Talking It Out: Psychological Debriefing After Trauma

By Srini Pillay, M.D.

The practice of psychological debriefing can be traced historically to a time when commanders engaged their soldiers in sharing battle experiences. This reporting was believed to lift spirits and prepare troops for future challenges. Even today, when a disaster occurs, people often gather in their communities or therapeutic settings like group therapy to “process” the event.

Yet is “talking out” a trauma always the right approach? This issue has generated considerable healthy debate.

One study demonstrated that a specific type of psychological debriefing called critical-incident stress debriefing was, in fact, an effective crisis intervention. A meta-analysis of five previously published investigations examining the effectiveness of the critical incident stress debriefing model of psychological debriefing as a crisis intervention confirmed its effectiveness.

However, a Cochrane review, conducted soon after the meta-analysis, examined eight randomized trials involving individuals recently exposed to a traumatic event, within one month or less, and found surprising results.

This review found a single session of individual debriefing was ineffective in preventing or reducing the onset of post-traumatic stress disorder (PTSD) or other psychological distress when compared to a control group. No notable decrease in the severity of PTSD symptoms was observed within one to four months, six to 13 months, or even after three years of receiving the intervention. Furthermore, the debriefing did not show any benefits in alleviating general psychological distress, depression, or anxiety, nor did it prove to be better than educational interventions.

More troubling, data from one trial indicated that after one year, the risk of PTSD was significantly higher in participants who received debriefing. These findings suggested that the traditional, single-session debriefing may not be an effective strategy for trauma response and called for a reevaluation of such practices in psychological care.

One hypothesis to explain why debriefing is ineffective is that it catastrophizes normal distress and generates the expectation of a pathological response. Consequently, the first edition of this committee’s book, “Disaster Psychiatry,” recommended that debriefing not be used. However, the most recent revision, soon to be published, recognizes that the use of debriefing needs to be revisited as critiques of earlier studies have drawn attention to reasons for reconsidering the earlier recommendation.

What has changed?

Typically, psychological debriefing was designed for groups of emergency team or disaster workers who had initially been briefed together. These sessions were designed to be led by two facilitators; however, for larger groups, up to four facilitators might be involved, including a mental health professional and a specially trained peer support worker from the same profession as the group members.

Debriefings usually involve a single session, lasting between one and three hours, and are typically facilitated 24 to 72 hours after the traumatic event, although significant delays can often occur.

In 2011, Hawker, Durkin, and Hawker pointed out that negative findings about debriefing may have been due to three factors, summarized as follows:

• First, the implementation of debriefing deviated from the standard protocol in several ways: timing, duration, and the qualifications and independence of the debriefer.
• Second, people who underwent debriefing initially reported more severe symptoms compared with those who did not receive debriefing.
• Last, debriefing was used for individuals for whom it was not originally intended: primary victims of unexpected trauma, such as medically hospitalized patients who experienced isolated traumatic events like burns or motor vehicle accidents.

Then some studies have shown debriefing can be helpful. One indicated that debriefing after perioperative critical events, such as cardiac arrest requiring resuscitation, may be effective for the healthcare personnel involved. Another study indicated that debriefing after healthcare incidents may help improve learning, patient outcomes, staff performance, and team dynamics. Also, when debriefing was used for clinical staff in medical settings who had been exposed to direct and vicarious trauma, four studies found some evidence of the benefit of debriefing for reducing psychological sequelae to traumatic events.

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What was helpful about debriefing? One paper in 2022 reported that seven studies commented on factors that clinical staff perceived to be important for the debriefing to feel helpful. These included having an opportunity for reflection, finding relief in a shared experience, and having a competent facilitator.

Despite these positive studies, a recent meta-analysis did not find consistent evidence that psychological debriefing helps to prevent or reduce PTSD symptoms following work-related trauma. Whether this can be generalized across all contexts remains to be seen.

How should clinicians proceed?

The decision to use debriefing is not straightforward, as it is not possible to entirely endorse or dismiss its effectiveness with confidence. Understanding the advantages and drawbacks of debriefing is crucial. This knowledge equips individuals to avoid inadvertently causing harm, such as worsening feelings of distress or undermining the affected individuals' sense of autonomy.

One way to enhance the potential of debriefing and optimize for success is to train people to debrief. One study of internal medicine residents found that those who had been trained felt more prepared to lead team debriefs than those who had not been trained.

The effectiveness of interventions, including debriefing, can vary significantly depending on the context. For example, positive data on the effectiveness of debriefing have been reported in the context of perioperative critical events and among clinical staff who have been exposed to trauma. However, it is important not to be overly rigid or overly confident, even in these cases, due to the lack of conclusive evidence supporting the universal effectiveness of debriefing.

Training can ensure a better way to notice if someone’s symptoms worsen. In such cases, one might instead opt for an early intervention focused on building resilience, which could foster post-traumatic growth. This alternative approach emphasizes the importance of being adaptable and responsive to the varied needs of individuals facing trauma.

Individualization is key

It is crucial to understand that responses to debriefing are deeply personal and can vary widely among individuals. Factors such as timing and personal circumstances play a significant role in how effective debriefing can be. Therefore, it is essential to approach each instance with flexibility, recognizing the unique and evolving needs of everyone encountered.

Srini Pillay, M.D., is a professor of psychiatry at Harvard Medical School and a member of the Committee on Disasters, Trauma, and Global Health at the Group for the Advancement of Psychiatry.