Causing More Grief

Every American calamity-from the shootings at Columbine High School and the Oklahoma City bombing to the latest terrorist attacks-now features TV news reporters earnestly assuring viewers that "grief counselors" are on their way to help victims cope with the disaster. The provision of grief counseling is now a culture-wide phenomenon. Bad stuff happens and grief counselors flock in. And why not? Surely, the maimed psyches of survivors and rescue personnel need healing nearly as much as do their wounded bodies.

Modern grief counseling is not just plain old-fashioned handholding and crying together. It's science. Practitioners claim that their counseling reduces the incidence of post-traumatic stress disorder (PTSD) in victims who submit to their therapeutic ministrations. But does it?

Not so fast, says Richard McNally, a Harvard University psychology professor. "Most studies show no difference in victim recovery," McNally says. "But more worrisome is the fact that two more recent studies showed that those who received critical incident stress debriefings did worse than those who did not. The counseling seems to be impeding recovery."

McNally and 19 colleagues submitted a letter earlier this month to the American Psychological Association's Monitor newsletter. The letter noted, "Several independent studies now demonstrate that certain forms of post disaster psychological debriefing (treatment techniques in which survivors are strongly suggested to discuss the details of their traumatic experience, often in groups and shortly after the disaster) are not only likely to be ineffective, but can be iatrogenic." "Iatrogenic" refers to diseases caused by treatment itself. Counseling, it seems, can make people feel worse, not better.

What McNally and his colleagues are concerned about is a type of grief counseling called "critical incident stress management" (CISM) that has become very popular in the past two decades. At the center of CISM is the "critical incident stress debriefing" (CISD) in which victims are encouraged to relive their traumatic experiences, usually in group sessions. One of the main clearinghouses for CISM practitioners is the International Critical Incident Stress Foundation, Inc. (ICISF) located outside Baltimore, Maryland.

CISM practitioners–generally, psychologists, psychiatrists, social workers, and licensed counselors–reject the colloquial term "grief counseling" for what they do. One debriefer, John Weaver, who is a Licensed Clinical Social Worker and a Board Certified Diplomat, recommends that therapists "encourage expression of the most vivid or graphic negative images and memories. Think of it as cleaning out an emotional wound before allowing it to try to heal with foreign material still on the inside." Such therapy talk resonates with Americans who are brought up with Oprah Winfrey-style confessional TV.

Jeffrey Mitchell, ICISF president and creator of the leading debriefing model, proudly asserts, "CISM is now becoming a 'standard of care' in many schools, communities, and organizations."

Indeed it is–critical incident debriefing is big business. The federal government paid over $4 million for critical incident debriefing services after the Oklahoma City bombing in 1995. The ISICF's network of several thousand certified counselors is ramping up to treat the survivors of the September 11 terrorist attacks. ISICF executive director Donald Howell, in a recent update to members, notes, "Several Non-Governmental agencies are providing focused/regional CISM Intervention Services within New York City and the surrounding communities. ICISF is actively supporting one of those agencies and is fulfilling their requests for CISM Teams. It is anticipated that the number of Teams to support their efforts will increase dramatically over the next several weeks."

"I have heard that 80 companies formerly in the World Trade Center are thinking about contracting for debriefing services," says McNally. "Apparently, the companies are worried about liability suits if they don't offer their employees this service, but I would worry more about forcing people to be debriefed who would later sue on the grounds that what a company forced them to go through doesn't work at best, and at worst is toxic."

Proponents of CISD respond that the studies upon which McNally and his colleagues are relying are flawed and that numerous clinical studies demonstrate the efficacy of critical incident debriefing interventions. McNally agrees that no studies are perfect, but points out that proponents don't have any scientific evidence in the form of double-blind experiments–in which subjects are assigned randomly to either treatment or control groups–to back up their claims. Instead, proponents rely chiefly on qualitative informal clinical impressions as evidence-essentially patient testimonials.

"Of course, when people are asked whether the sessions were helpful or not, most people say yes, even though the evidence shows that they are recovering more slowly than those who did not receive the debriefing," says McNally. "For some people, debriefing is like opening up a wound and not sewing it back up."

McNally points to a recent review of debriefing by the authoritative Cochrane Library, which is devoted to evidence-based medicine. The study forcefully concluded: "There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease."

McNally doesn't doubt the good intentions of the debriefers, but good intentions are not enough, especially when those wielding the intentions might end up doing more harm than good. If debriefing doesn't work, what should be done to heal the psychic wounds of the victims of mass catastrophe?

"In the immediate aftermath, go easy. Don't be intrusive. Have therapists available should people seek them, but no mandatory debriefings," McNally suggests. "Be empathetic, let people go at their own paces, permit people to cry, but don't compel them to cry. Some treatments for people who are still experiencing PTSD three months after an incident might include one-on-one sessions that help them learn to cope with going inside tall buildings or fly again."

The good news is that epidemiological studies of mass catastrophe survivors show that "even without counseling, most people are going to do OK in the long run," says McNally.

Asked what he would say to companies and agencies that are thinking of making critical incident debriefing available to survivors of the terrorist attacks, McNally replies, "Informed consent comes in here. You have to tell your employees that you are making a therapy available that, based on the best information in the scientific literature, will likely do nothing to help and might actually make matters worse-do you still want it?"

Probably not.