The recent tragic bus accident in the New South Wales Hunter Valley has again raised the issue of how we address the potential psychological effects of traumatic events.
It is interesting we revisit the same debate after each disaster, and few lessons have apparently been learned after decades of research. After the Hunter Valley accident, immediate psychological counselling was offered to those affected.
While we can’t say what form of counselling was offered, the traditional approach is known as “psychological debriefing”. This typically involves counsellors providing trauma survivors with a single counselling intervention within days of the event.
Although the content of the intervention can vary, it usually involves education about stress reactions, encouragement to disclose their memories of the experience, some basic stress-coping strategies and possibly referral information.
But the evidence shows this approach, however well-meaning, may not help – or worse, do harm.
The belief that feelings must be shared
The encouragement of people to discuss their emotional reactions to a trauma is the result of a long-held notion in psychology (dating back to the classic writings of Sigmund Freud) that disclosure of one’s emotions is invariably beneficial for one’s mental health.
Emanating from this perspective, the impetus for psychological debriefing has traditionally been rooted in the notion trauma survivors are vulnerable to psychological disorders, such as post-traumatic stress disorder (PTSD), if they do not “talk through their trauma” by receiving this very early intervention.
The scenario of trauma counsellors appearing in the acute aftermath of traumatic events has been commonplace for decades in Australia and elsewhere.
Following the 9/11 terrorist attacks in New York City in 2001, up to 9,000 counsellors were mobilised and more than US$200 million was projected to meet a surge in mental health needs. But fewer people than expected sought help under this program and $90 million remained unspent.
What do we know about psychological reactions to disasters?
The overwhelming evidence indicates the majority of people will adapt to traumatic events without any psychological intervention.
Long-term studies indicate approximately 75% of trauma survivors will not experience any long-term distress. Others will experience short-term distress and subsequently adapt. A minority (usually about 10%) will experience chronic psychological problems.
This last group are the ones who require care and attention to reduce their mental health problems. Experts now agree other trauma survivors can rely on their own coping resources and social networks to adapt to their traumatic experience.
The finding across many studies that most people adapt to traumatic experiences without formal mental health interventions has been a major impetus for questioning the value of psychological debriefing in the immediate aftermath of disasters.
In short, the evidence tells us universal interventions – such as psychological debriefing for everyone involved in a disaster – that attempt to prevent PTSD and other psychological disorders in trauma survivors are not indicated. These attempts do not prevent the disorder they are targeting.
Not a new conclusion
In the aftermath of the 2004 Indian Ocean earthquake and tsunami, the World Health Organization listed a warning (which still stands) that people should not be given single-session psychological debriefing because it is not supported by evidence.
Worse than merely being ineffective, debriefing can be harmful for some people and may increase the risk of PTSD.
The group of trauma survivors that are most vulnerable to the toxic effects of debriefing are those who are more distressed in the acute phase right after the trauma. This group of people have worse mental health outcomes if they are provided with early debriefing.
This may be because their trauma memories are over-consolidated as a result of the emotional disclosure so shortly after the event, when stress hormones are still highly active.
In normal clinical practice a person would be assessed in terms of their suitability for any psychological intervention. But in the case of universal psychological debriefing there is no prior assessment. Therefore, there’s no assessment of the risks the intervention may pose for the person.
Most international bodies have shifted away from psychological debriefing. Early intervention might now be offered as “psychological first aid”.
This newer approach is meant to provide fundamental support and coping strategies to help the person manage the immediate aftermath of adversity. One of the most important differences between psychological first aid and psychological debriefing is that it does not encourage people to disclose their emotional responses to the trauma.
But despite the increasing popularity of psychological first aid, it is difficult to assess its effectiveness as it does not explicitly aim to prevent a disorder, such as PTSD.
Wanting to help
So if there is so much evidence, why do we keep having this debate about the optimal way to assist psychological adaptation after disasters? Perhaps it’s because it’s human nature to want to help.
The evidence suggests we should monitor the most vulnerable people and target resources towards them when they need it – usually some weeks or months later when the dust of the trauma has settled. Counsellors might want to promote their activities in the acute phase after disasters, but it may not be in the best interest of the trauma survivors.
In short, we need to develop better strategies to ensure we are meeting the needs of the survivors, rather than the counsellors.
If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.