Single session debriefing sessions? Helpful or harmful? 


I write this from Uganda having just completed a Community of Practice conference hosted by the Ugandan Bible Society. This community of practice is for bible-based trauma healing facilitators and local mental and public health experts. I presented on an update to PTSD causes, effects, and treatment. We looked at the value of Scripture engagement around the topics of trauma, loss, and recovery as well as how it fits into the larger picture of trauma counseling. 

Much of what we clinicians know and do for treatment for PTSD symptoms is based on partial research but a significant dose of “clinical judgment.” What is that? Well, it is treatment models that may have some empirical support but mostly formed over long-held assumptions in the field. One of those assumptions is that we may be able to prevent PTSD if we provide group or individual debriefing sessions soon after a traumatic experience. These debriefing sessions have been offered for decades to first responders, humanitarians, and missionaries after exposure to traumatic and tragic events. In recent years we have seen some evidence that some may not be helped but these sessions. In fact, some may even be harmed. 

The evidence of possible harm is not new. Yet, debriefing is still offered indiscriminately. We find it hard to let go what seems to work. Today I was able to read a 2006 study published in the British Journal of Psychiatry (citation below). This bit of research compared emotional debriefing, educational only debriefing, and no treatment. This study of Dutch civilians who had experienced a single episode of trauma within the last two weeks found that all three groups (emotion oriented debriefing, education only, and no treatment) saw a decrease of symptoms at 2 and 6 weeks post intervention. There was no benefit from either form of debriefing found in this study. 

In addition to no benefit, those individuals with high arounsal trauma symptoms who completed emotional debriefing showed higher rates of PTSD symptoms than the those with higher arousal who did nothing or only the educational oriented debriefing intervention. So, some forms of debriefing may actually worsen symptoms. Why? The authors surmise, 

In previous studies it has been established that high degrees of arousal in the immediate aftermath of a traumatic event are associated with an increased risk for the development of PTSD, measured both by self-report (Carlier et al, 1997; Schell et al, 2004) and physiologically by means of heart rate response (Shalev et al, 1998; Bryant et al, 2000; Zatzick et al, 2005). Encouraging highly aroused trauma survivors to express their feeling and emotions concerning the trauma might activate the sympathetic nervous system to such a degree that successful encoding of the traumatic memory is disrupted. Moreover, during an emotional debriefing session negative appraisal of one’s sense of mastery may be promoted (Weisaeth, 2000). This is assumed to keep the hyperreactive individual in a state of high arousal which may cause symptoms of PTSD to escalate rather than resolve (McCleery & Harvey, 2004). 

So, what should we do with this information? Nothing? No. But what we do should not harm, especially when we know some may be harmed. I suggest a few possible outcomes:

  1. Education about PTSD and trauma should continue. This study does not reveal harm for this intervention and given the relatively low trauma symptoms in this study (and the possibility some may have already been aware of what trauma is), education is likely to be helpful. Education is not only about trauma but also about good coping skills and activities. It does not focus on the events of the trauma experienced.
  2. Bible-based trauma healing begins not with a person’s story but looks at culture and common reactions. It normalizes pain and suffering and connects people to God and others. We do not yet have great empirical evidence (it is being collected) that such an intervention is helpful or harmful. But it appears that giving people permission to ask questions of their faith and to see that God encourages lament may still be helpful. 
  3. We need assessment of the growing movement and art oriented responses to trauma. What do these non-talk therapies add to the prevention or intervention strategies? 
  4. Debriefing or talking about a trauma that has just happened should focus less on replaying the details and more on current cognitive and affective impact with focus on resilience and boosting existing capacities. Brief assessment of arousal symptoms may well be warranted by those who promote processing trauma stories. This may be why NET, CPT and DBT oriented PE have lower drop-out rates than classic PE (prolonged exposure) therapy. 

Citation: Emotional or educational debriefing after psychological trauma (Randomised controlled trial) by MARIT SIJBRANDIJ, MIRANDA OLFF, JOHANNES B. REITSMA, INGRID V. E. CARLIER and BERTHOLD P. R. GERSONS. In BRITISH JOURNAL OF PSYCHIATRY (2006), 189, 150-155. doi: 10.1192/bjp.bp.105.021121

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Dissociating during trauma makes PTSD worse by increasing negative narratives about the self? Connecting recovery with rejecting these narratives


It is somewhat common for individuals to experiences a period of dissociation and/or perception of being frozen and unable to move during a traumatic experience. Dissociation is a catch-all word to describe experiences where a person is somehow disconnected from a portion of their senses making what is happening feel somehow unreal. Experiences can include emotional numbness, feeling events are not real, not feeling in one’s own body, or not remembering what just happened.

In the April issue of the Journal of Trauma Stress researchers discuss possible connections between experiencing dissociation during a trauma and increased negative beliefs about the self. Dissociation during a trauma is called “peri-traumatic dissociation.” It is already understood that peri-traumatic dissociation is a strong predictor of subsequent PTSD diagnosis. 

This short study suggests that those who have dissociative experiences during trauma may be more likely to think negatively about themselves, both about their trauma experiences (e.g., I should have been able to stop it) and their present feelings about themselves (e.g., I’m unreliable). The researchers suggest that therapists ask clients about both forms of negative views of self if the client describes dissociative like symptoms during the trauma experience. 

It would have been helpful if the researchers connected their work with that of shame experiences. We continue to try to understand why some people find some experiences more traumatizing and thus have greater difficulty finding recovery. It seems that shame is distinctly tied to chronic trauma and being stuck in negative self-talk narratives. It may be that those who struggle the most with negative self-talk (I should have been able to stop my abuser) experience the most shame. But I have yet to see anyone try to parse that out. 

In my experience, negative attributions about the self are just about the hardest things for us to change. We may have developed these well-formed beliefs from failure experiences or we may have had them formed for us by our families. But whatever the cause, they are so very hard to let go. In fact, when others show kindness to our perceived uglyness, we tend to pull back, refusing to allow these parts to be acceptable.

What is it about letting go of our shame and accepting ourselves as normal, as valuable?  How would you articulate the problem?
*Thompson-Hollands, J., Jun, J.J. & Sloan, D.M. (2017). The Association Between Peritraumatic Dissociation and PTSD Symptoms: The Mediating Role of Negative Beliefs About the Self. JTS, 30, 190-194.  

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Podcast on Anxiety


Recently, I was interviewed for a podcast on the topic of anxiety by Walt Mueller and the good folks at the Center for Parent/Youth Understandings. You can listen here: https://cpyu.org/resource/episode-39-anxiety-with-dr-phil-monroe/

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Is it trauma or is it intensity/identity loss?


The current definition of PTSD requires an exposure to an intensely distressing event or events (either witnessed or told about in great detail) resulting in a pattern of intrusive re-experiencing, attempts to avoid such experiences and an ongoing negative cognitive/mood pattern. Such a diagnosis might be made after domestic and sexual violence, accidents, natural disasters, war, betrayal traumas, and even after hearing repeated stories of traumatic experiences to others (called secondary trauma).

Someone experiencing PTSD after life-threatening events might feel disconnected from family/friends, find it difficult to sleep, experience repeated nightmares, have difficulty not thinking about events during and after the traumatic experience, choose unhealthy coping patterns like alcohol abuse, or place themselves in situations where they re-enact parts of their trauma story.

But not everyone who has intrusive thoughts about a challenging situation, feels disconnected from their community (and previous self), drinks too much, or impulsively jumps back into danger have PTSD. Some of these same behaviors and experiences also show up in those who have left dangerous and all-consuming experiences and now do not know how to re-engage in regular life.

Consider these words of Dr. Steven Hatch, who spent time in Ebola clinics in Liberia at the height of the 2014 pandemic crisis in West Africa. He describes his experience after returning to his job at the University of Massachusetts.

To match the outside weather, my mood willingly turned dark. I withdrew from people, wandered about in a daze, and avoided public gatherings. When I did venture out, I carried myself in a completely different manner than I had before in my life.


The simple explanation was that I had post-traumatic stress disorder, and a few people, including some whose job it is to make such diagnoses, thought this to be true. (p. 239, Inferno)

He goes on to dispute his experience fighting Ebola as trauma. While difficult, he did not think it rose to the level of trauma experienced in war or even other more overwhelming Ebola clinics.

I could, however, recall the event [death of a toddler] in my mind without being emotionally overwhelmed, but also just as importantly I was able to still experience emotions about it, feeling appropriately somber. I just didn’t feel traumatized. (p 240)

So, what was his problem?

What I did share with many other volunteers was a sense that I didn’t belong in the States, for the work in West Africa was far from over. I desperately wanted to return, and almost within days of coming home I was trying to figure out how I could get back to an ETU [crisis Ebola center]. What I missed was the profound sense of purpose that such work had provided, and I slowly realized why people talked of “missing the war,” a phrase that always seemed discordant to my ears. You miss being in the midst of senseless butchery? Great. But I belatedly realized it was that purposefulness, the sense that you were doing something that was deeply and truly meaningful, that drove people back to such unstable situations. (p. 240-41)

There you have it. The seeming loss of crystal clarity or purpose in life can be very painful. When you are in an intense helping situation as Dr. Hatch was, every movement leads towards life or death. At the end of a day, you can count who lived and who died. No ambiguity. In addition, you are doing it with a team of people all committed to the same thing. You share the same vision, goal, and daily experience. You do not have to explain anything. And in these intense situations, you can have the kinds of intimacy not often experienced even in your immediate family. Also subtract mundane activities (grocery shopping, cleaning, taking care of children, etc.) that may not need to be done.

This is a recipe for distress upon return.

Return to regular life where you are expected to do these seemingly inconsequential activities AND where you have no one around to save AND no one who was present with your toughest experience…and you have a recipe for trouble. You may find it difficult to find joy in light of intrusive thoughts of recent emotionally intense experiences. You may long for a return to that sense of purpose and value. Because others do not understand and aren’t part of your “tribe” you may withdraw or find other ways to numb the pain.

Loss of identity and intensity may mimic trauma symptoms. They may be significant to need treatment. Military ending tours of duty, missionaries returning from field, humanitarians returning from doing crisis work, church planters leaving high stakes urban church plants, and trauma healing trainers returning from intense experiences may be at risk.

What can be done to prevent this distress?

  1. Probably nothing will take care of the problem. One could not go do intense work. Or one could become a crisis junkie. Neither are good options.
  2. But developing re-acclimation plans can help. Yes, training done before entering the intense experience will set the stage for healthy returns but post-tour of duty re-entry work is more important. The Army has develop protocols for re-entry by beginning the process even before leaving the “theatre.” Creating space for coming off the “high” giving time to process and following-up in the early days back can help. Involving family in the re-entry planning and building activities that can elevate family intimacy upon return will help immensely.
  3. Encouraging time and space to lament and process in group settings. This is where a therapist can help. Group process helps to put words to experiences and acknowledges impact on identity. This can also help re-connect with meaningful activities and experiences at home. One has to re-learn that meaning is not solely connected to intensity.

I have some very small personal experience with this. I’ve had intense experiences in international settings. When I have returned, I have sometimes found it hard to be at home when my head was still overseas. Being able to share with Kim and others helped. Practicing lament helped. Learning to be mindful of the present also helped me remember what has meaning and value in everyday life.

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Historic child abuse prevention course


Godly Response to Abuse in the Christian Environment and my seminary, Biblical Seminary, have teamed up to offer a 3 credit course for seminarians on the topic of child sexual abuse prevention and response. This course will run on our Hatfield campus on Monday nights during the month of June. To my knowledge, a course like this has not been offered before. I highly encourage you to send your pastors or church leaders for some continuing education.

Press release and details here: Curriculum Press Release or go to the BTS site to see it here.

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Complex Trauma: Going Deeper, By Diane Langberg


As part of our staff meeting today we watched this video by Diane Langberg. It reviews the 3 stages of typical trauma recovery process plus focuses on the impact of the work on the counselor. Self-care is a common conversation these days. However, a few lines stuck out to me:

Unless we take care of ourselves, we will not be able to bear witness…. Vicarious trauma is not something done to us but a consequence of having empathy…. Evil and suffering also provide an opportunity to expose the weak places in [the counselor]…. Seek out the antidotes to the poison that you sit with…[these antidotes] are not just good coping mechanisms but part and parcel to living the life obedient to God.

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Reading the bible through the lens of trauma?


What if you read the bible through the lens of trauma? Some are quite obvious–catastrophes are all throughout the bible. But are these stories of trauma in the bible merely keeping a record of it or attempts to deal with the trauma, to put the world back proper perspective after chaos?

Consider this 2015 video by Rev. Dr. Robert Schreiter entitled: Trauma in The Biblical Record. He gives some background about this newer way to read the bible through this lens and then ends with 3 examples. I’ve just ordered this book on the subject, but those wanting to jump ahead may wish to know about it as well.

 

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Diane Langberg: Living with ongoing trauma


A few years ago, Dr. Diane Langberg gave a talk about ongoing trauma experiences, when there is no “post” in the posttraumatic stress disorder. When there is no after trauma yet (e.g., ongoing domestic violence, living in a war zone, etc.), what kinds of help and hope might a survivor hold on to? Is there anything that can be done?

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What does resilience look like in the face of traumatic experiences?


Does a resilient individual appear as if stress and trauma has not lasting impact? Does it mean we bounce back as if it never happened? Are there better ways to think about resilience in real life?

In 2014 I gave a presentation reviewing the topic of resilience (definition, examples, threats to, and helps) at our annual Trauma Healing Community of Practice hosted by the American Bible Society.

Sometimes we consider only resilience as an individual trait. I spend a bit of time talking about community resilience. Video is 25 minutes and associated slides (not embedded in the video) can be found here: 2014 COP Resilience.

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Diane Langberg on Shame


A few years ago, Dr. Diane Langberg presented on the topic of shame at the 2014 Community of Practice hosted by the American Bible Society. She describes the toxicity of shame as a distinct part of trauma, especially betrayal trauma. You will learn about the cognitive phase of shame, kinds of shame experienced and how the response to shame takes one of 4 common forms (i.e., withdraw, avoid, attack self, attack others).

Make sure you watch to the end as she shares some insights to how God understands and responds to our problem of shame. See how Jesus enters in to our shame.

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