Lenore Meldrum

Does debriefing after psychological trauma work

Some people believe strongly that talking through traumatic or stressful experiences may help the psychological recovery of those who have suffered psychological wounding. This belief has led to military psychiatrists providing immediate interventions at the front line that are intended to heal and return soldiers to activity,1 and it has fuelled psychological debriefing methods such as Mitchells critical incident stress debriefing.2 Debriefing programmes have expanded rapidly, reflecting a powerful social movement that sees them as meeting the needs of workers in emergency services, victims of disasters, and those who have been affected by trauma and violence in wider society.3 4 5 Yet, although military psychiatry has succeeded in returning troops to action, outcome studies suggest that soldiers who are repeatedly traumatised by returning to combat may suffer even higher rates of severe and chronic post-traumatic stress disorder in the longer term.1 The proponents of debriefing agree that it needs evaluation, yet there is a dearth of systematic evaluation and outcome studies. In one of the few systematic evaluations, many subjects reported two weeks after debriefing that they had found it helpful and felt less stressed.6 Nevertheless, 41% of the group of chiefly female welfare workers (n=65) and almost 6% of the group of chiefly male emergency workers (n=102) reported the traumatic experience to be “still having considerable or great impact on them,” with a high frequency of cognitive and …

The therapeutic alliance: the key to effective patient outcome? A descriptive review of the evidence in community mental health case management

Objective: The aim of this review was to examine the level of evidence supporting the assumed link between a positive therapeutic alliance among patients and case managers and effective outcome for patients with a mental illness who are managed in community mental health services. Method: MedLine, PsychINFO and Social Sciences Index search of articles from 1986 to 2001 returned 84 articles and two texts. Inclusion criteria were the use of validated measures and relevance to psychiatry and community case management. Results: A definite correlation exists in the psychotherapy literature between the therapeutic relationship and improved outcomes, with its potential as a prognostic indicator acknowledged. Attempts to apply the concept to patients outside the field of psychotherapy have been slow, although expansion of the concept to other forms of change-inducing therapy was a current trend. Issues of definition, quantification and measurement of the relationship caused rigorous debate in the literature. Case management research demonstrating the importance of the therapeutic relationship and ‘goodness-of-fit’ between patients and case managers was sparse with no published Australian studies. Conclusions: The level of evidence supporting the link between the therapeutic alliance of patients with mental illness and improved outcomes although sparse is encouraging. It indicates the potential of the alliance as a predictor of outcome for patients engaged in case management services in community mental health. Research to determine the role and effectiveness of the alliance in the patient/case manager dyad is needed to define this potential. Effectiveness of clinical practice in the case management field could be enhanced if research findings confirmed the genesis and value of the alliance in case management. Focus on relationship strategies as a clinical tool gives the clinician and service provider a potential vehicle for promoting partnerships with the seriously mentally ill person in managing their illness and optimizing their strengths in the community.

Posttraumatic stress disorder: an exploratory study examining rates of trauma and PTSD and its effect on client outcomes in community mental health

BackgroundRates of trauma and Posttraumatic Stress Disorder (PTSD) were examined in order to compare the profile in clients of an Australian Public Mental Health Service with that reported in the international literature for clients with major mental illness and to explore the effect of this on client health outcomes. Potential factors contributing to increased levels of trauma/PTSD in this group of clients and the issue of causality between PTSD and subsequent mental illness was also explored.MethodsA convenience sample of 29 clients was screened for trauma and PTSD using the Posttraumatic Stress Diagnostic Scale™ (PDS) and selected outcome measures. Paired and independent samples t-test and ANOVA were applied to the data.ResultsHigh levels of undocumented trauma and PTSD were found. Twenty clients, (74%) reported exposure to multiple traumatic events; 33.3% (9) met DSM IV diagnostic criteria for PTSD. Significant difference was found for PTSD symptomatology, severity and impairment and for client and clinician-rated scores of Quality of Life (QOL) outcomes in the PTSD group. No effect for PTSD symptomatology on the Working Alliance (WA) was found. Factors that may influence higher rates of PTSD in this group were identified and included issues associated with the population studied, the predominance of assaultive violence found, and vulnerability and risks factors associated with re-traumatisation within the social and treating environments.ConclusionA similar trauma and PTSD profile to that reported in the international literature, including greater levels of trauma and PTSD and a poorer QOL, was found in this small sample of clients. It is postulated that the increased levels of trauma/PTSD as reported for persons with major mental illness, including those found in the current study, are primarily related to the characteristics of the population that access public mainstream psychiatric services and that these factors have specific implications for service delivery, and raise issues of efficiency and effectiveness of resource use in achieving successful outcomes in public mental health services for clients with co-morbid PTSD. Further research with a more rigorous design is needed to test these preliminary findings within Australian Community Mental Health Services.

The evolution of mental health responses and research in Australian disasters

This paper overviews the development of Australian mental health services during disasters as well as recording research conducted and outcomes published. A comprehensive review of disaster research conducted on the Australian continent over the past 15 years has been undertaken. This includes “natural disasters” of flood, bushfire, cyclone, and earthquake; as well as “man-made” disasters of rail accident, bus crash, shipwreck, and mass shootings. The Australian mental health response to disasters has evolved progressively through a changing focus from broad evaluations in early studies to systematic exploration of the mental health impact. Ongoing research should consider prevention at every level, further exploration of etiology, and the issues of service provision across the diverse nature of Australian society.

Does debriefing after psychological trauma work? Time for randomised controlled trials

This article first appeared in the British Medrcal]ournol (Vol. 310. he 1995: 1479-14801. The’bMJ Publishing Group ig the copyright holder of this article and it is reproduced with their kind permission. Some people believe strongly that talking through traumatic or stressful experiences may help the psychological recovery of those who have suffered psychological wounding. This belief has led to military psychiatrists providing immediate interventions at the front line that are intended to heal and return soldiers to activity (Soloman & Bendenishty 1986), and it has fuelled psychological debriefing methods such as Mitchell’s critical incident stress debriefing (Dunning 1988). Debriefing programmes have expanded rapidly, reflecting a powerful social movement that sees them as meeting the needs of workers in emergency services, victims of disasters, and those who have been affected by trauma and violence in wider society (Pennebaker & Susman 1988; Ersland et al 1989; Shapiro Kunkler 1990). Yet, although military psychiatry has succeeded in returning troops to action, outcome studies suggest that soldiers who are repeatedly traumatised by returning to combat may suffer even higher rates of severe and chronic posttraumatic stress disorder in the longer term (Soloman & Bendenishty 1986). The proponents of debriefing agree that it needs evaluation, yet there is a dearth of systematic evaluation and outcome studies. In one of the few systematic evaluations, many subjects reported two weeks after debriefing that they had found it helpful and felt less stressed (Robinson & Mitchell 1993). Nevertheless, 41% of the group of chiefly female welfare workers (n-65) and almost 6% of the group of chiefly male emergency workers (n-102) reported the traumatic experience to be ‘still having considerable or great impact on them,’ with a high frequency of cognitive and other symptoms. Symptoms were not, however, assessed systematically with standard measures. Randomised controlled trials of the effectiveness of debriefing have not been reported, although a few studies include comparison with a group that was not debriefed. A study of fnefighters two weeks after they dealt with a hotel fire in Norway showed that most of those who attended debriefing reported that it had helped and increased their self confidence. Their scores for intrusive thoughts and avoidance behaviour measured by the impact of events scale (Horowitz et al 1979) were no different from those of the group who had simply talked to their colleagues informally (Hytten & Hasle 1989). Nearly half of a group of emergency workers surveyed one year after attending serious bus crashes still reported considerable symptoms, and 13% thought that they would probably not recover (Griftiths & Watts 1992). Those who had been debriefed (182 of 285) had significantly higher scores for morbidity and distress on the general health questionnaire (Goldberg & Hillies 1979) and the impact of events scale. These findings provide little evidence that the debriefing, even though perceived as helpful, was effective in preventing negative outcomes. The group with high distress might have been worse without it, but the study was unable to show this. Similar findings were obtained in a longitudinal study of 195 people who had helped after an earthquake, of whom 62 had been debriefed and 133 had not (Kenardy et al in press). Screening for degree of stressfulness, threat, and psychological exposure over the subsequent two years found a general decrease in symptoms, with less improvement over time among those who had been debriefed, even though 80% rated the debriefing as helpful. Clearly, neither perceived helpfulness nor experience of debriefing was associated with more positive outcomes. These studies were not controlled trials. The groups may not have been comparable, perhaps experiencing different stressors (loss rather than trauma), having uncertain roles, and having more welfare or counselling functions, for which the debriefing model was inappropriate, or perhaps being more distressed at the outset. But it is conceivable that debriefing may exaggerate the traumatic process (Kenardy et al in press; Watts R 1994) or even be associated with a delayed presentation. In addition, exposure to informational social support, which forms part

The Impact of Terrorism on Palestinians in Israel: An Interview with Eyad El-Sarraj

Abstract Palestinian psychiatrist Eyad El-Sarraj, director of the Gaza Community Mental Health Programme, is interviewed by Australian psychologist Lenore Meldrum regarding the impact of terrorism on the Palestinian people. The differential effects of the loss of their homeland, the occupation, and the Intifada on various generations of the Palestinian community are discussed. A stable home and communicative mother are suggested to be stabilizing influences on the adjustment of Palestinian children in the midst of the violence in Israel. Valuation of the interests of the group over the individual, a tribal tradition that endorses revenge across generations, and the influence of extremist Islamic teachings are cited as forces that promote the practice of suicide bombing. The conflict in Israel is conceptualized as a cycle of violence between two communities that is only likely to be resolved through mutual respect by each faction for the humanity and rights of the other.