From trauma debriefing to trauma support: A South African developed model for early intervention fo

From trauma debriefing to trauma support: A				experiences. Our approach to early intervention is
South African developed model for early				flexible, pragmatic, problem-oriented, phased and
intervention following trauma.				multifaceted, and accords with guidelines emerging
Authors: Gerrit van Wyk, MA Clin Psych, Director,				internationally as described in the recent literature.
Traumaclinic Emergency Counselling Network,				2.1 Broad spectrum multi-component interventions:
Cape Town, South Africa				International models
Traumaclinic is a national network of practitioners				Salzer and Bickman (1999) draw attention to the
based in South Africa providing consultation,				host of practical matters that need to be
assessment and intervention for individuals,				addressed in the immediate aftermath of a
families, organisations and, communities affected				traumatizing event and the need for immediate
by traumatic events, mainly criminal violence,				priority to be given to stabilising the situation,
work related trauma and motor vehicle accidents.				ensuring that affected individuals have the basic
During the past ten years a model of trauma				necessities of life such as food and shelter, and
support has been developed at Traumaclinic based				creating a situation of safety where there are no
on practical experience in the particularly South				further threats to life and property. Alongside this,
African environment where criminal violence is				interventions are needed to strengthen and build
common. The terms ‘trauma counselling’				social support by helping individuals to work
and ‘trauma debriefing’ are in common				together to address the various effects of the
usage in the public domain. The most commonly				trauma, and to help members to talk about what
used early response model has been critical				has happened in a manner that enables them to
incident stress debriefing (CISD). However, the				find direction, solve practical problems and return
questions raised by a number of studies over the				to constructive everyday activity. In addition it is
last ten years concerning this popular model, have				important to identify vulnerable individuals,
forced Traumaclinic to review and rethink the				especially those who may not have access to
approach to recently traumatised individuals. This				helping resources, and offer them active
presentation provides an overview of the trauma				assistance.
support model that has evolved in response: a				Everly and Mitchell’s (2000) CISM is a set of
rationale, summary and case studies.				multiple interventions that can be drawn on as
1. THE PSYCHOLOGICAL DEBRIEFING				appropriate as a crisis unfolds. In addition to the
CONTROVERSY.				CSID group meeting, the approach includes stress
Early psychological intervention for those affected				inoculation training for emergency services
by traumatic events has long been associated				personnel in preparation for traumatic incidents,
with the term “debriefing”. The emphasis				assessment and referral for individual intervention,
on debriefing arose from the search for ways to				consultations with management in organizational
prevent the development of PTSD in trauma				settings, or with disaster response teams and
victims. It was widely believed that a focused				other emergency services personnel, support for
intervention that engaged individuals emotionally				pastoral intervention from religious leaders and
with the trauma they had experienced, served to				within religious institutions, group crisis meetings
protect them from psychological problems in the				with organizations or families.
future. “Debriefing” is a military term				Macy et al (2004) describe a comprehensive
referring to interviews in which critical incidents				approach called “posttraumatic stress
are examined by those involved in them and				management” (PTSM) developed by the
those in authority. These kinds of interventions				Community Services Program in Boston, USA,
have been widely used, for example by the police				which also provides an infrastructure for dealing
in Britain for at least 30 years (Dunning, 1999).				with disasters and traumatic incidents. They
The term “psychological debriefing” (PD) is				emphasise that all significant role-players need to
particularly attractive in the context of the military				be involved in a process of assessment and
and emergency services such as the police,				planning of a range of interventions to meet the
firefighters and ambulance services as it suggests				needs of all those affected. In the case of natural
that the intervention is not a form of counselling				disasters and traumas that affect a considerable
(i.e. a quasi-medical intervention) but a normal				number of people, liaison with community leaders
extension of institutional culture (Litz et al, 2002).				is essential as it is they who will play major roles
However the term now has very wide currency.				in organizing, motivating and giving constructive
As Bisson, McFarlane and Rose (2000, p. 39)				direction to community members.
observe, “forms of debriefing have become				For example, an intervention following a school
the most written about, widely practised and				bus accident in which four children died, included
well-recognised forms of early psychological				identifying specific groups of affected individuals
intervention following trauma.” It was widely				and providing support and “resiliency based
believed that if victims could have at least one				psychological coping groups” for each of
debriefing session in which they could talk about				them, identifying those in need of individual
and express some of the feelings evoked by the				counselling, providing support at funeral rituals and
event, their long term adjustment would be				the memorial service, facilitating classrooms
improved and they would be at less risk for				discussions, and running “meetings with school
developing PTSD.				administrators to help them assume leadership
1.1 Debriefing: Criticism and disillusionment				roles over time”(p. 221). A range of
However, approximately ten years ago, critical				psychotherapy interventions are incorporated
papers began to appear warning that debriefing				including psycho-education, expressive techniques,
could be harmful. Rather than being beneficial, it				exposure methods, mindfulness training, and
was claimed, it could actually increase the risk of				coping skills enhancement and resource building.
chronic PTSD. Even where it was not harmful,				Some interventions are similar to CSID, however,
there was little evidence that it was beneficial in				“rather than focusing primarily on disturbing or
the sense of serving a preventative purpose.				negative elements of the traumatic event, we
Bisson et al (2000) and Rose, Bisson, & Wessely				take great care to build a sense of safety and
(2001) in their Cochrane Review summarised the				stability at the beginning of our group sessions.
results of randomized controlled trials published in				We then focus on phenomena that elicit the
1996 and 1997. In two of these, one with motor				expression of, and that promote, the resiliency of
vehicle accident (MVA) survivors, and one with				the group members and of the community as a
women who had miscarried, there was no				whole” (p. 221).
evidence that debriefing was better than no				2.2 Traumaclinic trauma support: A three stage
debriefing. In another trial with burn survivors,				process
debriefing was associated with worse outcome,				Because addressing individual emotional distress
and significantly, the outcome was worse the				and supporting the emotional processing of what
longer the debriefing session took. In only one				has happened is only one aspect of intervention,
study, of debriefing for those affected by a				we refer to our work at Traumaclinic as
hurricane, was there any evidence of benefit, and				“trauma support” rather than “trauma
in that case the debriefing took place 6 months				debriefing” or “trauma counselling.”
later, not in the immediate aftermath.				The focus is on assessment and early
Several less well controlled studies failed to find a				identification of areas where intervention is
positive effect of debriefing in comparison to a				needed. There is no predefined procedure or
non-debriefed group. One study found that fire				prescription. A variety of possible interventions is
fighters who were debriefed were less likely to				available, mostly familiar components of trauma
develop an acute stress reaction, but they were				crisis intervention. Interventions are selected in
more at risk for delayed PTSD. Road accident				response to what is found in the initial and ongoing
victims who received debriefing were worse off				assessment process and, in keeping with the
three years later than those who had not been				emphasis of Gist and Woodall (1999, p. 217) on
debriefed in terms of general psychiatric				the importance of promoting resilience, ensuring
symptoms as well as in their overall level of				that they supplement and reinforce resilient
functioning (Mayou, Ehlers, and Hobbs, 2000).				responses of individuals and organisations, and do
Litz et al (2002) calculated effects sizes for the				not supplant or replace natural contacts and
more rigorous studies and concluded that				supports that promote autonomy and resilience,
debriefing resulted in “slightly worse PTSD				with artificial structures that may reinforce
scores at follow-up”. However, the effect				vulnerability and encourage reliance on
sizes were too small for it to be concluded (that)				inappropriate, ineffective, or ill-timed strategies of
PD was either “detrimental or helpful” (p.				coping and resolution.
116). They recommended against “the				A typical trauma support process will unfold in
indiscriminate use of single-session psychological				three stages. In Stage 1, which will occur in the
debriefing” and suggested that attention				first few hours or up to two days following the
should be given to identifying and assisting				incident, the focus is on providing direction and
“only those individuals who are not likely to				guidance in practical ways, structuring solutions to
recover over time on their own” (p. 118).				immediate problems (most importantly the need
1.2 Debriefing: Confusion of terms				for safety and protection), assessing and, if
The above research challenged many of the				necessary, bolstering individuals’ levels of
assumptions held by therapists offering crisis				social support, and responding empathically to the
intervention to traumatized individuals. Some				range of distressing emotions felt by the victims.
responded to the findings with incredulity and				These activities continue in Stage 2, which occurs
even denial, but in others it caused a backlash				after a few days and may last for two weeks,
with the term “debriefing” becoming				but, in addition, counselling or psychotherapy, or
synonymous with doing harm. It was concluded				other intervention strategies, are offered to those
that qualitative feedback from many participants				individuals who have been assessed to be at risk.
who found it valuable, was misleading with respect				Finally, in Stage 3, two to four weeks after the
to its actual impact. It was suggested that the				incident, we follow-up, re-assess whether further
fact that most trauma survivors do not go on to				interventions are needed at the individual or
develop chronic PTSD, may have generated				organizational level, and encourage organizations
“a spurious sense of efficacy regarding the				and individuals to consolidate their capacity for
preventative value of psychological debriefing”				support in a resilient manner.
(Bisson, et al, 2000).				Within these broad stages, we attend to several
Like most frontline organizations that offer				parallel objectives in a manner designed to
support in the aftermath of trauma, we at				support, facilitate and optimise the processes
Traumaclinic had worked on the assumption that				which have been shown to contribute to normal
it was important to provide debriefing style				recovery from trauma, and which occur naturally
interventions where possible, as a means of				in the families and social networks of affected
preventing the development of future mental				individuals. - Our trauma support staff act first as
health problems. In light of these research findings,				consultants or managers in the aftermath to
we began to re-evaluate our procedures for crisis				trauma, rather than as counsellors.
intervention. As we examined the literature				- They do not expect to deal exclusively with
closely, we recognized that it was important to				victims, and they give attention to other
clarify the meaning of terms and to separate out				important role players including work supervisors,
several different issues that might otherwise be				work colleagues and family members.
confused.				- We recognize that different victims require
Mitchell and Everly (1995, p. 271) describe Critical				different forms of help, and that different forms
Incident Stress Debriefing (CISD) which has been				of help are appropriate at different times for the
in use for twenty years and is the prototype of				same individual.
debriefing interventions. It is a structured seven				- We also attend to the traditional aim of trauma
phase “structured group meeting or				debriefing, namely to prevent the subsequent
discussion” usually lasting 2-3 hours in which				development of PTSD and other related disorders
affected individuals are given the opportunity to				by focusing on early identification of factors that
discuss their thoughts and emotions about that				might complicate or hamper recovery, and, where
event in a controlled, structured and rational				appropriate offer individual or group counselling or
manner. They also get the opportunity to see				therapy. First, we incorporate strategies for
that they are not alone in their reactions.				normalizing psychological responses to trauma,
The process has “both psychological and				explicitly through psycho-education, and implicitly in
educational elements, but it should not be				responding to people’s experiences in an
considered psychotherapy” (p.270). After, the				accepting manner. In the face of evidence that
facilitators have been introduced to the group,				many individuals incorrectly misattribute these
participants are asked to describe what happened				kinds of symptoms as evidence of character
“on a cognitive level” (i.e. intense display of				weakness, moral turpitude or impending insanity,
emotion is not encouraged at this point). Next				the offering of corrective information can have a
they are asked for their most prominent thoughts				stabilizing effect. We provide an informational page
about it and this is likely to evoke “some				entitled “Useful information for trauma
leakage of emotion into the discussion” (p.				victims” which lists common symptoms
272). The fourth phase focuses on questions like				(physical, emotional, behavioural and cognitive) of
“What was the worst thing about the				an acute stress reaction. They are described as
situation for you personally?” (p. 272) and is				“the typical after-shock of a horrible event
“the most emotionally powerful.”				– they are normal reactions to an abnormal
Following this there is a shift back from				experience” and readers are told that this
“emotionally laden content ... to more				reaction will likely “diminish after a few days
cognitively oriented material” by focusing on				and in most cases life will return to normal after
descriptions of specific symptoms that individuals				approximately three to four weeks.” The
have been experiencing. This is used as a				information sheet also includes guidelines for
springboard for psycho-education about likely				self-management such as “structure your
stress reactions, suggestions for practical coping				time – keep occupied”, “Reach out to
strategies and advice on a range of practical				others; ask for support – do not try to be
issues such as “diet, exercise, rest, talking to				‘strong’”, “do not make any big
one’s family, [and] working with				life decisions for a while”, and “Be careful
supervisors” on appropriate changes in				of drugs, alcohol and medication to make things
response to what has happened. There is a final				easier”. These accord with similar guidelines
re-entry phase in which further questions are				put out after the 2001 9/11 attacks in New York
answered and concerns clarified.				and Washington (Academy of Cognitive Therapy,
Although originally designed for emergency				2002) and after the London bombings in July 2005
services personnel, CSID has been used widely				(Traumatic Stress Clinic, 2005) and support a
with victims in many contexts including schools,				balance between carrying on with life
industrial settings and natural disasters. When first				constructively and expressing and sharing
introduced, CISD was not a stand-alone				one’s emotional distress with supportive
intervention, but part of a “comprehensive				friends or colleagues in a manner that promotes
intervention system [that] consists of multiple				reflection and processing of the implications of
crisis intervention components which functionally				what has happened. They are also in line with the
span the entire temporal spectrum of a crisis”				approach of Gist et al (1999, p. 287):
(Everly and Mitchell, 2000, p. 213). Unfortunately,				“People are resilient; friends are important;
the term CISD was used to refer to the specific				conversation helps; time is a great healer; look out
group intervention as well as to the overall				for others while you look out for yourself.”
package. This was rectified with the introduction				Second, we give a great deal of attention to
of the term Critical Incident Stress Management				social support, by identifying individuals who are
(CISM) for the overall programme.				vulnerable to isolation, and strengthening existing
There are large similarities between CISM and				social support within peer groups or the family.
other comprehensive approaches to be referred				We also work to prevent the families and peers
to later. In interpreting the data that has created				of affected individuals from undermining the
the debriefing controversy, it is important to				recovery process. The best professional
recognize that the confusion about the meaning				assistance is often neutralised by input from the
of CSID is part of a general tendency to use				significant persons in the world of the trauma
terms like counselling and debriefing quite loosely.				victim, such as spouses, managers, friends and
CISD was not designed to be a stand-alone				colleagues who can exert much more impact,
intervention or an individual intervention. One of its				constructive or destructive, than those offering
goals is to promote social support among group				professional help.
members. However, none of the studies that				Third, we try to identify distressed individuals who
found negative effects of debriefing used the				might not recover normally because of factors
Mitchell and Everly protocol and several of them				that are complicating or obstructing the normal
used single individual sessions of one hour in				recovery, and to address these complicating
duration (e.g. Mayou, Ehlers, & Hobbs, 2000). Such				factors through individual counselling or
interventions would be likely to activate intense				psychotherapy or interventions in the family or
emotions without contributing to social support,				workplace.
and Everly and Mitchell (2000) warn that				Fourth, we discourage measures that might
“clinicians should use caution implementing a				encourage victims from moving into a sick role.
group crisis intervention protocol with individuals				There is little evidence that rest alone is a major
singularly” (p.213).				factor in recovery. Although medication can play a
The confusion in the field can be seen from the				helpful role (Foa, Davidson, Frances and Ross,
fact that the Academy of Cognitive Therapy				1999), its provision can undermine the
(2005) guidelines for professionals involved in				individual’s sense of efficacy in being able to
responding to those affected by traumatic events				rely on their own resources. This could account
include the recommendation “Helpers are				for the findings of Gelpin, Bonne, Peri, Brandes &
advised not to include psychological interventions				Shalev (1996) who compared 13 survivors of
at this early phase.” It is not easy to				terrorist attacks and work accidents treated with
determine where practical support leaves off and				benzodiazepines, with a matched control group
psychological interventions begin, but hopefully, the				who were not given medication. At one month
writer is not warning us against offering empathic				and six month follow-up the benzodiazepine group
listening, giving information to normalize				was not more improved than the controls (nine
symptoms, or attempting to correct exaggerated				still met criteria for PTSD compared to three of
negative cognitive appraisals.				the controls). Thus we do not usually recommend
Offering emotional support and helping (assisting)				the use of medication, particularly benzodiazepines.
individuals to share difficult feelings is experienced				Similarly we advise against sick leave, particularly
as helpful by many people. The literature suggests				in work related trauma, unless a person has been
that it may be insufficient to prevent the				physically injured. Our experience has shown that
development of problems in the future when				leave of absence often creates problems with
offered in the format of a one-off session.				readjustment to work, and tend to lead to
However, protection is provided by an ongoing				further absenteeism. For example, when a
support system of trusted individuals with whom				correctional services employee escaped unhurt
one can share on an ongoing basis. For this				after his car was rocked, overturned and burnt
reason, it is best to give priority to encouraging				by a mob while driving in a township, we did not
individuals to draw on and consolidate their existing				recommend he be given sick leave as he was
social supports.				coping well. Management still offered it to him, but
Gist, Woodall and Magenheimer (1999) warn of				he did not take it and was found to be still coping
the danger of promoting what they call				well at follow-up. A number of his colleagues who
“trauma tourism”, where well-meaning				had experienced similar trauma previously, and
people travel to the site of disasters with the				who had been given sick leave afterwards, had
intention of offering debriefing style interventions.				still not returned to work months later.
This creates the misleading impression that all				Finally, we ensure that our Traumaclinic personnel
individuals need specialist counselling offered by				monitor their own capacity to work in trauma
outsiders. Nevertheless, there are many individuals				situations and take steps to protect them against
who are vulnerable because they lack social				burnout. In a study of lay trauma counsellors
support, and experience relief when trauma				working with another South African organization,
workers facilitate having some form of sharing				Ortlepp and Friedman (2001, 2002) found a
with other affected people, especially if they are				relationship between SOC and stress related to
work colleagues or family members.				trauma work. They also found that the trauma
While more research is needed to clarify these				counsellors obtained a great deal of satisfaction
points, contemporary practice is to ensure that				from their involvement in trauma work, and the
“psychological interventions” take their				guidelines which limited the amount of consultation
place as part of a comprehensive range of				and counselling had been effective in protecting
interventions designed to address problems at all				against burnout since scores on a scale that
levels, and that one-off emotionally intensive				measured this were generally low. The
interventions are avoided.				Traumaclinic recommendation is that counsellors
1.3 Debriefing in South Africa				should share their experiences with their peers
The idea that an intensive single session could be				informally or as part of peer supervision, and with
of therapeutic value has been very influential in				other persons in their primary support system,
South Africa. Straker and Moosa’s (1994)				just as it is recommended to trauma victims
work with those traumatized by government				themselves. 2.3 TRAUMACLINIC IN ACTION:
political repression and brutality, emphasised the				CASE EXAMPLES
value of providing the opportunity for those				Here are a few case examples which illustrate
affected, to talk and express what they were				aspects of our approach.
feeling. Although they did not specifically				Case study 1:
recommend a single session, they pointed out				- The Grassy Park petrol station murders: In June
that in the unstable political and social conditions				2002, six pump attendants on the night shift were
counsellors could not count on seeing these				shot dead at a petrol station in Grassy Park near
individuals more than once. The single session				Retreat on the Cape Flats. The members of the
assessment and intervention developed by				day shift arrived in the morning to find them
Pynoos & Eth (1986) was and still is widely used				dead. In many cases those who found them had
with children although nowadays it is usually part				family ties to, or were friends of the dead men.
of a series of interventions (Leibowitz-Levy, 2005,				Intervention involved a series of contacts with
this issue).				the survivors who were seen immediately and
In South Africa, the term ‘debriefing’ has				then one week, 3 weeks and 6 months after the
been used rather flexibly to refer to a range of				murders. Formal counselling or debriefing was not
interventions. Peeke, Moletsane, Tshivhula and Keel				possible because of language problems, but the
(1998) describe a ‘trauma debriefing’				owners and management were advised in how to
intervention offered to employees (mostly				provide practical support to the survivors in a
women) in a financial institution following an armed				number of ways. They paid to have the bodies
robbery by four black men one Saturday morning.				transported to the respective homes for the
No one was injured, but everyone had been held				funerals and they provided practical support for
hostage at gunpoint while robbers forced				the rituals that followed, for example, giving time
employees to open the safe. When staff returned				for them to attend the funerals. With a view to
on Monday they did not feel safe, fearing the				optimising social support they were advised to
robbers were still inside or might return. However,				arrange alternative living arrangements for those
there was pressure on employees to get back to				who were living alone or had no family support to
work. The human resources manager had been				turn to. Management was also advised on
trained in crisis intervention and had identified at				strategies to assist employees in overcoming the
risk individuals who, because of other recent				expected resistance to, and fear of returning to
losses, might need individual attention, and made				work, for instance by arranging safe transport to
arrangements for them. The intervention included				work and rearranging work hours. With this
three group debriefing sessions. The first was				intervention, all the survivors recovered within a
difficult to conduct because several women were				few weeks and none developed PTSD, even
in extreme distress and “cried and ran in and				though they received no formal counselling.
out of the session” (p. 24). The counsellor				Case study 2:
divided the group into two and dealt with those				- Absenteeism following an armed robbery: The
who were coping least first, and elicited those				positive response of management at the petrol
who were coping to support those who were not.				station can be contrasted with what happened at
Many white employees had developed a				a bottle store that was the target of an armed
generalized fear of, and anger towards, all black				robbery before closing time on a Saturday night.
people. This made it difficult to relate to their				The store manager was off duty and unavailable
black colleagues. This issue was constructively				and the staff phoned the regional manager who
addressed. In a later session employees felt				simply instructed them to close up and go home.
empowered by the fact that managers were also				Traumaclinic was called in the following Tuesday
undergoing emotional strain, and managers felt				because many staff were resisting coming to
supported by the way in which the crisis				work. The Regional Manager had not visited the
intervention staff assisted with immediate				store and the seven staff members felt that
decisions. Another problem was that staff who				management were not looking after them. They
(were) not on duty at the time of the robbery				could not regain a sense of safety in their place
became resentful of the attention given to the				of work and their fear was compounded by
others and intolerant of their distress. The final				resentment against management and a
session focused on re-empowerment and				pre-existing low morale. The store manager,
“the managers were able to reclaim their				caught in the middle between the reasonable
positions of leadership, which added to a sense of				needs of staff and the lack of interest on the
containment.”				part of Regional Management, became critical of
It can be seen how this ‘debriefing’				the employees. Staff were offered individual and
intervention involved a range of pragmatic as well				group sessions to assist them in regaining a sense
as psychological components.				of control and confidence, but absenteeism
1.4 Disability and compensation: The importance of				remained a problem. Staff turnover was high and
prevention				two of the original seven members were
Despite the emphasis on resilience, there is				eventually boarded on the grounds of stress.
continuing concern about PTSD among				Cases 3 & 4:
emergency services personnel. This is not only				- The role of family members in supporting or
motivated by the need to protect the health and				undermining an intervention is shown by what
effective functioning of employees, but also by				happened after another armed robbery at a
the cost to organizations of disability or				jewellery store in 2001 during which three staff
compensation payouts on the basis of PTSD				were held at gunpoint. Management were advised
(Edwards, Van Wyk, Sakasa and Bates, 2005).				on improved security and responded positively
Mitchell (1999) describes how, following the 1989				and the affected staff each had individual sessions
Hillsborough Football stadium disaster that				that focussed on establishing a sense of safety
happened in the United Kingdom in which 93				and overcoming behavioural avoidance. One of the
spectators died, there were several such disability				three became symptomatic and a probable
claims from policemen. This led to an investigation				significant factor was the response of her
into how the response to trauma was handled in				husband who, instead of being encouraging, said,
the police in the United Kingdom, and she found an				“I don’t want you to go back there,
absence of systematic infrastructure. Some units				it’s a dangerous place.” She remained
had trained peer debriefers who were				extremely fearful at her work place and
experienced as providing a valuable service, while				eventually had to be transferred to a position in
others provided little or no psychological support.				the head office. She was fortunate in that
Since debriefing in groups can heighten				another position was available.
interpersonal tensions “one-to-one counselling				- In another case the husband’s response also
is common, and there is evidence that individuals				seemed to be a factor contributing to the
may fare better using this modality” (p. 261).				maintenance of his wife’s symptoms. She
There were reports of “informal or natural				was accosted in her kitchen by a man wielding a
debriefing” (p. 257) in which peers				knife. When she screamed he ran away. Nothing
spontaneously discussed traumatic events among				was taken and she was unharmed. At first she
themselves, but nothing like this occurred in nearly				seemed to recover well, but a few days later she
40% of incidents described by respondents.				snapped at her domestic worker who had been
PTSD has also emerged as a significant problem in				with the family for many years, a close confident,
the South African Police Service (SAPS), where,				asking her, “Where were you when the
since 1994, when the first democratic				attacker appeared?” Affronted, the worker
government was elected, there has been a				resigned and left. As she became more
dramatic increase in disability claims on the basis				symptomatic, her husband accused her of being
of chronic PTSD. There is evidence that this is at				dramatic and giving in to exaggerated fears. She
least in part due to organizational changes in the				was given four sessions of cognitive behaviour
police, where a politically driven process of				therapy and a number of conjoint marital sessions
transformation has resulted in many of those in				in which she expressed the wish that they install
the police before 1994 experiencing lower job				higher fences and remove hedges to improve
satisfaction and lack of institutional support, both				visibility as a means of providing for more
significant factors in promoting resilience.				security in the home. He believed she was
For example, in the Eastern Cape, there was an				overreacting and would not agree to her
outcry as the SAPS attempted to force officers				suggestions. The eventual outcome of this case is
who had been on long term sick leave, to go				not known, but it does show how important it can
back to work. 110 officers were involved who had				be for recovery for victims to feel understood
been “certified ill by doctors - most suffering				and have their concerns validated by those close
from post-traumatic stress” (Mathewson,				to them (Herman, 2001).
2004, p. 1). This may be an example of the way				2.4 CONCLUSIONS
in which granting sick leave after trauma increases				The controversy resulting from the evaluation of
the incidence of avoidance behaviour leading to				certain specific ‘debriefing’ interventions
absenteeism and staff turnover. Another factor,				has resulted in a careful re-evaluation of the
however, may be the attractiveness of PTSD as				principles of trauma intervention, internationally and
a route to medical boarding, since SAPS				in South Africa. In line with the recommendations
authorities accused many of the claimants of				from current research, Traumaclinic’s
malingering, as they had been transferred to				approach aims to find the balance between
other centres and did not want to move. This				fostering resilience and offering specialist
conflict was exacerbated by the fact that the				interventions that address intense distress,
institutional culture did not provide support for the				including those that treat PTSD.
emotional processing of traumatic events. Many				As in most areas of psychological intervention in
emergency workers and police officers to whom				South Africa, there is a need for more research.
debriefing was offered, regarded it as a waste of				It would be particularly valuable to follow the
time.				example of Macy et al (2004) by writing case
Kopel and Friedman (1997, 1999) found that police				studies of specific interventions as a basis for a
appear to deal with exposure to traumatic events				comprehensive programme evaluation. 2.5
by distancing themselves from the unpleasant				REFERENCES
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of the Mitchell and Everly structure may				psychosocial-intervention continuum. Harvard
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focus on the horror of the trauma and its				Ortlepp, K. & Friedman, M. (2001). The relationship
negative impact can create the expectancy that				between sense of coherence and indicators of
psychopathology is a common consequence of				secondary traumatc stress in non-professional
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From trauma debriefing to trauma support: A South African developed model for early intervention fo

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