Thursday, November 03, 2011

I Still Don't Need To Talk

Three years ago in a post called I Don't Need to Talk I blogged about the evidence for and against critical incident stress debriefing (CISD) for preventing PTSD. Back then I suggested that CISD should not be mandatory for people who experience trauma for two reasons: most people don't develop PTSD after trauma and get better on their own even without therapy, and there was increasing evidence to suggest that CISD may make some people worse.

Today a story came across my Twitter feed (thanks USMCShrink!) about the medical response to the Japanese tsunami. Apparently psychological debriefing was strongly discouraged by Japanese mental health authorities for the reasons I just mentioned.

I think this is the leading indicator that attitudes are changing toward the role of psychiatry in disaster response preparedness.  It also may mean that we might have to change how we approach the mental health care of veterans. I've talked to a lot of vets who were required to go through post-deployment debriefing. Did it help? Did it hurt? Are we doing the right thing? While treatment should be offered to people who really do develop disorders, in this case preventive intervention may not be so preventive.


rob lindeman said...

Excellent points. See also erstwhile Shrink Rap commenter AEK's blog, Incompatible with Life, for discussions regarding the harms associated with suicide counseling. Regarding "preventive" counseling in schools post-disasters or student deaths, I don't know of data, but it's compelling to speculate that such counseling may not be effective, or worse, may be harmful.

wv = menta; breath freshener for geniuses. Freshens your breath while you solve differential equations in your head.

Anonymous said...

This is all speculation.

Dinah said...

Nice article. I agree that in a world of limited resources and no evidence for prevention of mental health issues, we should be focusing treatment on those who want it.

I hadn't thought of counselors being available at schools after an awful event as being preventative, I just thought of it as being something that is nice to provide to those who wish to talk.

I think one thing that doesn't sit right with me is the required nature of the debriefings. May be better to say "We have someone available to speak with you about your experiences" for those who wish to speak. It seems to me that people vary greatly with how much they want to articulate their feelings about any given event. Some find it helpful to talk, others don't. And the issue of whether these interventions then prevent future morbidity is it's own whole other dimension.

Anonymous said...

Really interesting stuff.

I have a brother that did a 15 month stint in Iraq two years ago - infantry, Stryker Brigade. Lost a guy in his platoon.

He came home, was finally diagnosed with a mood disorder, which I suspected for years.

But definite PTSD. He won't talk about his tour in war, and you can see him drift off, or clam up and tense up if you bring it up. He has nightmares from time to time. We have learned to not say anything, but he definitely could benefit from some psychotherapy. On the flip side, another guy in his brigade seems to be fine, well adjusted, and doing well inspite of the crap he saw as well.

Like you said, some need to talk and some don't.

jesse said...

Agreeing with Rob and Dinah. The problems with mandatory debriefings or counseling are many, but a primary one is that making it mandatory actually replicates the trauma that the person just suffered. They had no choice about what had happened, and here again they have no choice.

One of the primary dicta of psychotherapy is that the patient chooses when to talk about what. This is a subset of that.