chronic post-traumatic stress disorder.

Narrative reviews of research have several limitations;⁸ meta-analysis is a useful alternative. However, an earlier meta-analysis on the efficacy of psychological debriefing also had several limitations.⁹ First, only studies of group psychological debriefing were included, although in clinical practice individual debriefing is the rule rather than the exception. Thus, the conclusions drawn by the authors cannot be generally applied to clinical practice. Second, in two studies, psychological debriefing was done at 6 and 9 months after trauma, and at 6 months after trauma, respectively, thus, these interventions could hardly have been preventive.

We have done a meta-analysis of studies designed to assess the efficacy of single session debriefing in preventing post-traumatic stress disorder and non-post-traumatic stress disorder psychopathology. We included studies of group and individual debriefing interventions that had been administered within 1 month of a traumatic event. The fourth edition of the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-IV)³ states that to meet criteria for a diagnosis of post-traumatic stress disorder, symptoms have to persist for at least 1 month. Interventions done more than 1 month after trauma are therefore curative rather than preventive.