For personal use. Only reproduce with permission from The Lancet Publishing Group. Post-trauma debriefing: the road too frequently travelled See page 766 The meta-analysis by Arnold van Emmerik and colleagues in today’s Lancet about the efficacy of post-trauma psychological debriefing stands among the more potent entries in an increasing litany of reports, reviews, and consensus statements. The latest report raises significant concerns about this ubiquitous intervention. Despite limitations from poor data-quality and uneven design in the studies assessed, the analysis is consistent with those of other researchers, indicating that debriefing: (1) yielded no demonstrable effect on subsequent resolution of traumatic exposure and may inhibit or delay resolution for some participants; (2) showed a smaller effect than calculated for non-intervention controls, suggesting that natural proclivities toward resilience may be more potent than this style of intervention and (3) yielded lower effect-sizes than alternative interventions against which it was compared, raising the strong likelihood that other approaches are more likely to help. The findings echo and extend assessments of multiple randomised trials in Cochrane Collaboration reviews. 1 Although such meta-analyses have been criticised for lacking studies of group debriefing within the specific occupational settings in which the practice originated (rather than in traumatised individuals more generally), well-designed quasi-experimental field studies in those contexts have also yielded negative or equivocal findings, 2–4 which leaves the burden of proof about efficacy with proponents of debriefing. The implications for practice are unequivocal. Calls for caution and restraint have been heard from many responsible scientists and practitioners, 5–9 and are underscored in conclusions from consensus panels 10 and empirically-based practice guidelines that have recommended limitation 11,12 or contraindication. 13,14 But despite direct and publicised warnings from well-established researchers in trauma response and intervention, 15,16 reports from New York City after the attacks on the World Trade Center indicated that more than 9000 purveyors of debriefing and other popularised interventions—more than three counsellors for every person believed to have died in the attack—swarmed there, advocating intervention for any person even remotely connected to the tragedy. 17 Given the evidence, why should use of debriefing techniques not only persist but also seemingly flourish? Post-traumatic stress disorder is much debated. 18 Progressive dilution of both stressor and duration criteria has so broadened application that it can now prove difficult to diagnostically differentiate those who have personally endured stark and prolonged threat from those who have merely heard upsetting reports of calamities striking others. Moreover there are few systematic data about the normal course of resolution after traumatic exposure or the inherent variability of that course within and between individuals, a fact that leaves discernment between symptoms of arrested or abnormal processing and normal signs of sometimes profound but ultimately transient discomfiture a subject of speculation. The problem is compounded further in practice, where the enterprise of debriefing has become dominated by a prolific and parochial subculture of secondary providers whose understanding of these highly complex and elusive issues is often limited to proprietary workshops, trade magazines, and paperback books rather than the peer- reviewed venues of empirically guided professional practice. This has, in turn, created entrenched enclaves of self- THE LANCET • Vol 360 • September 7, 2002 • www.thelancet.com 741 COMMENTARY identified debriefers within various organisations—initially in public safety and military concerns, but now extending into schools, hospitals, and a widening range of other enterprises—who earnestly strive to help but stand severely hampered by the tools they have been sold. Although immediate debriefing has yielded null or paradoxical outcomes, the value of contemporaneous instrumental assistance and support—those kinds of practical help often learned better from grandmothers than from graduate training—has increasingly been found to be useful in disaster response. 19 Structured interventions, however, may be better embedded in models of stepped care, where the nature and level of intervention is conservatively tailored to the needs, context, and course of individual resolution. 20,21 Preliminary epidemiological data from New York City have revealed levels of post-traumatic stress disorder that, whilst clearly significant, fell below even conservative early prognostications 22 and which had dropped by more than two-thirds within 4 months. 23 These findings underscore the counterproductive nature of offering a prophylaxis with no demonstrable effect, but demonstrated potential to complicate natural resolution, in a population in which limited case-conversion can be anticipated, strong natural supports exist, and spontaneous resolution is prevalent. Promising approaches are emerging, with high sensitivity and specificity, allowing straightforward and relatively non- intrusive assessment to identify those at greatest risk of clinical progression to post-traumatic stress disorder. 24 These approaches are designed for implementation 2–4 weeks post-impact, when brief-series cognitive behavioural therapy has efficacy in treating post-traumatic stress disorder in high-risk populations. 21 *Richard Gist, Grant J Devilly *Kansas City, Missouri Fire Department, and University of Missouri-Kansas City, Kansas City, M0 64106, USA; and Departments of Criminology and Psychology, University of Melbourne, Melbourne, Australia (e-mail: Richard.Gist@kcmo.org) 1 Rose S, Bisson J, Wessley S. Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane Review). In: The Cochrane Library, issue 3. Oxford: Update Software; 2001. 2 Carlier IVE, Lamberts RG, van Uchlen AJ, Gersons BPR. Disaster related post traumatic stress in police officers. Stress Med 1998; 14: 143–48. 3 Gist R, Lubin B, Redburn BG. Psychosocial, ecological, and community perspectives on disaster response. J Personal Interpersonal Loss 1998; 3: 25–51. 4 Macnab AJ, Russell JA, Lowe JP, Gagnon F. Critical incident stress intervention after loss of an air ambulance: two-year follow-up. Prehospital Disaster Med 1998; 14: 8–12. 5 Bisson JI, Deahl MP. Psychological debriefing and the prevention of post-traumatic stress: more research is needed. Br J Psychiatry 1994; 165: 717–20. 6 Deahl MP, Bisson JI. Dealing with disasters: does psychological debriefing work? J Accid Emerg Med 1995; 12: 255–58. 7 Raphael B, Meldrum L, McFarlane AC. Does debriefing after psychological trauma work? Time for randomised controlled trials. Br J Psychiatry 1995; 310: 1479–80. 8 Gist R, Lohr JM, Kenardy JA, et al. Researchers speak on CISM. J Emerg Med Serv 1997; 22: 27–28. 9 Kenardy JA. The current status of psychological debriefing. BMJ 2000; 321: 1032–33. 10 Ritchie, EC. Draft consensus document of the Mass Violence and Early Intervention Workshop. Washington, DC: US Department of Defense 2001. 11 Bisson JI, McFarlane AC, Rose S. Psychological debriefing. In: Foa EB, Keane TM, Friedman MJ, eds. Effective treatments for PTSD. New York: Guilford Press; 2000: 39–59. 12 Raphael B. Mental health disaster training manual. Sydney: New South Wales Department of Health, 1999. 13 Parry G. Evidence based clinical practice guidelines for treatment choice in psychological therapies and counselling. London: UK Department of Health, 2001. 14 Wessely S, Krasnov V. NATO-Russia advanced workshop on social and