Monday, June 02, 2008

I Don't Need To Talk

Roy is the blogger who inspired me today. I recently posted about the use of medication to prevent depression, and Roy followed this up with a comment on our Podcast #46 post about willingness to talk and prevention of trauma-related psych problems. He referenced a University at Buffalo study of 3000 9/11 survivors who were asked to respond to an online survey immediately following the 9/11 attack. The survey asked questions about their willingness or need to talk about the event, and followed their adjustment for two years after the initial survey. The study found that those who were unwilling to talk about the event actually fared better over time than those who wanted to talk.

Now, there are a lot of obvious limitations here---and I don't have the actual published article to analyze the news releases' interpretation of the study---but those who responded to the study had not lost any loved ones or known anyone who died in the attack, and it doesn't say whether or not the respondents themselves had direct experience of the event. For all I know, they could have been people living on the other side of the country. Personally, I doubt that people who were really upset and had direct experience of the 9/11 attack would have much interest in responding to an online survey at the time. It also doesn't mention whether or not the people who wanted to talk about their feelings ever actually had the opportunity to do so or received therapy following the event. All of this would obviously make a difference on the outcome.

Nevertheless, I think it says something relevant about an area in which there is a significant body of published data, which is the issue of crisis debriefing counseling. Crisis debriefing is something that's being used for a lot yet it's controversial because its efficacy hasn't been proven and there are some studies suggesting it could harm people.

Critical incident stress debriefing (CISD) was developed with the idea that providing rapid intervention to people exposed to trauma would prevent the development of PTSD. It was used following events like hostage-takings, natural disasters, plane crashes or other mass casualty accidents. CISD uses peer facilitators and mental health professionals in a time-limited, single session group setting to provide peer support and to allow people to talk about their feelings about the event. They also talk about the impact of the event on their relationships or day-to-day functioning as well as coping techniques. In addition to providing an emotional outlet, CISD typically also involves education about stress-related symptoms and stress management.

A PubMed search of the term "crisis debriefing outcome" brings up 33 studies on the outcomes of crisis debriefing counseling. Once you eliminate the studies with no controls and no data, you find that CISD studies have been done on a huge mixed bag of subjects: children, crime victims, soldiers, anesthesia residents, post-partum inpatients, burn victims and emergency service workers. The good news is that the majority of the subjects got better over time, even if nothing was done. The interesting news is that participant satisfaction surveys showed that patients frequently reported satisfaction with CISD, found it helpful and would recommend it to others even though there was no measurable reduction in symptoms. In other words, they felt it was helpful even when there was no objective evidence it helped.

Out of all the studies that reported outcome data in a group-controlled fashion, three found CISD led to improved symptoms. Seven studies showed there was no significant difference between CISD and a control group---neither benefit nor harm. Three studies showed worsened symptoms following crisis debriefing. A couple review articles in the Pub Med search as well as one meta-analysis also showed mixed results, with most showing no clear benefit and a few documenting aggravation of symptoms.

In all, the main conclusion I could come up with from this is that CISD probably should not be mandatory for everyone following a trauma (eg. an employer probably shouldn't mandate that all employees must attend CISD following an episode of workplace violence). It might help some people, and will probably not harm the majority, but a few will be hurt by it. The trick is, you don't know in advance who will fall into which group.