Posttraumatic Stress Intervention: Challenges, Issues, and Perspectives

“Critical incident debriefing” following trauma was designed for primary prevention of posttraumatic stress disorder (PTSD) and widely employed before being evaluated. Numerous studies have since shown critical incident debriefing to have no effect or even detrimental consequences for some traumatized people. The authors in this edited volume denigrate critical incident debriefing and other unproven methods to prevent PTSD—a worthy quest that regrettably becomes repetitive in places. On the constructive side, the editors want to foster a new “salutogenic paradigm” for traumatic events, by which they mean a renewed emphasis on the potentially healthful or maturing properties of life-threatening or horrific experiences.

The salutogenic paradigm wanders a bit among chapters, so that a single salutogenic model does not evolve. That said, several chapter authors suggest that traumatized people may be oriented toward their own strategies to reduce the risk of subsequent PTSD. The latter may consist of 1) writing about the traumatic event, 2) discussing it with others who also experienced it, and 3) not abandoning thoughts and conversations regarding the event prematurely. Although some work does support these interventions, the data generally remain thin, with only a few studies or with the focus on a single type of trauma.

Literature reviews throughout the book are balanced. Some chapters review specific topics (such as Bartone’s studies from the Gulf War). MacLeod’s chapter addresses long-ago trauma, a common entity in clinical settings. Despite being extremely critical of critical incident debriefing, a few authors concede that it has taught some important lessons. Some authors’ strongest venom goes to “trauma industry” clinicians, whether for-profit specialists or well-meaning altruists, who rush blindly to the latest scene of violence. They are not alone in their harsh judgment (see psychiatrist Sally Satel’s recent editorial [1]).

Some authors’ rancor against critical incident debriefing soars so stridently that the clinician might be intimidated into doing nothing for recently traumatized, victimized, or otherwise suffering people. No mention is made of crisis intervention for traumatized people seeking clinical guidance or the importance of clinicians providing an opportunity for their ongoing patients to discuss traumatic experiences. More evenhanded chapters by Perren-Klinger and Pennemaker do provide helpful recommendations for working with recently traumatized people who have become distraught or disabled.

Although most contributors recognize the potential for trauma to produce PTSD, a few perceive demons in the “medical model” of PTSD, in the DSM-III addition of PTSD as a diagnosis, and in attorneys seeking gain from the “golden wound.” Some readers will find this hostility off-putting. However, despite the doctrinaire approach of the opening chapter, eclecticism-creep is apparent throughout. For example, one can find descriptions of the psychological processes and phases of adjustment to trauma that would please any psychodynamicist. It is heartening to read behavioral scientists writing about resilience, courage, meaning, and the symbolic dimensions of suffering—mainstays in the therapy of traumatized people who seek psychiatric care.

Colleagues with a special interest in PTSD will find a wealth of information on specialized topics, from laboratory studies of investigator-induced stress to reviews of special traumatic circumstances (e.g., the Gulf War) or special occupations (e.g., police, firefighter). Readers looking for guidance in the treatment and rehabilitation of patients with PTSD can find more compleat texts elsewhere. The comorbid disorders associated with PTSD are almost entirely missing, and vulnerabilities associated with PTSD receive scant attention.