Mental Health

and Mass Violence

Evidence-Based Early Psychological

Intervention for Victims/Survivors

of Mass Violence

A Workshop to Reach Consensus on Best Practices
Recommended Citation: 

National Institute of Mental Health (2002). Mental Health and Mass Violence: 

Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass 

Violence. A Workshop to Reach Consensus on Best Practices. NIH Publication 

No. 02-5138, Washington, D.C.: U.S. Government Printing Office. 

Single copies of this report are available through: 

The National Institute of Mental Health 

Office of Communications and Public Liaison 

6001 Executive Boulevard, Room 8184 

Bethesda, MD 20892-9663 

Telephone: 301-443-4513 

and are available on line at: http://www.nimh.nih.gov/research/massviolence.pdf
Mental Health

and Mass Violence

Evidence-Based Early Psychological

Intervention for Victims/Survivors

of Mass Violence

A Workshop to Reach Consensus on Best Practices

U.S. Department of Health and Human Services

U.S. Department of Defense

U.S. Department of Veterans Affairs

U.S. Department of Justice

American Red Cross

Airlie Conference Center

Warrenton, Virginia

October 29-November 1, 2001

Table of Contents

Acknowledgements ...................................................................................................... i

Executive Summary .................................................................................................... 1

Introduction ................................................................................................................ 5

Implications ................................................................................................................. 5

Core Questions ............................................................................................................. 6

Areas of Consensus ..................................................................................................... 6

Key Operating Principles of Early Intervention ...................................................... 6

Guidance on Best Practices Based on Current Research Evidence .......................... 7

Key Considerations for Timing of Early Interventions ............................................ 8

Screening for Survivors ......................................................................................... 8

Follow-Up (For Whom and Over What Period of Time?) ........................................ 9

Expertise, Skills and Training for Providers of Early Intervention Services ............ 9

Research and Evaluation ..................................................................................... 10

Ethical Issues ...................................................................................................... 11

Key Questions to Address Within the Field of Early Intervention ......................... 11

Appendix A: Key Components of Early Intervention ................................................... 13

Appendix B: Guidance for Timing of Early Interventions ........................................... 15

Appendix C: Resource Organizations ......................................................................... 17

Appendix D: Glossary of Terms ................................................................................. 22

Appendix E: Training of the Early Intervention Workforce ........................................ 28

Appendix F: Additions and Dissenting Opinions ....................................................... 34

Appendix G: Intervention Literature Review Tables ................................................... 37

Appendix H: Measures .............................................................................................. 98

Appendix I: References ............................................................................................ 100

i

Acknowledgments

We wish to thank the following individuals and organizations for sharing their time and expertise.

Planning Committee

Elspeth Cameron Ritchie, M.D., LTC, USA, Planning Committee Chair and Program Director, Mental

Health Policy, Office of the Assistant Secretary of Defense

Clete DiGiovanni, M.D., Psychiatrist, National Naval Medical Center

Joye Whatley, MHSM, Department of Justice

Matthew J. Friedman, M.D., Ph.D., Executive Director, National Center for Post-Traumatic Stress

Disorder, Department of Veterans Affairs

Farris Tuma, Sc.D., Chief, Traumatic Stress Program, National Institute of Mental Health

Robert J. Ursano, M.D., Chairman, Department of Psychiatry, Uniformed Services University of the

Health Sciences

Patricia Watson, Ph.D., Deputy for Education and Clinical Networking, National Center for PostTraumatic Stress Disorder, Department of Veterans Affairs

Gregory Belenky, M.D., COL, USA, Director, Division of Neuropsychiatry, Walter Reed Army Institute of

Research

Connie L. Best, Ph.D., Professor, National Crime Victims Center, Medical University of South Carolina

Robert DeMartino, M.D., CDR, USPHS, Associate Director, Program in Trauma and Terrorism, Center for

Mental Health Services, Substance Abuse and Mental Health Services Administration

Thomas A. Grieger, M.D., CAPT, USN, Associate Professor, Department of Psychiatry, Uniformed

Services University of the Health Sciences 

Susan E. Hamilton, Ph.D., Disaster Mental Health Services Associate, American Red Cross

Kenneth HoffmanM.D.,COL,USA, Medical Director, Military and Veterans Health Coordinating Board

Ann E. NorwoodM.D., COL, USA, Associate Professor, Department of Psychiatry, Uniformed Services

University of the Health Sciences 

Beverley Raphael, M.D., Centre for Mental Health, New South Wales, Australia

James R. RundellM.D., COL, USAF, Deputy Commander for Clinical Services, Landstuhl Regional

Medical Center

Josef Ian Ruzek, Ph.D., Associate Director for Education, National Center for Post-Traumatic Stress

Disorder, Department of Veterans Affairs

James W. StokesM.D., COL, USA, Combat/Operational Stress Control Program Officer, U.S. Army

Medical Command

Simon Wessely, M.D., Department of Psychological Medicine, King’s College London, and Institute of

Psychiatry, London, U.K.

Richard Jed Wyatt, M.D. (Deceased), Chief, Neuropsychiatry Branch, National Institute of Mental Health
ii

Literature Review Tables and Coding System for Levels of Evidence

Matthew J. FriedmanM.D., Ph.D., Executive Director, National Center for Post-Traumatic Stress Disorder,

Department of Veterans Affairs

Laura GibsonPh.D., National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs

Beverley RaphaelM.D.,Centre for Mental Health, New South Wales, Australia

Josef Ian RuzekPh.D., Associate Director for Education, National Center for Post-Traumatic Stress

Disorder, Department of Veterans Affairs 

Paula P. SchnurrPh.D., Deputy to the Executive Director, National Center for Post-Traumatic Stress

Disorder, Department of Veterans Affairs 

Patricia WatsonPh.D., Deputy for Education and Clinical Networking, National Center for Post-Traumatic

Stress Disorder, Department of Veterans Affairs

Simon WesselyM.D., Department of Psychological Medicine, King’s College London, and Institute of

Psychiatry, London, U.K.

Participants

Gregory BelenkyM.D.,COL, USA, Director, Division of Neuropsychiatry, Walter Reed Army Institute of

Research

Connie L. Best, Ph.D., Professor, National Crime Victims Center, Medical University of South Carolina

Randy BoddamM.D.,COL, Director, Mental Health Services, Canadian Forces, Base Hospital, CFB Borden

Richard Bryant, Ph.D., Associate Professor, School of Psychology, University of New South Wales,

Australia 

Carl Andrew CastroM.D.,LTC, USA, Division of Neuropsychiatry, Walter Reed Army Institute of Research

Joseph P. ChozinskiM.D., LTC, USAF, Psychiatry Consultant to the U.S. Air Force Surgeon General

Robert DeMartinoM.D., CDR, USPHS, Associate Director, Program in Trauma and Terrorism, Center for

Mental Health Services, Substance Abuse and Mental Health Services Administration

Clete DiGiovanni, M.D., Psychiatrist, National Naval Medical Center

Charles C. EngelM.D., M.P.H., LTC, USA, Associate Professor, Department of Psychiatry,

Uniformed Services University of the Health Sciences

George S. Everly, Jr., Ph.D., Chairman Emeritus, International Critical Incident Stress Foundation

Chip J. Felton, M.S.W., Associate Commissioner and Director, Center for Performance Evaluations and

Outcomes Management, New York State Office of Mental Health

Brian W. FlynnEd.D., RADM, USN, Director, Division of Program Development, Special Populations and

Projects, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration

Matthew J. Friedman, M.D., M.P.H., Executive Director, National Center for Post-Traumatic Stress

Disorder, Department of Veterans Affairs

Carol S. Fullerton, Ph.D., Associate Professor, Department of Psychiatry, Uniformed Services University of

the Health Sciences

Thomas A. GriegerM.D., CAPT, USN, Associate Professor, Department of Psychiatry, Uniformed Services

University of the Health Sciences

Fred D. Gusman, M.S.W., Director, National Center for Post-Traumatic Stress Disorder, VA Palo Alto

Healthcare System
iii

Susan E. Hamilton, Ph.D., Disaster Mental Health Services Associate, American Red Cross

Seth Daniel Hassett, M.S.W., Public Health Analyst, Emergency Services and Disaster Relief Branch,

Center for Mental Health Services

Kenneth HoffmanM.D., COL, USA, Medical Director, Military and Veterans Health Coordinating Board

Harry Charles Holloway, M.D., Professor of Psychiatry and Neuroscience, Uniformed Services University

of the Health Sciences

Terence M. Keane, Ph. D., Director, Behavioral Science Division, National Center for Post-Traumatic Stress

Disorder, VA Boston Healthcare System

John S. KennedyM.D., LCDR, USN, Staff Psychiatrist, Behavioral Healthcare Service Line, National Naval

Medical Center

Rayford Kytle, Writer/Editor, National Institute of Mental Health

Laurent S. Lehmann, M.D., Chief Consultant, Mental Health and Behavioral Sciences, Department of

Veterans Affairs 

Brett T. Litz, Ph.D., Associate Director, National Center for Post-Traumatic Stress Disorder, Behavioral

Science Division, VA Boston Health Care System and Boston University School of Medicine

David H. Marlowe, Ph.D., Senior Lecturer, Uniformed Services University of the Health Sciences

Randall D. Marshall, M.D., Director of Trauma Studies and Services, New York State Psychiatric Institute,

and Associate Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons

Yuval Neria, Ph.D., Tel Aviv University, Columbia University

Fran H. Norris, Ph.D., Professor, Department of Psychology, Georgia State University

Ann E. NorwoodM.D., COL, USN, Associate Professor, Department of Psychiatry, Uniformed Services

University of the Health Sciences 

John M. Oldham, M.D., Director, New York State Psychiatric Institute

Roderick J. Orner, Ph.D., Baverstock House, Lincoln, U.K.

Virgil J. PattersonPh.D., COL, USA, Social Work Consultant to the Army Surgeon General, U.S. Army

Medical Department Center and School

Kyle L. PehrsonD.S.W., COL, USAR, Reserve Social Work Consultant to the Army Surgeon General, U.S.

Army Medical Command

Betty Pfefferbaum, M.D., J.D., Chairman of Psychiatry, University of Oklahoma Health Sciences Center

Jack PierceM.D., CDR, MC, USNR, Clinical Program Officer, Headquarters, U.S. Marine Corps

Robert S. Pynoos, M.D., M.P.H., Co-Director, National Center for Child Traumatic Stress, and Professor of

Psychiatry, UCLA Department of Psychiatry

Beverley Raphael, M.D., Centre for Mental Health, New South Wales, Australia

Elspeth Cameron RitchieM.D., LTC, USA, Program Director, Mental Health Policy, Office of the Assistant

Secretary of Defense

James R. RundellM.D., COL, USAF, Deputy Commander for Clinical Services, Landstuhl Regional Medical

Center

Josef Ian Ruzek, Ph.D., Associate Director for Education, National Center for Post-Traumatic Stress

Disorder, Department of Veterans Affairs

Paula P. Schnurr, Ph.D., Deputy to the Executive Director, National Center for Post-Traumatic Stress

Disorder, Department of Veterans Affairs

Gregory Smith, Vice President/Deputy Director, Disaster Services, American National Red Cross
iv

Arieh Y. Shalev, M.D., Professor and Head, Department of Psychiatry, Hadassah University Hospital,

Israel

Zahava Solomon, Ph.D., Professor and Director, The Adler Research Center, Tel Aviv University, Israel

Anthony Speier, Ph.D.,Director, Division of Community Services, Louisiana Office of Mental Health 

James W. StokesM.D., COL, USA, Combat/Operational Stress Control Program Officer, U.S. Army Medical

Command

Eric S. SwansonGYSGT, USMC, Operational Stress Control and Restoration Team, Staff NonCommissioned Officer in Charge, Division Psychiatry, 2D Marine Division

John R. Tassey, Ph.D., Clinical Psychologist, American Red Cross/VA Medical Center 

Farris Tuma, Sc.D., Chief, Traumatic Stress Program, National Institute of Mental Health

Kathryn M. Turman, Deputy Director, Office for Victims of Crime, U.S. Department of Justice

Robert J. Ursano, M.D., Professor and Chairman, Department of Psychiatry, Uniformed Services University

of the Health Sciences

Patricia Watson, Ph.D., Deputy for Education and Clinical Networking, National Center for Post-Traumatic

Stress Disorder, Department of Veterans Affairs

Lars Weisaeth, M.D., Ph.D., Professor and Director, Defense Headquarters, Norway, Medical Staff

Simon Wessely, Ph.D., Professor, Department of Psychological Medicine, King’s College London and

Institute of Psychiatry, London, U.K. 

Joye Whatley, MHSM, Program Specialist, Office for Victims of Crime, U.S. Department of Justice

Richard J. Wyatt, M.D. (Deceased), Chief, Neuropsychiatry Branch, National Institute of Mental Health

Douglas Zatzick, M.D., Assistant Professor, Harborview Injury Prevention and Research Center, University

of Washington

TRW Systems

Todd Trafford, Program Manager

Bob Johnson, Operations Manager

Jose Salazar, Logistics Support

Bonnie Stephens, On-Site & Video Support

Scott Henderson, Technical Editor

Anne Saphara, Graphic Artist

And many others from the Systems Analysis Directorate of Information & Technical Services Division.

National Institute of Mental Health 

Editorial and Publications Staff

Rayford Kytle, Writer/Editor 

Principal Authors and Editors

Elspeth Cameron RitchieM.D., LTC, USA, Program Director, Mental Health Policy, Office of the Assistant

Secretary of Defense, Department of Defense 

Matthew J. FriedmanM.D., Ph.D., Executive Director, National Center for Post-Traumatic Stress Disorder,

Department of Veterans Affairs
v

Paula P. SchnurrPh.D., National Center for Post-Traumatic Stress Disorder, Department of Veterans

Affairs

Josef Ian RuzekPh.D., National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs 

Patricia WatsonPh.D., National Center for Post-Traumatic Stress Disorder, Department of Veterans

Affairs 

Beverley RaphaelM.D., Centre for Mental Health, New South Wales, Australia 

Simon WesselyPh.D., Department of Psychological Medicine, King’s College London and Institute of

Psychiatry, London, U.K.

Roderick OrnerPh.D., Baverstock House, Lincoln, U.K.

Glossary of Terms

Bruce H. Young, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs 

Fran H. NorrisPh.D., Professor, Department of Psychology, Georgia State University

Special Thanks

National Institute of Mental Health for their support in the publication of this report. 

Office of the Assistant Secretary of Defense for Health Affairs, Department of Defense;

Office of Victims of Crime, Office of Justice Programs, Department of Justice;

National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs; 

National Institute of Mental Health, National Institutes of Health, Department of Health and Human

Services; and 

American Red Cross for their financial support.

TRW Systems for pre-conference planning, conference execution, coordination, and post-conference

support.

1

Executive Summary

Americans have been exposed to increased levels

of mass violence during the past decade. School

violence, shootings in the workplace, and terrorist

acts both here and abroad—all have affected

individuals, families, communities, and our

country. This report addresses the urgent need to

evaluate the various psychological interventions

that are increasingly among the first responses to

these traumatic events.

At a workshop held from October 30 to November

1, 2001, 58 disaster mental health experts from

six countries were invited to address the impact of

early psychological interventions and to identify

what works, what doesn’t work, and what the

gaps are in our knowledge. Prior to the workshop,

leading mental health research clinicians from the

United States, Australia, and the United Kingdom

prepared a review of the published, peer-reviewed

literature (tables appear in Appendix G and

references appear in Appendix I).

For the purpose of this workshop and report, an

early intervention is defined as any form of

psychological intervention delivered within the

first four weeks following mass violence or

disasters. Once established, services may remain

in place for the long term. Mental health

personnel will provide some of the components of

early intervention, while other components have

mental health implications but will be provided by

non-mental health personnel.

Workshop participants examined research on

critical issues related to the following questions:

 What early interventions can be recommended

in mass violence situations? 

 What should the key operating principles be?

 What are the issues of timing of early 

intervention? 

 What is appropriate screening? 

 What is appropriate follow-up, for whom,

over what period of time?

 What expertise, skills, and training are 

necessary for early interventions, at what

level of sophistication? 

 What is the role of research and evaluation?

 What are the ethical issues involved in early

interventions?

 What are the key questions for the field of

early intervention that have not yet been

thoroughly researched?

There was general majority consensus among

participants on many points. Where significant

differences in opinion existed, participants were

invited to provide minority opinions (see

Appendix F). Some of those issues have been

reframed as research or ethical questions that can

benefit from further scientific inquiry and

discourse (see pp. 11-12).

Area of Consensus

Key Operating Principles of

Early Intervention

Workshop participants identified key components

of early psychological interventions as including

preparation, planning, education, training, and

service provision evaluation. It is essential that

these components be operationalized and used for

service delivery, research, education, and

consultation activities. Participants also indicated
2

that early mental health assessment and

intervention should focus on a hierarchy of needs,

e.g., survival, safety, food, shelter, etc. (see

Appendix A). 

Conference participants agreed that: 

 A sensible working principle in the immediate

post-incident phase is to expect normal

recovery; 

 Presuming clinically significant disorder in

the early post-incident phase is inappropriate,

except when there is a preexisting condition; 

 Participation of survivors of mass violence in

early intervention sessions, whether

administered to a group or individually,

should be voluntary.

 The term “debriefing” should be used only to

describe operational debriefings (see Appendix

D). Although operational debriefings can be

described as “early interventions,” they are

done primarily for reasons other than

preventing or reducing mental disorders.

Guidance on Best Practice Based 

on Current Research Evidence

Thoughtfully designed and carefully executed

randomized controlled trials have a critical role in

establishing best practices. There are, however, few

randomized controlled trials of psychological

interventions following mass violence. Existing

randomized controlled trial data, often from studies

of other types of traumatic events, suggest that:

 Early, brief, and focused psychotherapeutic

intervention can reduce distress in bereaved

spouses, parents, and children. 

 Selected cognitive behavioral approaches may

help reduce incidence, duration, and severity

of acute stress disorder, post-traumatic stress

disorder, and depression in survivors. 

 Early interventions in the form of single oneon-one recitals of events and emotions evoked

by a traumatic event do not consistently

reduce risks of later post-traumatic stress

disorder or related adjustment difficulties.

 There is no evidence that eye movement

desensitization and reprocessing (EMDR) as

an early mental health intervention, following

mass violence and disasters, is a treatment of

choice over other approaches.

Other practices that may have captured public

interest have not been proven effective, and some

may do harm. 

Key Considerations for Timing

of Early Interventions

Early interventions should be delivered as needed

in a manner acceptable to survivors and in

keeping with best available practice.

Acknowledging the need for more research,

participants identified various types of early

interventions and guidance on timing for their

delivery (see Appendix B).

Screening for Survivors

Effective early intervention following mass

violence can be facilitated by careful screening

and needs assessment for individuals, groups,

and populations. Screening programs for traumarelated problems should conform to Institute of

Medicine or similar standards for safety and

efficacy (http://books.nap.edu/books/

0309068371/html/index.html or

http://www.quic.gov/report/toc.htm). 

Follow-Up (for Whom and Over

What Period of Time?)

Follow-up should be offered to individuals and

groups at high risk of developing adjustment

difficulties following exposure to mass violence,

including those:
3

 Who have acute stress disorder or other

clinically significant symptoms stemming from

the trauma; 

 Who are bereaved;

 Who have a preexisting psychiatric disorder; 

 Who require medical or surgical attention; and 

 Whose exposure to the incident is particularly

intense and of long duration. 

Many trauma survivors experience some symptoms

in the immediate aftermath of a traumatic event.

These symptoms are not necessarily cause for longterm follow-up, since most eventually remit. In

general, survivors who manifest no symptoms for

approximately two months following exposure to

mass violence do not require routine follow-up. If

they request long-term follow-up, however, it

should be provided. 

Precise recommendations as to when follow-up

should occur are impossible owing to the number

of significant variables involved. 

Expertise, Skills, and Training for

Providers of Early Intervention

Services

Individuals who provide early mental health interventions or consultations need to make appropriate

referrals when additional expertise is needed.

Certain interventions—mass education via media 

outlets, psychological triage (see Appendices A and

D), leadership consultations, and interventions that

rely on detailed recall of traumatic experiences—

have a high potential for unintended harm. The

leadership should select professionals who have the

high degree of training, expertise, accountability,

and responsibility required to provide these

interventions. 

Although the topic was not specifically addressed

at the workshop, the planners have outlined a

sample training program for the early intervention

workforce (see Appendix E). Organizations that

provide training should subject themselves to

quality assurance programs.

Research and Evaluation

The scientific community must develop a national

strategy to examine the relative effectiveness of

early interventions following mass violence. This

strategy must be carried out by trained research

clinicians and have adequate resources for

systematic data collection and evaluation before,

during, and after incidents of mass violence. 

Ethical Issues

There is an ethical duty to conduct scientifically

valid research to improve assessment, early

intervention, and treatment of persons exposed to

mass violence. 

Early intervention policies should be based on

empirically defensible and evidence-based

practices. 

The use of ineffective or unsafe techniques should

be discouraged.

The Institute of Medicine, in collaboration with

the Office of Human Research Protections, is

encouraged to develop a strategy for educating the

broader research community (including

Institutional Review Boards) about these issues.

 

Key Questions to Address Within

the Field of Early Intervention

Workshop participants identified key questions

requiring further inquiry and discourse, including

questions related to the design of intervention

studies, the impact of commonly used

interventions for victims/survivors and first

responders, the development and use of standard

terminology, procedures and content of informed

consent, and unresolved ethical issues.
4

Implications

The guidance provided in the Mental Health and

Mass Violence Workshop report has wide-ranging

implications for funding, research, emergency

planning, clinical practice, training, and

procedures. It is therefore recommended that the

report be fully reviewed by those officials who must

decide what mental health help to support and to

include in the local, state, and national responses

to survivors of mass violence and terrorism.

Disclaimer

Views expressed in this report represent only

those of the workshop participants and should not

be construed to represent views of any of the

sponsoring organizations, agencies, or of any

government. 

The planning committee is most grateful to the

sponsoring organizations that supported this

forum. 
5

Mental Health and

Mass Violence

Evidence-Based Early Psychological Intervention

for Victims/Survivors of Mass Violence

	

	
	




Introduction

Americans have been exposed to increased levels of

mass violence and terrorism during the past

decade. School violence, terrorist acts both here

and abroad, mass shootings in the workplace—all

have affected individuals, families, communities,

and our country. There is an urgent need to

evaluate the various forms of early psychological

intervention that are increasingly offered as part of

the first response to these traumatic events. The

U.S. Departments of Defense, Justice, Health and

Human Services (National Institute of Mental

Health), Veterans Affairs (including the National

Center for PTSD), and the American Red Cross

joined together from October 30 through November

1, 2001, outside Washington, D.C., to examine the

evidence associated with these interventions and

attempt to identify what we know is effective, what

is not, and what questions require further research. 

The workshop was planned long before the tragic

events of September 11, 2001. Those events

heightened the importance of the work

accomplished. We recognized that alone, reviews of

the literature on early psychological interventions

could not serve as a vehicle for the transmission of

informed guidance due to the scarcity of data. We

therefore chose the consensus process, combining

what is known from research and expert opinion as

a way to examine the evidence in this field and

provide guidance.

For the purpose of this workshop and report, an

early intervention is defined as any form of

psychological intervention delivered within the first

four weeks following mass violence or disasters.

Once established, services may remain in place for

the long term. Mental health personnel will provide

some of the components of early intervention, while

other components that have mental health

implications will be provided by non-mental health

personnel.

Implications

Our goal was to make this document of value to the

variety of people who deliver help to emotionally

distressed persons following exposure to mass

violence. We also hope that this document will be
6

useful to those who research these issues and to

employers who want to help workers who have

experienced emotional trauma. Guidance provided

in this report has wide-ranging implications for

funding, research, emergency planning, clinical

practices, training, and procedures. It is, therefore,

recommended that this report be fully reviewed by

those officials who must decide what mental health

help to support and to include in local, state, and

national responses to victims/survivorsof mass

violence and terrorism.

Core Questions

Based on the available empirical literature and

expert opinion, the meeting participants addressed

the following core questions: 

 What should the key operating principles be?

– What should be done and why? 

– What should not be done and why? 

– What is the range of options for action in 

different circumstances?

 What current good practice would be 

recommended as a set of early interventions in

mass violence situations?

 What are the issues of timing of early 

intervention?

 What is the role of screening?

 What follow-up, for whom, and over what 

period of time is recommended?

 What expertise, skills, and training are 

recommended for early interventions and at 

what level of sophistication?

 What is the role of research and evaluation?

 What are the ethical issues involved in early

interventions?

 What are the key questions for the field of

early intervention that have not yet been

thoroughly researched?

There was general majority consensus among

participants on many points. Where significant

differences in opinion existed, participants were

invited to provide minority opinions (see Appendix

F). Some of those issues have been reframed as

research or ethical questions that can benefit from

further scientific inquiry and discourse (see pp. 

11-12).

Areas of Consensus

Key Operating Principles of Early

Intervention

Key components of early interventions include

preparation, planning, education, training, service

provision, and evaluation of efforts to assist those

affected by mass violence and disasters.

A sensible working principle in the immediate postincident phase is to expect normal recovery. The

presumption of clinically significant disorders in the

early post-incident phase is inappropriate, except for

individuals with preexisting conditions.

Mental health personnel have key roles to play

when integrated into mass violence or disaster

management teams. These personnel can help

coordinate service provision so that mental health is

an integrated element of comprehensive disaster

management plans. Mental health expertise can

guide the implementation of interventions to

maximize a positive mental health outcome for

those affected by mass violence.

Optimal efforts to conduct early mental health

assessment and intervention should recognize and

be conducted within a hierarchy of needs, e.g.:

 Survival 

 Safety 

 Security 

 Food 

 Shelter 

 Health (both physical and mental) 
7

 Triage (mental health triage for emergencies) 

 Orientation (orienting survivors to immediate 

local services) 

 Communication with family, friends, and 

community

 Other forms of psychological first aid.

Key aspects of early intervention include the

following: 

 Psychological first aid 

 Needs assessment 

 Monitoring the recovery environment 

 Outreach and information dissemination 

 Technical assistance, consultation, and 

training 

 Fostering resilience, coping, and recovery (i.e., 

facilitating natural support networks) 

 Triage 

 Treatment. 

(See Appendix A for a description of each type of

early intervention.)

Good practice in early intervention also takes into

account the special needs of those who have

experienced enduring mental health problems,

those who are disabled, and other high-risk groups

who may be vulnerable and less able to cope with

unfolding situations. 

Interventions are most likely to be helpful when

they are tailored to address individual, community,

and cultural needs and characteristics.

Early interventions should typically seek to address

diverse outcomes, including normal recovery,

resiliency, and personal growth, as well as 

collective outcomes such as social order and

community/unit cohesion. 

Adverse outcomes to be targeted by early

interventions may include acute stress disorder

(ASD), post-traumatic stress disorder (PTSD),

depression, complicated bereavement reactions,

substance use disorders, poor physical health, fear,

anxiety, physiological arousal, somatization, anger

control, functional disability, and arrest or

regression of childhood developmental progression. 

It is essential that the specific components of early

intervention be identified, operationalized, and used

for service delivery, research, education, and

consultation activities. See Appendix A for a

description of key components of early intervention. 

Use of the term “debriefing” for a variety of mental

health interventions is misleading. Workshop

participants recommended that this stand-alone

term no longer be used to describe early mental

health interventions following mass violence and

disasters. For clarity, “debriefing” should be used

only to describe operational debriefing,1

 and should

not be used to describe psychological debriefing,

critical incident stress debriefing (CISD), and so on. 

Participation of victims/survivors of mass violence

in early intervention sessions, whether administered

as group or individual support, should be voluntary. 

Guidance on Best Practices Based on

Current Research Evidence 

Few randomized controlled trials (RCTs2) have been 

1

 Operational debriefing is a routine, individual, or group review of

the details of an event, from a factual perspective, for the purposes of

(1) learning what actually happened for the historical record or

planning process; (2) improving future results in similar missions;

and (3) increasing the readiness of those being debriefed for further

action. Operational debriefings are conducted by leaders or

specialized debriefers according to the organization’s standard

operating procedure.

2

 RCTs are a type of experimental research involving comparison of a

group that receives the study intervention with a group that receives

other care or no intervention. Participants are randomly assigned to one

of these groups and may be matched for key demographic

characteristics. This study design permits researchers to assess causeand-effect relationships and can be used to determine intervention

effectiveness.
8

conducted that establish the distinct outcomes that

can be achieved for survivor populations through

early intervention following mass violence and

disasters. Thoughtfully designed and carefully

executed randomized controlled trials have a

critical role in establishing parameters for best

practices.

There is limited Level 13

 evidence to definitively

confirm or refute the effectiveness of any early

psychological intervention following mass violence

and disasters. The current evidence, often drawing

on other types of traumatic events, permits the

following conclusions:

 There is some Level 1 evidence for the 

effectiveness of early, brief, and focused 

psychotherapeutic intervention (provided on 

an individual or a group basis) for reducing 

distress in bereaved spouses, parents, and 

children.

 There is some Level 1 evidence that selected 

cognitive behavioral approaches may help 

reduce incidence, duration, and severity of 

ASD, PTSD, and depression in trauma 

survivors (e.g., victims of accidents, rape, and 

crime).

 There is some Level 1 evidence suggesting that 

early intervention in the form of a single oneon-one recital of events and expression of 

emotions evoked by a traumatic event (as 

advocated in some forms of psychological 

debriefing) does not consistently reduce risks 

of later developing PTSD or related adjustment 

difficulties. Some survivors (e.g., those with 

high arousal) may be put at heightened risk for 

adverse outcomes as a result of such early 

interventions.

 There is no evidence that eye movement 

desensitization and reprocessing (EMDR) as 

an early mental health intervention following 

mass violence and disasters is a treatment of 

choice over other approaches.

Key Considerations for Timing of Early

Interventions 

Early interventions should be delivered as needed,

in an acceptable manner, and in keeping with best

available expertise. Little research evidence

(particularly Level 1) has been published regarding

the optimal timing for early interventions. 

Data should be collected through systematic

research and evaluation so that the timing of early

interventions can be informed by reports published

and scrutinized in the public domain. 

In view of the current lack of specific research data

on optimal timing of early interventions, workshop

participants developed a guidance table (see

Appendix B) that describes, among other elements,

various types of early interventions and the timing

believed to be most appropriate for their delivery. As

new evidence is published, this guidance can be

revised and extended to include goals of each

intervention, their uses with specific populations

and types of disaster, as well as the most

appropriate systems to be put in place for their

delivery.

Screening for Survivors

Screening and needs assessments for individuals,

groups, and populations are important for the

provision of informed early interventions following

mass violence and disasters. 

Specific screening methodologies used for

individuals or groups considered to be at high risk

for chronic PTSD and other serious mental health

outcomes following mass violence and disasters

should be evaluated to ensure that their use is both

safe and effective.

3

 The Agency for Health Care Policy and Research (AHCPR) has

defined a system of classification for levels of evidence in scientific

trials. In the statements below, Level 1 evidence, which is considered

“the gold standard,” refers to randomized, well-controlled clinical

trials.
9

Screening programs for trauma-related problems

should conform to Institute of Medicine (IOM) or

similar standards for safety and efficacy

(http://books.nap.edu/books/0309068371/html/ind

ex.html or http://www.quic.gov/report/toc.htm).

Follow-Up (For Whom and Over What

Period of Time?)

Follow-up should be offered to individuals and

groups at high risk of developing adjustment

difficulties following exposure to mass violence

and disasters. These individuals and groups

include those:

 Who have ASD or other clinically significant 

symptoms stemming from the trauma; 

 Who are bereaved; 

 Who have a preexisting psychiatric disorder; 

 Who have required medical or surgical 

attention; and 

 Whose exposure to the event is known to have 

been particularly intense and of long duration. 

Many survivors experience some symptoms in the

immediate aftermath of a traumatic event. These

symptoms are not necessarily cause for long-term

follow-up because, in most cases, they will

eventually remit. Survivors of traumatic events

who do not manifest symptoms after

approximately two months generally do not require

follow-up. However, they should receive follow-up

if they request it.

Precise statements regarding exactly when followup should occur in each individual case are not

possible because of the many significant variables

that inform clinical recommendations for early

intervention.

Expertise, Skills and Training for

Providers of Early Intervention

Services 

Individuals who provide early mental health

interventions or consultations should remain within

the scope of their expertise and education, making

appropriate referrals when additional expertise is

needed.

Individuals who provide early interventions or

consultations should be sanctioned by, and operate

within, the structure responsible for coordinating

mass violence and disaster response. This structure

should include quality assurance reviews to make

sure that helpers have proper documentation to

certify their training credentials as well as the

appropriate expertise and experience.

Providers of early interventions that have the

highest potential for unintended harm should be

selected according to their degree of training,

expertise, accountability, and responsibility. These

early interventions include mass education via

media outlets, psychological triage (see Appendices

A and D), leadership consultations, and

interventions that rely on detailed recall of

traumatic experiences.

Mental health professionals––and others sanctioned

to provide early interventions––should avail

themselves of high-quality, empirically defensible

training that confers competence in specific

interventions and strategies for responding to mass

violence and disasters. Organizations with

experience and expertise in providing such

responses should collaborate to provide this

training.

Early interventions are usually provided with

limited resources in an atmosphere of chaos,

environmental pollution, and the possibility of

continued threats. To be effective, training should

incorporate content that addresses the 

organizational, procedural, emotional, and

environmental aspects of this operational reality.

Additionally, specialist education, training, and

certification programs should be developed so they
10

can be sanctioned or validated by appropriate

professional bodies and organizations. This will

ensure quality standards that are in the interest of

service users and providers as well as the

organizations that employ such staff. See 

Appendix E for guidance on training components. 

Research and Evaluation

Research and program evaluations are critically

important components in advancing our

understanding of, and ability to provide, effective

early interventions.

The scientific community has an obligation to

examine the relative effectiveness of early

interventions that seek to reduce adverse outcomes

and foster positive adaptations following mass

violence and disasters. A national strategy should

be developed to ensure that adequate resources are

available for systematic data collection, evaluation,

and research to be carried out before, during, and

after mass violence and disasters.

When the optimal forms of intervention are

unknown, there is an ethical duty to conduct

scientifically valid research to improve prevention,

assessment, intervention, and treatment. 

Efforts and initiatives to document and describe

what is done, by whom, and to what end are

currently inadequate and can be misleading. Mass

violence and disaster plans should involve experts

in research and evaluation when considering the

best methods available for systematic data

collection, evaluation, and research at each stage

of planning and response.

These systematic evaluation activities should be

planned and carried out in conjunction with

identified bodies that are responsible for organizing

and delivering early interventions following mass

violence and disasters.

Efforts should be made to facilitate collaboration

among federal, state, and local authorities

responsible for funding, planning, delivering, and

assessing the impact of early interventions to

facilitate systematic data collection, evaluation, and

research in this field.

A standard taxonomy (categorization) and

terminology need to be developed for program

evaluations and research protocols. A standard

taxonomy will help identify and operationalize the

following:

 The potentially most significant psychological 

and biological variables to monitor in the wake 

of mass violence or disasters. 

 The post-event physical and psychosocial 

(recovery) environment.

 Subgroups of the affected population, 

including responders.

 Mental health interventions that are provided.

 The characteristics of those deemed the most 

appropriate providers of early interventions.

As noted under ethical issues, a strategy should be

developed for informing the broader research

community, including Institutional Review Boards

(IRBs), of the necessity to conduct rigorous research

on sensitive topics.

Research should be conducted to determine which

elements of early interventions are most helpful.

Given the unplanned nature of mass violence and

disaster situations, as well as the logistical

difficulties of carrying out systematic data collection

in these situations, investigations into early

interventions following mass violence and disasters

may require new mechanisms for proposing and

funding this type of research. 
11

Ethical Issues

Workshop participants agreed that there is an

ethical duty to conduct scientifically valid research

to improve prevention, assessment, early

intervention, and treatment in order to enhance

outcomes achieved by early interventions.

The Institute of Medicine (IOM), in collaboration

with the Office of Human Research Protections

(OHRP), should be encouraged to develop a

strategy for educating the broader research

community (including IRBs) about the ethical

necessity of conducting rigorous research on

sensitive topics related to mass violence and

trauma. Ideally, this strategy will encompass

guidance on determining what types of research

are appropriate and when, given the existing

knowledge base on early interventions. 

Early intervention policies should be based on

empirically defensible and evidence-based

practices. An ethical duty exists to discourage the

use of ineffective or unsafe techniques.

Key Questions to Address Within the

Field of Early Intervention

What is the demonstrable impact of public

education initiatives on levels of knowledge,

attitudes, and behaviors among those who have to

live with endemic stress associated with ongoing

threats to safety and security?

Does “just-in-time” training4 for first responders

reduce the risk of adverse mental health outcomes? 

How feasible are RCTs with existing and novel

early interventions (not placebo controls) involving

high-risk traumatized cohorts? How acceptable

would they be to potential research subjects? 

To what extent can creative, naturalistic

experimental designs be used to examine the

relative benefits of existing early interventions?

To develop a standard taxonomy and terminology

for early intervention to use in evaluations and

research protocols, the following questions require

additional attention:

 How should the taxonomy be structured so 

that it can be expanded to include new 

variables as they are discovered?

 How should the taxonomy be distributed 

through multiple authorities and agencies to 

care providers as well as to researchers?

 How should the use of the taxonomy be 

monitored in the review process to ensure 

consistency for efficient automated data 

processing and meta-analysis across many 

program evaluations and for controlled studies 

over many years of data collection and followup? 

 Which entity (governmental, professional, etc.) 

might be the executive agent for overseeing, 

adding to, and disseminating the taxonomy?

Is screening during the first few weeks following

mass violence and disaster (often involving

education on biopsychosocial reactions) in itself an

effective intervention for reducing the risk of new

onset or exacerbation of preexisting

psychopathology?

Can screening harm some individuals exposed to

trauma? If so, what is the nature and extent of such

harm (i.e., the risk of the screening being used for

purposes not intended by the investigators)? Is the

risk of such harm offset by the risk of failing to use

screening instruments to identify those at high risk

for negative outcomes? 

What information should be included in statements

made to trauma survivors from whom informed

consent is being sought to participate in screening,

4

 Just-in-time training refers to training provided on site for responders

during a major incident or disaster.
12

early intervention, follow-up, and treatment

research?

What is best practice for seeking informed consent

for acute interventions following mass violence?

Do occasions arise (e.g., education on

biopsychosocial reactions) when obtaining consent

can induce negative effects?

What are the ethical issues involved in false

positives in screenings?

Is it acceptable to screen for conditions if care is

not provided or readily accessible? 

Guidance on ethical issues relating to research on

mental health interventions following mass

violence should be formed to assist IRBs in

evaluating these protocols. This guidance should

also identify bodies and organizations that can

serve as resources for IRBs and others evaluating

research protocols.

What are the distinct ethical implications for Level

I and Level II studies in the wake of mass violence

interventions? 

What ethical issues are introduced by the

widespread use of unproven interventions?

How does one balance clinical demand to provide

an intervention with the inadequacies in the

empirical evidence-based knowledge of effective

early interventions for trauma? 

What ethical issues arise from the shifts in

professional boundaries (professional setting, 

physical and psychological objectivity with the

client, etc.) in the context of early interventions? 

How should helpers, such as first responders and

emergency staff, be guided to identify their own 

mental health needs? What are the implications of

participation in mandatory group or individual

interventions. 

How should organizations that use operational

debriefing train their personnel to avoid

unintentional psychological harm and to identify

individuals who need mental health follow-up?

How can the scientific community encourage and

assist such organizations to collaborate in scientific

follow-up of potential long-term behavioral/mental

outcomes of the operational debriefing policies and

other critical incident management interventions

they use?
13

Appendix A: 

Key Components of Early

Intervention

The following is a description of the key

components of early intervention. Some of these

components would be provided by mental health

professionals while other components with mental

health implications would be delivered by service

providers other than mental health professionals.

Basic Needs

 Provide survival, safety, and security.

 Provide food and shelter.

 Orient survivors to the availability of 

services/support.

 Communicate with family, friends, and 

community.

 Assess the environment for ongoing threats.

Psychological First Aid

 Protect survivors from further harm.

 Reduce physiological arousal.

 Mobilize support for those who are most 

distressed.

 Keep families together and facilitate reunions 

with loved ones.

 Provide information and foster communication 

and education. 

 Use effective risk communication techniques.

Needs Assessment

 Assess the current status of individuals, 

groups, and/or populations and 

institutions/systems. Ask how well needs are 

being addressed, what the recovery 

environment offers, and what additional 

interventions are needed.

Rescue and Recovery Environment

Observation

 Observe and listen to those most affected.

 Monitor the environment for toxins and 

stressors.

 Monitor past and ongoing threats.

 Monitor services that are being provided.

 Monitor media coverage and rumors.

Outreach and Information

Dissemination

 Offer information/education and “therapy by 

walking around.”

 Use established community structures.

 Distribute flyers. 

 Host Web sites.

 Conduct media interviews and programs and 

distribute media releases. 

Technical Assistance, Consultation, and

Training 

 Improve capacity of organizations and 

caregivers to provide what is needed to 

– reestablish community structure,

– foster family recovery and resilience, and 

– safeguard the community.

 Provide assistance, consultation, and training 

to relevant organizations, other caregivers and 

responders, and leaders.

Fostering Resilience and Recovery

 Foster but do not force social interactions.

 Provide coping skills training.

 Provide risk assessment skills training.

 Provide education on stress responses, 

traumatic reminders, coping, normal versus 

abnormal functioning, risk factors, and 

services.

 Offer group and family interventions.

 Foster natural social supports.

 Look after the bereaved.

 Repair the organizational fabric.
14

Triage

 Conduct clinical assessments, using valid and 

reliable methods.

 Refer when indicated.

 Identify vulnerable, high-risk individuals and 

groups.

 Provide for emergency hospitalization.

Treatment

 Reduce or ameliorate symptoms or improve 

functioning via 

– individual, family, and group 

psychotherapy,

– pharmacotherapy, and

– short- or long-term hospitalization. 
15

Short-term or Phase Pre-incident Impact (0–48

hours)

Rescue (0–1

week) Recovery (1–4

weeks)

Return to Life (2

weeks–2 years)

Goals Preparation,

improve coping

Survival,

communication

Adjustment Appraisal/

Planning

Reintegration

Behavior Preparation vs.

denial

Fight/flight, freeze,

surrender, etc.

Resilience vs.

exhaustion Grief, reappraisal,intrusive

memories,

narrative

formation

Adjustment vs.

phobias, PTSD,

avoidance,

depression, etc.

Role of All

Helpers

Prepare, train,

gain knowledge

Rescue, protect Orient,

provide for

needs

Respond with

sensitivity

Continue

assistance

Role of Mental

Health

Professionals

Prepare

Train

Gain knowledge

Collaborate

Inform and

influence policy

Set structures for

rapid assistance

Basic Needs>

Establish safety/

security/survival

Ensure food and

shelter

Provide

orientation

Facilitate

communication

with family, friends

and community

Assess the

environment for

ongoing threat/

toxin

Psychological

First Aid>

Support and

"presence" for

those who are

most distressed

Keep families

together and

facilitate reunion

with loved ones

Provide

information and

education (i.e.,

services), foster

communication

Protect survivors

from further harm

Reduce

physiological

arousal

Needs

Assessment>

Assess current

status, how well

needs are being

addressed 

Recovery

environment

What additional

interventions are 

needed for

• Group

• Population

• Individual

Triage>

Clinical

assessment

Refer when

indicated

Identify vulnerable,

high-risk 

individuals and

groups

Emergency hospitalization or outpatient treatment

Outreach and

Information

Dissemination>

Make contact with

and identify

people who have

not requested

services (i.e.,

"therapy by

walking around")

Monitor the

Recovery

Environment>

Observe and

listen to those

most affected 

Monitor the

environment for

toxins

Monitor past

and ongoing

threats

Treatment

Reduce or

ameliorate

symptoms or

improve

functioning via

• Individual, family

and group

psychotherapy

• Pharmacotherapy

• Short-term or

long-term

hospitalization

Monitor services

that are being

provided

Appendix B:

Guidance for Timing of Early Interventions
16

Role of Mental

Health

Professionals

(continued)

Monitoring the

Impact on

Environment>

Observe and

listen to those

most affected

Monitor the

environment for

stressors

Technical

Assistance,

Consultation

and Training>

Improve capacity

of organizations

and caregivers to

provide what is

needed to

reestablish

community

structure, foster

family recovery/

resilience, and

safeguard the

community

Provide to

• relevent

organizations

• other

caregivers and

responders

• leaders

Outreach and

Information

Dissemination>

Inform people

about different

services, coping,

recovery process,

etc. (e.g., by using

established

community

structures, fliers,

Web sites)

Fostering

Resilience and

Recovery>

Social

interactions

Coping skills

training

Education about

stress response,

traumatic

reminders,

coping, normal vs.

abnormal

functioning, risk

factors, services

Group and family

support

Foster natural

social support

Look after the

bereaved

Repair

organizational

fabric

Operational

debriefings, when

this is standing

procedure in

responder

organizations

Spiritual support
17

Appendix C: 

Resource Organizations

American Association of Marriage and

Family Therapy (AAMFT). The professional

association for the field of marriage and family

therapy that represents the professional interests of

more than 23,000 marriage and family therapists

in the United States, Canada, and abroad. Founded

in 1942, AAMFT aims to increase understanding,

research, and education in the field of marriage

and family therapy. The organization conducts a

national exam for marriage and family therapists

used for licensure in most states.

http://www.aamft.org/

American Psychiatric Association.

Founded in 1844, the American Psychiatric

Association is the world’s largest psychiatric

organization. It represents over 38,000 psychiatric

physicians from the United States and around the

world. Members specialize in the diagnosis and

treatment of mental and emotional illnesses and

substance use disorders. http://www.psych.org/

American Psychological Association

(APA).A scientific and professional organization

that represents psychology in the United States.

With more than 155,000 members, it is the largest

association of psychologists worldwide. Founded in

1892, it aims to advance psychology as a science

and profession and as a means of promoting

human welfare by promoting research, establishing

and maintaining standards, and diffusing

knowledge. In 1991, APA established the Disaster

Response Network (DRN) to work collaboratively

with the American Red Cross and other relief

organizations to provide licensed psychologists on

site to aid disaster victims and relief workers. More

than 2,000 psychologists have received required

disaster response training and are DRN members.

http://www.apa.org/

American Red Cross (ARC).An

independent, tax-exempt charitable organization

granted a charter by the U.S. Congress in 1905 to

carry on a system of national and international

relief to mitigate suffering caused by pestilence,

famine, fire, floods, and other national calamities.

In 1998, the organization was composed of over

1,336,000 volunteers. http://www.redcross.org/

American Red Cross Disaster Services.

A division of the American Red Cross that focuses

on meeting people’s immediate emergency disastercaused needs, such as shelter, food, and health and

mental health services. This division also feeds

emergency workers, handles inquiries from concerned family members outside the disaster area,

provides blood and blood products to disaster

victims, and helps those affected to access other

resources. http://www.redcross.org/services/disaster

American Red Cross Disaster Services

Human Resources System (DSHR).

Through a network of approximately 3,000 local

chapters and Red Cross units supported by regional

offices and a national headquarters, the Red Cross

provides a nationwide program of disaster

preparedness and relief. DSHR is the American Red

Cross national personnel inventory that tracks

individual disaster workers. From this system,

volunteers are recruited to respond to major

disasters. To become a DSHR Disaster Mental

Health Services member, licensed mental health

professionals must meet specific training

requirements and be available for a minimum 12-

day operational assignment.

American Red Cross Shelter Services.

Provides temporary services for displaced

survivors. In general, ARC shelters open within 24

hours of impact and close after two to three weeks.

On-site services include support for survivors and

shelter staff. Services provided by ARC, are in 
18

coordination with local volunteers working under

the auspices of county mental health professionals.

Catastrophic Disaster Response Group

(CDRG).A component of the emergency response

of the Federal Emergency Management Agency

(FEMA), CDRG is composed of representatives of all

departments and agencies participating in the

Federal Response Plan. CDRG provides guidance

and policy direction. http://www.fema.gov/rrr/frp/

frpconc.shtm

Center for Mental Health Services

(CMHS).A component of SAMSHA, PHS, DHHS.

CMHS is charged with leading the national system

that delivers mental health services and

administers programs and funding for assisting

people with mental illness with treatment,

employment, housing, and transportation. CMHS

was established under the 1992 ADAMHA

Reorganization Act. The Emergency Services and

Disaster Relief Branch (defined below) is housed

within CMHS. http://www.mentalhealth.org/cmhs

Children’s Advocacy Centers.Established

by the Office of Juvenile Justice and Delinquency to

assist communities in improving their response to

child abuse. The Centers provide information,

consultation, training, and technical assistance;

help to establish child-focused programs; and

support coordination among agencies responding

to child abuse. http://www.nncac.org/rcac

Department of Defense (DoD).Cabinetlevel agency of the U.S. government formed in

1947 to subsume three earlier military departments

whose primary missions were to train and equip

their personnel to perform war fighting,

peacekeeping, and humanitarian/disaster

assistance tasks. In the Federal Response Plan

(FRP), DoD is the lead agency for emergency

support function 3, public works and engineering

(primarily through the U.S. Army Corps of

Engineers). DoD also plays a supporting role for all

12 functions, including mass care and

health/medical services. In consequence

management, DoD supports FEMA through

technical chemical-biological reconnaissance and

assessments, providing equipment, technical

expertise, and links to other interagency

organizations with identified capabilities. After

disasters, DoD makes additional assets available as

local capabilities are exhausted, may provide other

assets to secure the area, and may help to evacuate

areas at risk. http://www.defenselink.mil/

Department of Health and Human

Services (DHHS). The U.S. government’s

principal agency for protecting the health of all

Americans, and providing essential human

services, especially for those who are least able to

help themselves. The department’s 300 programs

cover a wide spectrum of activities and purposes,

from medical and social science research, disease

prevention, and food and drug safety to health

insurance for elderly, disabled, and low-income

Americans and maternal and infant health. In the

Federal response plan, DHHS is the lead agency

responsible for carrying out emergency support

function 8 (health and medical care) and plays a

supporting role in mass care and information and

planning. http://www.dhhs.gov. Medical Response

in Emergencies: HHS’s Role http://www.hhs.gov/

news/press/2001pres/01fsemergencyresponse.html

Department of Justice (DOJ).Cabinet-level

agency of the U.S. government responsible for

enforcing the law; providing protection against

criminals; ensuring healthy competition of

business; safeguarding the consumer; and

enforcing drug, immigration, and naturalization

laws. In the Federal Response Plan, DOJ is a

supporting agency for three emergency support

functions: health and medical, search and rescue,
19

and hazardous materials. DOJ houses the Office for

Victims of Crime. http://www.usdoj.gov/

Department of Veterans Affairs (VA).

Cabinet-level agency of the U.S. government

charged with providing benefits and services to

veterans and their dependents. The VA health care

system provides a broad spectrum of medical,

surgical, and rehabilitative care and also houses

the National Center for Post-Traumatic Stress

Disorder, Readjustment Counseling Service, and

the Emergency Mental Strategic Health Care Group.

In FRP, the VA plays a supporting role for four

emergency functions: public works, mass care,

resource support, and health and medical services.

www.va.gov/about_va/history

Emergency Information and

Coordination Center.A center in

Washington, D.C., that in 1999 was renamed the

National Interagency Operations Center. It is the

location from which FEMA coordinates efforts of

federal, state, and local agencies.

http://www.fema.gov/rrr/frp/frpconc.shtm

Emergency Services and Disaster Relief

Branch.A branch of the Center for Mental Health

Services that is responsible for meeting the mental

health needs of disaster survivors and responders.

The branch works in collaboration with FEMA to

implement the Crisis Counseling Assistance and

Training Program when a state has applied for a

CCP grant after a federally declared disaster. The

grants may be for immediate services, which

support services for 60 days past the declaration

date, or for regular services, which support services

for 9 to 15 months past the declaration date.

http://www.mentalhealth.org/publications/allpubs/

KEN95-0011/default.asp Disaster Mental Health

http://www.mentalhealth.org/cmhs/

EmergencyServices/default.asp

Federal Emergency Management

Agency (FEMA).An independent agency of the

U.S. government that was founded in 1979.

FEMA’s mission is to reduce loss of life and

property and protect the nation’s infrastructure

from hazards through a comprehensive program of

mitigation, preparedness, response, and recovery. 

http://www.fema.gov/about

International Critical Incident Stress

Foundation.A nonprofit, open-membership

foundation dedicated to preventing and mitigating

disabling stress through the provision of education,

training, and support services for all emergency

services professions, including continuing

education and training in emergency mental health

services for psychologists, psychiatrists, social

workers, and licensed professional counselors and

consultation in the establishment of crisis and

disaster response programs for varied

organizations and communities worldwide.

http://www.icisf.org/

International Society for Traumatic

Stress Studies (ISTSS).A membership

society providing a forum for sharing research,

clinical strategies, public policy concerns, and

theoretical formulations on trauma in the United

States and around the world. Members of ISTSS

include psychiatrists, psychologists, social workers,

nurses, counselors, researchers, administrators,

advocates, journalists, clergy, and others with an

interest in the study and treatment of traumatic

stress. http://www.istss.org/

National Association of Social Workers

(NASW).A membership organization that

promotes, develops, and protects the practice of

social work and social workers. NASW also seeks

to enhance the effective functioning and well 
20

being of individuals, families, and communities

through its work and its advocacy.

http://www.naswdc.org/

National Center for Post-Traumatic

Stress Disorder (NCPTSD).A seven-site

consortium created by public law. Housed within

the Department of Veterans Affairs, the mission of

the NCPTSD is to advance the clinical care and

social welfare of America’s veterans through

research, education, and training in the science,

diagnosis, and treatment of PTSD and stressrelated disorders. As a leading authority on PTSD,

NCPTSD serves and collaborates with many

different agencies and constituencies, including

veterans and their families, government

policymakers, scientists and researchers, doctors

and psychiatrists, journalists, and the lay public.

http://www.ncptsd.org/

National Institute of Mental Health

(NIMH).A part of the of the U.S. government’s

National Institutes of Health, PHS, DHHS, the

NIMH is responsible for research on mental health

and mental disorders, including research on the

mental health consequences of and interventions

after disasters and acts of mass violence.

http://www.nimh.nih.gov/

National Organization for Victims

Assistance (NOVA). A private, nonprofit

organization of victim and witness assistance

programs and practitioners, criminal justice

agencies and professionals, mental health

professionals, researchers, former victims and

survivors, and others committed to the recognition

and implementation of victim rights and services.

NOVA’s mission is to promote rights and services

for victims of crime and crisis. http://www.trynova.org/

National Voluntary Organizations

Active in Disaster (NVOAD). A national

organization that coordinates planning efforts of

member voluntary organizations responding to

disaster. Member organizations meet regularly.

When disasters occur, NVOAD or an affiliated state

VOAD encourages members and other voluntary

agencies to convene on-site to facilitate effective

cooperation among volunteers and organizations.

www.nvoad.org

Office for Victims of Crime (OVC).A

federal agency established by the 1984 Victims of

Crime Act to oversee diverse programs that benefit

victims of crime. OVC provides substantial funding

to state victim assistance and compensation

programs, the lifeline services that help victims to

heal. The agency supports training designed to

educate criminal justice and allied professionals

regarding the rights and needs of crime victims.

OVC is one of five bureaus and four offices with

grant-making authority within the Office of Justice

Programs, DOJ. http://www.ojp.usdoj.gov/ovc/ 

Public Health Service (PHS).A major

division of the Department of Health and Human

Services, PHS is the principal health agency of the

U.S. government. PHS is responsible for promoting

and ensuring the nation’s health through research

into the causes, treatment, and prevention of

disease. www.os.dhhs.gov/phs/phs.html

Substance Abuse and Mental Health

Services Administration (SAMHSA).The

lead mental health services agency of the PHS,

DHHS, which includes the Center for Mental Heath

Services (CMHS) and the Emergency Services

Branch within CMHS. Through these divisions,

SAMHSA provides assistance with assessing

mental health needs and mental health training for

disaster workers. SAMHSA also assists in

arranging training for mental health outreach
21

workers, assesses the content of applications for

federal crisis counseling grant funds, and

addresses worker stress issues and needs through

a variety of mechanisms. http://www.samhsa.gov/
22

Appendix D: 

Glossary of Terms

Acute stress disorder.A condition requiring

the presence of serious dissociative, reexperiencing, and arousal symptoms and

functional impairment that occurs within one

month of exposure to a traumatic stressor and

lasts for a minimum of two days and a maximum

of four weeks.

Advocacy.The act of protecting and advancing

the legal, human, and service rights of people.

http://www.advocacyinc.org/

Community-based interventions.

Interventions ranging from consultation with

disaster and community leadership to

encouragement of supportive post-disaster

environments, networks of support, information,

and ceremonies to facilitate recovery. They may

also be focused in particular settings (e.g.,

workplaces, schools, local government areas,

shelter, and accommodation sites). 

Community Emergency Response Team

(CERT).Citizen teams trained in disaster

preparedness and response. The program was

originally developed and implemented by the Los

Angeles Fire Department in 1985, and it was

eventually made available to communities

nationwide in partnership with FEMA and the

Emergency Management Institute. 

Complicated grief.Bereaved individuals with

high levels of complicated symptoms have

substantially greater dysfunction than those with

lower levels of these symptoms. Studies find that

complicated grief symptoms (1) form a coherent

cluster of symptoms distinct from bereavementrelated depressive and anxiety symptom clusters;

(2) endure several years for some bereaved

subjects; (3) predict substantial morbidity and

adverse health behaviors over and above

depressive symptoms; and (4) unlike depressive

symptoms, are not effectively reduced by

interpersonal psychotherapy and/or tricyclic

antidepressants. These findings suggest a need to

identify and treat complicated grief as a syndrome

distinct from major depressive disorder.

Crisis management.In the FEMA response

plan, this refers to measures to identify, acquire,

and plan the use of resources needed to anticipate,

prevent, and/or resolve a threat or act of terrorism.

It is predominantly a law enforcement response.

http://www.fema.gov/rrr/frp/frpterr.shtm

Critical Incident Stress Debriefing

(CISD).Mitchell and Everly (2000) refer to a

seven-phase, structured group discussion, usually

provided one to ten days post-crisis (three to four

weeks after mass disasters) and designed to

mitigate acute symptoms, assess the need for

follow-up, and, if possible, provide a sense of postcrisis psychological closure. The phases are:

1. Introduction and guidelines for participation

2. Discussion of relevant facts

3. Discussion of thoughts

4. Discussion of reactions/emotions

5. Discussion of emergent symptoms

6. Education about responses and coping 

strategies

7. Reentry (summarize, discussion of additional 

resources available)

Critical Incident Stress Management

(CISM).An integrated “system” of interventions

designed to prevent and/or mitigate the adverse

psychological reactions that so often accompany

emergency services, public safety, and disaster

response functions. CISM interventions are 
23

especially directed toward the mitigation of posttraumatic stress reactions. http://www.icisf.org/

Cross-cultural differences.Variations in the

meaning or expression of thoughts, feelings, or

behaviors related to ethnic or religious identity or

place of origin. Such differences may influence the

validity of assessment, response to treatment, and

appropriate ways of interacting with survivor

populations.

Debriefing.A generic term often used to refer to

Critical Incident Stress Debriefing or similar early

interventions. Historically, the term first referred to

a routine, individual or group review of an event

from a factual perspective for the purpose of

learning what actually happened. The results were

used for the historical record or planning process,

to improve future results in similar situations, and

to increase readiness of those being operationally

debriefed for future action. The term has also been

applied to many types of early psychological

interventions, but this use of the term alone is not

recommended (see also Critical Incident Stress

Debriefing). 

Defusing.A three-phase, structured, one-to-one

or small-group discussion provided within hours of

a crisis for purposes of assessment, triage, and

acute symptom mitigation.

Disaster.As defined under the Stafford Act, any

natural catastrophe (including any hurricane,

tornado, storm, high water, wind-driven water,

tidal wave, tsunami, earthquake, volcanic

eruption, landslide, mudslide, snowstorm, or

drought) or, regardless of cause, any fire, flood, or

explosion, in any part of the United States, which

in the determination of the President causes

damage of sufficient severity and magnitude to

warrant major disaster assistance under this Act to

supplement the efforts and available resources of

states, local governments, and disaster relief

organizations in alleviating the damage, loss,

hardship, or suffering caused thereby. 

Disaster application center. Facility

established by FEMA to accept and process

applications for federally funded disaster relief

assistance following a presidential declaration. 

Disaster field office.The primary location in

each affected state for the coordination of federal

response and recovery operations. Many office

buildings are actually used to house

comprehensive disaster field “office” operations.

http://www.fema.gov/rrr/frp/frpconc.shtm

Disaster Medical Assistance Team

(DMAT).One element of the National Disaster

Medical System, which is an interagency program

that provides the United States with a nationwide

medical aid system that may be activated at the

request of a governor, a state health officer, or

Secretary of Defense. DMATs include mental health

personnel. http://oep.osophs.dhhs.gov/dmat

Disaster Welfare Inquiry, American

Red Cross.Responsible for responding to

inquiries about the location and health and welfare

of individuals and families within the disaster

area, and for the preparation and distribution of

bulletins to non-affected chapters detailing

information about the disaster operation. 

Disaster Welfare Information, Federal

Emergency Management Agency.A

component of FEMA’s emergency support function

6 (mass care) that aims to report victim status to

family members outside of the affected area, and

assist in family reunification within the affected

area. http://www.fema.gov/rrr/frp/frpesf6.shtm

Disaster recovery center.A centralized

location where individuals affected by a disaster
24

can go to obtain information on disaster recovery

assistance programs from various federal, state,

and local agencies and voluntary organizations.

Trained staff is available to provide counseling and

advice. http://www.fema.gov/rrr/frp/frpconc.shtm

Early intervention.The provision of

psychological help to victims/survivors within the

first month after a critical incident, traumatic

event, emergency, or disaster aimed at reducing the

severity or duration of event-related distress. For

mental health service providers, this may involve

psychological first aid, needs assessment,

consultation, fostering resilience and natural

supports, and triage, as well as psychological and

medical treatment. 

Emergency.As defined in the Stafford Act, any

occasion or instance for which, in the

determination of the President, federal assistance is

needed to supplement state and local efforts and

capabilities to save lives and to protect property,

public health, and safety, including emergencies

other than natural disasters.

http://www.fema.gov/rrr/frp//frpappa.shtm

Emergency response team.The principal

interagency group that supports the Federal

Coordinating Officer (FCO) in coordinating the

overall federal disaster operation. It is located at

the disaster field office and ensures that federal

resources are made available to meet state

requirements specified by the state coordinating

officer. Functions include operation, information

and planning, logistics, and administration.

http://www.fema.gov/rrr/frp/frpconc.shtm 

Federal Coordinating Officer (FCO).The

person appointed by the director of the FEMA on

behalf of the President whose responsibility it is to

coordinate the timely delivery of disaster assistance

to affected state and local governments and

disaster victims. In many cases, the FCO is also the

disaster recovery manager, whose responsibility it

is to administer financial assistance as designated

under the Stafford Act. http://www.fema.gov/rrr/

frp//frppol.shtm

Federal response plan.The plan, involving

27 federal agencies, that establishes a process and

structure for the systematic, coordinated, and

effective delivery of federal assistance to address

the consequences of a federally declared disaster or

emergency. It describes basic policies, assumptions,

concept of operation, response and recovery

actions, and the responsibilities of various federal

agencies involved in carrying out the plan.

www.fema.gov/rrr/frp

Human-made disaster.An event caused by

human negligence, error, or intent that has

resulted in damage of sufficient severity and

magnitude to warrant assistance supplementing

state, local, and disaster relief organization efforts

to alleviate damage, loss, hardship, or suffering.

Human-made disasters include acts of terrorism,

large-scale industrial accidents, mass

transportation accidents, and civil disturbances. All

other things being equal, these disasters are

believed to have more serious consequences than

natural disasters for survivors’ mental health.

Incident command system.A standardized

system used by fire and law enforcement to

manage emergency operations.

Key informant method.An approach to

community mental health needs assessment based

on the assumption that certain individuals within

a community know it well enough to be able to

estimate mental health needs attributable to a

disaster and the resources required. 

Mass care.American Red Cross’s direct service

function responsible for providing congregate

shelter facilities and fixed mobile food service to
25

disaster victims and emergency workers in a 

disaster area. Provides for bulk distribution of

supplies and commodities to victims.

National Disaster Medical System

(NDMS).A cooperative asset-sharing program

among U.S. government agencies (Department of

Health and Human Services, Department of

Defense, Department of Veterans Affairs, and the

Federal Emergency Management Agency); state

and local governments; and private businesses and

civilian volunteers to ensure that resources are

available to provide medical services following a

disaster that overwhelms local health care

resources. NDMS is a federally coordinated system

that augments the nation’s emergency medical

response capability. Its overall purpose is to

establish a single, integrated national medical

response capability for assisting state and local

authorities in dealing with the medical and health

effects of major peacetime disasters and providing

support to the military and Veterans Health

Administration medical systems in caring for

casualties evacuated back to the United States from

armed conflicts overseas. www.ndms.dhhs.gov/

NDMS/ndms.html

Natural disaster.A geophysical or weatherrelated event causing damage of sufficient severity

and magnitude to warrant assistance

supplementing state, local, and disaster relief

organization efforts to alleviate damage, loss,

hardship, or suffering. Natural disasters include

earthquakes, floods, wildfires, volcanoes,

tsunamis, typhoons, cyclones, landslides,

blizzards, heat waves, and drought. 

Operational debriefing.A routine individual

or group review of the details of an event from a

factual perspective, for the purposes of: 

 Learning what actually happened for the 

historical record or planning process, 

 Improving future results in similar missions, 

and 

 Increasing the readiness of those being 

debriefed for further action. 

Operational debriefings are conducted by leaders or

specialized debriefers according to the

organization’s standard operating procedure.

Outreach.Array of disaster mental health

services extended to survivors wherever they

congregate, designed to increase understanding of

common reactions, coping, and when and where to

receive more in-depth help. Outreach is

recommended because most survivors do not seek

out mental health support services following a

catastrophic event. See also community-based

interventions.

Peri-traumatic stress reactions.Stress

symptoms that occur during or immediately after a

traumatic experience.

Post-traumatic stress disorder (PTSD).

An anxiety disorder (and diagnostic construct used

in the Diagnostic and Statistical Manual of Mental

Disorders-IV) that can develop after exposure to a

terrifying event, or ordeal in which grave physical

harm occurred or was threatened. The criteria for

PTSD require (see DSM-IV for details):

A. Exposure to a traumatic event

B. Reexperiencing of the event

C. Persistent avoidance of stimuli associated with

the trauma

D. Persistent increased arousal

E. Duration of B, C, D of more than one month

F. Clinically significant distress or impairment

Research indicates that victims of major disasters

are at risk for PTSD, especially if they have been

injured or have experienced life threat.
26

Preparedness plan.The pre-disaster plan for

organizational procedures intended for use in the

aftermath of disasters. Preparedness plans may

include crisis communication procedures for

addressing employees, media, and community

groups; security procedures to ensure safety of

employees and property; procedures to develop or

invoke relationships with law enforcement, firefighting, emergency medical, and related

government agencies; procedures to address and

monitor post-traumatic stress; and procedures to

manage department or operations shutdowns,

employee job reassignments, layoffs, or leaves of

absence.

Presidential declaration.A declaration of

an emergency or disaster made by the President of

the United States authorizing specialized federal

funds and assistance to state and local

governments after it is determined that disastercaused needs exceed the resources of state

governments.

Primary/direct victims.Generally refers to

individuals directly exposed to the elements of a

disaster.

Psychological debriefing. Widely used term

to describe a variety of structured events, led by a

person or team, which include education and

review processes with a positive focus on resilience

and coping strategies and sometimes detailed

review of emotional reactions.5

Psychological first aid.Pragmatically

oriented interventions with survivors or emergency

responders targeting acute stress reactions and

immediate needs. The goals of psychological first 

________________

5

Because the term “debriefing” has been overly applied in the

media and popular use to many types of early psychological

interventions, workshop participants recommend in the Key

Operating Principles that the term “debriefing” alone not be

used.

aid include the establishment of safety (objective

and subjective), stress-related symptom reduction,

restoration of rest and sleep, linkage to critical

resources, and connection to social support.

Public affairs or public information

officer.Disaster relief officer who has the

responsibility for implementing a system to provide

information about services available to disaster

victims, provide information to the general public

about services, and liaison with all media.

Referral.The process of recommendation and

linkage to other service providers.

Risk factors.Empirically validated variables

related to risk for long-term adjustment problems

(e.g., severity and type of traumatic exposure,

injuries, sudden unexpected death of loved one(s),

separation from family, previous psychological

disorder, age, socioeconomic class, chronic mental

illness, residential relocation, severe post-traumatic

reactions, degree of resource losses, degree of

community resource loss).

Robert T. Stafford Disaster Relief and

Emergency Assistance Act.The legislation

that provides the authority for the U.S. government

to respond to disasters and emergencies by

providing assistance to save lives and protect

public health, safety, and property.

http://www.fema.gov/library/stafact.shtm

Secondary/indirect traumatization.A

potential effect of “exposure” to individuals who

have been adversely affected by traumatic

stressors. It may occur between two or more

individuals (e.g., family members, groups of

victims), or in the process of helping trauma

victims.

Secondary/indirect victims.Generally

refers to individuals with close family and personal

ties to primary victims. 
27

Staging area.The designated area of

emergency operations serving to process and orient

incoming and exiting disaster workers.

State coordinating officer. The person who

coordinates the administration of state disaster

relief activities with response efforts of the federal

government and serves as the counterpart to

FEMA’s federal coordinating officer.

Stressors.Events or conditions that may cause

physiological and behavioral reactions and present

coping difficulties for the individual experiencing

them.

Stress reaction.The physiological and

behavioral responses to stressors, such as fatigue,

high blood pressure, anger, and psychological

distress.

Support system.Generic term referring to the

extent and quality of an individual’s social

resources.

Traumatic grief.A type of grief that is

characterized by suffering the death of a significant

person under traumatic circumstances (e.g.,

accidents, unexpected illness, homicide, suicide,

natural and human-made disasters, including

experiencing or witnessing the death in the midst

of horrific and/or life-threatening circumstances).

Recently the term has been used identically with

“complicated grief.” The basic cluster of grief

symptoms (including intrusive thoughts about the

deceased, yearning, searching, excessive

loneliness, numbness, purposelessness, difficulty

acknowledging the death, feeling life as

meaningless and empty, shattered worldview,

excessive anger and bitterness related to the death)

as distinguished from depression and anxiety

remain the same as in complicated grief. The

likelihood that a person who has suffered loss

under traumatic circumstances will develop a

complicated grief syndrome may be higher than in

the normal grief experiences. The interplay of

traumatic events and grief is not yet fully

understood.

Traumatic reactivation.The exacerbation of

residual stress-related symptoms precipitated by

stimuli after the original exposure to a traumatic

stressor.

Triage.The process of evaluating and sorting

victims by immediacy of treatment needed and

directing them to immediate or delayed treatment.

The goal of triage is to do the greatest good for the

greatest number of victims. 

Uncomplicated grief. Normal or

uncomplicated grief reactions are those that,

though painful, move the survivor toward an

acceptance of the loss and an ability to carry on

with his or her life. Indicators of normal

adjustment include the capacity to feel that life still

holds meaning, a sustained sense of self, selfefficacy, trust in others and an ability to reinvest in

interpersonal relationships and activities.

Weapons of mass destruction.Humandesigned chemical, biological, and explosive

mechanisms intended to cause severe and

widespread fatalities and environmental damage.

Reference

Mitchell, J.T. and Everly, G.S. (2000). Critical

incident stress management and critical incident

stress debriefings: Evolutions, effects and

outcomes. In: B. Raphael and J.P. Wilson (eds).

Psychological Debriefing: Theory, Practice and

Evidence (pp. 71-90). New York: Cambridge

Unversity Press. 

DisclaimerThis glossary of terms was developed

independently of the workshop. It was added

because it has been judged that it would be useful

to readers of this report.
28

Appendix E: 

Training of the Early Intervention

Workforce6

Background Considerations

Potential Audiences

Different forms of early intervention require

different sets of skills, training, and background

knowledge. Mental health practitioners are key

professionals in this respect. However, many early

intervention and follow-up activities may be

delivered to trauma survivors by individuals who

are not specifically pretrained in early intervention.

These individuals may include: 

 Paraprofessionals

 Community volunteers

 Medical professionals, including primary care 

practitioners, pediatricians, and family practice

doctors

 Disaster responders

 Clergy

 School personnel

 Staff of paraprofessional helping organizations

such as Alcoholics Anonymous. 

Core Training Modules

Much early intervention consists of providing

emotional and practical support. Thus, help in

reconnecting family or friends and in providing

information about services available can be

achieved by building on existing communication,

listening, and empathy skills, as well as other

personal qualities of the helpers. 

General training in the mental health aspects of

trauma should be delivered not only to mental

health professionals involved in providing 

________________

6

Participants in the workshop formulated this guidance;

however, it was not voted on by all participants as an area of

consensus at the workshop. All participants reviewed this

information by e-mail.

emergency mental health support but also, as

appropriate, to others who will respond to those

recently traumatized. (See the above list of

potential responders.) It is also important that such

training be made available to emergency

responders––for example, firefighters, police

officers, hospital trauma center personnel, and

coroners––to help these groups understand the

mental health implications of their work and to

foster appropriate competencies.

The need to educate trauma survivors and the

communities that provide their recovery

environment is widely accepted and should be a

part of any training program. There is general

agreement that such education should inform

survivors about the following:

 The nature of traumatic stress reactions

 Normal reactions to trauma

 Risk factors associated with more serious 

problems, without creating expectation of 

chronicity

 Ways of coping with and mastering the effects 

of mass violence and disasters

 Services available in the aftermath of mass 

violence and disasters (including mental health

counseling)

 Timing and the processes of self-referral for 

specialist help.

While this kind of educational activity forms a core

part of early intervention services, what such

education of trauma survivors can realistically

achieve is currently unclear.

It is often assumed that mental health workers

who have an understanding of disasters and their

consequences can pass on this information to

survivors and their closest relatives. Because of the

physical and psychological state of survivors in the

early aftermath of mass violence and disasters,

some survivors may find it difficult to learn and

remember the content of such information. It is,
29

therefore, important to train workers to appreciate

the importance of both the content and manner of

communicating effectively and systematically, as

well as to encourage the distribution of written

educational information.

Risks

There are potential risks of education efforts that

must be carefully addressed, including the

following:

 Dispensing erroneous information, current fad,

or uninformed opinion as proven fact

 Compounding the social stigmatization of 

those with more symptoms

 Causing “reverse stigmatization” and guilt 

(e.g., “If you don’t have these symptoms, then 

there’s something bad and unfeeling about 

you.”)

 Using vocabulary and concepts unfamiliar to 

the specific audience, especially technical 

terms and jargon that have unintended

negative effects (one script does not suit all

audiences)

 Over-pathologizing and focusing on therapy 

and disability compensation, rather than 

facilitating natural supports and resiliency.

Specialized Modules

Evidence-based specialized interventions that are

targeted to those who are at significant risk of

developing PTSD and other post-trauma problems,

require specialized skills. For example, the

cognitive-behavioral early interventions noted

above require practitioners to deliver structured

training in breathing and relaxation, imaginal and

in vivo exposure therapy, and cognitive

restructuring skills. The need for specialized skills

means that mental health professionals will be the

most appropriate group to deliver these

interventions. 

Two of the best-validated treatment elements for

PTSD and depression are direct therapeutic

exposure and cognitive restructuring. These

interventions are not systematically taught in

graduate schools, and it is not wise to assume they

can be administered by any mental health

professional whose repertoire of skills may not be

in keeping with those required for early

intervention after mass violence and trauma.

Additionally, there are important caveats to

delivering these interventions with the bereaved

and recently traumatized. This means that

specialized training will be necessary to

supplement mental health professionals’ existing

skill and knowledge base. 

Other forms of specialized training may be required

to assist workers involved in the delivery of

interventions to minimize the effects of trauma.

This training may include the following: 

 Screening and identification of risk factors for 

chronic post-trauma problems

 Providing support during and after death 

notification

 Working with traumatized children

 Working with the traumatically bereaved

 Working with special populations such as 

emergency services workers.

In addition to interventions targeting posttraumatic stress responses, follow-up service

providers should be alert to and be trained to

identify and intervene with other problems that

frequently come to light in the aftermath of

trauma, for example, alcohol and substance abuse

problems. Patients who might benefit from early

intervention to prevent development of PTSD may

already have established patterns of substance

abuse. Comprehensive care, therefore, requires

services to address both sets of problems. 

Broadly, the most important and challenging part

of follow-up training concerns which interventions

should be provided in the aftermath of traumatic

events. This decision is especially challenging
30

because specific skills must be taught and because

currently available research literature does not give

definitive signposts to identify these interventions.

However, early post-trauma interventions are now

receiving increased research attention, and relevant

evidence should be forthcoming in the next few

years. This means that it will be important to

design systems for periodically updating and

changing the content of early intervention training. 

In a recent review of training in mental health

response to disaster and community violence,

Young, Ruzek, and Pivar (2001) offered a set of

recommendations for improvements in training.

This training guidance applies to the context of

early intervention as well.

Guidance on Basic Content of Training

Response Structures and Processes

 Federal response plan, disaster agencies, and 

organizational relationships

 Mental health response in the disaster context

 The ethics of disaster mental health and 

community violence (DMH/CV) response

 What to expect

 Grant application.

Disaster Mental Health Resources

Evidence-based interventions, content and skills,

include the following:

 General goals of intervention

 On-scene support and psychological first aid

 Survivor education

 Social support

 Psychological debriefing and defusing

 Environmental interventions

 Pharmacotherapy

 Referral to mental health services

 Community organization and self-help group 

interventions

 Operational debriefing in responder

organizations.

Considerations in Intervention

 Matching of intervention and phase of disaster

 Matching of intervention and setting

 Matching of intervention and survivor

High-Risk Groups

 Identification of those at risk for mental health

problems

 Children

 Bereaved survivors

 Elderly survivors

 Survivors with existing mental health 

problems

 Wounded

Other Areas for Training

 Outreach

 Cultural issues

 Mass media

 Disaster worker stress

 Leading and managing disaster/mass violence 

mental health

 Nature and effects of disaster and mass

violence 

Additional Content Guidance

Use Existing Literature for Training

 Link training content (e.g., discussion of acute 

stress reactions) to existing empirical research.

 Devote more attention to educating workers

about research-based risk factors for chronic

mental health problems following exposure to 

disaster or mass violence.

 Train workers to use their awareness of risk

factors, as well as formal screening tools, to
31

select individuals who require referral to more 

intensive services and energetic follow-up. 

 Help workers understand the changed settings 

and dynamics for post-disaster intervention:

– Recognizing the different personal 

responses and dynamics or interpersonal 

relationships (i.e., lowered defensiveness, 

heightened neediness, affiliated behavior, 

need for comforting) 

– Increasing the capacity to work in a 

chaotic environment, without the 

protection of usual roles and office 

settings

– Conducting interventions in environments 

of need, such as shelters, temporary or 

crowded relief centers, and morgues.

Develop Educational Materials

 Materials focused on training survivors and 

emergency responders to support one another 

and on teaching parents how to talk with their 

children about the event and its consequences

 A comprehensive list of available disaster 

mental health training resources, along with 

recommendations identifying the most useful 

materials 

 Sanctioned training materials and handouts 

that are easily available to practitioners via 

Web and CD-ROM technology. 

Develop Specialized Training Modules for

Mental Health and Medical Practitioners

on:

 Providing consultation to disaster response 

leaders, team leaders and workers, and other 

members of the community on mental health 

aspects of mass violence 

 Explaining when and how to refer service 

users to more intensive mental health services 

 Providing effective didactic education to 

survivor groups and emergency workers

 Offering systems for follow-up of high-risk 

survivors 

 Providing mental health services to children of 

different ages 

 Identifying survivors presenting both initially 

and at later times by:

– Identifying the settings where those at 

highest risk for continuing psychological 

problems are likely to be encountered 

– Integrating mental health care into 

settings where emergency medical 

treatment is provided

– Providing evidence-based assessment 

methods for clergy, primary care providers,

and mental health professionals 

 Offer training in specific evidence-based, 

manual-driven interventions, such as:

– Brief cognitive-behavioral methods 

designed to prevent PTSD

– Bereavement support and treatment of 

traumatic bereavement

– Psychotropic medications for managing 

acute stress reactions

– Stress management (e.g., relaxation, 

breathing)

– Coping-skills training (e.g., problemsolving, giving and receiving help, mutual 

support communication skills for families 

and neighbors, assertion training)

– Relapse prevention

– Brief interventions designed to prevent 

abuse of alcohol and prescription medicine

 Recognizing mental health challenges 

associated with biological or chemical 

disasters, terrorism, or use of weapons of mass

destruction 

 Integrating counseling with welfare response 

and practical assistance

 Addressing secondary traumatization, burnout,

vicarious traumatization, and the need for 

gradual return to usual duties

 Offering community interventions

– Assessment of environments where 

survivors and emergency responders 
32

congregate and strategies for improving

those environments 

– The effects of disaster and violence on the 

functioning of larger groups of people, 

such as families, communities, and 

workplaces, and strategic interventions 

(e.g., assessment, consultation, support 

programs) for such groups

– Community organization and collaboration

with self-help organizations

– The role of media in the aftermath of

disaster and mass violence, along with

practical advice for managing common

aspects of media relations. 

 Addressing primary care practitioners

– Assess and treat traumatic stress and loss 

issues at the primary care level

 Executive skills training on how to: 

– Form, operate, and maintain a disaster 

mental health team

– Liaison with community, state, and federal

leaders

– Navigate the grant application process

– Identify potential needs

– Ensure that qualified and trained 

professionals are provided at appropriate 

points and settings of the post-disaster 

response

– Oversee and supervise general support 

workers

– Verify the multiplicity of counselors, 

operational debriefers, and others who 

offer help are appropriate

– Establish a place for counseling and 

command and control activities 

– Provide clear information to other postdisaster workforces on their roles, with 

clear delineation of what they can offer

– Offer and monitor outreach and follow-up 

(i.e., use of media, providing brochures, 

cards with contact details, etc.)

– Establish clinical issues and

responsibilities as professionals, including

documentation and review

– Establish the framework for follow-up

– Set up clear liaison with local and

neighboring agencies of response and local

care systems

– Effectively support the caregivers (i.e.,

preventing secondary traumatization,

burnout, vicarious traumatization)

– Consider ethical issues associated with

disaster mental health service delivery.

Improve the Process of Disaster Mental

Health Training

 Provide training in language that is readily 

understood, avoiding professional jargon and 

the pathologizing of normal responses.

 Develop hands-on training approaches that 

give trainees multiple opportunities to observe,

practice, and receive coaching as they attempt 

to employ various skills by increasing the use 

of:

Role-play exercises

Sample scripts that illustrate skills

Narratives describing real-world disaster 

scenarios

Interactive CD-ROM video materials.

 Increase use of videotapes showing aspects of 

disaster mental health care to give trainees a 

sense of what really takes place at disaster 

sites and settings, what they may see, and how

these settings typically look and feel.

 Move toward greater specification of training 

procedures and systematization of delivery of 

training. 

 Develop systems for continuing education of 

disaster mental health workers.

 Develop methods to evaluate the effectiveness, 

and perceived usefulness of disaster mental 

health training procedures.
33

Reference

Young, B.H., Ruzek, J.I., and Pivar, I. (2001). 

Mental Health Aspects of Disaster and Community

Violence. A Review of Training Materials. Menlo

Park, CA, National Center for PTSD and

Washington, D.C. Center for Mental Health

Services.
34

Appendix F: 

Additions and Dissenting

Opinions

Debriefing:

Dr. George Everly:

1) The call for caution as one considers early

psychological intervention subsequent to mass

disasters, warfare, and other significant critical

incidents is an admonition that must certainly be

heeded. As such, the historical record should

clearly reflect its empirical origins, beyond the

clinically intuitive and obligatory motives of

primum non nocere. The recent concern for early

intervention arose from publication of the Cochrane

Reviews (Rose, Bisson, and Wessely, 2002). The

Cochrane Reviews have made an important

contribution to the early intervention literature by

pointing out the difficulty in employing one-to-one

counseling (therein referred to as “debriefings”)

with hospitalized medical patients. However, by

using medical patients (as opposed to physically

healthy participants) and employing one-to-one

interventions (as opposed to the more standard

small-group intervention), the “debriefings” as

reviewed in the Cochrane documents tell us little

about early interventions as commonly practiced

subsequent to mass disasters, warfare, and related

critical incidents. As Ruzek (2001) notes, “the

controlled studies that have been conducted have a

variety of limitations; for example, debriefing as

tested in this research has differed significantly

from mainstream application of the method...”

 (p. 33). Due to its liberal usage, the term

“debriefing” has lost any sense of operational

meaning, thus conclusions regarding its

effectiveness must be anchored to an operational

definition of the term itself. Having made the

aforementioned recommendation, it is important to

note that the literature review committee did

identify two randomized controlled trials (RCTs)

(Campfield and Hills, 2001; Deahl et al., 2000)

providing evidence that may be seen as support for

the structured and standardized group crisis

intervention Critical Incident Stress Debriefing

(CISD). 

2) Even more fundamentally, any conclusion that

“psychological debriefing” may be harmful

engenders concern. The two randomized controlled

trials upon which such a conclusion may be based

are suspect regarding both internal and external

validity. Both randomized controlled trials (Bisson

et al., 1997; Hobbs et al., 1996, with follow-up by

Mayou et al., 2000) failed to achieve equivalent

group membership at pretest (“debriefed” groups

had more severe injuries in both studies). The

pretest differences may have served to influence

post-intervention outcomes. Clearly, scrutiny of the

manifest psychometric increases in the “debriefed”

group within the Hobbs study reveals a statistically

significant change that has no practical clinical

relevance. 

3) Total adherence to randomized controlled trials

as the sole source of evidence is in contradistinction to trends in the related field of

psychotherapy research. As Seligman (1996) has

noted, “But efficacy studies are not necessary,

sufficient, or privileged over effectiveness studies

in deciding whether treatment works” (p. 1077).

We appear to be using a double standard for what

we accept as evidence of psychotherapy outcome as

opposed to what we accept as evidence in early

intervention research. Flannery’s (Flannery et al.,

1995, 1998) multi-component crisis intervention

system, while selected as one of the ten best

clinical programs in 1996 by the American

Psychiatric Association, is, therefore, left out of

consideration due to its lack of randomized

controlled trials. It would seem myopic to disregard

from consideration non-equivalent controlled

group outcome research, whether relating to the

field of psychotherapy or early intervention.

Finally, Deahl (2002) has noted, “Outcome

research into the effectiveness of debriefing raises
35

important questions about the ethics as well as the

status of conventional randomized controlled trial

methodology... Clinicians might lament that in

attempting to satisfy such rigorous methodological

criteria randomized controlled trials have become

so divorced from clinical reality that their findings

become meaningless... Randomized controlled

trials are not the sine qua non of EBM [Evidence

Based Medicine]” (p. 21).

4) Finally, while it seems clear at this point that

there is insufficient randomized controlled trial

evidence to recommend “one off” crisis counseling

with medical patients (see Cochrane Reviews), this

finding has very little to do with the task of

addressing the mental health needs of victims in

the wake of a mass disaster such as the World

Trade Center terrorist attack. Evidence-based

practice guidelines pertaining to mass disasters,

warfare, and related critical incidents must be sure

to exhibit external validity, i.e., they should reflect

research (randomized controlled trials or not) that

has direct applicability to the focus of the extant

recommendations (i.e., mass disasters, etc.).

References

Bisson, J., Jenkins, P., Alexander, J., and Bannister,

C. (1997). Randomized controlled trial of

psychological debriefing for victims of acute burn

trauma. British Journal of Psychiatry, 171, 78–81.

Campfield, K. and Hills, A. (2001). Effect of timing

of critical incident stress debriefing (CISD) on

posttraumatic symptoms. Journal of Traumatic

Stress, 14, 327–340.

Deahl, M. (2002). Comments and criticism. In Rose,

S., Bisson, J., and Wessely, S. Psychological

debriefing for preventing post traumatic stress

disorder (PTSD). (Cochrane Review). In: The

Cochrane Library, Issue 1, Oxford: Update

Software.

Deahl, M., Srinivasan, M., Jones, N., et al. (2000).

Preventing psychological trauma in soldiers: The

role of operational stress training and

psychological debriefing. British Journal of Medical

Psychology, 73, 77–85.

Flannery, R.B., Jr., Hanson, M., Penk, W., et al.

(1995). The assaulted staff action program. In L.

Murphy et al. (eds.). Job Stress Interventions.

Washington, D.C.: APA Press.

Flannery, R.B., Jr., Hanson, M., Penk, W., et al.

(1998). Replicated declines in assault rates after

the implementation of the ASAP. Psychiatric

Services, 49, 241–243.

Hobbs, M., Mayou, R., Harrison, B., et al. (1996). A

randomized controlled trial of psychological

debriefing for victims of road traffic accidents.

British Medical Journal, 313, 1438–1439.

Mayou, R., Ehlers, A., and Hobbs, M. (2000).

Psychological debriefing for road traffic accident

victims. Three-year follow-up of a randomized

controlled design. British Journal of Psychiatry,

176, 589–593.

Rose, S., Bisson, J., and Wessely, S. (2002).

Psychological debriefing for preventing post

traumatic stress disorder (PTSD). (Cochrane

Review). In: The Cochrane Library, Issue 1, Oxford:

Update Software.

Ruzek, J.I. (2001). Early intervention: Clinical

forum. NC-PTSD Quarterly, 10 (2), 33–34.

Seligman, M. (1996). Science as an ally of practice.

American Psychologist, 51, 1072–1079.

Dr. Brett Litz

There is no available evidence from randomized

controlled trials to support the efficacy of CISD as

an early preventative intervention. CISD may assist
36

with group cohesion, morale, and other important

variables that have not been demonstrated

empirically. Further research may establish 

whether CISD promotes favorable outcomes and, if

so, what those outcomes might be.

Reference

Litz, B.T., Gray, M.J., Bryant, R., and Adler, A.B. (in

press). Early intervention for trauma: Current

status and future directions. Clinical Psychology:

Science and Practice.

COL James Stokes

“Critical incident stress debriefing” and the

acronym CISD should be used only in the

organizational context of preexisting teams that

have experienced traumatic mission events,

debriefed according to protocol with the intent of

sustaining capability to continue operations. 
37

Appendix G: 

Intervention Literature Review

Tables

Introduction

The following research tables attempt to

summarize the empirical literature related to early

interventions in the face of disasters. In the process

of gathering information for this project, a dearth

of well-designed studies of disaster interventions

led to a broadening of the literature review. The

tables below make reference to a range of studies

of both early-stage and later-stage interventions for

trauma-related symptoms resulting from a variety

of stressors. Because of the relatively small number

of studies that are specific to disaster

interventions, many of which are methodologically

limited, it may be useful to extrapolate findings

from well-designed and controlled studies in the

broader trauma intervention literature.

All articles contained in the following tables were

published between 1967 and the present, in

English. Studies were obtained primarily from a

review of Psych Info and PILOTS,7 but were also

obtained from reference lists and expert

recommendations. It should be emphasized that

the following tables are a work in progress. They

do not contain a comprehensive review of all

relevant studies, and we expect that the

information in the tables will continue to grow as

more studies are published and existing studies are

added. 

All studies are listed alphabetically within tables. 

The tables are divided as follows for ease of

reading:

______________

7

PILOTS stands for “Published International Literature on

Traumatic Stress,” the National Center for PTSD’s database of

abstracts for literature on traumatic stress. PILOTS contains over

22,000 abstracts and is currently the largest interdisciplinary

index to the worldwide literature on traumatic stress.

Table 1. Non-“debriefing” interventions, 

delivered within approximately one 

month of trauma 

Table 2. Self-described “psychological debriefing” interventions delivered within 

approximately one month of trauma

Table 3. Self-described “psychological debriefing” 

interventions delivered two to six 

months post-trauma

Table 4. Non-“debriefing” interventions delivered 

two to six months post-trauma

Table 5. Non-“debriefing” interventions delivered 

more than six months post-trauma

Table 6. Studies of traumatic bereavement and 

complicated grief in adults

Table 7. Recent and well-controlled studies of 

medications for PTSD

Table 8. Studies of children/adolescents with 

trauma symptoms related to singleincident stressors, including disasters

Table 9. Studies of traumatic bereavement/ 

complicated grief in children and 

adolescents

Table 10.Studies of children/adolescents with 

trauma symptoms related to sexual or 

physical abuse (potential problems with 

generalizability to disasters)

Coding of Studies Included in the Review

a) Study/Level. The studies contained in the

report are classified according to the Agency of

Health Care Policy and Research’s (AHCPR) Levels

of Evidence. This system of classification was used

in the recent set of PTSD practice guidelines from

the International Society for Traumatic Stress

Studies (Foa, Keane, and Friedman, 2000). Only

studies that met Level A, B, or C criteria are

included in the review. Therefore, evidence based

on widespread clinical practice or recently

developed treatment that has not been subjected to

empirical test is not included. Case studies also are

not included. 
38

While the Levels of Evidence allow the reader more

easily to categorize studies according to design

(i.e., randomization and placebo control), they

should not be interpreted as overall rankings of a

study’s merit. For example, some studies are coded

at a Level A because they are randomized and

controlled, but they suffer from serious

methodological limitations that limit interpretation

of the findings. In contrast, some studies that are

coded at a Level B or Level C have been well

controlled and demonstrate good internal validity. 

Evidence is based on randomized, 

well-controlled clinical trials for individuals 

with PTSD.8

Evidence is based on well-designed 

clinical studies, without randomization or 

placebo comparison for individuals with PTSD.

 Evidence is based on service and

naturalistic clinical studies, combined with

clinical observations that are sufficiently

compelling to warrant use of the treatment

technique or follow the specific

recommendation. 

	

 from which the study participants

were drawn. 

b) Study Group.Collective trauma vs. individual

trauma. Potentially traumatizing events such as

disasters or combat were classified as collectively

experienced, whereas events such as motor vehicle

accidents or sexual assaults were classified as

individually experienced. 

c) Interval Between Trauma and Assessment. 

Timing of intervention and assessments.

d) Conditions, Sample Size, and Individual

vs. Group Intervention. In addition to a basic

classification as CBT, EMDR, CISD, etc., a

functional description of the actual intervention is 

provided. We have recorded whether the

intervention was provided individually, to a family,

to a group, etc. 

e) Results.The main study findings are noted,

with particular attention to trauma-related

symptoms. Measures: The type of measurement is

noted (e.g., interview, self-report), with attention to

whether or not the measurement system is reliable

and valid. A reference list of the names of all

measures follows the tables.

f) Gold Standards, Met and Unmet. We have

noted methodological strengths and limitations with

reference to Foa and Meadows’ (1997) gold

standards for clinical research. In some cases, a “?”

is used to indicate that it is unclear whether or not a

given criterion has been met. Likewise, in some

cases, we have indicated that a given criterion has

been partially met. If other major limitations are

present, they are noted as well.

The Foa and Meadows (1997) criteria are as follows:

1. Clearly defined target symptoms

2. Reliable and valid measures

3. Blind evaluators

4. Assessor training9

5 Manualized, replicable specific treatment 

programs

6. Unbiased (random) assignment to treatment

7. Treatment adherence.

References

Foa, E.B., Keane, T.M., and Friedman, M.J. (eds.)

(2000). Effective Treatments for PTSD: Practice

Guidelines from the International Society for

Traumatic Stress Studies. New York: Guilford 

Press.



8

Studies that met less than three of Foa and Meadows’ gold

standards were given a “–” to indicate substantial limitations in

terms of internal or external validity. In contrast, if all seven gold

standard criteria were met for a given study, the study was

given a “+” to indicate its strengths.

9

The vast majority of studies reviewed did not provide detailed

information about the level of assessor training. The benefit of the

doubt was given in this area when it could not be determined

from information in the article itself.
39

Foa, E.B., and Meadows, E.A. (1997). Psychosocial

treatments for post-traumatic stress disorder: A

critical review. Annual Review of Psychology

48, pp. 449-480.
40 

Table 1. Non-“debriefing” interventions, delivered within approximately 1 month of trauma Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Brom, Kleber, & Hofman, 1993 Level A The Netherlands 

Individual trauma: Adult, male and female motor vehicle accident (MVA) survivors 

1 month after MVA Individual intervention: 

1. 3 to 6 sessions of treatment 

package including psychoeducation, support, “reality testing” (n=68). 

2. No-treatment, assessmentonly control (n=83). 

No significant differencebetween groups on trauma symptom improvement (IES). 

Bryant, Harvey, Dang, Sackville, & Basten, 1998 Level A+ Australia

Individual trauma: Adult motor vehicle accident survivors or industrial accident survivors 

Therapy commenced within 2 weeks of trauma Mean (M) = 10 days posttrauma 

Individual intervention: 1. Five 1.5-hour sessions of 

CBT (education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, in vivo exposure) (n=12). 

2. Five 1.5-hour sessions of 

supportive counseling (education, general problem-solving skills, unconditional support) as a control group (n=12). 

Fewer individuals in the CBT group met criteria for PTSD at posttreatment and 6 months post-trauma. Greater reductions in intrusive, avoidance, and depressive symptoms (IES; BDI) among the CBT group at posttreatment and 6-month follow-up. 
41 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Bryant, Sackville, Dang, Moulds, & Guthrie, 1999 Level A+ Australia

Individual trauma: Adult motor vehicle accident survivors and nonsexual assault survivors

M = 10 days post-trauma Therapy commenced within 2 weeks of trauma 

Individual intervention: 1. Five 1.5-hour sessions of 

prolonged exposure plus anxiety management (n=15). 

2. Five 1.5-hour sessions of 

prolonged exposure (n=14). 

3. Five 1.5-hour sessions of 

supportive counseling (n=16). 

Greater reductions in PTSD found in the prolonged exposure plus anxiety management and prolonged exposure groups as compared to supportive counseling group, at both posttreatment and 6-month follow-up (CAPS). 

Bunn & Clarke, 1979 Level A– Australia 

Individual trauma: Parents or immediate relatives of a seriously injured or ill person who had been brought to an ER. Excluded those with frequent attendance at hospital. 

Counseling session and assessment took place at ER visit (immediate) 

Individual intervention: 13 males and 17 females, ages 16–68. Study does not report distribution of participants per group. 1. 20 minutes of “supportive, 

empathic” counseling in quiet room adjacent to the ER. Counseling provided by primary investigator. Participants encouraged to express feelings and concerns re: crisis. Information about injury or illness and its prognosis was provided. 

2. 20 minutes alone in quiet 

room adjacent to ER. 

Used content analysis scales to analyze verbal samples before and after intervention/control. Pre-post decrease in leveof anxiety (as measured through content analysis scales) of the interventiogroup as compared to thcontrol group. 
42 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Duckworth, 1986 Level B– Leeds, United Kingdom

Collective trauma: UK police officers who worked in conjunction with Bradford fire disaster

One month, post-fire, all police officers involved were sent screening questionnaire (GHQ). Those with high scores were offered counseling. 

Individual intervention: 34 officers with high GHQ 

scores received individually tailored counseling by the principal officer, 2 months postdisaster. Treatment lasted between one and five sessions. 

Significant pre-post changes on GHQ-60 somatic symptoms, anxiety symptoms, sociadysfunction, and severe depression. 

Echeburua, de Corral, Sarasua & Zubizarreta, 1996 Level A Spain 

Individual trauma: Adult, female rape survivors 

M = 5 weeks post-trauma Individual intervention: 

1. Five 1-hour sessions of 

individual cognitive restructuring and coping skills training (n=10). 

2. Five 1-hour sessions of 

progressive muscular relaxation training (n=10). 

No significant differencebetween groups on fearsanxiety (STAI), or depression (BDI) at 1, 36, or 12-month followup. No differences between groups in rates of PTSD (SSPSDS) at any measurement time. Severity of PTSD symptoms significantly lower in Group 1 at 12-month follow-up. 
43 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Foa, HearstIkeda, Perry, 1995 Level B United States

Individual trauma: Adult, female survivors of rape or aggravated assault 

M = 12 days post-trauma Individual intervention: 

1. Four 2-hour sessions of brief 

cognitive behavioral program (n=10). 

2. Five 1.5-hour assessment 

interviews (n=10). 

CBT group had less severe PTSD symptoms (PSS) than control group at 2 months post-assaultHowever, at 5.5 months post-assault, groups differed only on reexperiencing symptoms. At 5.5 months, the CBT group had lower depression scores (BDI)

Gidron, Gal, Freedman, Twiser, Lauden, Snir, & Benjamin, 2001 Level A United States

Individual trauma: Adult motor vehicle accident survivors 

Treatment within 48 hours of ER visit. Assessment given 3–4 months after treatment. 

Individual intervention: 9 male and 8 female participants were assigned to either: 1. Two telephone sessions of 

memory structuring intervention (MSI), modeled on CBT. 

2. Two telephone sessions of 

supportive listening. 

Sessions took place on consecutive days within 48 hours of discharge from ER. 

Fewer participants in MSI than control group met criteria for PTSD, and greater reductions in PTSD found in the MSI as compared to supportive counseling group, at 3–4 month follow-up (PTSD). 
44 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Kilpatrick & Veronen, 1983 Level B United States 

Individual trauma: Adult, female rape survivors 

Treatment and assessment were less than 1 month after assault 

Individual intervention: 1. Repeated assessments 2. Delayed assessment 3. 4–6 hours of CBT (psychoed, exposure, cognitive 

restructuring, anxiety management) conducted in two sessions. 

No greater symptom reduction in active treatment than in control groups. 

Stevens & Adshead, 1996 (cited in and described only in Hobbs & Adshead, 1996) Level A London, England 

Individual trauma: Male and female survivors of a motor vehicle accident, dog bite, or assault by a stranger Recruited from ER of hospital

Session introduced in ER within 24 hours of medical treatment. Assessments given at 1week, 1 month, and 3 months after their attendance at ER.

Individual intervention: 44 male and 19 female participants. Numbers not reported per group. 1. One session standardized 

interview, “counseled group.” 

2. Untreated control group. 

All subjects showed reduction in SEQ, BDI and IES scores by 3 months post-trauma. No differences in counseled and control groups in terms of any symptoms, except that those with high entry SEQ and BDI scores had significantly better outcome at 3 months in the counseled group vs. the control group. (Study does not include specific 
45 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

outcome information.) 
46 

Table 2. Self-described “psychological debriefing” interventions delivered within approximately 1 month of tStudy/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Amir, Weil, Kaplan, Tocker, & Witztum, 1998 Level B– Israel

Collective trauma: Non-injured adult women who survived a terrorist attack in Israel 

Assessments given 2 days, 2 months, and 6 months post-attack First group session held 2 days after the attack.

Group intervention: Six-session “crisis group” given to all 15 women who survived terrorist attack. Group met once a week for 6 weeks. Groups emphasized “abreaction, normalization of feelings, coping with symptoms, cognitive restructuring” (n=15). 

IES full scale scores significantly higher at 2 days than at 2-month and 6-month follow-up. No significant changes seen over time in the SCL-90 or IES subscalewith the exception of increases in scores on thSCL-90 Interpersonal Sensitivity subscale. 

Bisson, Jenkins, Alexander, & Bannister, 1997 Level A Wales

Individual trauma: Adult, hospitalized burn victims

Psychological debriefing (PD) introduced at mean of 6 days post-trauma. Assessments completed at 3 months and 13 months post-trauma

Mixed individual/couples: Participants were randomly assigned to intervention or assessment-only control group. One session, termed “psychological debriefing” because it was based on Mitchell’s original (1983) model. Intervention “focused solely on the burn trauma and its effects, and was supplemented with written information describing common reactions following traumatic events, strategies to deal with them, and contact telephone numbers if 

Greater PTSD (IES and CAPS), anxiety (HADS)and depression (HADS) in “debriefed” group at 13 months. 
47 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

further help was required.” Average length of session 44 minutes. 1. Individual or couples session 

(n=57). 

2. Assessment only control 

(n=46). 

Campfield & Hills, 2001 Level A Australia

Collective trauma: Adult employees of a bank who had been involved in robberies 

Victims of robbery randomly assigned to either immediate (<10 hours) or delayed (>48 hours) debriefing group Assessments took place immediately post-debriefing, 2 days post-debriefing, 4 days post-debriefing, 2 weeks post-robbery

Mixed group/individual intervention: 1. “Debriefing” gro

up:

Participants were randomly assigned to a “debriefing” (either group or individual 2-hour debriefings) within 10 hours post-robbery at their place of work (n=36). 

2. Delayed-treatment control: 

Participants were randomly assigned to a debriefing more than 48 hours postrobbery at their place of work (n=41). 

Number and severity of PTSD symptoms (PDS) did not differ immediately postdebriefing, but were lower for the immediate than for the delayed group at each subsequentime interval (2 days posdebriefing, 4 days post debriefing, 2 weeks postrobbery). 
48 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Carlier, Lamberts, Van Uchelen, & Gersons, 1998 Level C Amsterdam, The Netherlands

Collective trauma: Police officers in Amsterdam who had responded to a plane crash. “for operational reasons about half of the officers involved failed to undergo debriefing”

Intervention took place “as soon as possible after the disaster” but is not specified. Assessments given at 8 and 18 months. 

Group intervention: 1. Group “psychological 

debriefing” according to the seven-phase CISD procedure (Mitchell, 1983), in groups of no more than 10 voluntary police officers, at police stations (n=46). 

2. Non-debriefed police officers 

who were also involved in the disaster but did not receive debriefing due to “operational reasons” (n=59). 

Immediately and 8 months post-disaster, groups did not show significant differences oPTSD symptoms (SIPTSD). Eighteen monthpost-disaster, debriefed showed significantly more disaster-related hyper-arousal symptoms

Carlier, Voerman, and Gersons, 2000 Level C Amsterdam, The Netherlands

Individual: Male and female police officers 

Debriefing sessions given at 24 hours, 1 month, and 3 months post-trauma. Assessments given predebriefing, 24 hours posttrauma (shortly after first debriefing), 1 week posttrauma, 6 months posttrauma (after second and third debriefing sessions). 

Individual intervention: Pre/post-test design of: 1. Police officers given three 

individual psychological debriefings; 24 hours, 1 month, and 3 months posttrauma (n=86). 

2. Non-debriefed internal 

control group (those who turned down opportunity for debriefing) (n=82). 

3. External control group (those 

who experienced traumas prior to debriefing program being introduced in police force) (n=75). 

One week post-trauma, debriefed subjects showed significantly more re-experiencing PTSD symptoms than either the internal or external control groups (DTS-PTSD; IES).

Six months post-trauma, no differences among groups. High levels of satisfaction with debriefing was not correlated with positive outcomes. 
49 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Conlon, Fahy & Conroy, 1999 Level A Ireland

Individual trauma: Adult motor vehicle accident (MVA) survivors 

Intervention took place at mean of 7 days postmotor vehicle accident. Initial assessment took place prior to intervention (M=7 days post-MVA). Follow-up assessments took place a mean of 3 months after a motor vehicle accident.

Individual intervention: 1. Single counseling session 

that followed standard protocol, of approximately 30 minutes’ duration. Contained psycho-education and encouragement of emotion (n=18). 

2. Assessment-only control 

(n=22). 

PTSD symptoms (IES and CAPS) decreased sharply for both groups, but there were no significant differences between groups at the 3-month follow-up assessment point. High initial distress, increasing age, and high levels of perceived threat were significant independent predictors of morbidity. 

Deahl, Gillham, Thomas, Searle, & Srinivasan, 1994 Level C Great Britain

Collective trauma: British soldiers (duties of handling and identification of bodies) in Gulf War 

Intervention given at end of service, either in Gulf or upon return to UK Assessment measures administered 9 months after return from Gulf 

Group intervention: Authors labeled the intervention “psychological debriefing.” 1. One session intervention 

given to 69% of soldiers. Intervention consisted of education re: PTSD and normal reactions to trauma, advice on where to get help, 

After 9 months, no difference between debriefed and nondebriefed on IES or GHQ-28. Increased symptoms associated with life threaand history of psychological problems 
50 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

 and small group “debriefing” 

session based on Dyregov (1989) model (n=42). 

2. Non-intervention control 

group of soldiers who did not receive debriefing because it was not “operationally possible” (n=20). 

IES caseness high, with 42% of non-intervention group and 50% of intervention group meeting caseness criteria (n.s.). 

Deahl, Srinivasan, Jones, Thomas, Neblett, & Jolly, 2000 Level B Great Britain

Collective trauma: Adult male Peacekeepers serving in Bosnia Soldiers were “randomly allocated” by commanding officers blind to which group would receive debriefing. Allocation to group was based on “individual availability and commitment to other duties,” introducing possibility of bias. 

Initial assessment took place prior to intervention (at end of 6-month tour). Follow-up assessments at 3, 6, and 12 months. Intervention took place at end of 6-month tour of duty.

Group intervention: 1. One 2-hour formal debriefing 

session (Mitchell & Dyregrov method) in groups of 8-10 (n=54). 

2. Assessment-only control 

(n=52). 

Two groups differed at baseline, with HADS anxiety and total score and both subscales of thIES higher in the nonintervention group. SCL90 scores and CAGE (alcohol) scores higher ithe non-intervention group at 1-year followup. 
51 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Eid, Johnsen, & Weisaeth, 2001 Level C Norway 

Collective trauma: Military personnel and firefighters exposed to severe car accident in tunnel — rescue effort placed workers in harms way. 

Intervention was done 1 day post-accident. Assessment was done 2 weeks after accident. 

Group intervention: Military trainees received group psychological debriefing, stress management, and operational debriefing (n=9). Civilian firefighters received stress management and operational debriefing, but no psychological debriefing (n=9). 

1 day post-accident, all members of military training group (n=9) voluntarily participated in semistructured group “psychological debriefing” based on Mitchell model. Psychological debriefing intervention lasted 2.5 hours. Later the same day, both groups (military trainees and civilian firefighters) received an “after–action review/ operational debriefing” and brief psychoeducational group intervention on stress management. 

The group that received additional PD intervention reported fewer PTSD symptoms (PTSS-10) 2 weeks laterNo differences on the IES (intrusion/avoidance symptoms) or the GHQ-30 (psychosocial adjustment and quality olife). 
52 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Hobbs, Mayou, Harrison, & Worlock, 1996 Level A Great Britain 

Individual trauma: Adult male and female motor vehicle accident (MVA) survivors randomly assigned to treatment or assessmentonly control 

Intervention and screening (interview, IES, BSI) took place within 24–48 hours of MVA “in most cases.” Reassessed by interview, IES, and BSI at 4 months. 

Individual intervention: 1. One session of 1-hour 

individual “psychological debriefing.” Authors describe intervention as “review of the traumatic experience, encouragement of emotional expression, promotion of cognitive processing of the experience.” Intervention noted by authors to have limited structure (n=54). 

2. Assessment only control 

(n=52). 

Psychological debriefing condition had worse outcomes on two BSI scales. No group differences on IES. Neither group showed significant reductions in any symptoms. 
53 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Jenkins, 1996 Level C United States 

Collective trauma: 34 male and 2 female emergency medical technicians, paramedics and firefighters who worked at the site of a 

mass shooting 

1st assessment took place 

8-10 days post-shooting;2nd assessment took place 

one month post-shooting. “CISD” offered within 24 hours of shooting. Participation was voluntary. No description of intervention provided. 

Group intervention (questionable): 

1. 52% of the sample (n=15) 

attended “at least onesession” of CISD.

2. Control group chose not to

participate in CISD (n not

reported, but approximately15). 

Pre-post symptoms (SCL-90-R) decreased over the course of one month in both the debriefed and nondebriefed groups. Participation in debriefing was correlatewith lower depression and anxiety scores 1 month post-shooting. 

Lee, Slade, & Lygo, 1996 Level A United Kingdom

Individual trauma: Adult women who experienced early miscarriage randomly assigned to intervention or no-treatment control 

Initial assessment given 2 days post-miscarriage. Intervention introduced 2 weeks post-miscarriage, by female psychologist, in participants’ homes. Follow-up assessment given 4 months postmiscarriage.

Individual intervention: 1. One 1-hour session. Authors 

termed intervention “psychological debriefing,” described as six-phase intervention based on Dyregrov (1989) and Mitchell (1983) methods. Limited information given. (n=21). 

2. No-intervention control 

group (n=18). 

Significant main effects of time on depression (HADS), anxiety (HADS), intrusion (IES)avoidance (IES). No main effects or interactions for the intervention. 
54 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 
55 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Mayou, Ehlers & Hobbs, 2000 Level A Great Britain 

Individual trauma: 3-year follow-up of Hobbs et al. (1996) 

3-year follow-up of Hobbs et al. (1996) 

Individual intervention: 3-year follow-up of Hobbs et al. (1996) 

Psychological debriefing group had significantly worse outcomes at 3-yeafollow-up (BSI; travel anxiety, financial status, and overall functioning)No differences between groups on IES. Patients who initially had high intrusion and avoidance symptoms (IES) remained symptomatic if they had received the intervention, but recovered if they did not receive the intervention. 
56 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Rose, Brewin, Andrews, & Kirk, 1999 Level A United Kingdom

Individual trauma: Adult male and female survivors of actual or attempted physical or sexual assault, or bag snatch 

Initial interviews (the intervention) were conducted within 1 month of crime (M=21 dayspost-crime). Follow-up interviews were conducted at 6 and 11 months. 

Individual intervention: 1. One session of 

“debriefing”(loosely based on Mitchell model), plus psycho-education (n=54). 

2. One session of psychoeducation only (n=52). 3. Assessment only control 

(n=51). 

All groups improved, but there were no differences among groups on measures of PTSD (PSS and IES) or depression (BDI) at 6 or 11 months. 
57 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Shalev, Peri, Rogel-Fuchs, Ursano, & Marlowe, 1998 Level B Israel 

Collective trauma: 39 Israeli soldiers (male) directly exposed to combat were asked to participate; 2 left the sessions before the end 

Debriefing within 48–72 hours after exposure. Assessment pre-post to debriefing. 

Group intervention: Soldiers in 6 small units participated in a 2.5-hour historical group debriefing (HGD) (defined as “describingthe combat with all possible details,” based on Marshall’s original model for combat) within 72 hours of combat (n=39). 

Pre-post debriefing scores showed that debriefing was correlatewith self-reported reduction in anxiety symptom (STAI), improvement in selfefficacy (SELF-C) 
58 

Table 3. Self-described “psychological debriefing” interventions delivered 2-6 months post-trauma Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Chemtob, Tomas, Law, &Cremniter, 1997 Level B– United States

Collective trauma: Adult peer counselors and mental health center staff who survived Hurricane Iniki 

Assessments at 6, 9, and 12 months post-hurricane. One debriefing/education session introduced 6 months post-hurricane.

Group intervention: Participants received one 5-hour intervention (3 hours of group debriefing, followed by 2 hours of education on post-disaster recovery) either 6 or 9 months following Hurricane Iniki (n=43). Two groups of participants were debriefed: the post-test of Group 1 corresponded with the pre-test of Group 2, to give a partial control for time. 

Those who were debriefed showed a significant decrease in symptoms (IES) 3 months post-intervention

Kenardy, Webster, Lewin, Carr, Hazell, & Carter, 1996 Level C– Australia

Collective trauma: Naturalistic study of police officers, emergency service workers, welfare volunteers, and counselors following the Newcastle earthquake 

Unclear when intervention was introduced. Assessments at 27, 50, 86, and 114 weeks postearthquake.

Not specified whether “debriefing” was group or individual. 1. Non-debriefed (n=133). 2. Intervention was classified as 

“debriefing” but no descriptive information on naturalistic interventions was provided (mean number of sessions = 1.49) (n=62). 

Debriefed showed highegeneral psychological morbidity (GHQ-12). Overall reduction of symptoms over the course of study in both groups. However, debriefed showed less improvement. No evidence of an improved rate of recovery among the debriefed group. 
59 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 
60 

Table 4. Non-“debriefing” interventions delivered 2-6 months post-trauma Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Bordow & Porritt, 1979 Level B– Australia

Individual trauma: Adult, male motor vehicle accident (MVA) survivors admitted to hospital for at least 1 week. Most had physical injuries. First 30 pts received no intervention, later served as delayed contact control. Next 40 pts were randomly assigned to either immediate review (one interview) or immediate re

view pl

us

2-10 

hours of in

divid

ual

support from social worker. 

3–4 months post-injury Individual intervention: 

1. Delayed contact control 

condition, contacted 3-4 months after injury (n=30). 

2. Immediate review group 

interviewed within 1 week of injury (n=10). 

3. Full intervention group, 

interviewed within 1 week of injury and offered support from a social worker (n=30). 

Results favored the full intervention group in terms of general distress (Langner, Langsley), work problems, pleasant and unpleasant experiences (PAS; NAShealth deterioration (HCQ), traumatic neurosis symptoms, length of stay in hospitaland quality of social support. 
61 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Grainger, Levin, Allen-Byrd, Doctor, & Lee, 1997 Level B– United States

Collective Trauma: Adult survivors of Hurricane Andrew 

Treatment began 2.5–5.5 months after hurricane Assessments done pre-, post-treatment, and at 3-month follow-up 

Individual intervention: 1. One session of EMDR 

(n=29). Sessions lasted from 30 minutes to 2 hours. 

2. Waitlist control (n=11). 

Recipients of EMDR showed significant reductions in PTSD symptom (IES) compareto waitlist control groupone month after receivinEMDR. 
62 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Guthrie, Wells, Pilgrim, Mackway-Jones, Minshull, Pattinson, French, & Williams, 1999 Level B Manchester, England

Collective trauma: Subset of pts who had presented to ER following Manchester bombing

Initial assessments took place 2 months postbombing 

Individual intervention: 102 pts presented to ER following bombing. 25 of the pts were screened 8 wks later and those who scored high (n=12 of the 25) on IES were put into “brief cognitive behavioral therapy.” Only 5 of the 12 were considered appropriate for shortterm CBT. 3 pts with more complex trauma histories were put into brief psychodynamic interpersonal treatment. 

Of the 5 pts offered CBT2 successfully completed 6 sessions and showed resolution of PTSD symptom (IES, PSS). PTSD symptom resolved in the 3 pts offered brief psychodynamic interpersonal treatment. 
63 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Lindy, Green, Grace, & Titchener, 1983 Level B– United States

Collective trauma: Adult survivors of a fire 

Treatment and initial assessment introduced between 6 months and 1 year after fire. Assessments took place pre-treatment, 3 months, 1 year.

Individual intervention: Treatment was provided for 30 survivors who requested therapy after the fire, after being contacted in an outreach program. Individual therapy based on short-term (6–12 session) psychodynamic model for acute trauma survivors. Treatment introduced between 6 months and 1 year after fire. All treatments ended within 18 months after the fire. 

Those survivors who completed treatment did better on outcome measures (change in target symptom as judgeby therapist, SCL-90) than those who dropped out of treatment. 
64 

Table 5. Non-“debriefing” interventions delivered more than 6 months post-trauma Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Devilly & Spence, 1999 Level B Australia

Individual trauma: Varied Adults 

Trauma occurred >4 weeks prior to assessment Mean duration of trauma: symptoms = 112.44months (SD = 147.49 months)

Individual intervention: 1. Up to 8 sessions of EMDR

(n=11). 

2. 9-session CBT intervention

(n=12). 

CBT intervention more effective at reducing PTSD symptom (IES; PSS-SR). At 3-month follow-up, CBT pts continued to show improvement, while EMDR pts had begun to relapse. 

Fecteau & Nicki, 1999 Level A New Brunswick, Canada

Individual trauma: Adult survivors of motor vehicle accidents

M = 18.8 months after motor vehicle accident 

Individual intervention: 1. Four 2-hour individual, 

weekly sessions of CBT (n=10). 

2. Waitlist control (n=10). 

CBT group showed decreased PTSD symptoms (CAPS), anxiety (BAI) scores, andepression (BDI) scores compared to control at post-treatment. Treatment gains maintained at 6-month follow-up. 
65 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Foa, Dancu, Hembree, Jaycox, Meadows, & Street, 1999 Level A+ United States

Individual trauma: Female sexual and nonsexual assault survivors 

Not reported Individual intervention: 

1. 9 biweekly individual 

treatment sessions of prolonged exposure (n=23). 

2. 9 biweekly individual 

treatment sessions of stress inoculation training (n=19). 

3. 9 biweekly individual 

treatment sessions of combined prolonged exposure and stress inoculation training (n=22). 

4. 5-week waitlist control 

(n=15). 

All 3 active treatments reduced severity of PTS(PSS) and depression (BDI) compared with controls, but did not differ significantly from each other, throughout 12-month follow-up. At 12-month follow-up, the prolonged exposure group had lower anxiety (STAI) and higher sociaadjustment (SAS) scoresand effect sizes were larger on PTSD severitydepression, and anxiety. 

Foa, Rothbaum, Riggs, & Murdock, 1991 Level A+ United States

Individual trauma: Female survivors of attempted or completed rape 

M = 6.2 years post-assault Individual intervention: 

1. 9 biweekly 1.5-hour sessions 

of prolonged exposure (n=10). 

2. 9 biweekly 1.5-hour sessions 

of stress inoculation training (n=14). 

3. 9 biweekly 1.5-hour sessions 

of supportive counseling (n=11). 

4. 5-week waitlist control 

(n=10). 

All conditions produced improvement on all measures immediately post-treatment and at follow-up. Stress inoculation training produced more improvement on PTSD (ARI) than supportive counseling and waitlist control at post-treatmentProlonged exposure produced superior outcome on PTSD symptom at 3.5-month follow-up. No significangroup differences on anxiety (STAI), or depression (BDI). 
66 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Gersons, Carlier, Lamberts, & van der Kolk, 2000 Level A Amsterdam, The Netherlands

Individual trauma: Dutch police officers with PTSD 

Mean of 4 years since trauma while on police duty, specific type of trauma not specified. Mean number of traumas in line of police work was 19 for brief eclectic psychotherapy group and 15 for waitlist group. Assessments done 1 week pre-treatment, after session 4, after last session, and 3 monthsfollow-up. 

Individual intervention: Randomly assigned to either 16-session manualized brief eclectic psychotherapy (which combines CBT and psychodynamic techniques) or to waitlist control: 1. 16 weekly 1-hour sessions of 

brief eclectic psychotherapy, a manualized treatment which combines CBT and psychodynamic techniques (n=22). 

2. 7-month waitlist control 

(n=20).

No differences between groups at pre-test or aftesession 4. At post-test (end of 16-week treatment) and follow-up (3 months posttermination), brief eclectic psychotherapy group showed significanimprovement in PTSD and anxiety symptom (SI-PTSD, SCL-90, ADIS-R), work resumption, and some comorbid conditions. 
67 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Ironson, Freund, Strauss, & Williams, 2002 Level A United States 

Individual trauma: Varied Primarily rape and crime victims Male and female 

Does not specify how long since trauma. Assessments took place pre, post and 3-month follow-up. 

Individual intervention: 

1st three sessions identical for 

both groups. 1st session = 

assessment, 2nd and 3rd sessions = psycho-education regarding normal reactions to trauma, construction of in vivo hierarchy. 1. Sessions 4-6 of EMDR, 

supplemented with in vivo homework and relaxation homework (n=10). 

Both PTSD (PSS-SR) and depression scores (BDI) decreased equally in both treatments, at post-test and at 3-month follow-up. Reduction in PTSD symptom was faster in EMDR condition, and dropout rate was significantly lower in EMDR condition. 

Lange, van de Ven, Schrieken, & Emmelkamp, 2001 Level A Amsterdam, The Netherlands

Individual trauma: Varied traumatic events among undergraduate men and women in the Netherlands 

M= 6 years post-trauma at assessment 1 and at treatment. Assessments took place pre- and post-treatment, and at 6-week follow-up. 

Individual intervention: 1. CBT, writing-based 

protocol administered over the internet. Experimental group consisted of 5 weeks of 10 writing sessions, two 45-minute sessions per week (n=13). 

2. Waitlist control group 

(n=12).

At post-treatment, intrusion and avoidance symptoms significantly lower in the experimentagroup (IES), general psychopathology scores (SCL-90) lower in the experimental group, morimprovement in mood scores (POMS). Gains were maintained or improved upon at the 6-week follow-up. 
68 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998 Level A+ London, England 

Individual trauma: Varied (28% physical assault, 20% road accident, 15% witnessing, 8% non-road accident, 6% sexual assault, 5% held hostage, 5% bombing, 3% combat, 11% miscellaneous) 

Treatment: M: 4.5 years prior to treatment Assessments: M = 0, 6, and 11 (posttreatment) weeks, and at 1-, 3-, and 6-month follow-up thereafter.

Individual intervention: Ten 1.5-hour treatment sessions over 16 weeks: 

1. Exposure treatment 

(n=20). 

2. Cognitive restructuring 

(n=18). 

3. Combination treatment 

(n=19) *105-minute sessions. 

4. Relaxation (n=20) (placebo 

control for therapist contact). 

Cognitive restructuring, exposure treatment, and combination treatment were all better than relaxation control and otherwise equal at posttreatment and 6-months on most measures. On CAPS, combination treatment was inferior to either individual treatment. 

Resick & Schnicke, 1992 Level B United States

Individual trauma: Female sexual assault survivors 

At least 3 months postassault (M=6.4 years; SD=6.9) Assessments took place at pre-treatment, posttreatment, 3- and 6-month follow-up 

Group intervention: 1. Twelve 1.5-hour weekly 

sessions of CPT (n=19). 

2. No-treatment, waitlist control 

(n=20). 

CPT group showed decreased PTSD and (SCID, SCL-90-R, IES) depression (SCID, SCL-90-R, BDI) scores compared to waitlist controls at post-treatment. Treatment gains maintained at 6-month follow-up. 
69 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Resick, Jordan, Girelli, Hutter, & MarhoeferDvorak, 1990 Level B United States

Individual trauma: Female sexual assault survivors 

At least 3 months postassault (range 3 months – 34 years; M=5 years, SD=7.7 years). Assessments took place at pre-treatment, posttreatment, 3- and 6-month follow-up. 

Group intervention: 1. Six 2-hour weekly group 

sessions of either stress inoculation, assertion training, or supportive psychotherapy (n=37). 

2. No-treatment, waitlist control 

(n=13). 

All three types of therapwere effective in producing lasting improvement, particularly with fear ananxiety, and with assertiveness, selfesteem, self-concept, and depression to a lesser extent (SCL-90-R, MFSTSCS, ASES, IES), compared to waitlist controls. None of the three treatment types superiorTreatment gains maintained at 6-month follow-up. 

Rothbaum, 1997 Level A+ United States 

Individual trauma: Female sexual assault survivors 

At least 3 months post-assault

Individual intervention: 1. Four 1.5 hour weekly 

individual sessions of EMDR (n=10). 

2. No-treatment, waitlist control 

(n=8). 

EMDR-treated participants showed greater improvement on PTSD (PSS) and depression (BDI) from pre- to post-treatment. 
70 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Tarrier, Pilgrim, Sommerfield, Faragher, Reynolds, Graham, & Barrowclough, 1999 Level A Manchester, England 

Individual trauma: Varied (52% crime, 34% accident, 15% other) Adult male and female pts referred from primary and secondary health services organizations 

Time of trauma: 34% < 12 months; 40% between 12–24 months; 26% > 24 months. Duration of PTSD had to be at least 6 months but not more than 10 years, to be included in the study. Pts included in the study only if they continued to meet criteria for PTSD after 4 weeks of selfmonitoring of PTSD symptom and discussion of monitoring in outpatient appointments. Assessments took place at pre-treatment, posttreatment, and 6-month follow-up.

Individual intervention: 1. Cognitive treatment (n=33). 

Mean of 12 individual sessions over 24 weeks. 

2. Imaginal exposure treatment 

(n=29). Mean of 10 individual sessions over 24-weeks. 

Cognitive treatment and imaginal exposure both showed significant improvements at posttreatment and follow-uprelative to pre-treatmentwith no differences between them (CAPS, IES, BDI, BAI). Between pre- and posttreatment, more imaginaexposure pts showed a worsening of PTSD symptoms on the CAPS (9 imaginal exposure pts vs. 3 cognitive treatment pts). This effect was not evident at the 6-month follow-up. 
71 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Brom, Kleber, & Defares, 1989 Level A Amsterdam, The Netherlands 

Individual trauma: Varied traumatic events; primarily loss of loved one. 83 of 112 participants (74%) had lost loved one to murder or suicide. Inclusion criteria: DSMIII criteria for PTSD. 

No more than 5 years post-trauma Assessments took place pre-treatment, posttreatment, and at 3-months after treatment. 

Individual intervention: 1. Systematic desensitization 

(n=31, m=15 sessions). 

2. Hypnotherapy (n=29, m=14 

sessions). 

3. Psychodynamic treatment 

(n=29, m=19 sessions). 

4. Waitlist control (n=23). 

All treatments equally significant and better than waitlist control on trauma symptom (IES). General drop in level of general distress, anxiety and anger (SCL-90, STAI, STAXI) in the treatment groups. Non-significant changes in general distress in control group. 

Mawson, Marks, Ramm, & Stern, 1981 Level B London, England

Individual trauma: Bereavement 11 of the 12 subjects were women Inclusion criteria: “persistent distress of over 1 year duration since the loss, or which had been greatly exacerbated by the loss,” plus two or more of a list of symptoms of complicated grief reactions (e.g., anniversary reaction, avoidance behavior toward deceased, excessive guilt or hostility towards deceased or those involved with deceased). 

Death occurred between 1-10 years prior to assessment (median = 3 years). Treatment provided within 2 weeks of initial assessment. 

Individual intervention: 6 individual 1.5-hour sessions over the course of 2 weeks. Supportive follow-up until 28 weeks after entering trial. 1. “Guided mourning” 

treatment, encouraged to face cues concerning their bereavement (n=6). 

2. Control treatment, asked to 

avoid bereavement cues (n=6). 

Patients self-rated at wee

ks 0, 2, 4, 8, 10, 28 

on measures of grief, depression, anxiety, and social adjustment. Patients in both groups improved between week0 and 4 on depression (Wakefield), hostilityanger-guilt scale, bereavement-avoidance task performance, and difficulty thinking about the deceased. Pts in experimental grouimproved more by week 4 on phobic avoidance, bereavement avoidancetask performance and distress, and by week 10 on TRIG. Improvementmaintained at 10 and 28 weeks. Patients in control group 

did not improve more 
72 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

than experimental group on any measure. 
73 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Murphy et al., 1998 Level A United States 

Individual trauma: Parents bereaved by violent deaths of 12–28 year old children 

Treatment offered 4 months post-homicide, suicide, or accident Assessments given preintervention, immediately post, and at 6-month follow-up 

Group therapy: 1. 12-week group therapy 

protocol, with 1st and last sessions used for orientation and data collection. The other 10 sessions were 2 hours long, with info-giving and skill-building during 1st hour and “emotion-focused support” during 2nd hour (n=153). 

2. Waitlist control group 

(n=108). 

For mothers: 6 months post-treatment, no differences between intervention or control groups on overall distres(BSI), PTSD total score (TES), physical health status (HHB) or marital satisfaction (DAS). Control group showed lower grief responses (GES) at 6 months. For mothers with high GSI and grief at baselinethose in intervention group improved more than those in control group. In contrast, those with low GSI and grief abaseline did worse than those in control group. For fathers: 6 months post-treatment, control group showed lower overall distress. No differences in PTSD, grief responses, physical health, or marital satisfaction at 6 months between intervention and control groups. 
74 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Raphael, B., 1977 Level A– Sydney, Australia 

Individual trauma: Berea

vement 

Female widows recruited from Social Security Dept, where they had applied for benefits. Widows selected for the study were deemed to be at high risk, based on: (a) high level of perceived non-supportiveness in social support network, (b) moderately unsupportive social network with traumatic circumstances of death, (c) ambivalent marital relationship and traumatic death, and (d) concurrent life crises. 

Initial assessment and treatment within the first 7 weeks following the deaths of their husbands. Subjects completed follow-up assessment, 13 months after completion of treatment. 

Individual intervention: High-risk individuals (e.g., traumatic death, low social support, concurrent life crisis) were randomly assigned to individual treatment or nointervention control group. 1. Treatment was nondirective, supportive. Goal was “promotion of normal grieving – expression of bereavement effects, and the accomplishment of a significant degree of mourning.” Treatment was individual, provided by the principal investigator in participants’ homes. Mean number of sessions was 4, with range of 1–9 (n=27). 2. Untreated control group (n=29). 

At 13 month follow-up: The intervention group showed less health impairment on a “generahealth questionnaire” compared to matched control group. More doctor visits for general symptoms in the control group. More weight loss, more increased smoking, greater frequency of increased intake of etoh in control group. 
75 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Reynolds, Miller, Pasternak, Frank, Perel, Cornes, Houck, Mazumdar, Dew, & Kupfer, 1999 Level A United States 

Individual trauma: Bereavement Adult men and women with onset of major depressive episode between 6 months prior to 12 months after death of significant other 

Mean time postbereavement was 8 months 

Individual intervention: 16-week, double-blind trial of four treatment conditions. 1. Medication clinic, 

nortriptyline (n=25). 

2. Medication clinic, placebo 

(n=22). 

3. Interpersonal treatment plus 

nortriptyline (n=16). 

4. Interpersonal treatment plus 

placebo (n=17). 

No differential effect of any treatment condition on bereavement intensity (TRIG, ICG). Nortriptyline was superior to placebo in achieving remission of bereavement-related major depressive episodes (HAM-D, BDI, GAS). Combination of medication and treatmenwas associated with highest rate of treatment completion. 
76 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Shear, Frank, Foa, Cherry, Reynolds, Bilt, & Masters, 2001 Level B United States 

Individual trauma: Adult men and women who had experienced variety of types of traumatic bereavement Inclusion criteria: scored > 25 on ICG 

Subjects were at least 3 months post-loss of significant other. Mean time since death was 2.9 years. 

Individual intervention: Pilot study – treatment for traumatic grief used strategies from interpersonal treatment for depression and cognitive behavioral treatment for PTSD. Treatment rooted in imaginal exposure to death scene and in vivo exposure to avoided activities and situations, and interpersonal therapy. Manualized treatment designed to be delivered in approximately 16 sessions over 4 months (n=21). 

Significant and very large pre-treatment—posttreatment differences found for ICG scores in both the completer group (n=13) and the intent-totreat group (n=21). Also reductions in BAI and BDI in both intent-to-treaand completer groups. Mean decrease in ICG scores in intent-to-treat group was nearly twice that observed in prior study of depressed pts whose scores were consistent with traumatic grief and who received interpersonal treatment only. 

Sireling, Cohen, & Marks, 1988 (extension and replication of Mawson et al., 1981) Level A London, England 

Individual trauma: Berea

vement 

Men and women between ages of 16–70, most prominent symptoms had to relate in time and content to loss of a significant other and needed to have persisted more than 1 year 

At least 1 year post-loss to be eligible for study Mean time post-loss not reported. Assessments at weeks 0, 2, 14, 28, 54 

Individual intervention: 10 weekly 1–1.5-hour sessions, with a 4-week interval between sessions 9 & 10, of either: 1. “Guided mourning” – used 

exposure to cognitive, affective, and behavioral cues concerning bereavement. Encouraged ventilation of negative feelings (n=14). 

2. “Anti-exposure” – 

encouraged pts to “get on with life,” not to think about the loss, avoid anything painful connected with the 

Both groups improved oa variety of measures (anxiety, anger, general health, general distress, depression) up to the 9-month follow-up. The only differences between the groups were in avoidance and distress to bereavement cues, with the guided mourning group showing more improvement in these specific areas. 
77 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

 loss, think about the future 

rather than dwell on the past (n=12). 

Vachon, Lyall Rogers, FreedmanLetofsky, & Freeman, 1980 Level A Ontario, Canada 

Individual trauma: Bereavement All female widows, ages 67 and younger. No specific inclusion criteria in terms of symptoms. Median age = 52 years, range of 22–69 

Assessments at 1, 6, 12, 24 months after husband’s death. 

Mixed individual/group intervention: 1. Intervention group was 

assigned a “widow contact” for support, indefinitely. Initially held one-to-one meetings, eventually also included small group meetings. Contact in person and by phone (n=24). 

2. No treatment control group 

(n=38). 

Positive change on interpersonal adaptation12 months postbereavement: 92% of intervention vs. 66% control. 24 months postbereavement: significant reduction in Goldberg GHQ, 58% (interventionvs. 23% (control). 
78 

Table 7. Recent and well-controlled studies of medications for PTSD Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Brady, Pearlstein, Asnis, Baker, Rothbaum, Sikes, & Farfel, 2000 Level A+ Sertraline United States 

Individual trauma: Varied Excluded: psychotic disorder, organic mental disorder, malingering, bipolar disorder, alcohol or substance use, use of any psychotropic medicine, primary diagnosis of major depression, obsessive-compulsive disorder, anxiety disorder, or psychotherapy initiated or ended during the trial. 

Minimum of 6 months duration of PTSD 

Individual medication: 12 weeks of double-blind, RCT, flexible-dose: 1. Sertraline (n=94). 2. Matched placebo (n=93). 

Sertraline yielded greateimprovement than placebo on 3 of 4 primaroutcome measures – CAPS-2 total score, CGI-S, CGI-I. Trend towards significance on the IES total score. 53% of sertraline pts vs. 32% of placebo pts were much or very much improved at treatment end point (p=.008 vs. placebo), with 70% of reduction in PTSD symptom severity on CAPS-2 and IES achieved within first 4 wks of drug treatment. Sertraline had significanefficacy vs. placebo on the CAPS-2 clusters of avoidance/numbing (p=.02) and increased arousal (p=.03), but not on re-experiencing/ intrusion (p=.14). 

Connor, Sutherland, Tupler, Malik, & Davidson, 1999 Level A+ Fluoxetine United States 

Individual trauma: Varied Non-combat related Adult and predominantly female sample with DSM-V criteria for PTSD. Excluded: psychotic disorder, bipolar disorder, antisocial 

personality

Median

years of

P

TSD = 

6 

years

Individual medication: 12 weeks of: 1. Fluoxetine (n=27). 2. Placebo (n=26). 

PTSD severity (DTS) scores lower in fluoxetingroup at weeks 4, 6, 10, 12. By week 12, fluoxetine group lower on measureof PTSD severity (DTS, Duke, SI-PTSD), disability and stress vulnerability (SDS, VS)Drug vs. placebo effects 

were most evident in the 
79 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

disorder, risk of suicide/homicide alcohol/substance use. 

less chronic PTSD groupPlacebo response rate higher in the more longstanding PTSD group. 

Davidson, Pearlstein, Londborg, Brady, Rothbaum, Bell, Maddock, Hegel, & Farfel, 2001 Level A+ Sertraline United States 

Individual trauma: Varied 96 responders who completed phases 1 and 2 of larger sertraline study. They completed 12 weeks of double-blind, placebocontrolled acute-phase treatment and subsequent 24-week open-label study of continuation treatment with sertraline. Patients were randomly assigned in double-blind design to 28 weeks of maintenance treatment with sertraline. 

Minimum 6 months of PTSD; mean duration of PTSD was 12.2 years in sertraline treatment group; 13.9 years in placebo treatment group. 

Individual medication: Randomly assigned in double-blind fashion to 28 weeks of maintenance treatment with: 1. Sertraline (50-200 mg, 

n=46). 

2. Placebo (n=50). 

Continued treatment with sertraline yielded lower PTSD relapse ratethan placebo (5% vs. 26%) as measured by combination of CAPS, CGI, investigator opinioon two consecutive clinivisits. Pts who received placebwere 6.4 times as likely to experience relapse as were pts receiving sertraline. Sertraline-related adversevents were below 10%. 

Davidson, Rothbaum, Van der Kolk, Sikes, & Farfel, 2001 Level A+ Sertraline United States 

Individual trauma: Varied Excluded: Psychotic disorder, organic mental disorder, malingering, bipolar disorder, alcohol or substance use, use of any psychotropic medication, 

primary diagnosis of 

Minimum 6 months of PTSD, average of 18 years 

Individual medication: 12 weeks of double-blind, RCT, flexible-dose: 1. Sertraline (n=98). 2. Placebo (n=104). 

Significantly steeper improvement slopes on PTSD symptoms in sertraline group (CAPS-2IES, CGI-I, CGI-S). 60% responder rate for sertraline vs. 38% responder rate for placebo40–50% reduction of 
80 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

major depression, obsessive-compulsive disorder, anxiety disorder, or CBT initiated or ended during the trial. 

PTSD severity, 70% of which occurred in first 4 weeks. Rapid and significant improvement in social and occupational functioning. 9% discontinuation rate due to medication-relateadverse events, vs. 5% for placebo. 

Gelpin, Bonne, Peri, Brandes, & Shalev, 1996 Level B Clonazepam and Alprazolam Israel

Individual trauma: Varied All consecutive ER admissions who had undergone a traumatic event and met DSM-III-R PTSD Criterion A were assessed. Those who reported “excessive distress” (e.g., panic, agitation, persistent insomnia) at week 1 were offered high-potency benzodiazepines. Of 162 subjects evaluated for larger study, 13 (8%) were judged by psychiatrist to require benzodiazepines. 

Medication introduced at mean of 7 (SD=6) days post-trauma 

Individual medication: 1. Treatment with 

benzodiazepines (either clonazepam, n=10 or alprazolam, n=3). All 13 subjects took meds for at least 1 month, 9 continued meds for full 6 months of study. 

2. Subjects matched with 

same-gender controls who had similar week 1 IES score, from larger study of PTSD, drawn from ER. 

Participants in the BZ group did not differ from controls in 1-month and 6-month PTSD (IES, MISS) and anxiety score(STAI). Repeated measures ANOVA showed no group or group by time effect on psychometric measures. Nine BZ subjects and three controls met PTSD diagnostic criteria 6 months post-trauma (CAPS). 
81 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Hertzberg, Butterfield, Feldman, Beckham, Sutherland, Connor, & Davidson, 1999 Level A Lamotrigine United States 

Mixed individual/ collective trauma: Adult male and female pts who met criteria for PTSD, recruited from treatment centers Varied trauma – primarily combat or sexual violence 

Not reported Individual medication: 

12 weeks of: 1. Lamotrigine (n=11). 2. Placebo (n=4). 

In the experimental group, 50% of patients improved on the Duke v25% of pts in control condition. Pre-post improvement seen in experimental group on re-experiencinand avoidance symptombut not in control group. 

Londborg, Hegel, Goldstein, Goldstein, Himmelhoch, Maddock, Patterson, Rausch, & Farfel, 2001 Level B Sertraline United States 

Individual trauma: Varied 252 patients who had completed 12 weeks of double-blind, placebocontrolled, acute-phase treatment were continued into 24-week open-label continuation phase. This study reports on 128 patients who were assigned in the first study to the sertraline condition (124 who had been given placebo in initial phase of study were not included in these analyses). 

Minimum 6 months of PTSD, mean duration of PTSD for women in study was 11.4 years, for men was 17 years 

Individual medication: 128 patients initially treated with sertraline in the acutephase feeder studies (Brady et al. 2000, Davidson et al., 2001) continued in this open-label sertraline treatment phase of the larger studies. 

92% of acute-phase responders maintained their response during the full 6 months of continuation treatment. 54% of acute phase nonresponders converted to responder status (> 30% decrease in CAPS-2 total severity score) during continuation therapy. A high pre-treatment CAPS-2 score (>75) predicted a longer time to response and a greatelikelihood that response occurred after 12 weeks of acute treatment. 
82 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 
83 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Marshall, Beebe, Oldham, & Zaninelli, 2001 Level A Paroxetine United States 

Individual trauma: Varied 

Mean years of PTSD = 15.7

Individual medication: Randomly assigned to 12 weeks, fixed-dose, double-blind treatment with: 1. Placebo (n=186). 2. Paroxetine, 20 mg (n=183). 3. Paroxetine, 40 mg (n=182). 

Paroxetine-treated patients in both dose groups showed greater improvement on primary outcome measures (CAPS-2, CGI) compared to placebotreated pts. Paroxetine treatment resulted in more improvement on all 3 symptom clusters (CAPS-2, DTS), on social and occupational impairment (SDS), and comorbid depression (MADRS). Treatment response did not vary by trauma type, time since trauma, or severity of baseline PTSD or depressive symptoms. Medication was effectivwith both men and women. 
84 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Petty, Brannan, Casada, Davis, Gajewski, Kramer, Stone, Teten, Worchel, & Young, 2001Level B Olanzapine United States

Collective trauma: Combat-induced PTSD 91% Vietnam 9% Persian Gulf 

Mean duration of PTSD diagnosis was 6 years prior to study entry, with range of 1–17 years

Individual medication: Patients completed 8-week trial of olanzapine (n=30). 

PTSD (CAPS) decreaseby approximately 30%. Depression (HAM-D) and anxiety (HAM-A) scores decreased by 30% and 31%, respectively. BPRS total score decreased by 23%. Each CAPS symptoms cluster subscale improved significantly from baseline. Improvement on intrusive symptom on thCAPS was independent of improvement on the depressive and anxiety symptoms. 

Pitman, Sanders, Zusman, Healy, Cheema, Lasko, Cahill, & Orr, 2002 Level A Propranolol United States 

Individual trauma: Adult, varied 

Medication given within 6 hours of index trauma First full assessment given 1 month posttrauma 

Individual medication: 1. 10-day course of doubleblind propranolol, 40mg, 4 x 

daily (n=11). 

2. 10-day course of placebo 

control (n = 20). 

Groups did not differ on PTSD (CAPS) at 1 or 3-month assessments. 0% of the propranolol vs. 43% of the placebo patients were classified as physiological responders in physiological assessmen3 months post-trauma. 
85 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Sernyak, Kosten, Fontana & Rosenheck, 2001 Level C NeurolepticsUnited States

Collective trauma: Male veterans seeking treatment for combatrelated PTSD 

Duration of trauma symptoms not reported, but traumas were combatrelated. 

Individual medication: Secondary analysis of an observational outcome study of 831 inpatients and 554 outpatients receiving treatment for combat-related PTSD. Patients classified into groups based on VA records: 1. Patients who were never prescribed neuroleptics during the course of their 1 year in the study. 2. Patients who received neuroleptics at one or more time point during the year of the study. 

Outcomes after one year were not significantly different in the group treated with neuroleptics and the group that did noreceive them. At 12 months, no significant changes on measure of PTSD (Missnumber of psychiatric symptoms, etoh/drug useor employment, or overall subjective distrein the neuroleptic groupThe non-neuroleptic group showed significanimprovement only in drug/etoh use. 
86 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Tucker, Zaninelli, Yehuda, Ruggiero, Dillingham, & Pitts, 2001 Level A Paroxetine United States 

Individual trauma: Varied 

Mean years of PTSD: 16 in placebo group 14 in paroxetine group 

Individual medication: Randomly assigned to 12 weeks of double-blind treatment with: 1. Paroxetine (20-50mg, 

n=151). 

2. Placebo (n=156). 

At end of treatment, paroxetine group showesignificantly greater reduction of PTSD symptom on CAPS-2, CGI-I, DTS, TOPS-8, MADRS, and SDS. Approximately 60% of paroxetine group reacheresponse by 12 weeks vs40% of placebo group. Nearly 30% of paroxetingroup achieved remissiovs. nearly 20% of placebo patients. Significantly greater improvement on CAPS-was seen at 4 wks in the paroxetine group, and significantly greater proportion of paroxetinetreated patients achieved response (p<.001) and remission (p=.008) by week 12. 

Van der Kolk, Dryfuss, Michaels, Shera, Berkowitz, Fisler, & Saxe, 1994 Level A Fluoxetine United States 

Individual trauma: Varied Adult men and women Excluded: Psychotic disorder, organic mental disorder, alcohol or substance use, use of any psychotropic med for 2 weeks prior to study, prior treatment with fluoxetine, clinically significant physical condition. 

Not reported, but the majority of participants had either been in Vietnam War or experienced childhood abuse, so on average several decades had passed since the index trauma. 

Individual medication: Double-blind, randomized trial of 5 weeks of either: 1. Fluoxetine (n=33). 2. Matched placebo (n=31). 

Significant reduction in CAPS score, primarily in numbing and arousal in fluoxetine group. Significant reduction in depression (HAM-D) in fluoxetine group. Significant reduction in affect deregulation, distorted relationships, and loss of sustaining beliefs (SIDES). Results showed reductio
87 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

in PTSD symptoms only in trauma clinic population of more recently traumatized, previously untreated subjects, not in veterans
88 

Table 8. Studies of children/adolescents with trauma symptoms related to single incident stressors, including Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Chemtob, Nakashima, & Carlson, 2002 Level A+ Hawaii, United States 

Collective trauma: Children exposed to Hurricane Iniki. Population of elementary public school children screened for disasterrelated symptoms. The most symptomatic children were randomly assigned to 1 of 3 treatment groups for brief, school-based psychosocial intervention. Current study group comprised of those children who continued to have disaster-related PTSD 1 year post-initial group (3 years post hurricane). 32 children of 40 potentially eligible children participated. 

3.5 years post-hurricane Assessments took place pre-treatment, posttreatment, and at 6-month follow-up

Individual intervention: Randomized lagged groups design, initial assessment session, followed by 3 weekly EMDR sessions: 1. Immediate treatment (n=17). 2. Delayed treatment (n=15). 

Substantial reductions in PTSD symptoms (CRI). Significant but more modest reductions in anxiety (R-CMAS) and depression (CDI) scores56% of the children in the study no longer met criteria for PTSD after treatment. Those childrewho lost their PTSD diagnoses showed a significant reduction in visits to the school nurse

Field, Seligman, Scafidi, & Schanberg, 1996 Level A– United States 

Collective trauma: Child survivors of Hurricane Andrew 

Pre-test and treatment offered 1 month after hurricane Assessments at pre- and post-treatment 

Individual intervention: 1. 30 minutes of back massage 

therapy, 2 × week for 1 month (n=30). 

2. 30 minutes attention control 

condition (viewing videotape with graduate student), 2 × week for 1 month (n=30). 

Children in massage therapy condition showegreater reductions in anxiety (RCMAS) and depression, (CESD) and showed greater increasein relaxation levels than children in video control group. 
89 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Goenjian, Karayan, Pynoos, Minassian, Najarian, Steinberg, & Fairbanks, 1997 Level B– Armenia 

Collective Trauma: Adolescents exposed to earthquake in Armenia Adolescents in two schools were given treatment, adolescents at two comparable schools without treatment served as the control 

Assessment and treatment took place 1.5 years after earthquake, follow-up assessment at 3 years post-earthquake 

Mixed group/individual: 1. Four 30-minute trauma/grieffocused treatment groups; 

Two 1-hour individual sessions. (n=35). 

2. Non-treatment control 

(n=29). 

Severity of PTSD symptoms (Child PRI) decreased in treatment group, while depressive symptoms (SR) did not change. PTSD and depressive symptoms worsened in nontreatment group. 

March, AmayaJackson, Murray, & Schulte, 1998 Level B United States

Individual trauma: Children and adolescents with single-incident stressors (e.g., fires, gunshot wounds, motor vehicle accidents) 

Not reported: average duration of PTSD symptoms for younger and older subjects was 1.5 years and 2.5 years, respectively Assessments took place pre-treatment, posttreatment, and at 6-month follow-up

Group intervention: 18-week, group administered CBT protocol using a single case across time and setting experimental design (n=17). 

57% of group completerno longer had PTSD (CAPS-C) posttreatment. 86% of completers no longer haPTSD at 6-month followup. Depression, anxiety, and anger also decreased
90 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results  
91 

Table 9. Studies of traumatic bereavement/complicated grief in children and adolescents Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Black & Urbanowicz, 1987 Level A– London, England 

Individual trauma: Bereavement Children with one parent who had died 

Death occurred 3–5 months prior to intervention. Follow-up interviews conducted 1 year and 2 years post-bereavement.

Family intervention: 1. 6 family therapy sessions, at 

2-3 week intervals, 3-5 months after bereavement (n=21 families, 38 children). 

2. No-treatment control group 

(n=24 families, 45 children). 

At 1-year follow-up, the following factors were significantly less common in intervention group, based on clinical interview and Rutter A. Scale: (a) parent depressed, (b) restlessness in child, (c) nail biting in child, and (d) sought help from professional agency At 2-year follow-up, significant child findings have disappeared. Parenless likely to report health problems in the intervention group. 
92 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Sandler et al., 1992 Level A United States 

Individual trauma: Bereavement Children (ages 7–17) who experienced the death of a parent 

Time since death at first interview, M=15 months, SD=7 months. Follow-up interview 6 months later. 

Group/family intervention: 1. Immediate treatment (n=23). 

Treatment consisted of a 3- session workshop on grief attended by up to 8 bereaved families per session. This was followed by a 12-session family treatment focused on “parental demoralization,” “parental warmth,” “stable positive events,” and “negative stress events.” Manualized treatment. 

2. 6-month delayed treatment 

control (n=29). 

Treatment associated with increased parental perceptions of warmth in their relationship with their children (CRPBI), increased parental satisfaction with their social support, and decreased grief discussions. Treatment also associated with reduced parent reports odepression and conduct disorder problems for older children, but not younger children (CBCL). There were no differences between the groups in child reports osymptomatology. 

Salloum, Avery, & McClain, 2001 Level B United States 

Individual trauma: Adolescent homicide survivors 

Time since homicide ranged from 1 month to 10 years, with a mean of 2 years at intervention 

Group intervention: 10-week community-based grief and trauma therapy group (n=45 adolescents began six groups at four different public schools; 37 adolescents completed the groups). Combination of psychoeducation, coping skills, and support. 

58% of the pre-test scores on the Child PRI were in the clinical rangfor PTSD; 22% of the post-test scores were in the clinical range. Significant reductions in the re-experiencing and avoidance clusters, but not in arousal symptoms
93 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 
94 

Table 10. Studies of children/adolescents with trauma symptoms related to sexual or physical abuse (potentiageneralizability to disasters)Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Berliner & Saunders, 1996 Level A United States 

Individual trauma: Sexually abused male and female children with fear and anxiety symptoms, ages 4–13 

Not reported Assessments at pre- and immediately posttreatment 

Group intervention: 10 sessions of group treatment: 

1. CSA-specific CBT (n=32). 2. CSA-specific CBT plus 

stress inoculation training and gradual exposure (n=48). 

(CSA=child sexual abuse) 

Both groups improved omost outcome measuresNo group differences on fear or anxiety symptom(R-CMAS, FSSC-R). 

Cohen & Mannarino, 1996 Level A+ United States 

Individual trauma: Sexually abused male and female children, ages 3–7, with at least a WBR of 7 or sexually inappropriate behavior. 

Most recent episode of sexual abuse occurred no more than 6 months prior to treatment Assessments at pre-, immediately post-, 1 year post-, 2 years posttreatment 

Group intervention: Twelve 1.5-hour, weekly treatment sessions: 1. CBT-SAP – structured 

treatment for sexually abused preschoolers and their nonoffending parents (n=39). 

2. NST – supportive 

counseling with nonspecific treatment components not 

Significantly greater reduction of symptoms/behavior in parent-report (CBCL, CSBI, WBR), and clinical findings, than in NST group. No differences in child report measure (PRESS) between groups. 
95 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

directly addressing sexual abuse (n=28). 

 

Deblinger, Lippmann, & Steer, 1996 Level A United States 

Individual trauma: Male and female children, ages 7–13, with at least 3 symptoms of PTSD – one from each cluster 

66% of children experienced child sexual abuse in last 6 months; 16% between 6 months–2 years, 18% 2 or more years ago 

Group intervention: 12 weekly treatment sessions in the experimental groups 1. “Community control” = 

standard community care (n=21). 

2. “Child intervention only” 

(n=22). 

3. “Non-offending parent 

intervention only” (n=22). 

4. “Combined non-offending 

parent and child” (n=24). 

Mothers assigned to treatment (i.e., parentonly, parent/child) described greater decreases in their children’s externalizing behaviors (CBCL). Theichildren showed greater improvement on depression scores (CDI)Significantly greater reductions in PTSD symptoms (K-SADS-E) in children assigned to child-only or parent/chiltreatments, compared to parent-only and community conditions. 
96 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

Deblinger, Steer, & Lippmann, 1999 Level A United States 

2-year follow-up of Deblinger, Lippmann, & Steer, 1996 (above) 

See Deblinger, Lippmann, & Steer, 1996 (above) 

See Deblinger, Lippmann, & Steer, 1996 (above) 

Gains present at the post-test (externalizing behavior problems, depression, PTSD symptoms) remained at months, 6 months, 1 yeaand 2 years posttreatment. 
97 

Study/Level Study Group Interval between trauma 

and assessment 

Conditions/n Results 

King et al., 2000 Level A Australia 

Individual trauma: Children ages 5.2–17.4 years who had been sexually abused, M = 11.4 years, 69% girls, 31% boys: To be eligible for study, children had to exhibit a total of at least three PTSD symptoms, including at least one of avoidance or reexperiencing 

M=4.5 years post last sexual abuse experience at time of treatment and first assessment Range = 3 months to 8 years, 10 months 

Mixed group/individual intervention: 1. Family CBT. Child protocol 

described below, plus nonoffending parents received 20 weekly 50-minute sessions of training in child behavior management skills and parent-child communication skills (n=9). 

2. Child-only CBT. 20 weekly 

50-minute individual treatment sessions based on provision of coping skills and graded exposure (n=9). 

3. Waitlist control (n=10). 

Children in both treatment groups showed significant improvementin PTSD (child ADIS), fear (FT) and anxiety (R-CMAS) symptoms reported by child. Parents in the treatment groups reported more improvement in their children’s PTSD symptoms (CBCL) than parents in the waitlist control group. 
98

Appendix H: 

Measures 

ADIS-R Anxiety Disorders Interview Schedule – 

Revised (DiNardo and Barlow, 1988) 

ARI Assault Reaction Interview (Foa et al., 

1991) 

ASES Adult Self-Expression Scale (Gay et al., 

1975) 

BAI Beck Anxiety Inventory (Beck, 1990) 

BDI Beck Depression Inventory (Beck, 1988) 

BSI Brief Symptom Inventory (Derogatis, 

1992) 

CAGE The Cage Questionnaire (Ewing, 1984) 

CAPS Clinician Administered PTSD Scale (Blake 

et al., 1990) 

CBCL Child Behavior Checklist(Achenbach and 

Edelbrock, 1983) 

CDI Child Depression Inventory (Kovacs, 1985) 

CESD The Center for Epidemiological Studies 

Depression Scale (Radloff, 1977) 

CGI Clinical Global Impression Scale (Guy, 

1976) 

Child ADIS Child Version of the Anxiety Disorders 

Interview Schedule for DSM-IV (Silverman 

and Albano, 1996) 

Child PRI Child PTSD Reaction Index (Nader et al., 

1990) 

CRI Children’s Reaction Inventory (Pynoos et 

al., 1987) 

CRPBI Children’s Reports of Parental Behavior 

Inventory (Schaefer, 1965) 

CSBI Child Sexual Behavior Inventory (Friedrich 

et al., 1992) 

DAS Dyadic Adjustment Scale (Spanier, 1976) 

DTS Davidson Trauma Scale 

 (Davidson et al., 1997a) 

Duke Duke Global Severity Rating for PTSD 

(Davidson et al., 1998) 

FSSC-R Fear Survey Schedule for Children-Revised 

(Ollendick, 1983) 

FT Fear Thermometer for Sexually Abused 

Children (Kleinknecht and Bernstein, 

1988) 

GAS Global Assessment Scale (Endicott et al., 

1976) 

GES Grief Experiences Scale (Murphy et al., 

1998) 

GHQ General Health Questionnaire (Goldberg 

and Williams, 1988) 

HADS Hospital Anxiety and Depression Scale 

(Zigm and Snaith, 1983) 



HAM-A Hamilton Rating Scale for Anxiety 

(Hamilton, 1959) 

HAM-D Hamilton Rating Scale for Depression 

(Hamilton, 1960)



HCQ Health Change Questionnaire (Maddison 

and Walker, 1967) 

HHB Health Status/Health Behaviors Scale 

(Murphy et al., 1998) 

ICG Inventory of Complicated Grief (Prigerson 

et al., 1995) 

IES Impact of Event Scale (Horowitz et al., 

1979) 

K-SADS-E Schedule for Affective Disorders and 

Schizophrenia for School-Age Children 

(Orvaschel et al., 1982) 

Langner Langner Scale of Psychiatric Symptoms 

(Langner, 1962) 

Langsley Langsley Symptom Scale 

 (Langsley et al., 1971) 

MADRS Montgomery-Asberg Depression Rating 

Scale (Montgomery and Asberg, 1979) 
99

MFS Veronen-Kilpatrick Modified Fear Survey 

(Veronen and Kilpatrick, 1980) 

Miss Mississippi Rating Scale for CombatRelated PTSD-civilian trauma version 

(Keane et al., 1988) 

NAS Negative Affect Scale (Bradburn, 1969) 

PAS Positive Affect Scale (Bradburn, 1969) 

PDS Post-traumatic Stress Diagnostic Scale 

(Foa, 1995) 

POMS Profile of mood states (Wald and 

Mellenbergh, 1990) 

PRESS The Pre-School Symptom Self-Report 

(Martini et al., 1990) 

PSS Posttraumatic Stress Disorder Symptom 

Scale (Foa et al., 1993) 

PTSS-10 Post-traumatic Symptom Scale – 10 

(Weisaeth and Mehlum, 1993) 



R-CMAS Revised Children’s Manifest Anxiety Scale 

(Reynolds and Richmond, 1985) 

Rutter Rutter Behavior Scales (Rutter et al., 

1970) 

SAS Social Adjustment Scale (Weissman and 

Paykel, 1974) 

SCID Structured Clinical Interview for DSM-III-R 

(Spitzer et al., 1987) 

SCL-90 Symptom Checklist-90 (Derogatis, 1977) 

SDS Sheehan Disability Scale (Sheehan, 1983) 

SELF-C Self-Efficacy Questionnaire (Solomon et 

al., 1988) 

SEQ Spielberger Self Evaluation Questionnaire 

(Spielberger et al., 1983) 

SIDES Structured Interview for Disorders of 

Extreme Stress (Pelcovitz et al., 1997) 

SI-PTSD Structured Interview for PTSD (Davidson 

et al., 1997b) 

SSPSDS Scale of Severity of Post-traumatic Stress 

Disorder Symptoms (Echeburua et al., 

1994) 

STAI State-Trait Anxiety Inventory (Spielberger 

et al., 1970) 

STAXI State Trait Anger Inventory (Spielberger, 

1991) 

TSCS Tennessee Self Concept Scale 

 (Fitts, 1965) 

TES Traumatic Experiences Scale (Murphy et 

al., 1998) 

TOP-8 Treatment Outcome PTSD Scale (Davidson 

and Colket, 1997) 

TRIG Texas Revised Inventory of Grief 

(Faschingbauer, 1981) 

VS Vulnerability to the Effects of Stress 

(Sheehan et al., 1990) 

Wakefield The Wakefield Depression Questionnaire 

(Snaith et al., 1971) 

WBR Weekly Behavior Report 

(Cohen and Mannarino, 1993) 


100

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