Counseling sessions frequently given to survivors immediately after disasters, such as the debriefings given to people traumatized by the Sept. 11 attacks, do nothing to prevent psychiatric disorders and may even be harmful, according to two comprehensive analyses released yesterday.
Though debriefing has been embraced by officials and a range of practitioners, there is little evidence that recipients' long-term mental health is better than people who get no counseling, or those who just talk to friends and family, according to a Dutch study of debriefing in multiple situations. Debriefing "may even put some survivors at heightened risk for later developing mental health problems," said experts at the National Institute of Mental Health who independently evaluated the technique after Sept 11.
"If this was a drug, we would take it off the market," said Richard Gist, a psychologist at the University of Missouri in Kansas City. Referring to the widespread popularity of debriefing, he added, "What we have here is something between a social movement, a pyramid scheme and a cult."
The controversy over debriefing has grown as tens of thousands of people have received sessions after the Sept. 11 attacks, the Oklahoma City bombing and the Columbine school shootings. Researchers struggling to figure out how and whether to help bystanders and witnesses after national catastrophes have been left dumbfounded as a host of practitioners -- often armed with what Gist called "proprietary workshops, trade magazines and paperback books" -- have raced far ahead of the science.
No firm number on the extent of debriefing after Sept. 11 is available. But Gist, who wrote an editorial in The Lancet medical journal accompanying the Dutch study, said that "more than 9,000 purveyors of debriefing" and similar interventions raced to New York, "advocating intervention for any person even remotely connected to the tragedy."
The debriefers were well-intentioned, but NIMH experts said the blanket intervention was inappropriate because most people who received counseling would have recovered on their own. Shock and grief were widespread after Sept 11, but those were considered normal reactions to tragedy and the experts said the "sensible" policy was "to expect normal recovery."
Debriefing consists of individual or group sessions lasting one to three hours where survivors describe what they have been through and talk about their feelings. Offered within hours or days of a tragedy, the technique seems superficially similar to established therapies that encourage people to relive traumatic memories and thereby gradually grow less sensitive to them. But debriefing usually offers no follow-ups and may simply cause people to become more distressed, researchers said.
The Dutch study analyzed seven studies that examined the effectiveness of debriefing among victims of burns, car accidents, miscarriage, violent crime and combat. The U.S. report is the result of a workshop that brought together senior experts from many of the top branches of the federal government, including the National Institute of Mental Health and the Department of Defense. Those experts analyzed studies measuring the effectiveness of debriefing and examined the range of efforts provided after Sept 11. Many experts at the workshop treated survivors or offered guidance about debriefing and other interventions to relief officials in New York and Washington.
Farris Tuma, chief of the NIMH's traumatic stress research program, said the experts concluded "it's probably inappropriate to recommend blanket or universal emotional recall of events because of the likelihood of creating additional distress among people who may be coping just fine."
A much better approach, Tuma and others said, would be to wait a few weeks to separate the majority of resilient people who are recovering on their own from those who are not getting better. Special attention could be paid to survivors, families of victims and first responders such as firefighters, who are at higher risk for long-term problems. At that point, administering intensive treatments such as cognitive behavioral therapy to specific individuals has a much better chance of reducing the risk of long-term trauma, the researchers said.
No one knows how long clinicians should wait after a traumatic event to evaluate individuals to see whether they are getting better on their own. One school of thought is to keep help available whenever people seek it. The bottom line, the experts agreed, is to avoid one-size-fits-all interventions and to encourage individuals to talk only when they are ready to do so. Talking to friends and family, and regular exercise can also help hasten recovery.
"What we need to do is a good assessment rather than rushing in and offering therapy," said Lt. Col. Elspeth Cameron Ritchie, a psychiatrist and director of mental health policy at the Defense Department. "There has been a tendency to be Superman with your cape offering counseling, and we don't know whether it's helpful or harmful."
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