Posttraumatic stress disorder, it would seem, is potentially an ideal candidate for early intervention and prevention, since it is possible to accurately identify the precipitating event. In recent years, there has been considerable debate regarding the extent to which it may be possible to modify the course of traumatic stress reactions, and to facilitate recovery, by means of an early intervention. A whole culture and industry has built up around the assumption that early interventions following trauma are effective.
Primary prevention aims to reduce the incidence of new cases through intervention before the disorder occurs. These interventions are provided to the whole of the affected population, with no attempt to identify high-risk survivors (although that may be an important outcome of the process). Much debate has revolved around the area of psychological debriefing as described by Mitchell and Bray (1990). As noted by several authors, there is a paucity of adequate empirical evidence to support the use of brief early interventions, such as debriefing, following trauma. That is not to say that debriefing is not helpful – the methodological problems inherent in the available research simply do not permit firm conclusions to be drawn either way. There is an urgent need for rigorous evaluation of debriefing strategies to answer not only the obvious questions regarding the efficacy of debriefing, but also a range of other very basic questions about which, at present, there is little consensus. What exactly is debriefing? What are the goals? To whom is it suited – which populations and following which types of incident? When should it be provided? Who should provide it? And, perhaps most importantly, can debriefing be harmful? A comprehensive discussion of this debate is beyond the scope of this chapter. Suffice to say that it places mental health professionals in a difficult position in the immediate aftermath of trauma. It is not reasonable to abrogate all responsibility simply because solid empirical data are not yet available; rather, it is incumbent upon health professionals to provide some kind of psychological first aid to survivors of recent trauma. In doing so, it may be necessary to develop general principles by drawing upon our knowledge of preventive strategies in other mental health areas, as well as on our knowledge of effective treatments for Posttraumatic stress disorder.
As a general guide, however, it is important to distinguish between those events that occur within an organizational context and within the expected range of experience (e.g., in the emergency services) from those unpredictable events that are clearly beyond normal expectations (e.g., random acts of extreme violence in the community). The predictable nature of the former, combined with the ongoing structure and support provided by the organization, may render standard interventions such as Critical Incident Stress Management and debriefing as appropriate. However, when working with those populations for whom the only (or main) thing they have in common is their experience of the trauma, it maybe preferable not to adopt a CISM or debriefing model. Rather, the focus may be limited to the provision of information and support, with clear guidelines of when and how to obtain professional assistance. This may help to promote expectations of recovery and the use of existing coping strategies and support mechanisms. In the final analysis, however, the field of primary prevention following trauma is characterized, at this stage, by educated guesswork rather than solid empirical data.
Secondary prevention and the treatment of acute stress disorder
Secondary prevention aims to reduce the prevalence of disorders through early identification of problems, with intervention before the disorder becomes severe. Thus the next question is whether it is possible to intervene early, and prevent long-term problems such as Posttraumatic stress disorder in survivors identified as high risk as a result of their acute response. In this area of prevention, the data are a little more positive. Foa and her colleagues (1995a) investigated the efficacy of a brief prevention program aimed at arresting the development of chronic pathology in assault victims with acute Posttraumatic stress disorder. (That is to say, participants met all criteria for Posttraumatic stress disorder except for the duration requirement.) Participants in the active condition received four sessions of cognitive behavioral treatment within a few weeks of the assault and were compared with a wait-list control group. The intervention included education about common reactions to assault, anxiety management, in vivo and imaginal exposure, and cognitive restructuring. Two months postassault, participants who received the active condition had significantly less severe Posttraumatic stress disorder symptoms than participants in the control condition; 10% of the former group met criteria for Posttraumatic stress disorder versus 70% of the latter group. Five and a half months postas-sault, victims in the active condition were significantly less depressed, and had significantly less severe re-experiencing symptoms, than victims in the control condition. Interestingly, the rate of Posttraumatic stress disorder in the wait-list condition had dropped to 20% by follow-up, providing further evidence of the trend towards recovery over the first 6 months posttrauma, even in the absence of formal treatment.
The advent of acute stress disorder as a diagnostic category has provided the opportunity to determine whether specific interventions may prevent the progression from acute stress disorder to Posttraumatic stress disorder. Although only one controlled trial is available at this time, many more are likely to appear in the literature over the coming months. Bryant and colleagues (1998) investigated survivors of civilian trauma with a diagnosis of acute stress disorder, comparing a cognitive behavioral therapy intervention (similar to that of Foa et al.’s study) with supportive counseling. Only 8% of patients in the cognitive behavioral therapy group met criteria for Posttraumatic stress disorder at posttreatment, as compared with 83% in the supportive counseling condition. At 6-month follow-up, the figures were 17% and 67%, respectively, with the cognitive behavioral therapy group showing significantly greater reductions in intrusive, avoidance, and depressive symptomatology. In a subsequent extension of that study, Bryant and colleagues (1999) found that prolonged exposure, as well as a combination of prolonged exposure and anxiety management, were both superior to supportive counseling. Interestingly, the combination treatment was not superior, suggesting that exposure may be the most critical component.
In summary, there is now sufficient evidence to suggest that it is worth targeting symptomatic survivors in the immediate aftermath of trauma with the provision of specific interventions. Such treatment can be expected to significantly reduce the subsequent prevalence of more serious and chronic pathology such as Posttraumatic stress disorder.