Psychological treatments Debriefing

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Critical incident stress debriefing is a widely practised intervention that has the goal of promoting adaptation to traumatic events. Debriefing is generally conducted in a group within 24 to 72 h of the trauma. However, these parameters have been modified to permit more flexible interventions. Mitchell (43> proposes that debriefing comprises seven phases:

1. an initial outline of the purpose and benefits of debriefing;

2. the fact phase, in which participants relate what happened to them;

3. a thought phase, in which participants relate their initial thoughts after the critical incident;

4. a feeling phase, which requires participants to focus on the worst aspects of the incident and engage in their emotional reactions to the incident;

5. an assessment phase, in which participants are trained to note their physical, cognitive, emotional, and behavioural symptoms;

6. an education phase, which provides information about stress responses and ways to manage them;

7. the re-entry phase, in which the information given is summarized and referral information offered.

These phases may take 1 to 5 h, and are usually co-ordinated by a trained mental health professional.

Anecdotal evidence and clinical reports attest to the efficacy of debriefing. However, despite its widespread use, very few controlled trials have been conducted. A Cochrane review of randomized controlled studies of individual debriefing (44) found that although participants usually found the intervention useful, debriefing had no overall positive effect on psychological symptoms. Out of six studies included in the review, two actually found that the debriefing group had a worse outcome than the control group.(4 4 and 47) A recent randomized controlled study confirmed the conclusion that individual debriefing has no beneficial effect on post-trauma symptoms. (48)

In line with these results on individual debriefing, the first two non-randomized controlled studies of the efficacy of group debriefing found that the intervention had no beneficial effects on post-trauma symptoms.(4 5,0,) One of the studies found negative effects of the intervention after 18 months.(59

Cognitive-behaviour therapy

Cognitive-behavioural interventions are effective in treating PTSD (see ChapterÔÇ×4.6.2). The results of two randomized controlled studies of rape victims and road traffic accident survivors suggest that a brief four-session version of this treatment is effective in acute stress disorder and prevents the development of chronic post-trauma reactions.'5 52> Treatment involved the following:

1. education about trauma reactions;

2. progressive muscle relaxation;

3. prolonged exposure;

4. cognitive restructuring of fear-related beliefs;

5. graded in vivo exposure.

However, the results remain preliminary as other studies have shown a significant rate of spontaneous recovery within the first year after trauma. (3 49 Psychopharmacological treatment

Case studies report on the utility of tricyclic antidepressants, (53) benzodiazepine anxiolytics,(54) and benzodiazepine hypnotics(55) in acutely traumatized individuals. However, no randomized controlled trials have been completed. Research on PTSD suggests that selective serotonin-reuptake inhibitors are, to date, the best pharmacological treatment for persistent reactions to traumatic stress (see Chapter4.,6..2).

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