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Book Forum: Posttraumatic Stress Disorder   |    
Early Intervention for Trauma and Traumatic Loss
JUDITH L. HERMAN, M.D.
Am J Psychiatry 2005;162:1036-a-1037. doi:10.1176/appi.ajp.162.5.1036-a
View Author and Article Information
Cambridge, Mass.

Edited by Brett T. Litz. New York, Guilford Publications, 2004, 338 pp., $40.00.

"First, do no harm," could be the motto of this book, a message that always bears repeating. The authors offer a critique of critical incident stress debriefing in the aftermath of traumatic events. Although this type of group intervention has become an established practice, even mandatory in many first-responder organizations, rigorous clinical trials suggest that critical incident stress debriefing is ineffective for preventing the development of posttraumatic stress disorder. The authors are at their most persuasive and impassioned when presenting their case against critical incident stress debriefing. In the words of the editor,

It is not acceptable that early interventions for trauma be based exclusively on the understandable human need to help people who appear to be suffering or out of the motivation to promote organizational or corporate goals. (p. 6)

One problem with interventions such as critical incident stress debriefing is that most people may neither want nor need this sort of professional "help." Although extreme distress is common in the immediate aftermath of a traumatic event, most survivors will recover spontaneously, with support from the people they know and trust. Litz recommends a minimally intrusive crisis response called "psychological first aid": providing information and practical problem-solving assistance and comforting survivors without pressuring them to explore the details of the traumatic event. This sensible approach respects the privacy and resiliency of survivors.

Since only a minority of trauma survivors will develop posttraumatic stress disorder (PTSD), Litz and the chapter authors recommend targeting high-risk individuals for more intensive interventions (particularly cognitive behavior treatments). This approach has a number of limitations. First, at present we lack a simple and reliable screening method. Although numerous risk factors have been identified, no single factor is either necessary or sufficient to predict who will develop PTSD (1). Second, the authors do not consider the social implications of singling out individuals for treatment. The secondary prevention model they present is mainly derived from brief treatment of motor vehicle accident survivors, a population for whom the issues of shame, secrecy, and stigma are not particularly salient. Finally, this individualistic approach fails to address the need for repair of social relationships in the aftermath of traumatic events, despite the fact that social support is one of the most powerful predictors of recovery. (A refreshing exception is the excellent chapter by van Horn and Lieberman on treatment of infants, toddlers, and preschoolers. Here the therapeutic intervention is aimed specifically at repairing the relationship between mothers and children who have survived domestic violence.)

In general, the authors seem insufficiently aware of basic social ecology (2). Individual treatments are the only alternative proposed in place of the discredited large-group interventions. Participatory models of intervention that engage members of a traumatized community in designing their own crisis responses are simply ignored. Despite these limitations, this book will be of interest to researchers and policy makers seeking to develop an evidence-based approach to early intervention and disaster planning.

Ozer EJ, Weiss DS: Who develops posttraumatic stress disorder? Curr Dir Psychol Sci  2004; 12:169–172
 
Ager A: Psychosocial needs in complex emergencies. Lancet 2002; 360(suppl 1):S43-S44
 
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References

Ozer EJ, Weiss DS: Who develops posttraumatic stress disorder? Curr Dir Psychol Sci  2004; 12:169–172
 
Ager A: Psychosocial needs in complex emergencies. Lancet 2002; 360(suppl 1):S43-S44
 
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