Psychological debriefing in schools

School staff, administrators and health care providers are often called upon to deal with suicides, violent incidents and emergencies affecting students. Critical incident stress debriefing and management are techniques of psychological debriefing commonly applied following traumatic events (Box 1). 1^,2 The widespread acceptance of these techniques was based on the assumption that they were effective and safe and would substantially reduce acute symptoms of distress associated with exposure to traumatic events, thereby decreasing the risk of post-traumatic stress disorder. However, recent research suggests that these interventions are ineffective and may be harmful. 1^,3^–7

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Box 1: Psychotherapeutic techniques

Cochrane reviews of single-session and multiple-session interventions for psychological debriefing indicated that they neither prevent post-traumatic stress disorder nor significantly reduce acute psychological distress when compared with control treatments in adults. 1^,3 Further, the reviews recommended against routine use of psychological debriefing to prevent post-traumatic stress disorder. Other analyses showed that people who received psychological debriefing exhibited more severe symptoms of post-traumatic stress disorder than controls; 7 that the intervention increased the risk of the stress disorder; 5 and that critical incident stress debriefing, in particular, was potentially harmful. 4 These findings are in stark contrast to the positive results noted in earlier studies by the creators and marketers of critical incident stress debriefing and management. 2^,8

Research on the effectiveness and safety of such interventions in schools is very limited. 9 Authors in one Cochrane review noted that they were “unaware of the evidence base surrounding debriefing in children” (16 years or younger). 1 Despite evidence of ineffective and indeed harmful effects in adults and the absence of evidence in children, some schools use these interventions following suicide, accidental death or other traumatic events among their students. Several provinces recommend these interventions in school policy documents, and some school boards employ crisis or grief counsellors. In this light, perhaps we should consider McNally and colleagues’ comments about companies and employees: “Given the absence of data showing that debriefing works, and given some studies suggesting that debriefing may impede natural recovery from trauma, companies may be at heightened risk [for liability] if they do debrief their employees, especially if they fail to provide informed consent.” 6

The evidence clearly points to the ineffectiveness of these interventions in preventing post-traumatic stress disorder or any other psychiatric disorder in adults. Further, with the lack of controlled studies in schools, it is not possible to endorse the use of psychological debriefing in schools on scientific, ethical or legal grounds.

So what should mental health professionals and policy-makers consider as appropriate crisis intervention in schools? Given our current knowledge, it is prudent to develop interventions that promote the following empirically supported principles: a sense of safety; calmness; a sense of self and community efficacy; connectedness; and hope. 10 Preliminary analyses of two programs developed according to these principles show promise of effectiveness: Psychological First Aid 11 could be applied immediately after an incident, and Cognitive Behavioural Intervention for Trauma in Schools 12 could be provided to students who experience psychological distress weeks after a trauma has passed. These interventions could also form part of screening strategies or training of school personnel to help them identify students most at risk. 7

Mental health interventions should be based on best scientific evidence. Our analysis shows no evidence to support the use of psychological debriefing in schools. There is an urgent need to conduct methodologically sound evaluations of psychological debriefing and other mental health interventions in schools before they are widely implemented and to make the results easily available to both educators and health professionals.

Key points

• Critical incident stress debriefing and management are interventions for psychological debriefing often used in schools for students affected by suicide, accidental death and trauma.

• There is a lack of controlled studies that prove the effectiveness or safety of these interventions in schools.

• Given evidence that these interventions are ineffective and potentially harmful in adults, there is no compelling reason to implement them in schools.

• Psychological first aid and cognitive behavioural intervention for trauma in schools are showing promising results.