"Psychological debriefing" is penetrating most mental health communities in preparation for and response to disastrous events involving humans. A partial list of events receiving attention include personal violence, transportation accidents (viz., aircraft, motor vehicle, train, and shipping accidents), bombings, military actions, civil unrest, natural disasters (viz., tropical storms, hurricanes, tornadoes, earthquakes, mud slides, forest fires, and floods), hazardous material spills, and building collapses. Specific vocational clusters outside of civilians exposed to disastrous events such as law enforcement personnel, health care providers, and rescue workers were originally targeted for psychological debriefing.

Psychological debriefing is designed to prevent or inhibit event-related distress. Although, human event-related acute distress has been documented as early as 1870 for combat (U.S. Government Printing Office, 1870), active efforts to prevent event-related distress did not become common until the mid-1980's. Mitchell's early work (1983) was vital for goading the behavioral science community into action to explore psychological debriefing.

Presently, there are 213 publications representing "debriefing" in the PILOTS database. This literature base has the typical evolution of an immature domain in the science of human behavior. There are ample case studies and anecdotal reports, with a more recent shift toward research designs geared toward experimentation with heightened attention to scientific rigor. The base of knowledge being sought in these research endeavors has focused on the hypothesis that "psychological debriefing" may "cause" prevention of event-related distress and its potential psychological sequelea. As is common in an immature research domain, there has been little published attention to grounding the technique, "psychological debriefing," to theory. This paper is an application of a learning theory known as Mowrer's two factor learning to event-related distress and comments on the development of the debriefing intervention from a fear conditioning perspective.

Much of the research on debriefing is premature since we do not have a scientifically sound theoretical understanding of event-related distress and debriefing. Although Everly (1993) has provided a neurophysiological explanation for stress with applications to event-related distress, little empirical support exists to assist in understanding the impact of debriefing. We propose that a learning or conditioning conceptualization may advance the dearth of theoretical approaches to event-related distress and debriefing as was done by Keane, Zimering, and Caddell (1985) in posttraumatic stress disorder (PTSD) and exposure based treatment. This treatment is

now acknowledged as an empirically supported intervention.

Mowrer (1947) was particularly interested in a learning interpretation of emotional reactions similar to the phenomenon known as "event-related distress." Mowrer's original theory developed the distinction between classical and instrumental conditioning by considering two forms of learning: sign learning and solution learning and more importantly a two stage relationship between these two forms of learning. Sign learning represented what is referred to as classical conditioning or the conditioning of respondent behavior and solution learning represented instrumental conditioning or learning of operant behavior.

Let's consider an example in which a man is hit by an automobile. The pain from hitting the car is an unconditioned stimulus (UCS) which produces emotional responses characteristic of fear representing an unconditioned response (UCR). External sensory stimuli associated with the UCS including vision (e.g., sight of the car), audition (e.g., squealing of tires), olfaction (e.g., burned rubber), and gustation (e.g., blood in mouth) may become the conditioned stimuli (CS) for fear as a conditioned response (CR). Thus, straightforward classical conditioning or sign learning has taken place. When exposed to external sensory stimuli (CSs) in the future, fear (CR) is inappropriately experienced. The man learns that avoiding or escaping from these CSs reduces fear (CR), thus this behavior is reinforced.

Operant conditioning or solution learning takes place with the avoidance or escape sequence. Mowrer (1960) reformulated this theory by focusing on the similarities of sign and solution learning. In our example, the accident victim produces sensations (e.g., danger signs) via his behavior that become CSs for fear. Mowrer applied this same thinking to solution learning. In essence, he suggested that danger signs from the accident victim's behavior could lead to escape or avoidance behavior and result in fear reduction suggesting that internal sensations, thoughts and/or emotions could be conditioned. This addition introduced a more cognitive sounding solution to the connectionist approach to classical and operant conditioning by Mowrer. Skinner's radical behavioral acknowledgement of "private events" was being recognized as potentially conditionable stimuli in Mowrer's final two factor learning theory (1953).

Presently, the use of Critical Incident Stress Debriefing (CISD) (Mitchell, 1983) and similar psychological debriefing techniques are being suggested as methods for the prevention of PTSD and for "mitigating the harmful effects of work-related trauma" (Mitchell & Everly, 1997). Implicitly, many debriefing proponents suggest that all persons exposed to the aforementioned type of events or occupations should routinely undergo psychological debriefing. However, using Mowrer's conceptualization this would assume that all humans exposed to these events or occupations experience conditioned fear. Rachman (1977) addresses the difficulty of this assumption in his cogent review of fear conditioning theory. He draws several conclusions regarding fear acquisition which are particularly relevant when applying Mowrer’s two factor model to event-related distress and psychological debriefing.

Briefly, Rachman reasoned that 1) even though fear conditioning takes place in humans and animals, neither always acquires fear in situations that "should" lead to fear conditioning; 2) stimuli equipotentiality does not exist in fear conditioning; 3) human fear is variable and difficult to predict; and 4) partial evidence supports the existence of vicarious transmission of fear. The application of his fear conditioning review to the psychological debriefing process draws into question the wisdom of blanket prescriptions of these techniques and may help to explain its potentially harmful effects (Bisson, Jenkins, Alexander, & Bannister, 1997). An expanded application of Rachman’s conclusions to event-related distress and psychological debriefing follows.

Fear conditioning can and does take place in humans and animals. However, neither group always acquires fear in situations that should lead to fear conditioning. Rachman (1977) exemplified this by noting that the majority of people exposed to WWII air raids managed extraordinarily well, in spite of experiencing acute intense reactions. These reactions typically dissipated spontaneously. In a more recent example, Kulka et al. (1990) reported that 15% of Vietnam veterans experienced PTSD or other psychological problems at the time of their study. Conversely, this suggested that 85% of these veterans were problem-free.

Thus, the majority of people exposed to traumatic events may not need crisis intervention or psychological debriefing and the appropriateness of utilizing psychological debriefing is questionable. In fact, Koopman, Classen, and Spiegel (1994) cautioned against blanket prescriptions of psychological debriefing because assessment of certain factors, including subjective levels of arousal, current coping processes, cognitive impairments, or past exposure to previous trauma, are often not assessed prior to these interventions. The absence of assessment and the failure to address these factors may be one of the reasons why debriefing has not systematically yielded positive results for all those involved in a traumatic event (Koopman, Classen & Spiegel, 1994). Research studies that assess these pertinent individual or group factors are needed. Multimodal measures assessing behavioral, cognitive, emotional, and physiological changes in individuals following a traumatic event may be greatly beneficial during the initial assessment process. For example, utilizing portable psychophysiological monitoring apparatus (e.g., ambulatory blood pressure or heart rate monitors) (Muraoka, Carlson, & Chemtob, 1998), collateral reports, and self-report monitoring systems (possibly using palmtop computers) may provide more proximal measures of intense or negative responses to CSs associated with disastrous events. This would help guide appropriate levels of interventions or treatment.

Rachman (1977) also addressed the issue of stimuli equipotentiality in relation to fear conditioning. While fear conditioning theory assumes that all stimuli have roughly an equal chance of being transformed into fear signals or conditioned stimuli, in reality, this is not the case. Seligman’s (1971) preparedness theory hypothesized that some fears are acquired more rapidly than others, generalize broadly to other stimuli, and are more resistant to extinction. Seligman stated that the body’s preparedness to fear certain events has biological significance in that the majority of phobias concern objects of natural importance (e.g., snakes, spiders, dangerous weather, etc.) which may be related to survival of the fittest. When individuals are exposed to an event that may be considered traumatic, certain stimuli may later trigger negative responses more so than others and therefore be more resistant to extinction. In this case, future research investigating which CSs following event-related distress are especially extinction-resistant would assist with more appropriate treatment on an individual basis.

Another of Rachman’s positions stipulates that the distribution of human fear is variable and is extremely difficult to predict. Not every person will react to a traumatic event in the same manner or with extremely intense emotional, behavioral, or physiological responses. Rachman (1977) suggested that some fears may be more innate than others, are exceedingly common (e.g., animal phobias, fear of the dark), and may be culturally-influenced. Future research should address what is the human fear distribution when exposed to disastrous events and attempt to identify cultural differences.

Finally, Rachman (1977) supported the idea that fear could be acquired directly or vicariously. Bandura (1969, 1971) initially reported that behavioral and emotional responses could occur through vicarious learning situations via observational learning or modeling. Rachman further proposed that fears could be learned in a similar manner when stimuli are associated with fear directly or vicariously. His question pertaining to "Can fear reactions be acquired to stimuli which a person has never encountered personally?" is still relevant today. An early source of support for this indirect phenomenon of fear conditioning was the finding that children showed more fear behavior during WWII air raids if their mothers displayed intense fear. Today, vicarious learning could, in part, account for those individuals who suffer from event-related distress without direct exposure to the event. The notion is that "hearing" about the event could lead to a "learned" CR. However, as mentioned earlier the majority of emergency response/mental health professionals do manage their jobs without seeking professional assistance. When is the most appropriate time to offer assistance, if any? How does one differentiate "normal" reactive responses that are part of basic coping mechanisms versus psychopathic responses that should be treated?

Clearly, there are several questions that continue to require empirical validation in the area of psychological debriefing. Since its inception, there have been few controlled studies regarding the efficacy of these techniques. Case studies, anecdotal reports, and the occasional randomized study have resulted in varied positive, negative, or neutral findings. The current paper applied Mowrer’s two factor learning model to event-related distress in an effort to highlight the importance of developing debriefing techniques from a theoretical stance. The complexity of fear acquisition was also discussed noting that fear does not always occur in situations that should lead to such conditioning, stimuli equipotentiality does not exist in this area, fear is variable and difficult to predict, and

vicarious transmission of fear appears to occur.

Given these conclusions and the inherent difficulties associated with conducting research in the area of event-related distress, one can understand why this remains a relatively undeveloped field of study. However, among mental health providers, one might presume that it is inappropriate to treat any condition until one has conducted a careful assessment of the problem or completed a functional analysis of the targeted behaviors. In the area of psychological debriefing, this has yet to be done. Only with accurate and complete assessments before and after the application of debriefing procedures can we truly know who is affected, how so, and for what length of time. Presently the influence of debriefing is unpredictable and remains controversial.

Establishing an understanding of debriefing and fear conditioning mechanisms will provide a pathway to development of empirically supported use of psychological debriefing. According to Agras (1997), understanding the factors related to successful interventions is derived by dismantling studies that utilized procedures believed to be central to therapeutic change. Once the literature is able to clarify whether or not debriefing, in general, is a beneficial technique to use (or can target specific populations, events, or time-periods), further research will need to address which are the most effective components. Utilizing a learning model may be helpful in designing future research questions and help answer if we are really preventing what we think we are.

References

Agras, W. S. (1997). Helping people improve their lives with behavior therapy. Behavior Therapy, 28, 375-384.

Bandura, A. (1969). The principles of behavior modification. New York: Holt, Rinehart & Winston.

Bandura, A. (1971). Psychological modeling. Chicago, IL: Atherton Press.

Bisson, J. I., Jenkins, P. L., Alexander, J., & Bannister, C. (1997). Randomised controlled trial of psychological debriefing of acute burn trauma. British Journal of Psychiatry, 171, 78-81.

Everly, G. S. (1989). A clinical guide to the treatment of the human stress

response. New York: Plenum.

Everly, G. S. (1993). Neurophysiological considerations in the treatment of posttraumatic stress disorder. In J. P. Wilson & B. Raphael (Eds.), International Handbook of Traumatic Stress Syndromes (pp. 795-801). New York: Plenum Press.

Keane, T. M., Zimering, R. T., and Caddell, J. M. (1985). A behavioral formulation of posttraumatic stress disorder in Vietnam veterans. The Behavior Therapist, 8, 9-12.

Koopman, C., Classen, D., & Spiegel, D. (1994). Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkley California firestorm. American Journal of Psychiatry, 151, 888-894.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam War generation. New York: Brunner/Mazel.

Mitchell, J. T. (1983). When disaster strikes…The critical incident stress debriefing process. Journal of Emergency Medical Services, 8 (1), 36-39.

Mitchell, J. T. & Everly, G. S. (1997). Critical incident stress management: The basic course workbook. Ellicott City, MD: International Critical Incident Stress Foundation, Inc.

Mowrer, O. H. (1947). On the dual nature of learning: A re-interpretation of

"conditioning" and "problem-solving." Harvard Educational Review, 17, 102-148.

Mowrer, O. H. (1960). Learning theory and behavior. New York: Wiley.

Muraoka, M. Y., Carlson, J. G., & Chemtob, C. M. (1998). Twenty-four hour ambulatory blood pressure and heart rate monitoring in combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11, 473-484.

Rachman, S. (1977). The conditioning theory of fear-acquisition: A critical examination. Behavior Research and Therapy, 15, 375-387.

Seligman, M. (1971). Phobias and preparedness. Behavior Therapy, 2, 307-320.

Skinner, B. F. (1953). Science and human behavior. New York: Collier Macmillan Publishers.

U.S. Government Printing Office. (1870). Medical surgical history of the war of the rebellion (Vol 1). Washington, DC: Author.

-Lang’s theory centered around subjective report, avoidance beahvior, and psychophysiological distrubance

-McFarlane (1988) found that Australian firefighters involved in a series of bushfires who developed a delayed-onset PTSD reaction were more likely to receive debriefing that those who hadn’t

-Deahl et al. (1994) found no differences between Gulf war soldiers (gravediggers) who recieved PD soon after the incident and those who did not

-Hyton & Hasle (1989) did not find differences between those firefighters who recieved PD and those who did not after exposure to multiple dead bodies following a major hotel fire

-Griffiths & Watts, 1992 - even though reported to be helpful, those who attended PD showed sig. higher scores for morbidity and distress on general health questionnaire and impact of Events scale

-Kenardy et al., - workers after earthquake had general decrease in sx w/ less improvement over 2 yrs - still rated as helpful

-Brom et al., 1993 - demonstrated no difference w/ grp of road treaffic accidente victims

Early interventions found to be effectuve, but riddled with problems from research design problems included (Raphael 77, Duckworth 86)

-Robinson & Mitchell, 1993 - welfare workers subjective reports 2 wks after debriefing were positive and indicative of decreasing stress

Mitchell said "not everyone in every instance will benefit from a CISD." Some may not need any additional professional assistance following a distress-related event whereas some may need more.

-Flannery et al 1991 said - may lead to passive participation and resentment if "forced" to attend these programs (amer. hostage/Iran)

-McFarlane (1989) concerned that overenthusiasm for primary prev. mehtods may delay dx and effective treatment of those who DO suffer psych. sequelae

-Raphael, Meldrum, McFarlane, 1995 - debriefing may exaggerate the traumatic process or may be assoc. w/ delayed presentation as in Kenardy & Watts 94 said

-threat to life and hx. of psych. problems correlated w/ psot-traumatic morbidity and subsequent relationship problems

-Koopman et al., 94 - debriefing may not work ucz doesn’t take account of subjects levels of arousal, defensive styles and coping processes, cogn. impairments assoc. w/ acute trauma, dissociatvie phenomena relating to traumatic experienc, and other pathogenic influences (past trauma reflects this concept - but no studies on effectiveness - not all trauma composed of single element (ex., threat of life), loss, separation, and dislocation also separate stressors to address - need diff. interventions/timing

-what if PD medicalizes normal responses to stress

-are reactive processes in PD really "symptoms" or natural phases to recovery

lead to secondary traumatization?? (Raphael & Muldrum et al, 95)

-presence of absence of factors such as acute stress reaction, personality, past psychiatric hx. , adeuqate social support are likely to affect psych. outcome more than presence/absence of PD, If indiv. have an adquate support network and don’t have other vulnerability factors, PD may be redundate

-Bisson & Deahle, 94 - future research use sound methodologyw/ propsective controlled design and random allocation, attn to adeuqate measrurement of dimensions of truama, vars that may affect the outcome, and both pre and pst tx asessement

-working group of Lincolnshire Joint Emergency Services Initiative for Staff at risk follwoing critical incidents to review published outcome evidence and consider implications for future delivery of staff-supported services m- said pub. evid inconclusive - imprudent to continue calims for PD - d/c use of CISD protocol in fall of ’97

-it can improve quality of life for emergency providers, allow them to discuss their feelings and reactions to a critical incident, and deal with burnout, safety issues, stress, anxiety, and grief (Ostrow, 96)

-prevents long-term psychotherapy? – havent’ seen clear results on that yet

-it is very difficult for people to self report the onset of fear. Even after witnessing or being involved in a traumatic event, individuals may have difficulty attributing later problems to actual events that occurred at the time of the disaster. Are those w/ delayed onset different from those with observable acute sx. after trauma

-Rachman went on to discuss fear acquisition by transmission of information and/or instruction. While there may not be sufficient evidence to support these notions, Rachman identified these alternative pathways (either vic or info-driven) as important paths to consider.