After the trauma: What doesn’t help and what may

(This article was first printed in the November, 2003 issue of the Harvard Mental Health Letter. For more information or to order, please go to http://health.harvard.edu/mental.)

We know a great deal about emergency treatment for physical trauma — how to bind up the wounds, ward off infection, and prevent long-term damage. First aid for psychological trauma, especially protection against post-traumatic stress disorder (see Harvard Mental Health Letter, January 2002) has been more elusive. Some studies suggest that one of the most popular approaches — getting people to talk about it soon afterward — is ineffective or worse. Cognitive behavioral therapy may help, and so may certain drugs. And a questionnaire may help predict children’s risk for post-traumatic symptoms.

Originally developed for firefighters and named after a military procedure, critical incident stress debriefing (also called single-session psychological intervention) has become part of standard emergency planning in some places. Sometimes it is the only psychological help offered after trauma. Its purpose is to reduce immediate stress, prevent post-traumatic symptoms, and identify people who need further treatment.

Debriefing is the interrogation of a soldier or government official returning from a mission. In critical incident stress debriefing, a counselor or facilitator encourages trauma victims to tell the story of their experience and convey their feelings about it, while reassuring them that they are responding normally to an abnormal situation. The theory is that, as a result, they will be less likely to suffer the anxiety, flashbacks, avoidance symptoms, and emotional numbing of post-traumatic stress disorder (PTSD).

A meta-analysis of controlled studies supports what has been suspected for some time — it doesn’t work.

The review covers 11 clinical trials with a total of more than 2,000 participants comparing critical incident stress debriefing with standard care and other forms of counseling. Although the authors regard the quality of the research as poor, they feel able to draw some conclusions from it. In three studies, debriefing was more effective than the alternatives, in six studies it made no difference, and in two it made the outcome worse. The average follow-up time was three months, but the studies of highest quality and those with the longest follow-up — a year or more — gave particularly poor results.

The reviewers have some thoughts about the disappointing findings. Many people may be better off distancing themselves from the experience immediately afterward instead of re-exposing themselves, especially if they do so only once rather than repeatedly and therefore have no time to become habituated and desensitized. The invitation to debriefing may also inhibit natural recovery by creating unnecessary fears and causing catastrophic misinterpretation of any symptoms that appear later on.

Cognitive behavioral therapy (CBT), another kind of early post-trauma intervention, may do some good. In one study, 16 weekly sessions of CBT beginning one to four months after the trauma proved to be more effective than supportive counseling or no treatment in preventing chronic post-traumatic stress disorder for up to four years. But the only study that has compared CBT to repeated clinical evaluation (weekly meetings to discuss symptoms with a health care provider) found no difference. CBT may be more effective if carried on longer and with selected patients.

Drug treatment may also help. A drug candidate is propranolol (Inderal), now widely used to control blood pressure and performance anxiety (stage fright). Propranolol belongs to a class of drugs called beta blockers that suppress physical symptoms of anxiety by occupying receptors for adrenaline. Beta blockers have also been found to slow the formation of emotionally disturbing memories. In two preliminary, controlled studies published in 2003, immediate treatment with propranolol (within hours or days after the trauma) reduced post-traumatic symptoms and lowered the risk of PTSD.

Early single-session counseling may show poor results because of the faulty assumption that everyone has a use for it. Before intervening, it may make more sense to try to distinguish the majority who will cope well from the minority who will probably need help. Researchers reported in 2003 in the Journal of the American Medical Association on a brief (12-item) questionnaire developed to estimate the risk for PTSD in children and adolescents (ages 8–17) injured in traffic accidents, and their parents (see box).

Properly scored, the answers identified 50% of the children and adults who went on to develop PTSD and 90% of those who did not. This kind of questionnaire, modified for other situations, might be helpful in deciding who does not need early psychological counseling.