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Psychological Debriefing(PD)

Dr. Reem Ibrahim Ahmed

What is psychological debriefmg

psychological debriefmg (PD) is an example of an intervention provided shortly after a traumatic event to prevent later psychological consequences. critical incident stress debriefing (CISD), first described by Mitchell (I 983), and other forms of debriefing have become the most written about, widely practiced, and wellrecognized forms of early psychological intervention following trauma.

critical incident stress debriefing CISD was first described by Mitchell (1983) as a group intervention for ambulance personnel following exposure to traumatic situations in their work. It was described as a form of crisis intervention as opposed to a form of psychological treatment, and therefore does not have the same philosophy (i.e., debriefmg does not explicitly treat a pathological response).

CISD and other models of psychological debriefmg PD have become recognized as semistructured interventions designed to: reduce initial distress and to prevent the development of later psychological disorders such as PTSD following traumatic events by promoting emotional processing through the ventilation and normalization of reactions, and preparation for possible future experiences. Further aims are to identify individuals who may benefit from more formalized treatment and to offer such treatment to them and provide early support.

It has generally been considered that any individual exposed to the traumatic event is eligible for PD irrespective of the presence of psychological symptoms. It is, however, apparent that many participants of debriefmgs would have fulfilled the criteria for acute stress disorder or have symptoms of PTSD, anxiety, and depression. Debriefings have been used with survivors, victims, emergency care workers, and providers of psychological care.

The focus of a PD is on the present reactions of those involved in a trauma rather than earlier experiences that may shape their individual reactions. Psychiatric "labeling" is avoided and the emphasis is placed on normalization. The participants are assured that they are normal people who have experienced an abnormal event. Mitchell and Everly (1995) have argued that debriefing should be considered one part of a comprehensive, systematic, multi-component approach to the management of traumatic stress (critical incident stress management; CISM) and that it should not be used as a one-time stand-alone intervention. Despite this assertion, many practitioners have used debriefing as a stand-alone intervention.

Mitchell's (1983) CISD is a 7 -phase technique: The introduction phase of CISD concerns explanation of the purpose of the debriefmg, guidelines, and some introductions. During the fact phase, a factual description of exactly what happened is produced, with acknowledgment of accompanying emotions if they are expressed, but these are not considered in detail at this time. The thought phase considers participants' thoughts at the time of the incident. The reaction phase focuses on participants' emotions associated with the event.

The symptoms phase aims to help move participants from the emotional reaction to a more cognitively orientated stage in which various trauma-related symptoms are discussed. The teaching phase flows from the symptoms phase and is led by the facilitators who discuss typical symptoms and coping strategies for stress. The reentry phase clarifies issues, gives the opportunity for questions, provides a summary of the debriefing, and ends with closure.

Dyregrov PD Model
Since Mitchell's initial description of CISD, several other authors have described other, different forms of psychological debriefing (Rose, 1997). Dyregrov (1989) described PD, which represents his interpretation of Mitchell's technique and is indeed very similar, although it specifically discusses sensory information experienced at the time. Dyregrov also appears to devote more attention to individual reactions and to the normalization of reactions. The seven stages of PD as described by Dyregrov are detailed as follows:

1. The introduction.
The debriefer(s) states that the purpose of the meeting is to review the participant(s) reactions to the trauma, to discuss them, and to identify methods of dealing with them to prevent future problems. The debriefer assumes control and specifies his or her own competence in order to lend confidence to those attending.

Three rules are made explicit: (a) Partipants are under no obligation to say anything except why they are there and what their role was vis-a-vis the traumatic event; (b) confidentiality is emphasized in groups and the members understand not to divulge outside the group what others have said; and (c) the focus of the discussions is on the impressions and reactions of the participants.

2. Expectations and facts.

The details of what actually happened are discussed in considerable detail without focusing on thoughts, impressions, and emotional reactions. This is felt to be extremely important in certain situations, for example, unexpectedly encountering injured children can magnify the intensity of a traumatic situation.)

3. Thoughts and impressions

When the facts are being described, thoughts and impressions are elicited by asking questions such as "What were your thoughts when you first realized you were injured?" and "What did you do?" . This information aims to (a) construct a picture of what happened, (b) put individual reactions into perspective, and (c) help with the integration of traumatic experiences. Sensory impressions in all five modalities are elicited, for example, "What did you see, hear, touch, smell, taste?" The aim is to produce a more realistic reconstruction of the trauma.

4. Emotional reactions.
This is usually the longest stage in the PD. The earlier questions concerning thoughts and impressions lead to answers concerning emotions. The debriefer attempts to aid the release of emotions with questions about some of the common reactions during the trauma, such as fear, helplessness, frustration, self-reproach, anger, guilt, anxiety, and depression. Emotional reactions experienced since the event are also discussed.

5. Normalization.
After the emotional reactions have been expressed, the debriefer aims to facilitate their acceptance. This is done by stressing that the reactions are entirely normal. When more than one person is present in the PD, it is likely that emotions will be shared. This universality aims to help with normalization. The debriefer stresses that individuals do not have to experience all of the emotions that normally occur after a trauma, but it is normal to react after a critical incident.

The debriefer also describes common symptoms that individuals may experience in the future: intrusive thoughts and images, distress when reminded of what happened; attempts to avoid thoughts, feelings, and reminders; detachment from others; loss of interest in things that once gave pleasure; anxiety and depressed mood; sleep disturbance, including nightmares; irritability, shame, guilt, and anger; hyper vigilance and increased startle reactions.

6. Future planning/coping.
This stage allows the debriefer to focus on ways of managing symptoms should they arise and to attempt to mobilize internal support mechanisms (e.g., discussing coping mechanisms) and external support (e.g., family and friends). Emphasis is on the importance of open discussion of feelings with family and friends and highlights the possibility of needing additional support from them for a while.

7. Disengagement.
In this stage, other topics are discussed. Leaflets describing normal reactions and how to cope with them, such as the British Red Cross's Coping with Personal Crisis, can be distributed. Guidance is also given regarding the need for further help and where it may be obtained if necessary: Participants are advised to seek further help if for example symptoms increase over time; there is ongoing loss of function and occupational family difficulties; or others marked personality changes.

Raphael PD Model
Raphael (1986) described a psychological debriefing that was less structured than the Mitchell and Dyregrov models, yet still had much in common with them, including the fact that it was designed as a group intervention for secondary rather than primary victims. She suggested particular topics for discussion that may be useful during the debriefing, including personally experienced disaster stressors such as death encounter, survivor conflict and loss dislocation; positive and negative feelings, victims and their problems, and the special nature of disaster work and personal experiences.

Multiple Stressor Debriefing Model

designed for use with American Red Cross personnel (Armstrong, O'Callahan, & Marmar, 1991), contains elements from the other debriefings but for the first time focuses on pretrauma strategies adopted by individuals to deal with stressful situations. Four stages are completed.

The first stage, disclosure of events, followed by consideration of feelings and reactions. Coping strategies are then discussed, including the previous ways individuals have dealt with stressful events. Finally, the termination phase considers what it will be like leaving the disaster, the positive work done, and the need to talk to significant others about experiences and feelings.

In many regards, debriefing is a form of psycho education. This is an impotant component of many cognitive-behavioral treatments. It questions the extent to which treatments of psychological trauma owe their treatment effects to nonspecific factors. There appears to be little doubt that giving traumatized individuals a psychological map to understand their reactions does much to contain their distress and to allow them to institute a series of self regulatory processes.

Theoretical/Conceptual Framework
Acute preventive interventions can only be implemented if there is collective responsibility and the value of group survival and care for individuals. the effectiveness and theoretical foundation of debriefing are critically dependent upon the general systems of leadership and the management of morale. acute preventive interventions could be seen to be as much social movements as interventions emerging from refinement in clinical practice. However, theoretical origins of debriefing appear to come from a variety of sources.

The Proximity, Immediacy, and Expectancy (PIE) Model

The management of acute combat stress disorders was a school of treatment that emerged in World War I and was then rediscovered in World War II. The PIE model is based on the three principles of proximity, immediacy and expectancy . where individuals were treated close to the battle zone (proximity), as soon as possible (immediacy), and with the expectation of returning to duty (expectancy).

The Narrative Tradition

During World War II, General Marshall, the chief historian of the U.S. Army at that time, used and subsequently wrote about debriefing (Marshall, 1944). He advocated holding debriefing sessions on the battlefield as soon as possible after the action and estimated that 7 hours were needed to debrief one fighting day. Marshall noted that the emotional effects of the debriefmg were a "spiritually purging," "moralebuilding" experience, and one that the men usually relished.

Marshall's debriefing method provided a structured intervention that recognized and respected individuals' experiences, grief, and expression of emotional responses. exploration of the events of battle gave the troops an opportunity to develop a narrative, or internal verbal representation, of the experience.

Group Psychotherapy
Another model employed in the critical incident debriefing model is that of group psychotherapy. Lindy, Green, Grace, and Titchener (1983) have spoken of the trauma membrane that forms around the community involved in disaster. This notion refers to the mutual and tacit understanding that envelops people who have similarly suffered.

These principles are central to the efficacy of group intervention. Groups use the therapeutic forces within the group and the constructive support and interaction to heal people and modify their reactions. The adaptive outcome of the group is the primary aim rather than the focus on individuals.

Crisis Intervention
Social psychiatry has a particular focus on the role of life events as a cause of psychiatric illness. The accompanying arm of intervention was crisis intervention championed by Caplan and Lindemann. The essence of crisis intervention is that a clear precipitant exists and that the individual's distress is clear.

It attempts to remove such distress and presumes that the patient has experienced an offense that has caused this disequilibrium because of its suddenness, which has not allowed the individual time to master his or her emotional response. The essence of the intervention is that the temporary support of the mental health professional will bring about mastery. The critical dimension is to assist the person in reestablishing rational problem solving.

The expression of affect associated with the memory of an event is also a central component of debriefing. The notion of catharsis goes back to Breuer and Freud's (1893) first lecture, "On the Psychical Mechanism of Hysterical Phenomena: Preliminary Communications." A technique used to relieve tension and anxiety by bringing repressed feelings and fears to consciousness. The therapeutic result of this process; abreaction.

It seems important to focus interventions on individuals who appear to be at highest risk of developing psychological disorders, for example, individuals who suffer from ASD, as they appear to be at highest risk of developing PTSD. There is a clinical consensus that the earlier treatment is provided, the better the longterm prognosis, and that the treatment principles for emerging PTSD are similar to those for established PTSD.