Effect of timing of critical incident stress debriefing (CISD) on posttraumatic symptoms

Revisiting the debriefing debate: does psychological debriefing reduce PTSD symptomology following work-related trauma? A meta-analysis

Psychological debriefing is an early post-trauma intervention which aims to prevent the development of PTSD and accelerate normal recovery through discussing, validating, and normalising group members responses to trauma. While originally designed in the 1980s for groups of emergency service personnel, the scope of psychological debriefing extended to individual primary victims of trauma. A Cochrane review in 2002 concluded that psychological debriefing was ineffective, yet some authors have argued that many of the studies that informed the Cochrane review did not adhere to key elements of psychological debriefing. This meta-analysis sought to re-examine the effectiveness of psychological debriefing in preventing or reducing PTSD symptoms following work-related trauma. Appropriate studies were selected from three databases (MEDLINE, Embase and PsycINFO). Inclusion criteria was intentionally broad so that features of psychological debriefing that may determine its effectiveness could be explored through a series of subgroup analyses. The overall synthesis did not find consistent evidence that psychological debriefing helps to prevent or reduce PTSD symptoms following work-related trauma. Shortcomings in the methodology and reporting of many of the studies meant that several important subgroup analyses could not be conducted. Further well-designed studies in this field are warranted to ensure that employees exposed to potentially traumatic events receive the effective support they need and deserve.

Evolving Needs of Critical Care Trainees during the COVID-19 Pandemic: A Qualitative Study

Background

Critical care trainees were integral in the coronavirus disease (COVID-19) pandemic response. Several perspective pieces have provided insight into the pandemic's impact on critical care training. Surveys of program directors and critical care trainees have focused on curricular impact. There is a lack of data from the trainee perspective on curricular enhancements, career development, and emotional and well-being needs to succeed in a critical care career in the ongoing COVID-19 pandemic.

Objective

Our objective was to elicit perspectives from critical care trainees on their personal and professional needs as they continue to serve in the COVID-19 pandemic.

Methods

This was a hypothesis-generating qualitative study. Individuals in a U.S. critical care training program during the COVID-19 pandemic participated in either focus groups or semistructured interviews. Interviews were conducted between July 2020 and March 2021 until data saturation was achieved. Audio recordings were professionally transcribed and analyzed using qualitative content analysis. A codebook was generated by two independent coders, with a third investigator reconciling codes when there were discrepancies. Themes and subthemes were identified from these codes.

Results

Thirteen participants were interviewed. The major themes identified were as follows: 1) Curricular adaptation is necessary to address evolving changes in trainee needs; 2) COVID-19 impacted career development and highlighted that trainees need individualized help to meet their goals; 3) receiving social support at work from peers and leaders is vital for the sustained well-being of trainees; 4) fostering and maintaining a sense of meaning and humanity in one's work is important; and 5) trainees desire assistance and support to process their emotions and experiences.

Conclusion

The needs expressed by critical care trainees are only partially captured in conceptual models of physician well-being. The need for multilevel workplace social networks and identifying meaning in one's work have been magnified in this pandemic. The themes discussing curricular gaps, career development needs, and skills to process work-related trauma are less well captured in preexisting conceptual models and point to areas where further research and intervention development are needed.

Are psychological debriefing groups after a potential traumatic event suitable to prevent the symptoms of PTSD?

Psychological debriefing is a psychotherapeutic approach developed for early intervention in civilians and professionals who have to cope with a potential traumatic event (PTE). Although initial works claimed that this approach may decrease symptoms of posttraumatic stress disorder (PTSD), some studies have concluded that the clinical benefits of psychological debriefing were limited. Several methodological variations could explain the discrepancies observed among studies. Among these variations, how the approach is administered to participants should have importance, and clinical evidence suggests that debriefing groups instead of individuals could have a beneficial clinical effect. We conducted a systematic search of the literature investigating the clinical effects of psychological debriefing groups on PTSD symptoms after a PTE according to the PRISMA guidelines. Among the 790 articles found, 11 met our inclusion criteria. Most of these articles did not support any beneficial effect of psychological debriefing groups on PTSD symptoms. A large number of methodological variations that may influence the outcomes of these studies were observed. Psychological debriefing groups did not seem efficient in alleviating PTSD symptoms. Further studies of high methodological quality are needed to elucidate the effect of psychological debriefing groups on specific PTSD symptoms and on nonspecific symptoms.

Prevalence of Mental Illness and Mental Health Care Use Among Police Officers

IMPORTANCE

Limited literature has characterized patterns of mental illnesses and barriers in seeking mental health care among police officers.

OBJECTIVES

To assess the prevalence of mental illness (diagnosis) and symptoms of mental illness, evaluate the characteristics of officers interested in seeking mental health care, and characterize perceptions of mental health care use.

DESIGN, SETTING, AND PARTICIPANTS

This survey study was conducted among officers at a large police department in Dallas-Fort Worth, Texas. Focus group sessions were conducted from April 1, 2019, to November 30, 2019, and the survey was conducted from January 1 to February 27, 2020. A total of 446 sworn, employed patrol officers who were present during the recruitment briefing were eligible to participate in surveys and focus groups.

MAIN OUTCOMES AND MEASURES

Officers reported lifetime or current diagnosis of depression, anxiety, and posttraumatic stress disorder, as well as current mental health symptoms (using validated screeners of depression, anxiety, posttraumatic stress disorder, and suicidal ideation or self-harm) and mental health care use in the past 12 months. Focus group data were collected to contextualize mental health care use. Logistic regression analyses were used for quantitative data, and focus groups were iteratively coded by 4 coders using inductive and deductive thematic identification.

RESULTS

Of the 446 officers invited to participate, 434 (97%) completed the survey (mean [SD] age, 37 [10] years; 354 [82%] male; 217 White [50%]). Of these officers, 19 (17%) had sought mental health care services in the past 12 months. A total of 54 officers (12%) reported a lifetime mental health diagnosis, and 114 (26%) had positive screening results for current mental illness symptoms. Among officers with positive screening results, the odds of interest in using mental health services was significantly higher for officers with suicidal ideation or self-harm than for those who did not (adjusted odds ratio, 7.66; 95% CI, 1.70-34.48). Five focus groups were conducted with 18 officers and found 4 primary barriers in accessing mental health services: (1) inability to identify when they are experiencing a mental illness, (2) concerns about confidentiality, (3) belief that psychologists cannot relate to their occupation, and (4) stigma that officers who seek mental health services are not fit for duty.

CONCLUSIONS AND RELEVANCE

The study found that although few officers were seeking treatment, they were interested in seeking help, particularly those with suicidal ideation or self-harm. Additional interventions appear to be needed to systematically identify and refer officers to health care services while mitigating their concerns, such as fear of confidentiality breach.

A Video-based Debriefing Program to Support Emergency Medicine Clinician Well-being During the COVID-19 Pandemic

Introduction

Emergency clinicians on the frontline of the coronavirus pandemic experience a range of emotions including anxiety, fear, and grief. Debriefing can help clinicians process these emotions, but the coronavirus pandemic makes it difficult to create a physically and psychologically safe space in the emergency department (ED) to perform this intervention. In response, we piloted a video-based debriefing program to support emergency clinician well-being. We report the details of our program and results of our evaluation of its acceptability and perceived value to emergency clinicians during the pandemic.

Methods

ED attending physicians, resident physicians, and non-physician practitioners (NPP) at our quaternary-care academic medical center were invited to participate in role-based, weekly one-hour facilitated debriefings using Zoom. ED attendings with experience in debriefing led each session and used an explorative approach that focused on empathy and normalizing reactions. At the end of the pilot, we distributed to participants an anonymous 10-point survey that included multiple-answer questions and visual analogue scales.

Results

We completed 18 debriefings with 68 unique participants (29 attending physicians, 6 resident physicians, and 33 NPPs. A total of 76% of participants responded to our survey and 77% of respondents participated in at least two debriefings. Emergency clinicians reported that the most common reasons to participate in the debriefings were “to enhance my sense of community and connection” (81%) followed by “to support colleagues” (75%). Debriefing with members of the same role group (92%) and the Zoom platform (81%) were considered to be helpful aspects of the debriefing structure. Although emergency clinicians found these sessions to be useful (78.8 +/− 17.6) interquartile range: 73–89), NPPs were less comfortable speaking up (58.5 +/− 23.6) than attending physicians (77.8 +/− 25.0) (p = < 0.008).

Conclusion

Emergency clinicians participating in a video-based debriefing program during the coronavirus pandemic found it to be an acceptable and useful approach to support emotional well-being. Our program provided participants with a platform to support each other and maintain a sense of community and connection. Other EDs should consider implementing a debriefing program to safeguard the emotional well-being of their emergency clinician workforce.

Working with prisoners who self-harm: A qualitative study on stress, denial of weakness, and encouraging resilience in a sample of correctional staff

BACKGROUND

Rates of self-harm are high among prisoners. Most research focuses on the vulnerable prisoner, and there is little on the impact of these behaviours on staff.

AIMS

To investigate staff perceptions of self-harming behaviours by prisoners, including their views on its causes, manifestation, prevention in institutions, and impact on them.

METHODS

Semistructured interviews were conducted with 20 administrative and 21 therapeutic prison staff who are responsible in various ways for prisoners who self-harm. Their narratives were explored using interpretative phenomenological analysis.

RESULTS

Despite prison staff being experienced with prisoners' self-harming behaviours, including severe acts of self-harm, they were apt to reject any negative impact on their own mental health or well-being. This denial of negative impact was accompanied by perceptions of the inmate's actions being manipulative and attention seeking. Prison staff also perceived institutional responses to self-harming behaviours by prisoners as being mixed, ambiguous, or showing preference for relying on existing suicide protocols rather than task-specific guidance.

CONCLUSIONS

Although staff gave explanations of prisoner self-harm in terms of "manipulative behaviour," prisoners' self-harm is, in fact, complex, challenging, and often severe. This staff perception may reflect denial of impact of often distressing behaviours on them personally and their own coping mechanisms. This could be feeding in to a perceived lack of clear and effective institutional responses to the self-harm, so further research is needed to determine how staff could broaden their views, and respond more effectively to prisoners. Psychologically informed group work and/or reflective practice are among the candidates for such help for staff.

Post-traumatic stress disorder among the staff of a mental health hospital: Prevalence and risk factors

BACKGROUND

Mental health service providers are frequently exposed to stress and violence in the line of duty. There is a dearth of data concerning the psychological sequelae of the frequent exposure to stress and violence, especially among those who work in resource-limited countries such as Botswana.

AIM

To determine the prevalence and predictors of post-traumatic stress disorder (PTSD) among mental health workers in a tertiary mental health institute in Botswana.

SETTING

The study was conducted in Sbrana Psychiatric Hospital, which is the only referral psychiatric hospital in Botswana.

METHODS

The study used a descriptive cross-sectional design. A total of 201 mental health workers completed a researcher-designed psycho-socio-demographic questionnaire, which included one neuroticism item of the Big Five Inventory, and a PTSD Checklist-Civilian Version (PCL-C), which was used to assess symptoms of PTSD.

RESULTS

Majority of the study participants were general nurses (n = 121, 60.5%) and females (n = 122, 60.7%). Thirty-seven (18.4%) of the participants met the criteria for PTSD. Exposure to violence in the past 12 months (AOR = 3.26; 95% CI: 1.49-7.16) and high neuroticism score (AOR = 2.72; 95% CI: 1.19-6.24) were significantly associated with the diagnosis of PTSD among the participants.

CONCLUSION

Post-traumatic stress disorder could result from stressful events encountered in the course of managing patients in mental health institutes and departments. Pre-placement personality evaluation of health workers to be assigned to work in psychiatric units and post-incident trauma counselling of those exposed to violence may be beneficial in reducing the occurrence of PTSD in mental hospital health care workers.

Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?

In the wake of the terrorist attacks at the World Trade Center, more than 9,000 counselors went to New York City to offer aid to rescue workers, families, and direct victims of the violence of September 11, 2001. These mental health professionals assumed that many New Yorkers were at high risk for developing posttraumatic stress disorder (PTSD), and they hoped that their interventions would mitigate psychological distress and prevent the emergence of this syndrome. Typically developing in response to horrific, life-threatening events, such as combat, rape, and earthquakes, PTSD is characterized by reexperiencing symptoms (e.g., intrusive recollections of the trauma, nightmares), emotional numbing and avoidance of reminders of the trauma, and hyperarousal (e.g., exaggerated startle, difficulty sleeping). People vary widely in their vulnerability for developing PTSD in the wake of trauma. For example, higher cognitive ability and strong social support buffer people against PTSD, whereas a family or personal history of emotional disorder heightens risk, as does negative appraisal of one's stress reactions (e.g., as a sign of personal weakness) and dissociation during the trauma (e.g., feeling unreal or experiencing time slowing down). However, the vast majority of trauma survivors recover from initial posttrauma reactions without professional help. Accordingly, the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery. The need for controlled evaluations of early interventions has only recently been widely acknowledged.

Psychological debriefing—the most widely used method—has undergone increasing empirical scrutiny, and the results have been disappointing. Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma.

Recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. Providing information about the trauma and its consequences is also important. However, research evaluating the efficacy of such “psychological first aid” is needed.

Some researchers have developed early interventions to treat individuals who are already showing marked stress symptoms, and have tested methods of identifying those at risk for chronic PTSD. The single most important indicator of subsequent risk for chronic PTSD appears to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (provided that the event is over and that there is no ongoing threat).

Cognitive-behavioral treatments differ from crisis intervention (e.g., debriefing) in that they are delivered weeks or months after the trauma, and therefore constitute a form of psychotherapy, not immediate emotional first aid. Several controlled trials suggest that certain cognitive-behavioral therapy methods may reduce the incidence of PTSD among people exposed to traumatic events. These methods are more effective than either supportive counseling or no intervention.

In this monograph, we review risk factors for PTSD, research on psychological debriefing, recent recommendations for crisis intervention and the identification of individuals at risk of chronic PTSD, and research on early interventions based on cognitive-behavioral therapy. We close by placing the controversy regarding early aid for trauma survivors in its social, political, and economic context.

Psychological Trauma in the Workplace: Variation of Incident Severity among Industry Settings and between Recurring vs Isolated Incidents

BACKGROUND

Psychologically traumatic workplace events (known as critical incidents) occur within various work environments, with workgroups in certain industries vulnerable to multiple incidents. With the increasing prevalence of incidents in the USA, incident response is a growing practice area within occupational medicine, industrial psychology, occupational social work and other occupational health professions.

OBJECTIVE

To analyze a measure of incident severity based on level of disruption to the workplace and explore whether incident severity varied among different industry settings or between workgroups experiencing multiple vs single traumatic incidents.

METHODS

Administrative data mining was employed to examine practice data from a workplace trauma response unit in the USA. Bivariate analyses were conducted to test whether scores from an instrument measuring incident severity level varied among industry settings or between workgroups impacted by multiple vs isolated events.

RESULTS

Incident severity level differed among various industry settings. Banks, retail stores and fast food restaurants accounted for the most severe incidents, while industrial and manufacturing sites reported less severe incidents. Workgroups experiencing multiple incidents reported more severe incidents than workgroups experiencing a single incident.

CONCLUSION

Occupational health practitioners should be alert to industry differences in several areas: pre-incident resiliency training, the content of business recovery plans, assessing worker characteristics, strategies to assist continuous operations and assisting workgroups impacted by multiple or severe incidents.

Subjective appraisal of threat (criterion A2) as a predictor of distress in childbearing women

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, has removed criterion A2 from the diagnosis of posttraumatic stress disorder. The current study aimed to assess the claim that criterion A2 has low use in predicting distress, while addressing the shortcomings of previous research looking at criteria A1 and A2. Data from a longitudinal, prospective study was used, with 933 women having been assessed at four time points both prebirth and postbirth. In our sample of women, model comparisons suggest that criterion A2 should be reintroduced into the diagnostic criteria as it provides a better indicator of who goes on to have problems after giving birth than criterion A1 on its own. There is also evidence that this subjective reaction to event confrontation (A2) should include anger, shame, and guilt.

Interventions to prevent post-traumatic stress disorder: a systematic review

CONTEXT

Traumatic events are prevalent worldwide; trauma victims seek help in numerous clinical and emergency settings. Using effective interventions to prevent post-traumatic stress disorder (PTSD) is increasingly important. This review assessed the efficacy, comparative effectiveness, and harms of psychological, pharmacologic, and emerging interventions to prevent PTSD.

EVIDENCE ACQUISITION

The following sources were searched for research on interventions to be included in the review: MEDLINE; Cochrane Library; CINAHL; EMBASE; PILOTS (Published International Literature on Traumatic Stress); International Pharmaceutical Abstracts; PsycINFO; Web of Science; reference lists of published literature; and unpublished literature (January 1, 1980 to July 30, 2012). Two reviewers independently selected studies, extracted data or checked accuracy, assessed study risk of bias, and graded strength of evidence. All data synthesis occurred between January and September 2012.

EVIDENCE SYNTHESIS

Nineteen studies covered various populations, traumas, and interventions. In meta-analyses of three trials (from the same team) for people with acute stress disorder, brief trauma-focused cognitive behavioral therapy was more effective than supportive counseling in reducing the severity of PTSD symptoms (moderate-strength); these two interventions had similar results for incidence of PTSD (low-strength); depression severity (low-strength); and anxiety severity (moderate-strength). PTSD symptom severity after injury decreased more with collaborative care than usual care (single study; low-strength). Debriefing did not reduce incidence or severity of PTSD or psychological symptoms in civilian traumas (low-strength). Evidence about relevant outcomes was unavailable for many interventions or was insufficient owing to methodologic shortcomings.

CONCLUSIONS

Evidence is very limited regarding best practices to treat trauma-exposed individuals. Brief cognitive behavioral therapy may reduce PTSD symptom severity in people with acute stress disorder; collaborative care may help decrease symptom severity post-injury.

Vulnerability and Resilience in a Group Intervention with Hospital Personnel during Exposure to Extreme and Prolonged War Stress

The current study presents a pilot demonstration of a new therapeutic procedure to mitigate symptoms of post-traumatic stress disorder (PTSD). The pilot took place during the Second Lebanon War. Vulnerability and resilience statements, as well as post-traumatic symptoms, were measured among special army administrative staff (SAAS) who worked in a hospital setting during extreme and prolonged war stress. All 13 soldiers in the unit studied participated in seven group therapy intervention sessions. It was hypothesized that shifting the focus of therapeutic intervention from the scenes of the events to the personal and professional narratives of preparing for the event would change the content of the soldiers’ narratives. It was believed that subtracting the number of positive statements from the number of negative statements would yield increasingly higher “resilience scores” during and after the war. It also was believed that such a change would be reflected in reduction of post-traumatic symptoms. As expected, the participants showed a decrease in vulnerability and an increase in resilience contents, as well as a decrease in traumatic symptoms during and after the war. These findings may reflect the effects of the ceasefire, the mutually supportive attitude of the participants, and the therapeutic interventions.

Interventions following a critical incident: developing a critical incident stress management team

This article describes the development and implementation of a stress management model for assisting hospital staff after critical incidents using an adaptation of Mitchell's model (J. Mitchell, 1983). A survey was conducted following the first major incident using M. Horowitz, N. Wilner, and W. Alvarez's (1979) Impact of Event Scale 10 days after and again 6 weeks following the incident to measure its emotional impact on staff. Outcomes included being symptom-free of critical incident stress after a 3-month period. The interventions were intended to help staff at a large metropolitan multispecialty hospital in Queensland in the immediate period following critical incidents. The implications of this program indicated the importance of emotional support at critical times for health professionals.

Medial prefrontal cortex activation facilitates re-extinction of fear in rats

It has been suggested that reduced infralimbic (IL) cortical activity contributes to impairments of fear extinction. We therefore explored whether pharmacological activation of the IL would facilitate extinction under conditions it normally fails (i.e., immediate extinction). Rats received auditory fear conditioning 1 h before extinction training. Immediately prior to extinction, rats received microinfusions into the IL of the GABA(A) receptor antagonist, picrotoxin, or the NMDA receptor partial agonist, D-cycloserine. Although neither drug facilitated extinction, they both facilitated the subsequent re-extinction of fear when animals were trained in a drug-free state, suggesting that activating the IL primes behavioral extinction.

Long-term maintenance of immediate or delayed extinction is determined by the extinction-test interval

Short acquisition-extinction intervals (immediate extinction) can lead to either more or less spontaneous recovery than long acquisition-extinction intervals (delayed extinction). Using rat subjects, we observed less spontaneous recovery following immediate than delayed extinction (Experiment 1). However, this was the case only if a relatively long extinction-test interval was used; a relatively short extinction-test interval yielded the opposite result (Experiment 2). Previous data appear consistent with this observation suggesting that, although delayed extinction appears more beneficial in the short term, immediate extinction may have more favorable long-term effects. These observations may have important implications for attenuation of relapse in clinical situations.

Single-unit activity in the medial prefrontal cortex during immediate and delayed extinction of fear in rats

Delivering extinction trials minutes after fear conditioning yields only a short-term fear suppression that fully recovers the following day. Because extinction has been reported to increase CS-evoked spike firing and spontaneous bursting in the infralimbic (IL) division of the medial prefrontal cortex (mPFC), we explored the possibility that this immediate extinction deficit is related to altered mPFC function. Single-units were simultaneously recorded in rats from neurons in IL and the prelimbic (PrL) division of the mPFC during an extinction session conducted 10 minutes (immediate) or 24 hours (delayed) after auditory fear conditioning. In contrast to previous reports, IL neurons exhibited CS-evoked responses early in extinction training in both immediate and delayed conditions and these responses decreased in magnitude over the course of extinction training. During the retention test, CS-evoked firing in IL was significantly greater in animals that failed to acquire extinction. Spontaneous bursting during the extinction and test sessions was also different in the immediate and delayed groups. There were no group differences in PrL activity during extinction or retention testing. Alterations in both spontaneous and CS-evoked neuronal activity in the IL may contribute to the immediate extinction deficit.

Lack of medial prefrontal cortex activation underlies the immediate extinction deficit

We conducted a series of experiments to investigate the neural basis of the immediate extinction deficit, the lack of extinction when the interval between fear memory acquisition and extinction is short. In experiment 1, rats were given extinction training composed of 15 conditioned stimuli (CSs) either 15 min (immediate extinction: I-EXT) or 24 h (delayed extinction: D-EXT) after five tone-shock pairings. In the retention test performed 48 h after conditioning, I-EXT group exhibited significantly higher freezing than D-EXT group. In experiment 2, functional activation in the medial prefrontal cortex (mPFC) was detected using c-fos immunoreactivity. The number of Fos-positive neurons in the mPFC was significantly lower in I-EXT group than in D-EXT group. In experiment 3, rats received immediate extinction with microstimulation of the infralimbic region (IL) of the mPFC, either contingently paired or unpaired with the CS. In a subsequent retention test, the paired stimulation group exhibited decreased freezing relative to the unpaired stimulation group. Together, our results suggest that the immediate extinction deficit may be linked to the lack of neuronal activity in the IL.

Delayed extinction attenuates conditioned fear renewal and spontaneous recovery in humans

This study investigated whether the retention interval after an aversive learning experience influences the return of fear after extinction training. After fear conditioning, participants underwent extinction training either 5 min or 1 day later and in either the same room (same context) or a different room (context shift). The next day, conditioned fear was tested in the original room. When extinction took place immediately, fear renewal was robust and prolonged for context-shift participants, and spontaneous recovery was observed in the same-context participants. Delayed extinction, by contrast, yielded a brief form of fear renewal that reextinguished within the testing session for context-shift participants, and there was no spontaneous recovery in the same-context participants. The authors conclude that the passage of time allows for memory consolidation processes to promote the formation of distinct yet flexible emotional memory traces that confer an ability to recall extinction, even in an alternate context, and minimize the return of fear. Furthermore, immediate extinction can yield spontaneous recovery and prolong fear renewal. These findings have potential implications for ameliorating fear relapse in anxiety disorders.

Debriefing to help perinatal nurses cope with a maternal loss

The death of a mother in a perinatal unit is a devastating event for the family and for the perinatal staff. An unexpected maternal death may be considered a critical incident, requiring leadership to reflect on the emotional well-being of all the staff who were involved in the patient's care. In order to assist staff in coping with the impact of a maternal loss, the organization and leadership team can apply the principles of debriefing, during which an expert in crisis intervention works to help the group recognize both healthy and unhealthy coping skills, and follows up with affected individuals who require ongoing help. This article presents a review of different techniques of debriefing, applies debriefing to maternal loss, and provides a review of coping skills for nurses. The leadership team's support is essential to promoting healthy coping and emotional healing when a tragedy occurs on the perinatal unit.

Preclinical assessment for selectively disrupting a traumatic memory via postretrieval inhibition of glucocorticoid receptors

BACKGROUND

Traumatic experiences may lead to debilitating psychiatric disorders including acute stress disorder and posttraumatic stress disorder. Current treatments for these conditions are largely ineffective, and novel therapies are needed. A cardinal symptom of these pathologies is the reexperiencing of the trauma through intrusive memories and nightmares. Studies in animal models indicate that memories can be weakened by interfering with the postretrieval restabilization process known as memory reconsolidation. We previously reported that, in rats, intraamygdala injection of the glucocorticoid receptor antagonist RU38486 disrupts the reconsolidation of a traumatic memory. Here we tested parameters important for designing novel clinical protocols targeting the reconsolidation of a traumatic memory with RU38486.

METHODS

Using rat inhibitory avoidance, we tested the efficacy of postretrieval systemic administration of RU38486 on subsequent memory retention and evaluated several key preclinical parameters.

RESULTS

Systemic administration of RU38486 before or after retrieval persistently weakens inhibitory avoidance memory retention in a dose-dependent manner, and memory does not reemerge following a footshock reminder. The efficacy of treatment is a function of the intensity of the initial trauma, and intense traumatic memories can be disrupted by changing the time and number of interventions. Furthermore, one or two treatments are sufficient to disrupt the memory maximally. The treatment selectively targets the reactivated memory without interfering with the retention of another nonreactivated memory.

CONCLUSIONS

RU38486 is a potential novel treatment for psychiatric disorders linked to traumatic memories. Our data provide the parameters for designing promising clinical trials for the treatment of flashback-type symptoms of PTSD.

Building resistance, resilience, and recovery in the wake of school and workplace violence

Incidents of school and workplace violence are rare but devastating events that can result in significant psychological consequences in communities. The majority of people in the United States will experience some type of traumatic event in their lifetime, but most of them will have no disruption or only transient disruption in functioning. They are either resistant to the development of symptoms or resilient, able to bounce back quickly. By enhancing resistance and promoting resilience, even fewer individuals may develop mental disorders. This article takes a closer look at the concepts of resistance, resilience, and recovery and the need for research on interventions that promote them, in the hope of applying the concepts and interventions to schools and the workplace.

Evidence for recovery of fear following immediate extinction in rats and humans

Fear responses can be eliminated through extinction, a procedure involving the presentation of fear-eliciting stimuli without aversive outcomes. Extinction is believed to be mediated by new inhibitory learning that acts to suppress fear expression without erasing the original memory trace. This hypothesis is supported mainly by behavioral data demonstrating that fear can recover following extinction. However, a recent report by Myers and coworkers suggests that extinction conducted immediately after fear learning may erase or prevent the consolidation of the fear memory trace. Since extinction is a major component of nearly all behavioral therapies for human fear disorders, this finding supports the notion that therapeutic intervention beginning very soon after a traumatic event will be more efficacious. Given the importance of this issue, and the controversy regarding immediate versus delayed therapeutic interventions, we examined two fear recovery phenomena in both rats and humans: spontaneous recovery (SR) and reinstatement. We found evidence for SR and reinstatement in both rats and humans even when extinction was conducted immediately after fear learning. Thus, our data do not support the hypothesis that immediate extinction erases the original memory trace, nor do they suggest that a close temporal proximity of therapeutic intervention to the traumatic event might be advantageous.

A randomised controlled trial of group debriefing

There has never been published a randomised controlled trial of group debriefing. In this study we employed an analogue study with students to conduct the first such trial. Sixty-four participants were shown a stressful video of paramedics attending to injured and dead victims of a road traffic accident. Half the participants were subsequently debriefed and half were provided with tea and biscuits and allowed to talk amongst themselves. A 1 month follow-up was administered. It was found that, while the video was rated as distressing, there were no significant differences between the debriefed and non-debriefed groups on measures of affective distress and trauma symptoms. Those who were debriefed later recalled having wanted to talk more to someone about the video than those who were not debriefed. It is suggested that cognitive dissonance may explain this result.

Recent fear is resistant to extinction

In some individuals, fearful experiences (e.g., combat) yield persistent and debilitating psychological disturbances, including posttraumatic stress disorder (PTSD). Early intervention (e.g., debriefing) after psychological trauma is widely practiced and argued to be an effective strategy for limiting subsequent psychopathology, although there has been considerable debate on this point. Here we show in an animal model of traumatic fear that early intervention shortly after an aversive experience yields poor long-term fear reduction. Extinction trials administered minutes after aversive fear conditioning in rats suppressed fear acutely, but fear suppression was not maintained the next day. In contrast, delivering extinction trials 1 day after fear conditioning produced an enduring suppression of fear memory. We further show that the recent experience of an aversive event, not the timing of the extinction intervention per se, inhibits the development of long-term fear extinction. These results reveal that the level of fear present at the time of intervention is a critical factor in the efficacy of extinction. Importantly, our work suggests that early intervention may not yield optimal outcomes in reducing posttraumatic stress, particularly after severe trauma.

Group crisis intervention for children during ongoing war conflict

The aim of this study was to evaluate the short-term impact of a group crisis intervention for children aged 9-15 years from five refugee camps in the Gaza Strip during ongoing war conflict. Children were selected if they reported moderate to severe posttraumatic stress reactions, and were allocated to group intervention (N=47) encouraging expression of experiences and emotions through storytelling, drawing, free play and role-play; education about symptoms (N=22); or no intervention (N=42). Children completed the CPTSD-RI and the CDI pre- and post-intervention. No significant impact of the group intervention was established on children's posttraumatic or depressive symptoms. Possible explanations of the findings are discussed, including the continuing exposure to trauma and the non-active nature of the intervention.

Debriefing: its evolution and current status

Debriefing, like trauma counseling, and even grief counseling, has been taken up as an instant solution. Some suggest it is a part of the trauma industry. It may be seen as something to hold onto in the face of disaster or other chaos, because it offers the security of a structure, some sense of control over what to do to help when one wishes to undo what has happened, help others and the self, to make meaning of a horrific or shocking experience. The need to pursue a way of responding suggests that those who would offer help fear being overwhelmed, or do not trust their normal compassionate, protecting, and comforting responses. It would be sad if these spontaneous, caring, and altruistic reactions that so bind human society in times of tragedy were devalued or put aside, for they, ultimately are the beginning of the healing process.

[Efficiency of psychological debriefing in preventing post-traumatic stress disorders]

BACKGROUND

Traumatic events are frequently followed by an acute stress reaction that may develop into a post-traumatic stress disorder. An intervention called psychological debriefing has been proposed to prevent these disorders. Although this method is widely used at present, its preventive effect is controversial. This article consist in a review of the studies which evaluated psychological debriefing efficiency in the prevention of post-traumatic stress disorder and associated disorders in adults.

METHOD

We carried out a bibliographical search on MEDLINE (1966-2001), PASCAL (1987-2001), EMBASE (1988-2001), FRANCIS (1984-2001) and SCIENCEDIRECT (1967-2001). The key words were posttraumatic stress disorder, debriefing, treatment, psychological follow up, and prevention. We selected the studies with the following criteria: adults, one psychological debriefing session in the Month following the event, inclusion of a control group, more than 20 persons per group and evaluation of psychological disorders with standardized instruments more than one Month after the trauma.

RESULTS

Twenty nine studies were identified and 8 selected. Four studies did not show any intervention effect, 3 suggested a negative intervention effect, and 1 suggested a positive effect on anxiety, depressive symptoms and alcohol dependence.

CONCLUSION

Psychological debriefing implies re-exposure through memory processes to the trauma, which can interfere with the natural course of adjustment and recovery. Several Authors have suggested that psychological debriefing may delay the diagnosis and thus the early treatment of post-traumatic stress disorder. Psychological debriefing may not be appropriate to all victims of every type of incident or trauma. We discuss the intervention and its design. This review did not show evidence for psychological debriefing efficiency, as a unique session, in the prevention of posttraumatic reactions. The design and the objectives may be re-examined. Further evaluations following rigorous methods are warranted.

Applying learning principles to the treatment of post-trauma reactions

Posttraumatic stress disorder (PTSD) can be characterized as a failure of recovery caused, in part, by a failure of fear extinction after trauma. By studying the process of extinction, we can be informed regarding the etiology and maintenance of PTSD. The normal response to trauma in humans includes a set of predictable reactions including reexperiencing, avoidance, and hyperarousal that typically extinguish in the days and weeks after the trauma. In the majority of people exposed to trauma, these responses extinguish over time. However, in a substantial minority, extinction fails and these persisting responses become the symptoms of PTSD. Therefore, one of our fundamental hypotheses is that PTSD is a disorder caused in part by the failure of extinction of predictable posttraumatic physiological and psychological reactions. The most empirically validated treatments for PTSD involve exposure of the patient to trauma-related cues in the absence of danger that then lead to the extinction of these reexperiencing, avoidance, and arousal symptoms. There is also mounting evidence that individuals with PTSD are more resistant to extinction. Regarding early interventions with traumatized individuals, there is mounting evidence that some early one-time interventions actually may impede extinction, whereas interventions delivered in more than one session, at least several weeks after the trauma, to individuals continuing to experience above average reactions, generally are effective in preventing the development of PTSD. Thus, there appears to be an interaction between timing of the intervention, number of intervention sessions, and either arousal level and/or risk status in determining whether the intervention will be helpful, harmful, or neutral.

Early Psychosocial and Pharmacological Interventions After Traumatic Events

1. There is no evidence to suggest that routine provision of single-session psychological interventions after traumatic events prevents the development of psychological sequelae. Some such evidence exists regarding multiple-session, cognitive-behavioral interventions. 2. There is no evidence to suggest that routine use of pharmacological agents prevents development of psychological sequelae in traumatized individuals. 3. Given the current evidence base, development of stepped-care programs focusing on education, screening, and treatment is warranted. 4. Currently, the main role of mental health professionals early on is to ensure emotionally supportive systems of care are in place, which will help identify individuals who appear most distressed so evidence-based interventions can be offered.

Single-session early psychological interventions following traumatic events

Single-session early psychological interventions became widely advocated during the 1980s and 1990s as a way to prevent the development of psychological sequalae following traumatic events. There have now been 13 randomised controlled trials of single-session interventions within 1 month of a traumatic event. Notwithstanding their methodological shortcomings and clinical heterogeneity, the results are neutral overall in terms of clinical effectiveness. Possible explanations include a failure to encourage individuals' personal coping mechanisms and defence mechanisms and that insufficient time was allowed for habituation to intense exposure to occur. With the present evidence, the routine use of single-session interventions following traumatic events cannot be justified. This does not mean that there should be nothing offered, as many individuals involved in traumatic events clearly have emotional needs. Hopefully, future research will identify alternative forms of early intervention that prove useful to those individuals who would otherwise develop more significant psychological difficulties.

Single session debriefing after psychological trauma: a meta-analysis

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.

Managing acute stress response to major trauma

In this article, the authors review the current empiric literature on early interventions. Findings on the effects, course, help-seeking, and recovery from disasters are first reviewed, with recommendations given that are pertinent to intervention following mass casualties. In reviewing the most commonly used interventions, it is clear that evidence from well-controlled studies showing that early intervention can help prevent longer-term problems is limited. The authors discuss the approaches that have received the most attention or empiric support as early interventions following trauma, which include psychologic debriefing, cognitive-behavioral interventions, eye movement desensitization and processing (EMDR) and other neoteric approaches, and psychopharmacology. At this time, the most promising results for prevention of psychopathology have been achieved with brief four- or five-session cognitive-behavioral therapy. In contrast, randomized clinical trials on psychologic debriefing currently suggest that this approach is either ineffective at preventing psychopathology, or contributive to post-traumatic stress disorder symptoms. Research support is currently lacking for EMDR and pharmacotherapy as early interventions. A major challenge to the field is to integrate the practical experience and knowledge of professional responders with well-controlled, timely intervention research, and to effectively disseminate these findings to practitioners in the field.

Brief psychological interventions ("debriefing") for trauma-related symptoms and the prevention of post traumatic stress disorder

OBJECTIVES

To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder.

SEARCH STRATEGY

Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health, CDSR and the Trials Register of the Depression, Anxiety and Neurosis group. Hand search of Journal of Traumatic Stress. Contact with leading researchers.

SELECTION CRITERIA

The inclusion criteria for all randomized studies was that they should focus on persons recently (one month or less) exposed to a traumatic event, should consist of a single session only, and that the intervention involve some form of emotional processing/ventilation by encouraging recollection/reworking of the traumatic event accompanied by normalisation of emotional reaction to the event.

DATA COLLECTION AND ANALYSIS

8 trials fulfilled the inclusion criteria. Quality was generally poor. Data from two trials could not be synthesised.

MAIN RESULTS

Single session individual debriefing did not reduce psychological distress nor prevent the onset of post traumatic stress disorder (PTSD). Those who received the intervention showed no significant short term (3-5 months) in the risk of PTSD (pooled odds ratio 1.0, 95% ci 0.6-1.8). At one year one trial reported that there was a significantly increased risk of PTSD in those receiving debriefing (odds ratio 2.9, 95% ci 1.1-7.5). The pooled odds ratio for the two trials with follow ups just included unity (odds ratio 2.0, 95% ci 0.9-4.5). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety.

REVIEWER'S CONCLUSIONS

There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease.