The magnitude-9.0 earthquake and lethal tsunami that hit Japan in March were expected to leave profound emotional scars on survivors. But medical personnel arriving in the affected areas were discouraged from giving immediate counselling. The hands-off approach was questioned in the pages of a medical journal, but recent studies suggest that it may be the best way to help survivors avoid developing post-traumatic stress disorder (PTSD).
Anxiety and vivid flashbacks following a traumatic event, such as battlefield horrors, rape or natural disaster, are the signs of PTSD. It is thought to be caused by "an increased engraving of the horrifying memories in the brain, reducing their potential to fade", says David Forbes of the Australian Centre for Posttraumatic Mental Health in Melbourne.
After PTSD became a medically accepted condition in the 1980s, psychologists and counsellors thought people could be spared it by discussing their experience of a traumatic event immediately after it occurred. This "psychological debriefing" was popular in the 1980s and '90s – and was used in the aftermath of the 11 September 2001 attacks on New York and the Pentagon.
Psychological debriefing was not on offer in Japan after the earthquake and tsunami, though. In fact, it was strongly discouraged by Japanese mental healthcare authorities, says Yoshiharu Kim at the National Institute of Mental Health in Tokyo. Instead, medical personnel were advised that most people would recover without professional help.
Worse than useless?
A broad sweep of evidence seems to bear this out: an international review found that just 5 to 10 per cent of those who experience natural disasters develop PTSD. Offering psychological debriefing soon after the event makes it impossible to identify who would otherwise be destined to become part of that minority. This means many people will receive counselling that they ultimately do not require.
But the rationale for avoiding debriefing in Japan went beyond mere efficiency savings. The approach has been under scrutiny since the late 1990s. An international review published this month found no evidence that intervention immediately following a crisis prevents PTSD. And a review in the UK in 2002concluded that debriefing might even raise people's risk of developing the disorder. It is unclear why, but Simon Wessely of King's College London, who was involved in the review, suggests that it might prime people to expect that they will develop PTSD.
Not all of those working in Japan at the time felt that counselling should be avoided. Kim points to a letter written by a witness to the emergency response that appeared in The Lancet just two weeks after the quake and tsunami. "[The letter] emphasised that acute psychological intervention would prevent future post-traumatic symptoms, an idea no longer supported by any contemporary guidelines," he says.
There is an alternative, however. Last year Justin Kenardy at the University of Queensland in Brisbane, Australia, completed a review of 15 randomised-control trials that used interventions other than debriefing to treat PTSD. The most promising approach was a specially tailored version of cognitive-behavioural therapy (CBT). The technique involves four to 12 psychological sessions, administered at least a month after the trauma. By this time, most survivors will have begun to deal with the stress of the event in their own way, leaving those at most risk of PTSD more readily identifiable.
Unlike psychological debriefing, CBT sessions are designed to "gradually and repeatedly go back through the experience of the event and through this process become less distressed about it", says Kenardy. Phillipa Hay at the University of Western Sydney, Australia, likens PTSD to a phobia. "CBT gradually reintroduces that phobia to reduce arousal," she says. According to Kenardy, this allows victims to integrate new information about the event and more effectively reverse anxiety and avoidance about what happened.
CBT is currently being given to victims of the tsunami who show symptoms of PTSD. Kim expects the first scientific studies into the effects of the strategy to be published within the next few years.