A Model for the Treatment of Post Traumatic Stress Disorder

by Barry Fowler, Clinical Psychologist

"Its all very well talking about Proximity, Immediacy and Expectancy, 1,2 but how about some clear guidelines on what to do with someone who is plainly suffering from Post Traumatic Stress Disorder, 3,4 and is looking at me to ease their suffering?"

As the `Gulf Crisis' turned into a war, and local British hospitals developed contingency plans to provide for the psychological needs of injured servicemen returning from the Gulf, I found myself called upon to provide lectures and workshops to varied professionals on how traumatised people should be `debriefed'. I have lectured on the model I describe below, which I have used with apparent success, but I have been unable to find it clearly documented to date. Although it was developed with the idea of debriefing military personnel, this model has also been used effectively with traumatised civilians.

In this article, it is assumed that one therapist is working with one traumatised person. Group debriefing procedures are described in Mitchell (1983). Traumatic events often occur within a wider social or political context but an examination of such issues is beyond the scope of this paper. Similarly, it is important that evaluations and outcome studies are conducted, but again these are beyond the scope of this paper. This article is intended rather as a suggested approach to helping people within hours of having been exposed to a potentially traumatic event, and it expected to be used as part of an integrated plan for the treatment of traumatised people. It is not intended to be seen as sufficient treatment in itself.

A debriefer will, of course, be using the usual counselling skills while using this model to debrief traumatised people. Of particular importance is working at the pace of traumatised people, and not attempting to hurry them along.


THE INTRODUCTION STAGE: It is often helpful for a traumatised person if the helping professional uses the phrase `debriefing', which does not have the possibly threatening connotations to the person's self concept that use of the words `counselling' or `therapy' might conjure up.

It might be necessary to address doubts or reservations which the person may have, such as "What is the use of talking about it? It won't bring my friend back."

Some comfort might be derived for the traumatised person from knowing that the debriefing technique has been used with people who have been similarly traumatised previously, thereby indicating that other people have suffered what they are presently experiencing, and thus that their suffering is not unique or abnormal.

It can also be helpful to inform the person that there is no limit to the time that the session may last, that the process will be followed until it has been concluded, and the person will not suddenly be stopped while he or she is emotionally vulnerable. Confidentiality, and the possible limitations of this should be outlined in advance of the debriefing.

THE STORY STAGE: Invite the person to describe the traumatic event which he or she experienced which has led to the referral and presentation for treatment. Many people who suffer from Post Traumatic Stress Disorder present a history of having coped well with adversity, and often they may try to block out the feelings which might now be overwhelming them. Initially, a traumatised person is likely to produce a very short and factual account of the traumatic event, devoid of any emotional content.

THE BACKGROUND STAGE: Ask the traumatised person to try to describe his or her situation or context before the first hint of the traumatic event. Focus on feelings, mood, and expectations of the immediate future during which the traumatic event then took place. This may help people to realise how unexpected the trauma was for them, and might help them to accept their lack or preparation in dealing with the trauma, or their initial disorientation during the traumatic event.

THE RETELLING STAGE: Take the person through the story they have already provided, but ask them to describe their thoughts and feelings during the time of the trauma. The normality of their actions and feelings would be pointed out by the debriefer. Sometimes the traumatised person will, realising what is expected of them, provide a more detailed account of the traumatic event that the one originally presented, but most are likely to try to gloss over the actual emotions experienced at the time, which may be very threatening. The debriefer often has to try to slow the person down, and to ask specific questions about the thoughts and feelings at what he or she might consider to be `traumatic highlights' noted either during the initial story telling, or else during this stage.

The most common emotions which seem to be expressed are anger and guilt. Anger can either be expressed (often initially) at others; people who should have helped but failed to do so, ambulances taking a long time to arrive, etc., and (often later) anger directed at themselves; at their lack of preparation, knowledge or skills which might have improved the situation, or saved a life. Guilt may be expressed, often about any actions carried out which might have proved to have been incorrect, and which thereby exacerbated the problem. There may also be guilt about actions which the person failed to perform, which they, rightly or wrongly, believe that they should have done. The people might also blame themselves for not having followed standard procedures which they might have forgotten in the `heat of the moment'.

Thoughts remembered from during the traumatic event can some times be found to be `cognitive distortions', and the person can benefit by examining and restructuring them. Common irrational thoughts and beliefs expressed during such debriefings include the idea that it was within the ability of the traumatised person to have saved the life of an injured person who subsequently died. It can be reassuring to a traumatised person to be convinced, if true, that any number of medical specialists in the most modern of Intensive Care Units would not have been able to save the life of that person either.

THE `GOING BEYOND' STAGE: Ask the traumatised person to continue to narrate the sequence of events which followed the point at which they ended their initial account of the story. This might flow on naturally from the above stage. This can provide more information which the person might originally have tried to forget, which might include reactions from others, possibly relatives of the deceased who might blame the traumatised person for not having saved the life of their loved one. This may have reinforced existing feelings of guilt.

It can be useful to encourage the traumatised person to describe what happened when they went home; family reaction to the person's traumatic experience, and the manner in which they spent the day or days following the traumatic event. Ask about how they resumed their usual way of life, including their return to work; the reaction of colleagues, superiors and subordinates to their return. Specific attention might be paid to media coverage of the traumatic event, as well as rumours concerning the traumatic event which the traumatised person might have encountered.

Before moving on to the closing stage, and especially if the person has `warmed up' to the way of exploring their thoughts and feelings, it might be valuable to ask them if there are any points which they feel that the debriefer might have overlooked. This might enable people, who feel that they have to comply with the structure imposed on them by the debriefer, to reveal new relevant material.

THE TERMINATION STAGE: Having worked through the above stages, at a pace which has allowed the traumatised person to meaningfully re-evaluate their emotions and thoughts, the following techniques might be useful:

Ask a question along the lines of; `If you were back in the traumatic situation, but knowing what you know now, what would you do differently?' This may help the person to further clarify how they might have acted differently if more knowledge or skills had been available to them at the time; more time to act during the trauma, or fewer distractions. It might also help them, where relevant, to realise that they would not actually have done much differently, which can be used to point out the appropriateness of their actions, even thought they might have felt inadequate at the time.

A similar question could be along the lines of `What help would you have found most helpful during the traumatic event?'5Guardian Angel. This may help to identify assistance which the traumatised person felt they needed during the time, but which was not available or forthcoming. This might help to reassure the person that they coped well considering the circumstances and lack of help they received.

It can be useful for the debriefer to ask how the traumatised person feels there and then after the possibly gruelling debriefing procedure, and to help them to `de-role' back to the present day. Ask for feedback from the traumatised person, and invite them to ask questions of the debriefer. The session would then be drawn to a close in a conventional manner, though the debriefer might decide to inform the traumatised person of where he or she might be able to receive further support, preferably on a twenty-four hour basis. The person's return to family, place of residence or occupation after the intense emotional experience of the debriefing should also be addressed.

THE `DEBRIEFING THE DEBRIEFERS' STAGE: Such debriefing sessions, of unpredictable length, and involving intense concentration and empathy with much raw emotion to deal with can be stressful and draining for the debriefer. It is very important for the debriefer to arrange for their own debriefing, as soon as possible after the debriefing session that they have conducted.6


It is important for the traumatised person to feel that their debriefer is credible. If one has been involved in any publicised disaster, this could be mentioned, but it can be damaging to the debriefer's credibility if he or she recounts an experience from their own lives in an attempt to establish that `I've been through this too!' Such comments might make the person feel that their trauma is being trivialised, or that the debriefer is trying to compete with them. Similarly, comments attempting to establish rapport should be carefully evaluated before being expressed. A comment like `I know exactly how you feel!', though said with the best of intentions, might be met with annoyance and disbelief by a traumatised person.

Many stories from traumatised people include very gory descriptions of mutilated bodies, and of being covered with body fluids; blood, vomit or excrement. It is important that the debriefer anticipate this, and does not suddenly show revulsion. Similarly, trauma stories can reveal information where people have behaved in socially unacceptable ways; such as killing or mutilating people, which might produce an unhelpful emotional reaction from the debriefer.

Traumatised people might find difficulty accepting their emotional state, especially if they bare no physical indications of the trauma. They might feel vulnerable to accusations that they have no reason to be suffering because they have not suffered physical injury.

Traumatised people are often those who expect that they will be able to cope with traumatic events, especially those employed in the emergency services. They might not have prior experience of `not coping'. Such people often feel very vulnerable during debriefing sessions, resulting in a strong transference relationship with the debriefer.

Following some disasters, efforts have been made to ensure that all staff who have been exposed to possible trauma are debriefed. The wishes of each individual should be respected in such cases, and while the debriefer might describe what they have to offer, and suggest that other people have found debriefing helpful in the past, no attempt should be made to debrief people against their will.


Charl de Wet introduced me to the basics of this model in 1987.


1.McManners, H. Mental Wounds of war are often the Worst. In OBSERVER, 3 March 1991, p. 14.

2.Gabriel, R. A. Stress in Battle: Coping on the Spot. In Army 1982 Vol. 32, No. 12. pp. 36 - 39, & 42.

3.APA Diagnostic and Statistical Manual of Mental Disorder (3rd edn., revised) (DSM- III-R). Washington DC: APA., 1987.

4.Horowitz, M. J. Stress Response Syndromes. New York: Jason Aronson, 1976.

5.Gregory, P. B. Treating Symptoms of Post- Traumatic Stress Disorder with Neuro-Linguistic Programming. In Bandler, R. (ed.). Magic in Action. California: Meta Publications, 1984.

6.BPS Psychological Aspects of Disaster. Leicester: BPS, 1990.

7.Dyregrov, A. Caring for helpers in Disaster Situations: Psychological Debriefing. Disaster Management. 1989; 2: 1, 25-30.

  1. Hodgkinson, P.E., Stewart, M. Coping with Catastrophe. London: Routledge, 1991.

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

Extracted from: Fowler, Barry (1996) Grensvegter? South African Army Psychologist United Kingdom: Sentinel Projects. ISBN 0 9524423 2 9 pp. 123-127.

Published: 1 July 2000.

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