Monday, June 02, 2008

I Don't Need To Talk

Roy is the blogger who inspired me today. I recently posted about the use of medication to prevent depression, and Roy followed this up with a comment on our Podcast #46 post about willingness to talk and prevention of trauma-related psych problems. He referenced a University at Buffalo study of 3000 9/11 survivors who were asked to respond to an online survey immediately following the 9/11 attack. The survey asked questions about their willingness or need to talk about the event, and followed their adjustment for two years after the initial survey. The study found that those who were unwilling to talk about the event actually fared better over time than those who wanted to talk.

Now, there are a lot of obvious limitations here---and I don't have the actual published article to analyze the news releases' interpretation of the study---but those who responded to the study had not lost any loved ones or known anyone who died in the attack, and it doesn't say whether or not the respondents themselves had direct experience of the event. For all I know, they could have been people living on the other side of the country. Personally, I doubt that people who were really upset and had direct experience of the 9/11 attack would have much interest in responding to an online survey at the time. It also doesn't mention whether or not the people who wanted to talk about their feelings ever actually had the opportunity to do so or received therapy following the event. All of this would obviously make a difference on the outcome.

Nevertheless, I think it says something relevant about an area in which there is a significant body of published data, which is the issue of crisis debriefing counseling. Crisis debriefing is something that's being used for a lot yet it's controversial because its efficacy hasn't been proven and there are some studies suggesting it could harm people.

Critical incident stress debriefing (CISD) was developed with the idea that providing rapid intervention to people exposed to trauma would prevent the development of PTSD. It was used following events like hostage-takings, natural disasters, plane crashes or other mass casualty accidents. CISD uses peer facilitators and mental health professionals in a time-limited, single session group setting to provide peer support and to allow people to talk about their feelings about the event. They also talk about the impact of the event on their relationships or day-to-day functioning as well as coping techniques. In addition to providing an emotional outlet, CISD typically also involves education about stress-related symptoms and stress management.

A PubMed search of the term "crisis debriefing outcome" brings up 33 studies on the outcomes of crisis debriefing counseling. Once you eliminate the studies with no controls and no data, you find that CISD studies have been done on a huge mixed bag of subjects: children, crime victims, soldiers, anesthesia residents, post-partum inpatients, burn victims and emergency service workers. The good news is that the majority of the subjects got better over time, even if nothing was done. The interesting news is that participant satisfaction surveys showed that patients frequently reported satisfaction with CISD, found it helpful and would recommend it to others even though there was no measurable reduction in symptoms. In other words, they felt it was helpful even when there was no objective evidence it helped.

Out of all the studies that reported outcome data in a group-controlled fashion, three found CISD led to improved symptoms. Seven studies showed there was no significant difference between CISD and a control group---neither benefit nor harm. Three studies showed worsened symptoms following crisis debriefing. A couple review articles in the Pub Med search as well as one meta-analysis also showed mixed results, with most showing no clear benefit and a few documenting aggravation of symptoms.

In all, the main conclusion I could come up with from this is that CISD probably should not be mandatory for everyone following a trauma (eg. an employer probably shouldn't mandate that all employees must attend CISD following an episode of workplace violence). It might help some people, and will probably not harm the majority, but a few will be hurt by it. The trick is, you don't know in advance who will fall into which group.


Awake and Dreaming said...

I saw another article about the study in my rss feed this morning and so I've been thinking about it on and off all day. I find it really interesting, and maybe it goes to how we process things and how we deal with things on a normal day to day basis.

The street outreach team I'm apart of debriefs every night we go out. We sit around a table and talk. I'm a big talker, sort of like how I'm a big writer... Anyway, after one particularly stressful evening during which we had to call an ambulance for one of our regulars I really encouraged everyone to share how they were feeling. Some people did, but some people didn't. The people who shared where the extroverts and those who didn't, were the introverts.

Talking about situations always helps me. It's the way I process things. Maybe some people just need to process by themselves though. Or process with others; quietly. Some people just need to sit together and cry, while others need to talk the whole thing out.

Further, I remember in Crisis Intervention class we talked about not traumatizing people who weren't traumatized and so being selective in critical incident debriefing. I found it interesting, because how do you pick? How do you know who needs to be there? Do they do know themselves?

Anonymous said...

Interesting, still dreaming. I'm an introvert, and my reaction to reading this post was that I wouldn't want to do an immediate debrief of a crisis. I wouldn't be ready to talk about it until I had processed it a while. I just can't dump it all out there immediately. I think that later, after I had had time to think, I would find it helpful to talk with other people.

Anonymous said...

Yeah, i'm the same as Sherri i think. When I get stressed, i need to sleep alot. Then one morning i'll wake up and talk about it, just kinda out of the blue.

I guess everyone's different.


Midwife with a Knife said...

I think what would be helpful (or would have been helpful to me, at least, even though I didn't really want to talk to people after my bad c-section), is for someone (ideally one of my attendings) to sort of sit me down and say something to the effect of, "Please feel free to talk to me if you need to. This is going to feel bad for a while, but if you have problems with sleep, or anxiety, or being distracted by being unable to not think about it, or distracted by certain very vivid memories, or having a hard time doing my job etc. that last more than X amount of time, you really need to talk to someone about it.", along with a list of suggested people that I may or may not choose to use.

Because when I kept feeling bad, I really felt like the situation was all my fault , I was the chief resident, and a terrible thing happened, and, at the time, no matter how bad I felt, it was nothing compared to what we did to that patient. (Now, with the perspective that several years gives, I don't feel that way, but when you're sort of mired and stuck in that place, it can be really tough to find your way out).

Anonymous said...

Tricky area since there are so many variables that could play a role here from response bias to the simple differences between each counsellor and situation and traumatic experience. I agree with your conclusions re CISD - that it could well help people and won't harm the majority. But I think it needs to be done sensitively and people shouldn't be forced to go. My unscientific view is that if people already have a good support structure then they get most of that 'talking about it' or debriefing from their loved ones without the further stress of having to be vulnerable with strangers (and risk further hurt). Offering people a place to talk about their experiences must be better than nothing - but we also need to trust that people will talk when they are ready. (BTW, really like your blog.)

ClinkShrink said...

Dreaming: Exactly. I think that's why CISD also includes the educational component, to teach people what to expect or look for and what to do when it happens in case problems come up later.

MWAK: One of the articles was a study of anesthesiology residents who underwent CISD following critical incidents on the job. This was one of the studies that showed satisfaction with the intervention with no decrease in symptoms. The other thing the residents mentioned on the survey was that many of them didn't feel supported by their department following the incident.

ClinkShrink said...

Pete: Thanks!

Anonymous said...

So what do you recommend for someone who doesn't want to talk and is forced into attending sessions?

shraddha said...

I was amidst similar kind of discussion on a while back.
It was how a parent dealt with trauma of losing a child.What was encouraged by moms there was talking about it, joining a support group and taking as much help as possible.
Enters me, and I gave example of my mom -in -law who did not mention the loss of her infant son to my husband until I was pregnant and suffering complications.
You would be surprised to know , this was received with much criticism and some books and doctors statements were quoted; as to how, not talking about the loss of a child and not informing the sibling about death of their twin or sis/brother affected the psychology of the child.It seems the children raised like that were over acheivers and were not satisfied with life.
Well!All I can say is my hubby did over acheive but he is most satisfied and well balanced individual I know!!!
So I guess it is right to say, talking about the trauma should be individual perrogative!!!!!

shraddha said...
This comment has been removed by the author.
Gerbil said...

The health insurance company I used to work for provided CISD facilitators to large employers (read: who paid lots of money for the benefit). I personally am critical of CISD and always felt kinda funny putting in the requests.

Clink, I checked out your PubMed search link because I was intrigued about post-partum CISD. After reading the abstract for Priest et al., I have to say that I'm not surprised that CISD didn't have any significant effect on the rate of post-partum depression. Having had some crazy labor myself two months ago, and then being hit with PPD (which I'd expected anyway), I can't see how CISD would've done anything to help. This is why we have spouses, moms, aunts, grandmas, etc... oh, and Zoloft. ;)

Alison Cummins said...

Soldiers are a group who often don’t want to talk about it. “Look, it was awful. Why would I want to talk about it?”

Sometimes old soldiers will talk about their experiences for the first time with their grandchildren. By the time they have grandchildren they know they are going to be ok. They’ve accumulated a stack of positive memories to put between themselves and the past, and now they can afford to look back in time and see what was there.

I think I would want to process something bad or difficult happening to me by talking about it. But something where I played some kind of role, passive or active? If I felt I let something happen to someone else, and felt guilty? (Like MWWAK, or like a soldier whose buddy gets blown up beside them.) If I let something happen to me, and didn’t stand up for myself? I am too fragile to stare that in the face. I don’t think I’d talk about it. I’d carry it around like shame.

While getting to a place where you can talk about it may be a sign of healing, I don’t know that it’s necessarily a cause of healing. Sometimes it just takes time. Behavioural theory suggests that *not* rehearsing terrible stuff would be most helpful.

I saw a documentary about Canadian SARTECs once. The camera crew accompanied them on a mission that involved flying helplessly around drowning sailors, throwing drowning-sailor kits out of the helicopter into the water, then throwing out everything else they could find that might float, then having to go back to shore because they were out of gas, knowing that most of the sailors would die of hypothermia before they could be rescued.

The SARTECs had at one point been given the services of a psych team to “talk about it” and “process it” when they came back from this kind of horrible mission, but SARTECs are not the talking-about-it kind. So what they did instead was coach the SARTECs to look after eachother, to watch out for someone showing signs of withdrawal after a traumatic event and to make sure they were included in the team. (Watching football and eating pizza or something.) That seemed to work much better.

Awake and Dreaming said...

mwak: That makes total sense. Giving people education and resources can be so effective. It's too bad that it isn't more understood among professionals.

CS: I'm glad to here that CISD does the education piece.

Anonymous said...

Wow, that's what my dad's been doing. He's been talking about the war in the past few years but only to them (his grandkids) and only since they've been in their 20's.

Thank you so much for saying that... roses

Anonymous said...

I could say alot here, as I am a University at Buffalo grad student. However, I am in social work, different field! However our school focuses alot of research in Trauma and addictions (together or apart).

I think the most important variable that effects a person's response to trauma is their psychological health and developmental age when the trauma occurs. This is a hard variable to measure pre-trauma in research.

I do know from my internship at the VA was that combat veterans respond to trauma is very different depending on the age of the person. As an example, I have "treated" veterans of all ages with PTSD. I had a vet who was held in a concentration camp as a European Allied troop (who later immigrated to US and served in Korea). His experiences there were horrible. He had severe symptoms of PTSD, but he never "showed" them.
Alot of vets from WWII seem to not be suffering as severely as those from vietnam. One possiblity is that those with the most severe PTSD are not alive any longer. Another factor is that the the vets from vietnam served at a younger age.
Men were drafted at 18, 19, 20. They still have not emotionally matured into adults.

I don't know. I am babbling now. Here is the study:

Dinah said...

great pic....gators or crocs?

Roy said...

Dinah: um, the photo's name is alligators.jpg...

Lady: thanks for the link.

I wonder if there are any data looking at Meyers-Briggs types and PTSD risk. I'm mostly an INTP, in case you couldn't guess.

ClinkShrink said...

Dinah: They're gators. I liked the pic because some of them had their mouths wide open while others had their mouths tightly closed.

Gerbil: I hope you're feeling better. Regards to the littlest gerbil.

Thanks to Roy, I now have a pre-publication copy of the study I linked to. If I get a chance I'll read it in more detail tonight and report later. It looks interesting, and it sounds like they've got more than one publication coming out of the study.

Gerbil said...

Clink-- yes, much better, thank you; and the gerb sends some happy drool :)