Evaluation of Stress Debriefing Interventions with Military Populations

Military Medicine, Dec 2003 by MacDonald, Catherine M

Military members are frequently exposed to traumatic events. In an attempt to mitigate the psychological impact of traumatic events, formal interventions, such as Critical Incident Stress Debriefing and Process Debriefing, have been developed and implemented. Through a literature review of psychological debriefing interventions in the military, several anecdotal and research-based observations are discussed. Suggestions for clinical application and programmatic research are made based on these empirical findings.

Introduction

Over the past 60 years, formal preventive interventions have been implemented in an attempt to mitigate the psychological impact of traumatic events, alleviate acute stress response, and reduce the incidence of post-traumatic stress disorder (PTSD). This article synthesizes the current literature addressing psychological debriefing interventions with military populations after duty-related trauma exposure and includes an analysis of published military empirical data. Clinical implications and research considerations are also addressed.

Background

"The few, the proud, the Marines" is an advertisement alluding to the surreal nature of those who join this elite organization. Military members have been characterized as "macho" or as immune to the trauma they experience because it is "just part of the job." Mitchell' called this the "John Wayne Syndrome- you're not hurt unless a bone is showing" (p 36). When Canadian military members did not live up to this stereotype in World War I, they were shot by their allies, and in World War II, they were labeled as "lacking in moral fiber."2 Seeking psychiatric help was seen as a weakness, and members feared being "black listed."

Compounding this stereotype is the erroneous belief that humanitarian missions are less hazardous than wartime missions; the "peacekeeping" troops in Bosnia and Somalia would likely disagree. Soldiers are deployed to war-torn areas that may not appreciate their presence. Although not engaged in the actual war, they are frequently fired upon and seldom are allowed to return fire to maintain the "peacekeeping efforts." They witness death, trauma, and atrocities and yet must remain neutral.2,3 In a survey of 1,300 Canadian soldiers returning from Bosnia, 20% endorsed symptoms of depression, anxiety, and PTSD.3

The post-trauma psychological sequelae military members experience has many names: shell shock, combat fatigue, war neurosis, and combat stress reaction (CSR), among others. This is seen as a transient reaction and as a possible precursor to PTSD.

A CSR occurs when a soldier is stripped of [his/her] psychological defenses and feels so overwhelmed by the threat that [s/he] becomes powerless to counteract or distance [him/herself] from it and is inundated by feelings of utter helplessness and anxiety. In this state, the soldier is a danger to self and unit and is no longer able to perform military duties (p 11).4

Mitchell describes critical incident stress symptoms of fatigue, insomnia, restlessness, irritability, anxiety, hypervigilence, depression, and somatization in soldiers dating back to the American Civil War.1 Reported prevalence rates of CSR and PTSD in war veterans vary according to sampling and methodology.4,5 Solomon reports World War II prevalence rates of CSR ranging from 10 to 48% and Vietnam rates as low as 1.2% but notes these rates have been challenged as misdiagnosis, underestimation, and underreporting.4 These latter allegations result from inconsistent lifetime prevalence rates for PTSD and partial PTSD of 53.4% in male and 48.1% in female Vietnam veterans from the National Vietnam Veterans Readjustment Study.5

Prevention

Friedman et al.5 suggested careful recruit screening and psychoeducation as primary preventive techniques for duty-related psychological sequelae. Because screening is not absolute and neither trauma nor individual appraisal of traumatic events are predictable with complete accuracy, secondary prevention methods have been developed and implemented. Three such interventions are historical group debriefing (HGD), critical incident stress debriefing (CISD), and process debriefing (PD).

Historical Group Debriefing

Brigadier General Marshall, the U.S. Army's chief historian during World War II, developed HGD. The intent of HGD was to reconstruct complex historical data on military engagements through a group narrative. General Marshall professed the importance of addressing the psychological factors of human nature as a critical aspect of combat behaviors and outcomes.6

When troops have been hard used in battle, and especially when green troops have taken heavy losses during their first engagement, talk itself is the easiest and most effective first step toward re-establishment of a fighting morale. Nothing is more likely to break the nerve of an intelligent and sensitive young commander in the aftermath of a costly and bloodletting experience than to leave him alone with his thoughts. That holds true also of the men under him. Men need to talk it out. . . . (p 118).6