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First of all, it must be stressed that there are many possible forms of crisis intervention. Thus, it is absolutely vital that the exact form of the intervention used be operationalized and described. Secondly, the intervention of Critical Incident Stress Debriefing was developed by Mitchell (1983) for application to groups of emergency workers not primary victims. Thirdly, "psychological debriefing" as described by Dyregrov (1991,1997) was developed for use with groups of survivors, and it makes group processes central to the whole intervention. Fourthly, the recently attempted meta-analyses of published random control trials have mainly examined very brief, individual crisis interventions bearing little resemblance to psychological debriefing and at times applied to situations where major stress reactions are not even expected (Bisson, et al. 2000; Dyregrov 1998; Yule 2001a).
It has to be admitted that there are very few studies that evaluate the effects of psychological debriefing with children. It has also to be faced that inappropriate intervention given by inadequately experienced people and given at the wrong time can possibly slow down natural recovery if not actually make things worse. There is a responsibility on child mental health services to undertake proper evaluations of crisis interventions.
Having said that, there is a need to respond to children traumatized by an emergency event. What should be done? There are two studies that have generally positive outcomes. Yule and Udwin (1991) screened some survivors from a shipping disaster--children from the same school--and provided a structured psychological debriefing 10 days after the incident. The children were offered help individually or in small groups, and it was found that those who scored highest on the screening battery were those who availed themselves of the offer. Five months later, the children were doing better than those in a neighboring school that had not arranged crisis help for their charges. However, in this natural experiment that was not planned, debriefing and early intervention are confounded.
Stallard and Law (1993) show more convincing evidence that debriefing greatly reduced the distress of girls who survived a school bus crash. The researchers provided help a few weeks after the crash, and the girls responded positively to only two group sessions.
However, we still do not know when best to offer such debriefing to survivors of a disaster, nor indeed whether all survivors benefit. There is evidence from work undertaken in the Armenian earthquake (Pynoos et al. 1993), in many action research studies undertaken under the auspices of UNICEF in Bosnia, and more recently from the Turkish and Greek earthquakes (Giannopolou 2000; Yule 2001b), that group interventions many months after an event can still greatly reduce psychological suffering.
Based on this slowly emerging evidence, on my own experience, and on many fruitful discussions with colleagues around the world, I make the following recommendations:
The current debate regarding crisis intervention for primary survivors of disasters centers around the timing of the initial intervention. My argument is that during the first few days, children are likely to be in shock. They need reassurance and to be reunited with their parents. Thought should be given to such reunion occurring at the scene of the disaster, so that children can better link a variety of reminders with safety signals. Some contact should be made by mental health professionals, but the adult literature strongly suggests that the wrong sort of contact in the first few days may be harmful--hence, the recommendation that 5-to-10 days afterwards is probably optimal. Obviously, an issue as important as this should be settled by evidence rather than theorizing.
Reflection Exercise #12
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