Scientific American has a useful piece on how the immediate treatment of psychological trauma has changed since 9/11. The issue is interesting because recent progress has turned lots of psychological concepts on their head to the point where many still can’t grasp the concepts.
The article notes that at the time of the Twin Towers disaster, the standard form of treatment was Critical Incident Stress Debriefing – also known as CISD or just ‘debriefing’ – a technique where psychologists would ask survivors, usually in groups, to describe what happened and ‘process’ all the associated emotions by talking about them.
This technique is now not recommended because we know it is at best useless and probably harmful – owing to the fact that it seems to increase trauma in the long-term.
Instead, we use an approach called psychological first aid, which, instead of encouraging people to talk about all their emotions, really just focuses on making sure people feel secure and connected.
Although the article implies that 9/11 was a major turning point for our knowledge of immediate post-trauma treatment, the story is actually far more complex.
Studies had been accumulating throughout the 90s showing that ‘debriefing’ caused harm in some, although it wasn’t until around the turn of the century that two meta-analyses sealed the deal.
Unfortunately, the practice of ‘debriefing’ by aid agencies and emergency psychologists was very hard to change for a number of interesting reasons.
A lot of aid agencies don’t deal directly with the scientific literature. Sometimes, they just don’t have the expertise but often it’s because they simply have no access to it – as most of it is locked behind paywalls.
However, probably most important was that even the possibility of ‘debriefing’ having the potential to do damage was very counter-intuitive.
The treatment was based on the then-accepted foundations of psychological theory that said that emotions always need to be expressed and can do damage if not ‘processed’.
On top of this, for the first time, many clinicians had to deal with the concept that a treatment could do damage even though the patients said it was helpful and were actually and genuinely getting better.
This is so difficult to grasp that many still continue with the old and potentially damaging practices, so here’s a quick run down of why this makes sense.
The theoretical part is a hang-over from Freudian psychology. Freud believed that neuronal energy was directly related to ‘mental energy’ and so psychology could be understood in thermodynamic terms.
Particularly important in this approach is the first law of thermodynamics that says that energy cannot be created or destroyed just turned into another form. Hence Freud’s idea that emotions need to be ‘expressed’ or ‘processed’ to transform them from a pathological form to something less harmful.
We now know this isn’t a particularly reliable guide to human psychology but it still remains hugely popular so it seemed natural that after trauma, people would need to ‘release’ their ‘pent up emotions’ by talking about them lest the ‘internal pressure’ led to damage further down the line.
And from the therapists’ point of view, the patients said the intervention was helpful and were genuinely getting better, so how could it be doing harm?
In reality, the psychologists would meet with heavily traumatised people, ‘debrief’ them, and in the following weeks and months, the survivors would improve.
But this will happen if you do absolutely nothing. Directly after a disaster or similarly horrible event people will perhaps be the most traumatised they will ever be in their life, and so will naturally move towards a less intense state.
Statistically this is known as regression to the mean and it will occur even if natural recovery is slowed by a damaging treatment that extends the risk period, which is exactly what happens with ‘debriefing’.
So while the treatment was actually impeding natural recovery you would only be able to see the effect if you compare two groups. From the perspective of the psychologists who only saw the post-trauma survivors it can look as if the treatment is ‘working’ when improvement, in reality, was being interfered with.
This effect was compounded by the fact that debriefing was single session. The psychologists didn’t even get to see the evolution of the patients afterwards to help compare with other cases from their own experience.
On top of all this, after the ‘debriefing’ sessions, patients actually reported the sessions were useful even when long-term damage was confirmed, because, to put it bluntly, patients are no better than seeing the future than professionals.
In one study, 80% of patients said the intervention was “useful” despite having more symptoms of mental illness in the long-term compared to disaster victims who had no treatment. In another, more than half said ‘debriefing’ was “definitely useful” despite having twice the rate of postraumatic stress disorder (PTSD) after a year.
Debriefing involves lots of psychological ‘techniques’, so the psychologists felt they were using their best tools, while the lack of outside perspective meant it was easy to mistake instant feedback and regression to the mean for actual benefit.
It’s worth saying that the same techniques that do damage directly after trauma are the single best psychological treatment when a powerful experience leads to chronic mental health problems. Revisiting and ‘working through’ the traumatic memories is an essential part of the treatment when PTSD has developed.
So it seemed to make sense to apply similar ideas to those in the acute stage of trauma, but probably because the chance of developing PTSD is related to the duration of arousal at the time of the event, ‘going over’ the events shortly after they’ve passed probably extends the emotional impact and the long-term risks.
But while the comparative studies should have put an end to the practice, it wasn’t until the World Health Organisation specifically recommended that ‘debriefing’ not be used in response to the 2004 tsunami [pdf] that many agencies actually changed how they went about managing disaster victims.
As well as turning disaster psychology on its head, this experience has dispelled the stereotype that ‘everyone needs to talk’ after difficult events and, in response, the new approach of psychological first aid was created.
Psychological first aid is actually remarkable for the fact that it contains so little psychology, as you can see from the just released psychological first aid manual from the World Health Organisation.
You don’t need to be a mental health professional to use the techniques and they largely consist of looking after the practical needs of the person plus working toward making them feel safe and comfortable.
No processing of emotions, no ‘disaster narratives’, no fancy psychology – really just being practical, gentle and kind.
We don’t actually know if psychological first aid makes people less likely to experience trauma, as it hasn’t been directly tested, although it is based on the best available evidence to avoid harm and stabilise extreme stress.
So while 9/11 certainly focussed people’s minds on psychological trauma and its treatment (especially in the USA which is a world leader in the field) it was really just another bitter waymarker in a series of world tragedies that has shaped disaster response psychology.
So unusually for a psychologist, I’ll be hoping we’ll have the chance to do less research in this particular area and have a more peaceful coming decade.
Link to SciAm piece on psychology and the aftermath of 9/11.
Ron Huxley LMFT 