The leading preventive psychiatry recommendation for the military is keep soldiers together through training, combat and the return home. In Vietnam, soldiers often traveled there aboard a planeload of strangers as replacements doled out to units in need. Soldiers often were sent home on short notice aboard another planeload of strangers to a country divided over the war.

"That sets people up for PTSD -- for having a lot of unfinished, unresolved thoughts, feelings, emotions that they can't tell to anybody," said Col. James Stokes an Army psychiatrist.

Around the end of the Vietnam War, scientists found that the hormones boosting physical and mental strength in combat, adrenaline and cortisol also effect memory.

JAMES MCGAUGH, NEUROSCIENTIST, US IRVINE: These hormones will activate a part of your brain that's sitting there ready to be turned on. This system gets turned on; it sends instructions to the other regions of the brain where memories are being stored, and in effect it says, make a stronger memory. It's an amplifier system.

After World War II, in which a controversial study found that only 25 percent of soldiers actually fired their weapon at the enemy, the Army began using targets shaped like human beings and eventually pop-up targets to get soldiers used to the idea of hitting the real thing. By Vietnam, firing ratios approached 100 percent.

"It made a tremendous difference because now with conditioned stimulus, a man-shaped silhouette pops up in the field of view," said Lt. Col. Dave Grossman, a retired West Point psychology instructor and author of "On Killing: The Psychological Cost of Learning to Kill in War and Society."

"Conditioned response: You have a split second to engage the target. Stimulus feedback, you hit the target, the target drops. Stimulus-response, stimulus-response. What we've done is we've made killing an unthinking, conditioned reflex."

CAUTIONS AND CONTRAINDICATIONS FOR DEBRIEFINGS

1. Clarification of Terms
a. "Debriefing" is distinct from a briefing or a class. It is a meeting that calls upon the participant(s) to recall the details of an event from the individual(s) perspective(s).
b. "Psychological debriefings" are intended to have a beneficial effect on the individual(s) future mental health. They are single events, unlike individual or group therapy that also may involve recall of events, including psychologically traumatic ones, but over multiple sessions. There are many other early interventions for psychological distress following traumatic events besides debriefing, some of which must or should be implemented before debriefing is considered.
c. "Operational debriefings" are conducted by organizations according to standing operating procedures and protocols, for operational purposes to which participants' future mental health may be secondary. Purposes include: collecting intelligence or lessons-learned for future plans or system changes; acquiring evidence for legal action; achieving an accurate historical record; enhancing the capability of individuals and teams to return to immediate action.
d. "Critical Event Debriefings" (CED) are operational debriefings of service teams following events during their mission with high risk of meeting Criterion A for PTSD. The purposes are to: help the team clarify what happened and reduce misperceptions; encourage everyone to share what they saw and did; normalize emotions and physical reactions; promote ongoing openness and mutual support; restore the organizational and social "fabric" (unit cohesion)." CEDs are led by trained debriefers, only when complicating factors make routine leader-led debriefings insufficient.

2. Evidence.
a. Although psychological debriefings are very widely accepted as beneficial for mental health after traumatic events, random controlled trials (RCT) have not confirmed that such debriefings of individuals (and to a lesser studied extent, of groups) do decrease PTSD symptoms months later.
b. Several RCTs found increased PTSD symptoms following psychological debriefing, and in one case increased diagnosed PTSD. The RCTs to date cover only a limited variety of traumatic stressors, subject populations, and debriefing protocols. Most controlled studies have been of one-on-one, one-time individual debriefing of victims of motor vehicle accidents or crime such as rape. A few studies of groups have also reported no or negative benefit for PTSD symptoms. Other mental health outcomes other that PTSD symptoms, such as attrition or substance abuse, have not been well studied, but one study of British troops returned from the Balkans found the debriefed groups were less likely to overuse alcohol soon after returning than were the undebriefed groups. The longest negative follow-up study is at 3 years.
c. While it is premature to reject all psychological debriefings of symptomatic survivors or patients, some best practices precautions and contra-indications can be derived from the scientific and clinical literature. [None of these contra-indications are of such strength that all research on them should cease, except the first ethical issue, listed below.]

3. Cautions and contraindications

a. All psychological debriefings and Critical Event Debriefings should be voluntary.

b. Psychological debriefing and CED should always be part of a critical event management plan that includes pre-debriefing preparation and provision for individual follow-up and/or continuing group mutual support.

c. Psychological debriefing of individual patients should NOT focus on recalling in detail the traumatic experience, its sensory stimuli, and the evoked emotions, especially not in the acute phase for injured patients. That can increase PTSD risk.

d. Individually or in group, do not debrief until hyperarousal has decreased, physiological and safety/security needs are satisfied, and medical condition (including pain relief) is stable.

e. Do not debrief bereaved individuals unless group support is certain and/or until after effective bereavement counseling or other resolution of acute grief has been accomplished.

f. Group debriefing of members of a pre-existing group who will remain together should:
* Focus on review of the facts from everyone's unique perspective;
* Clarify misunderstandings;
* Promote a common group "narrative" of the event;
* Validate and normalize reactions;
* Reinforce group solidarity.

g. Group debriefing of strangers from the same, similar, or different events (e.g. families of airline crash victims, survivors of rapes, or survivors of diverse combat or disaster traumas), who will not remain together long:
* Requires different techniques;
* Requires special concern for individual follow-up.
* May be unwise unless it initiates group therapy or other programmed mutual support activities.

h. The debriefing protocol must be adapted to the nature of the traumatic event, the specific group's or individual's characteristics, and special situations. Considerations include:
* Mission-related vs. accidental event;
* Event is finished vs. ongoing vs. likely to recur;
* Familiar vs. unfamiliar group members;
* "Elite" vs. regular vs. substandard service members or group.
* Grievance versus no grievance involved;
* Legal or compensation issues.

i. Improperly done debriefing can harm. It can:
* Retraumatize an individual by re-arousing ("reliving") vivid memories of the traumatic experience before they are tolerable.
* Retraumatize individuals by exposing them in demeaning ways.
* Further traumatize individuals by exposing them to the horrible memories and suffering of other group members with whom they identify or are "competing."
* Increase guilt or misdirected anger, scape goating, intra-group conflict.
* Aggravated issues and leave them to fester.
* Present PTSD as a likely chronic (and compensable?) disability.

4. Prophylactic psychological debriefings of individuals or groups (including most team CED) who are not yet symptomatic patients share most of these concerns and warnings.
a. The requirement to "Do No Harm" and for only voluntary participation is especially strong.
b. Survivors who are handling the trauma well can be encouraged to participate on the grounds that their perspectives on the event may be important to everyone's understanding of what really happened, and may benefit others.

5. All Operational debriefings of service teams after traumatic events share these considerations and concerns, but they have other objectives that may override individual mental health protection.
a. In military combat and in emergency lifesaving or law enforcement, failure and defeat itself causes death, injury or disease, and perhaps captivity under inhumane conditions. Ultimate defeat makes psychological trauma incurred during the operation substantially worse. In war or disaster it may expose the losers to many new trauma. Therefore, the possible or even certain harm to operating teams must sometimes be accepted to prevent even worse predictable or certain harm.
b. All operational debriefings should use protocols and train the debriefers to minimize psychological harm to the participants.

COL Jim Stokes, MD; MCHO-CL-H, MEDCOM, FSH TX
210-221-8235 (DSN471-8235), james.w.stokes@us.army.mil
4 November, 2002