Beyond the debriefing debate: Providing appropriate care after chaos
CrossCurrents
Andrea Zoe Aster
Originally from northern Sri Lanka, he's now living in Toronto -- he lost 40 relatives to the tsunami, including his mother
and sister. "This man was desperate, but there was no point going back to Sri Lanka -- there was nothing left," says Dr. Joseph
Chandrakanthan, president of Vasantham, a Tamil outreach centre in Toronto. Since the tsunami hit, Chandrakanthan has offered
grief counselling services in homes and through churches within the stricken Tamil community.
With 160,000 members, Toronto harbours the largest Tamil diaspora in the world. As the shock of the tsunami's impossible devastation
seeps in, those who may require trauma counselling include local Tamils who have lost relatives, new immigrants from afflicted
zones and crisis volunteers from the Tamil community returning to Canada.
Yet with so many well-meaning volunteers rallying to support the afflicted, a long-standing debate is again rekindled: Does
trauma counselling really help?
Trauma experts are keen to stress that certain types of trauma response -- specifically so-called "psychological debriefing"
-- may be, at best, useless, and may actually cause more damage than good. Such one-off single sessions, generally organized
through international and local organizations, typically work on the premise that coaxing people to talk themselves through
and relive the trauma is therapeutic.
Experts temper their caution by conceding that certain types of trauma counselling may be effective, but only for the relatively
small numbers of trauma survivors who truly appear to be at risk for post-traumatic stress disorder (PTSD). It is impossible
to screen for risk, many agree, in the first month following disasters such as the recent tsunami -- naturally, everyone is
anxious and nightmares are common.
"The biggest mistake in catastrophic situations is to offer prescriptive one-off counselling without follow-up," says Dr.
Suzanna Rose, a clinical nurse specialist at Berkshire Traumatic Stress Service in Berkshire, UK. She is lead author of a
1998 Cochrane Review about single-session debriefing for preventing PTSD, soon to be updated to include a review of longer
interventions.
Examining 11 studies exploring the effect of single-session psychological debriefing, the review found that people who underwent
debriefing showed no significant reduction in risk of developing PTSD than people who did not receive debriefing. In fact,
one study reported a significant increase in risk for PTSD for those receiving debriefing. The review concludes that "recalling
the event may be a 'secondary trauma' -- attempting to forget/distance may be an adaptive response. Intervention may interfere
with adaptive defense mechanisms."
Beyond individual debriefing, certain types of group sessions may also be harmful. "Exposing people to others' accounts of
experiences they didn't directly witness may not be supportive," says Dr. Lisa Andermann, an assistant professor of psychiatry
at the University of Toronto and a psychiatrist at Mount Sinai Hospital. Andermann tells of a group of employees exposed to
a workplace accident. One man went on to develop PTSD. Later, in a group session, he listened to co-workers' graphic tales
of their experience. As a result, he suffered a relapse.
Most experts estimate that about 80 per cent of trauma survivors do not develop PTSD. But for those who do, what kind of therapy
works? Andermann mentions the work of Harvard professor Dr. Judith Herman, which offers a phase-based approach to recovery.
"First, stabilize the person's symptoms, and only then address the trauma. Recovery could take months or years," says Andermann.
"The process must be slow and safe, with the goal to rework the experience into normal memory." To naturalize the memories
and make them less traumatic as they surface, Andermann suggests asking gentle questions, progressing slowly and in detail
through the experience: "What were you doing before you saw the wave? What were you thinking? What happened next?"
Rose suggests a cognitive-behavioural approach to change thought patterns. "These are people who thought they'd die -- and
didn't," she says. Rose recommends about eight sessions of such work.
Trauma levels may also be affected by cultural attitudes toward death, says Andermann. "Does the person believe in reincarnation?
What if there was no priest there to administer last rites? There may be different levels of grief responses depending on
people's beliefs."
Within the Tamil community, grief is a "community-based activity," says Chandrakanthan. "The whole family goes through the
process." It is this experience that offers the real foundation of grief counselling for most trauma survivors. Says Rose:
"Most people who survive cope well with the support of family and friends."
Centre for Addiction
