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Causing More Grief

May 23, 2002
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Every American calamity -- from the shootings at Columbine High School andthe Oklahoma City bombing to the latest terrorist attacks -- now features TVnews reporters earnestly assuring viewers that "grief counselors" areon their way to help victims cope with the disaster. The provision of griefcounseling is now a culture-wide phenomenon. Bad stuff happens and griefcounselors flock in. And why not? Surely, the maimed psyches of survivors andrescue personnel need healing nearly as much as do their wounded bodies.

Modern grief counseling is not just plain old-fashioned handholding andcrying together. It’s science. Practitioners claim that their counselingreduces the incidence of post-traumatic stress disorder (PTSD) in victims whosubmit to their therapeutic ministrations. But does it?

Not so fast, says Richard McNally, a Harvard University psychology professor."Most studies show no difference in victim recovery," McNally says."But more worrisome is the fact that two more recent studies showed thatthose who received critical incident stress debriefings did worse than those whodid not. The counseling seems to be impeding recovery."

McNally and 19 colleagues submitted a letter earlier this month to theAmerican Psychological Association’s Monitor newsletter. The letter noted,"Several independent studies now demonstrate that certain forms of postdisaster psychological debriefing (treatment techniques in which survivors arestrongly suggested to discuss the details of their traumatic experience, oftenin groups and shortly after the disaster) are not only likely to be ineffective,but can be iatrogenic." "Iatrogenic" refers to diseases caused bytreatment itself. Counseling, it seems, can make people feel worse, not better.

What McNally and his colleagues are concerned about is a type of griefcounseling called "critical incident stress management" (CISM) thathas become very popular in the past two decades. At the center of CISM is the"critical incident stress debriefing" (CISD) in which victims areencouraged to relive their traumatic experiences, usually in group sessions. Oneof the main clearinghouses for CISM practitioners is the International CriticalIncident Stress Foundation, Inc. (ICISF) located outside Baltimore, Maryland.

CISM practitioners -- generally, psychologists, psychiatrists, socialworkers, and licensed counselors -- reject the colloquial term "griefcounseling" for what they do. One debriefer, John Weaver, who is a LicensedClinical Social Worker and a Board Certified Diplomat, recommends thattherapists "encourage expression of the most vivid or graphic negativeimages and memories. Think of it as cleaning out an emotional wound beforeallowing it to try to heal with foreign material still on the inside." Suchtherapy talk resonates with Americans who are brought up with OprahWinfrey-style confessional TV.

Jeffrey Mitchell, ICISF president and creator of the leading debriefingmodel, proudly asserts, "CISM is now becoming a ‘standard of care’ inmany schools, communities, and organizations."

Indeed it is -- critical incident debriefing is big business. The federalgovernment paid over $4 million for critical incident debriefing services afterthe Oklahoma City bombing in 1995. The ISICF’s network of several thousandcertified counselors is ramping up to treat the survivors of the September 11terrorist attacks. ISICF executive director Donald Howell, in a recent update tomembers, notes, "Several Non-Governmental agencies are providingfocused/regional CISM Intervention Services within New York City and thesurrounding communities. ICISF is actively supporting one of those agencies andis fulfilling their requests for CISM Teams. It is anticipated that the numberof Teams to support their efforts will increase dramatically over the nextseveral weeks."

"I have heard that 80 companies formerly in the World Trade Center arethinking about contracting for debriefing services," says McNally."Apparently, the companies are worried about liability suits if they don’toffer their employees this service, but I would worry more about forcing peopleto be debriefed who would later sue on the grounds that what a company forcedthem to go through doesn’t work at best, and at worst is toxic."

Proponents of CISD respond that the studies upon which McNally and hiscolleagues are relying are flawed and that numerous clinical studies demonstratethe efficacy of critical incident debriefing interventions. McNally agrees thatno studies are perfect, but points out that proponents don’t have anyscientific evidence in the form of double-blind experiments -- in which subjectsare assigned randomly to either treatment or control groups -- to back up theirclaims. Instead, proponents rely chiefly on qualitative informal clinicalimpressions as evidence -- essentially patient testimonials.

"Of course, when people are asked whether the sessions were helpful ornot, most people say yes, even though the evidence shows that they arerecovering more slowly than those who did not receive the debriefing," saysMcNally. "For some people, debriefing is like opening up a wound and notsewing it back up."

McNally points to a recent review of debriefing by the authoritative CochraneLibrary, which is devoted to evidence-based medicine. The study forcefullyconcluded: "There is no current evidence that psychological debriefing is auseful treatment for the prevention of post traumatic stress disorder aftertraumatic incidents. Compulsory debriefing of victims of trauma shouldcease."

McNally doesn’t doubt the good intentions of the debriefers, but goodintentions are not enough, especially when those wielding the intentions mightend up doing more harm than good. If debriefing doesn’t work, what should bedone to heal the psychic wounds of the victims of mass catastrophe?

"In the immediate aftermath, go easy. Don’t be intrusive. Havetherapists available should people seek them, but no mandatorydebriefings," McNally suggests. "Be empathetic, let people go at theirown paces, permit people to cry, but don’t compel them to cry. Some treatmentsfor people who are still experiencing PTSD three months after an incident mightinclude one-on-one sessions that help them learn to cope with going inside tallbuildings or fly again."

The good news is that epidemiological studies of mass catastrophe survivorsshow that "even without counseling, most people are going to do OK in thelong run," says McNally.

Asked what he would say to companies and agencies that are thinking of makingcritical incident debriefing available to survivors of the terrorist attacks,McNally replies, "Informed consent comes in here. You have to tell youremployees that you are making a therapy available that, based on the bestinformation in the scientific literature, will likely do nothing to help andmight actually make matters worse -- do you still want it?"

Probably not.

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