Research Proposal on "Treatment Modalities for Post-Traumatic Stress Disorder"

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II: Literature Review

There is a range of literature on debriefing models that have arisen, generally from the military psychiatry approach to deal with combat stress reactions, one pattern of acute post trauma reaction. While Degeneffe, C.E. (2001) has critically reviewed models and placed these in educational and psycho educational contexts, the popularity of the ?Mitchell model? (Craine, 2008) means that this is usually equated to debriefing. This model has been widely used across the world, and extensive presentation and training concerning its use has occurred. Debriefing was originally suggested as an intervention for emergency service workers such as police, rescue, fire services, and other emergency personnel. It was situated in an occupational health context with aims of diminishing adverse consequences of critical incidents experienced in the course of work, such as job turnover, stress, and sick leave. As the model evolved it became situated in a critical incident stress management (CISM) framework and became known as CISD (critical incident stress debriefing). It was seen as on a continuum with other acute interventions, including defusing, peer support, crisis intervention and possibly counseling (Army News Service, 2007; CBS News, 2007).

This debriefing model has a number of stages and is intended to be carried out in the earliest days posttraumatization. It provides a structured group process in which the incident is reviewed, knowledge shared, feelings expressed, and education provided about symptoms that may occur. While it is frequently perceived as helpful by those who receive it, this helpfulness does not appear to correlate with improved outcomes. Nevertheless, DePalma, et al. (2005), following a range of reviews of their own and others work, conclude there is ample evidence of its effectiveness in reducing symptoms of stress in the posttraumatic period, of increasing workers' capacity to function, and of lessening levels of sick leave and job turnover in the emergency professions. Thus it can be seen, if this proves to be the case, as a form of stress management relevant to 'critical incident stress' (Army News Service, 2007).

The authors carefully delineate this from traumatic stress and do not claim that it lessens risk for or levels of PTSD, although this possibility is frequently inferred by those who use this debriefing model. Furthermore, the extensive spread of CISD and the social demand generated have occurred alongside a reluctance to evaluate it, and to systematically examine any negative effects, while claiming its undoubted benefit. Recent studies such as those of Sontag & Alvarez, (2008) and Kennedy et al. (2007) contest the benefits of debriefing. They have not found it to be beneficial in their studies of disaster-affected populations or, for those workers using a CISD model for support. This leads to considerable debate between those supportive of the Mitchell model specifically or debriefing generally, on one side, and those who do not find benefit and even suggest that there is the potential for those provided with this type of acute intervention to fare worse, on the other.

Furthermore, studies using the model as an acute one-off intervention in other settings such as acute intervention for psychological traumatization following serious burn injuries (Martenyi, 2005) and following the trauma of motor vehicle accidents (Sontag & Alvarez, 2008) have found it to be of no benefit in reported trials. A recent Cochrane review came to the same conclusion (Caplan, 1964). Thus there must be a call for caution in the broad use of the model, concern about the potential to ?make worse,' perhaps through mechanisms suggested by Degeneffe, (2001). Moreover, some of these studies have suggested that those who have had several debriefings were worse. Many research criticisms can be placed on the findings of both groups of protagonists, but there is certainly a growing body of negative findings which must challenge any universal application of de- briefing as an acute posttraumatic intervention (Schubert & Lee, 2009).

Military Interventions

These interventions evolved with the recognition of combat stress and its detrimental effects on soldiers, in the immediate period of the battle, when their ability to continue fighting was critical to the achievement of military goals, and subsequently when long-term disability brought a burden of personal damage and social cost. Two types of intervention which have been utilized in this setting sit in the acute posttraumatic framework.

These are forward ppehiatg based on the principles of proximity, immediacy, and expectancy (PIE), and debriefing. The former intervention is a specific treatment format for soldiers who develop combat stress reactions and are unable to continue to fight effectively. They are taken from their unit but kept close to the front (proximity), treated immediately with supportive measures including rest and possibly medication (immediacy), and with an orientation to return them rapidly to their unit where they will continue to function as soldiers (expectancy). This treatment modality has been studied and validated (Defense Link, 2008; Degeneffe, 2001). It has been found to be very effective in achieving its goals, with the soldier usually reengaging with his unit and returning to combat (Martenyi, 2005).

Thus it is effective in diminishing symptoms and supporting function. Whether or not it can prevent PTSD has not been established, however. Solomon and associates' work and longer-term follow-up of these men in the Israeli army and subsequently have shown that those with repeated combat stress reaction, even though continuing to function as soldiers at the time, were in many instances later more vulnerable to developing chronic and disabling PTSD (Army News Service, 2007).

Whether keeping people functional but in so doing keeping them in a situation where they may be traumatized again (and again) is ultimately helpful to outcomes is a critical question for future research. Here as elsewhere findings need to be extended to better encompass the role of pre-trauma factors such as the following: previous experience and mastery or vulnerability; vulnerable personal styles such as those of obsessive rumination; resilience characteristics such as those of hardiness and personal hopefulness; and background preparation and training. Post trauma interventions cannot be really evaluated without taking these things into account.

Debriefing in military contexts has evolved somewhat differently Atwater, (2009), a U.S. military historian, undertook to interview soldiers in groups to get a full and clear picture of what had happened in combat in particular battles.

All were treated as equal, every soldier's story was encouraged, and no interpretations were made. These narratives appeared to help the soldiers (as well as the interviewer) to gain a coherent or "whole" picture of what had gone on and appeared to be helpful to them psychologically, although no specific research was done to formally establish this. While debriefing has been widely used in the military since that time, it has, with the recent uptake of interest in debriefing models, usually been in the CISD format. More recent concerns about debriefing have called this into question, and this review suggests that it may be more appropriate to return to the use of the earlier type of model. Degeneffe, (2001) describes the effectiveness of this ?historical group debriefing in decreasing arousal in soldiers and suggests that, as this is a crucial pathway to PTSD, this intervention may help to prevent it.

DePalma, et al. (2005), again talking of the military context, suggests that debriefing is of most use when it is for those who have been briefed for an incident and that the leaders of groups of soldiers or emergency workers, for instance, should be trained and supported to provide this type of debriefing as part of their leadership roles. DePalma, et al.… READ MORE