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Post-Trauma Counseling? Thanks, but No Thanks
11/18/2008
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Studies indicate that counseling can harm victims of accidents and violence, and that unaffected bystanders don’t need or benefit from it
by Craig Weatherby 


Some soldiers subjected to the stresses and shocks of combat suffer from post-traumatic stress disorder (PTSD).

PTSD was called “soldier's heart” in the American Civil War, “combat fatigue” or “shell shock” in World Wars I and II,

Combat-related post-traumatic stress disorder usually results from prolonged or continuous exposure to traumatic events, and is characterized by long-lasting emotional and social problems.

And there is no doubt that counseling and group therapy helps many, if not most, military personnel diagnosed with PTSD.

So it may seem logical to send teams of psychologists and psychiatric social workers to the scenes of natural disasters, mass shootings like Columbine, and to schools in the aftermath of the off-campus deaths of students.

But many observers have noted the lack of evidence that these knee-jerk responses to transitory trauma – and counseling for people not directly involved in traumatic situations – does any good.

And the evidence is now accumulating that those doubts are well founded.

Though it’s gone largely unreported in the media, quite a few clinical and epidemiological studies have examined the effects of counseling in non-military situations of transitory trauma, such as car accidents and natural disasters.

And the results suggest that the counselors' ministrations may actually reinforce trauma that the human mind would otherwise allow to melt away.

Counseling is based on the “hydraulic hypothesis” of emotions, which holds that people's emotions build up inside until the mind can no longer contain the pressure.

People who choose not to let off steam by talking about it are popularly seen as being “in denial”, and this is often seen as harmful.

However, the hydraulic metaphor has no actual evidence, and the therapies that implicitly rely on it have not stood up under serious scrutiny.

In fact, studies on “Critical Incident Stress Debriefing” (CISD) indicate that, aside from providing no benefit to trauma sufferers, it may be harmful.

Controlled studies show no benefit, and possible harm
Five years ago, British researchers analyzed 11 extant studies of the effects of “single-session psychological interventions such as psychological debriefing”.

Three studies showed positive outcomes, six demonstrated no difference in outcomes, and 2 showed negative outcomes among counseled victims.

As the authors wrote, “This review suggests that early optimism for brief early psychological interventions including debriefing was misplaced and that it should not be advocated for routine use.” (Rose S et al. 2003)

One the better studies followed auto accident victims – some of whom received counseling (called “intervention”), and other who did not – for three years.

Their conclusion was stark: “Psychological debriefing is ineffective and has adverse long-term effects. It is not an appropriate treatment for trauma victims” (Mayou RA et al. 2000).

And the researchers who conducted a controlled clinical trial of psychological debriefing for burn victims found that those who received counseling were worse off than the un-counseled control group: “This study seriously questions the wisdom of advocating one-off interventions post-trauma, and should stimulate research into more effective initiatives” (Bisson JI et al. 1997).

Study finds no 9/11 benefit from counseling or "venting"
A study led by psychologist Mark Seery, Ph.D., of the University at Buffalo used a Web-based survey to examine people’s responses to the terrorist attacks of Sept. 11, 2001 (Seery MD et al. 2008).

Dr. Seery and his colleagues tested people's responses to the terrorist attacks of 9/11, beginning immediately after the event and continuing for the following two years. In an online survey, respondents were given the chance to express their thoughts and feelings on the day of 9/11 and a few days afterward.

The researchers then compared people who chose to express their thoughts and feelings versus those who chose not to express.

If the assumption about the necessity of expression is correct – that failing to express one's feelings indicates some harmful repression or other pathology – then people who chose not to express should have been more likely to experience negative mental and physical health symptoms over time, the researchers point out.

“However,” as Seery said, “we found exactly the opposite: people who chose not to express were better off than people who did choose to express” (UAB 2008).

And when the Buffalo-based team looked only at people who chose to express their thoughts and feelings, and tested the length of their responses, they found a similar pattern. People who expressed more were worse off than people who expressed less.

“We assessed various alternative explanations in secondary analyses, but nothing else accounts for this effect,” Seery noted (UAB 2008).

Dr. Seery says the results should not be interpreted to mean that expressing one’s thoughts and feelings is harmful or that if someone wants to express their emotions they should not do so.

He put it this way: “It’s important to remember that not everyone copes with events in the same way, and in the immediate aftermath of a collective trauma, it is perfectly healthy to not want to express one's thoughts and feelings.” (UAB 2008)

Seery points out that immediately after last year's tragic shootings at Virginia Tech University there were many “talking head” psychiatrists in the media describing how important it is to get all the students expressing their feelings.

As he said, “This perfectly exemplifies the assumption in popular culture, and even in clinical practice, that people need to talk in order to overcome a collective trauma. Instead, we should be telling people there is likely nothing wrong if they do not want to express their thoughts and feelings after experiencing a collective trauma. In fact, they… are likely to be better off than someone who does want to express his or her feelings” (UAB 2008).

It seems past time to throw out the old hydraulic metaphor of trauma-related stress and the presumption that counseling relieves this imagined pressure, instead of reinforcing it, which it appears to do.


Sources
  • Aulagnier M, Verger P, Rouillon F. [Efficiency of psychological debriefing in preventing post-traumatic stress disorders] Rev Epidemiol Sante Publique. 2004 Feb;52(1):67-79. Review. French.
  • Bisson JI, Jenkins PL, Alexander J, Bannister C. Randomised controlled trial of psychological debriefing for victims of acute burn trauma. Br J Psychiatry. 1997 Jul;171:78-81.
  • Friedman MJ, Schnurr PP, McDonagh-Coyle A. Post-traumatic stress disorder in the military veteran. Psychiatr Clin North Am. 1994 Jun;17(2):265-77. Review.
  • Holman EA, Silver RC, Poulin M, Andersen J, Gil-Rivas V, McIntosh DN. Terrorism, acute stress, and cardiovascular health: a 3-year national study following the September 11th attacks. Arch Gen Psychiatry. 2008 Jan;65(1):73-80.
  • Mayou RA, Ehlers A, Hobbs M. Psychological debriefing for road traffic accident victims. Three-year follow-up of a randomised controlled trial. Br J Psychiatry. 2000 Jun;176:589-93.
  • Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2001;(3):CD000560. Review. Update in: Cochrane Database Syst Rev. 2002;(2):CD000560.
  • Rose S, Bisson J, Wessely S. A systematic review of single-session psychological interventions ('debriefing') following trauma. Psychother Psychosom. 2003 Jul-Aug;72(4):176-84. Review.
  • Seery MD, Silver RC, Holman EA, Ence WA, Chu TQ. Expressing thoughts and feelings following a collective trauma: immediate responses to 9/11 predict negative outcomes in a national sample. J Consult Clin Psychol. 2008 Aug;76(4):657-67.
  • Seery MD, Silver RC, Holman EA, Ence WA, Chu TQ. Expressing thoughts and feelings following a collective trauma: immediate responses to 9/11 predict negative outcomes in a national sample. J Consult Clin Psychol. 2008 Aug;76(4):657-67.
  • Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA. 2002 Sep 11;288(10):1235-44.
  • Stallard P, Velleman R, Salter E, Howse I, Yule W, Taylor G. A randomised controlled trial to determine the effectiveness of an early psychological intervention with children involved in road traffic accidents. J Child Psychol Psychiatry. 2006 Feb;47(2):127-34.
  • University at Buffalo (UAB). It's Okay to Keep Those Feelings Inside, New Study Suggests. June 1, 2008. Accessed online June 3, 2008 at http://www.buffalo.edu/news/9421

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