© 2000 The Royal College of Psychiatrists
Correspondence |
Psychological debriefing: historical military perspective
Royal Defence Medical College, Fort Blockhouse, Gosport, Hampshire PO12 2AB
May I offer a historical military perspective on the paper by Mayou et al (2000). Proponents of psychological debriefing have misused the military experience from the Russo-Japanese War 1904/5 onwards to justify early psychological intervention using PIES - proximity (close to the scene - in safety), immediacy (as soon as possible), expectancy (that individuals will return to duty - not to prevent ensuing psychological illness) and simplicity (respite, rest, recollection, rehabilitation and return to duty). Proponents conveniently forget that PIES was only ever applied to those who were deemed to be suffering and was conducted by individuals who shared and understood their experience.
There may be many reasons why Mayou et al arrived at their conclusions but the same caveats apply as are appended to Bisson et al (1997), Kraus (1997) and Turnbull et al (1997), among others. Perhaps we (psychiatrists) are at fault in trying to categorise human responses to unpleasant events into medical conditions and are naïve to think that one intervention could prevent post-traumatic stress reactions and illnesses that are multi-factorial and complex in genesis.
In trying to understand and manage post-traumatic stress reactions there are a number of useful metaphors. Garb et al (1987) find the grieving process particularly useful as both post-traumatic and grieving are responses to loss events. Although an unfashionable term, psychological defence mechanisms exist to protect the individual (at least initially); to interfere with such mechanisms carelessly courts disaster. Perhaps psychological debriefing does just this. In both posttraumatic reactions and grief there is a period of introspection during which individuals do not wish to talk. Such needs should be respected, and usually are in the case of grief. Why should traumatic events be different?
This period is followed by a time when assistance and advice is welcome, even sought, and in post-traumatic situations, as in grief, this should first be sought from the social support network. If this does not work, then professional help may be required, but we as professionals must question the seemingly ubiquitous societal belief that exposure to traumatic events is always an entirely negative experience and that post-traumatic stress disorder is the only post-traumatic mental illness.
I do not share the authors' reassurance that the three-year follow-up rate was only 48% as it provides ammunition for those who will, I fear, continue to provide psychological debriefing. Perhaps it is cynical to question their motives but I am troubled by the almost pornographic nature of human experiences outwith the normal. There is a voyeurism and the potential vicariously to become part of a traumatic event, even of history, by intervening. Society's or is it the media's cry is ‘something must be done’, and despite the growing body of evidence that psychological debriefing does not work, or is harmful, I suspect such work will not be halted unless society changes from its ‘psychologicalisation’ of human distress. There is an old military adage that applies here: ‘the only thing harder than trying to get a new idea into a military mind is trying to get the old one out'.’.
Perhaps Mayou et al's paper reinforces the reality that there are no ‘quick fixes’ for human experiences. The provision of help should be directed towards those who are defined as affected by their experiences. Identifying these cases should be the challenge for psychiatry. Perhaps then the advice proffered by Salmon (1917) will be correctly applied, although such interventions are unlikely to be so simple.
REFERENCES
- Bisson, J. L., Jenkins, P. L., Alexander, J., et al
(1997) Randomised controlled trial of psychological
debriefing for victims of acute burn trauma. British Journal of
Psychiatry, 171,
78-81.
[Abstract/Free Full Text] - Garb, R., Kutz, I., Bleich, A., et al
(1987) Varieties of combat stress reaction: an immunological
metaphor. British Journal of Psychiatry,
151,
248-251.
[Abstract/Free Full Text] - Kraus, R. P. (1997) Psychological debriefing for victims of acute burn trauma (letter). British Journal of Psychiatry, 171, 583.
- Mayou, R. A., Ehlers, A. & Hobbs, M. (2000)
Psychological debriefing for road traffic accident victims. Three-year
follow-up of a randomised controlled trial. British Journal of
Psychiatry, 176,
589-593.
[Abstract/Free Full Text] - Salmon, T. W. (1917) The care and treatment of mental diseases and war neuroses (‘shell shock’) in the British Army. Mental Hygiene, 1, 509-547.
- Turnbull, G., Busuttil, W. & Pittman, S. (1997) Psychological debriefing for victims of acute burn trauma (letter). British Journal of Psychiatry, 171, 582.
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