Psychological Debriefing: Current Status, Future Directions

       
                    Presenter:     Julian D. Ford, Ph.D.
                                        National Center for PTSD
                                        Dartmouth Medical School
        

Psychological debriefing has become  widely-used generic term
describing secondary nd tertiary prevention interventions following crises and
major societal and community upheavals.  In the emergency medical and rescue
services venue, Mitchell's (1983) critical incident stress debriefing (CISD)
model has developed and disseminated a structured phase-model for debriefing. 
Although, designed initially f or rapid (i.e., 24-72 hour) small to
medium-sized group single meetings co-led by a CISD-trained mental health
professional and a peer (e.g., EMS, law enforcement, fire fighter), subsequent
elaboration of the model by Mitchell (1986; Critical Incident Stess Management;
CISM) and by other groups (e.g., Armstrong et al., 1995; Dyregrov, 1997) have
addressed the additional complexities of large scale civilian and military 
traumas and disasters by  incorporating multiple interventions in a continuum
of care over time.   There has been some cross-fertilization between the EMS,
disaster, and military sectors in developing debriefing procedures that
incorporate acute post-scenario risk factor assessment and group process,
cognitive-behavioral, and family systems intervention.  Randomized trials of
brief variants of these heterogeneous "psychological debriefing" approaches
with accident (Hobbs et al., 1996), burn (Bisson et al., 1997), and miscarriage
(Lee et al., 1996) survivors have produced mixed and generally  negative
outcomes, although two early randomized studies with accident survivors (Bordow
& Porritt, 1979) and family members of emergency room admissions (Bunn &
Clarke, 1979) reported favorable outcomes .  Recent nonrandom control  group
design studies and single group pre-post studies of psychological debriefing
protocols are reviewed and critiqued.  Findings are mixed for debriefing
following disaster (e.g., Kennardy et al., 1996) or military (e.g., Perconte et
al., 1993; Solomon et al., 1992) operations, tending to be more positive with
conceptually-grounded (e.g., continuum of care, narrative reconstruction)
multicomponent (versus single session) interventions implemented in close
proximity to events but not in the immediate impact phase (e.g., Chemtob et
al., 1997; Ford, Greaves et al., 1997).  Findings are more negative for
single-impact accident survivors, calling into question the appropriateness of
single brief one-to-one "debriefings" in the immediate impact phase off
accidents in the absence of more individually-targeted psychological screening
and intervention.  Recent studies on the longitudinal course of trumatic stress
following adult (e.g., Shalev et al., 1997) and pediatric (e.g., Ford, Daviss
et al., 1997) accidents are consistent with a view that preventive and
ameliorative psychological intervention must be staged and titrated
appropriately to the survivors' and family's phase of adaptation and level of
clinical symptomatology.  Recommendations for the practical utilization of
psychological debriefing  with disaster survivors and workers, and for further
scientific and programatic evaluation are discussed.

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