Trauma: How to Help (and how not to!)
A guide for Mental Health professionals. Psychology lecturer, Jane Callaghan examines how psy professionals can help in the aftermath of traumatic events.
When terrible things happen, it’s the helpers that get us through. Seeing something awful brings out the best in all of us. Our instinct is to help, in any way we can. We want to reach out, to bandage the wounds. It is a wonderful impulse. For psy professionals (psychologists, counsellors, psychotherapists) this can be an intense desire — we are helpers by nature and inclination.This is wonderful. But we do need to be careful about the form that support takes.
What NOT to do:
Debriefing
Since we first identified the cluster of experiences that are often termed ‘post traumatic stress’, psy professionals have tried to develop some preventative strategy, some kind of ‘innoculation’ to ward off the frightening and often debilitating reactions that some people have to trauma. Into that space the intervention of ‘debriefing’ was inserted — a kind of psychological first aid.
Debriefing involves getting people to relive, in detail, the experience of the trauma, in a supportive context, often with other survivors, the experience of the trauma. The idea is that we help people work through and re-remember the trauma, processing it properly, and helping to put it into perspective.
It sounds good. Unfortunately it doesn’t work.
Successive systematic reviews, exploring both single session debriefing and multiple session debriefing, have found that it is ineffective in reducing people’s risk of PTSD. In fact, and more worryingly, for a sizeable chunk of the population, debriefing makes things worse. Further, whilst there is some limited evidence for exposure based CBT, results here are still early stage, and its effect is very varied. It is also a highly specialist field, that requires very careful training and strong protocol adherence — it’s not to be dabbled in.
In the immediate aftermath of a traumatic event, people experience the impact of the event, and a phase called ‘recoil’ or ‘rebound’ — the numb period when we can’t take in what has happened, we might be weepy or very quiet, we might be angry…we may even experience post traumatic responses like flashbacks or being preoccupied with the event we have seen.
We may want to talk all the time about what happened. We may not want to talk at all. We might want to go to bed and never get up again, or be incredibly hyped up and not be able to sleep at all. Many people experience some or all of these feelings. All of these responses are normal, ordinary responses. They are not ‘pathological’.
They are not a sign we are not coping — indeed feeling we are overwhelmed and can’t cope are also part of the normal response. They are the first stage of us processing what has happened.
When we debrief people in the impact stage, we are taking people who are already vulnerable, and by getting them to tell their experiences in great detail, we are effectively taking them through that experience again. Potentially we are re-exposing them to trauma. Their defences are low, they are already upset, agitated, hypervigilant and stressed… and we are effectively getting them to relive what happens. It is a second round of traumatisation.
People who are in the aftermath of trauma do NOT need to be debriefed. Well meaning interventions of this kind are potentially harmful.
What to do:
1) Psychoeducation
Psychoeducation is very helpful. When you are feeling all those terrible, scary feelings, having someone explain that they are normal and OK is helpful. Supportive counselling can also help.
2) Listen
Just being there to listen to the person, if they want to talk. No pressure to ‘work through’ anything, just being together.
3)Relaxation techniques
4) Supporting their supporters
make sure they understand the natural and normal trauma response, given them a place to sound off if they feel they’re not coping with what is happening to their friend, their child, their partner, their parent.
5) Let people recover naturally
Telling and re-telling is a powerful intervention, that helps people who have survived terrible things get an understanding of how it fits in the larger narrative of their lives. But the immediate aftermath of trauma is not the time for it. Let people recover naturally if they can — it’s the most helpful thing we can do. You can’t save people from the emotional work that is needed to heal from trauma. You can’t short circuit the process by psychological band aid. You can help by containing and supporting, and being there, perhaps a few weeks or months down the line if the person still needs support.
For more information on why debriefing is not a good idea, see:
Cochrane Review — single session debriefing as prevention for PTSD
Cochrane Review — multiple session debriefing for prevention of PTSD
For the evidence on exposure based CBT:
Exposure based CBT — meta review (not Cochrane)
Also be cautious about medications — no evidence that beta blockers, antidepressants etc — are helpful in preventing PTSD.
Cochrane review — medication as preventative for PTSD
See Jane’s personal blog for more.
