Posttraumatic Stress Intervention: Challenges, Issues, and Perspectives.

Abstract

Violanti, John M., Paton, Douglas, Dunning, Christine. Posttraumatic Stress Intervention: Challenges, Issues, and Perspectives. Springfield, IL: Charles C Thomas, 2000. xvii + 225 pp. $49.95. This text, a collection of writings by international experts in the field of acute posttraumatic stress intervention, critically evaluates current practices in the field and offers ideas and recommendations for future investigation. Acute posttraumatic stress interventions refer to brief interventions implemented usually by a mental health professional soon after a stressful or traumatic event with the purpose of preventing posttraumatic stress disorder (PTSD). These protocols are frequently referred to as "psychological debriefings" and are distinguished from treatment interventions for PTSD. As explained by the authors, these debriefings have been widely adopted since the early 1980s by many different types of organizations and tend to involve either individual or group meetings with a mental health professional or trained peer after a stressful or traumatic event. The most common method, and one that has been implemented in numerous work-related settings, has been Critical Incident Stress Debriefing (CISD). These methods of debriefing, and CISD in particular, have been extremely popular and continue to receive widespread support from professions such as law enforcement and emergency services. Research studies examining the efficacy of these interventions, however, have not found a lower incidence of PTSD among those who participate in debriefing. In fact, some studies have found that debriefing interventions have been associated with increased incidence of PTSD. In light of this disparity between the continued use of standard psychological debriefing and the lack of research to support its efficacy, this book makes an important contribution to the field. It addresses problems with current methods of acute posttraumatic stress intervention and offers alternative approaches to conceptualizing and implementing these protocols. Paton, Violanti, and Dunning provide an introduction and overview of the text in addition to describing their model based on resilience and growth rather than negative symptomatology. Stuhlmiller and Dunning argue that the present pathogenic paradigm underlying current debriefing models hinders the facilitation of resilience at both an individual and collective level. They also provide some historical background to psychological debriefing and describe how debriefing has appealed to organizations as a method of containing litigation and compensation costs related to workers' claims for stress-related problems. The authors discuss how this factors into the decision of organizations to continue implementing such protocols with little empirical support. Stuhlmiller and Dunning also raise important issues such as whether acute posttraumatic interventions are necessary for everyone and when and who should administer an intervention. A chapter by Carlier and Gersons provides a detailed description of debriefing, describes theories about how it prevents PTSD, and reviews the research literature assessing its efficacy. In their review of the literature, they distinguish between assessments of satisfaction, which have shown a high level of satisfaction from participants, and evaluation of outcomes, which have failed to find that interventions are able to prevent PTSD. They also provide some discussion of reasons for the lack of significant findings across studies. Gist and Woodall provide a critique of the CISM model for use with occupational stress, and in particular in fire and rescue work. They stress the importance of facilitating and enhancing resilience in any acute intervention with this population and emphasize individual differences among these workers and the problems inherent in debriefing all workers in a uniform way. From a very different perspective, psychiatrist Perren-Klingler raises cross-cultural issues related to acute posttraumatic stress intervention. She provides clinical examples of intervening after a traumatic event with people of different cultures, including refugees from Kosovo. The remaining chapters present arguments for the need to develop and implement strategies grounded in a strength-based model that foster people's inherent ability to successfully cope with trauma, and in certain cases, even experience positive growth as a result. Pennebaker briefly summarizes the theoretical and empirical literature on coping with trauma in addition to his ongoing research on the positive effects of writing about upsetting experiences on both mental and physical health. He also discusses the implications of his research for posttraumatic interventions. Bartone describes in detail the personality construct of "hardiness" and how it relates to resilience from traumatic stress. He presents findings from two studies that demonstrate the protective effects of hardiness on post Gulf War psychological adjustment. Calhoun and Tedeschi present the concept of posttraumatic growth, which suggests that experiencing a traumatic event, can lead to positive changes for people. They also offer specific suggestions about how to facilitate posttraumatic growth in an acute intervention. In another chapter, Violanti argues that pathogenic models of intervention can "script" a person into having posttraumatic symptoms and emphasizes the importance of viewing the individual as an agent of change who can control how he or she copes with a traumatic event. Moreover, MacLeod discusses the role of temporal orientation to coping with trauma and describes the ways that a past orientation can lead to greater and longer lasting distress. Paton, Smith, Violanti, and Eranen present a risk management model for understanding and managing the effects of exposure to traumatic stress among professions such as law enforcement, emergency services, and disaster relief. Finally, Paton, Violanti, and Dunning conclude by summarizing the efforts already made in the field as demonstrated by the contributions to this text and encouraging further efforts toward developing and disseminating interventions focused on resilience and growth. A primary theme running throughout all 12 chapters of this text is the deficiency of the standard debriefing model and the need for a shift in paradigm from what is described as the current model's "pathogenic" nature to a more "positive" or "salutogenic" approach to acute posttraumatic intervention. For example, Stuhlmiller and Dunning argue that standard debriefing approaches are based on underlying assumptions that experiencing a traumatic event causes "problems" and that people who experience a traumatic event need to be "treated." This text should be an extremely helpful resource to anyone engaged in researching, developing, or implementing acute interventions related to trauma. The contributors to this text have demonstrated a need for alternative approaches and agree that interventions should be designed to foster and enhance people's inherent resources for resilience and coping and to facilitate growth in those affected by trauma. M. Kay Jankowski, Ph.D. Postdoctoral Fellow; Dartmouth Medical School