Summary of the impact

UK and international government and healthcare institutes have incorporated Cardiff University research findings relating to the management of intervention for individuals post-trauma into public healthcare policy, strategy and services. Results from a randomized controlled clinical trial of psychological debriefing (PD) following traumatic events delivered strong evidence against the (then) standard approach of advocating these one-off interventions post-trauma. The Cardiff findings led to the global understanding that by not providing PD post-trauma many tens of thousands would benefit, resulting in better patient care and reduced healthcare costs.

Underpinning research

Between 1994 and 1997, a Cardiff University team led by Jonathan Bisson (Lecturer, 1994-96; Consultant Psychiatrist and Hon Senior Lecturer, 1997-2004; Senior Lecturer, 2004-08; Reader, 2008-2009; Director of Research and Development, 2010-13; Professor, 2013-present), undertook Welsh Office for Research and Development funded research^3.1 aimed at assessing the adequacy of psychological debriefing following trauma as an approach to preventing psychiatric consequences. In particular, the research focused on Post-Traumatic Stress Disorder (PTSD).

What is a psychological debriefing?

A psychological debriefing (PD) is a semi-structured intervention designed to prevent psychological sequelae (a consequential condition) following traumatic events, by promoting emotional processing through the ventilation and normalisation of reactions and by preparation for potential future experiences. PD had become widely used following major traumatic events in an attempt to reduce psychological sequelae.

Underpinning research to assess psychological debriefing following trauma

Bisson's team undertook a randomized controlled trial of one hundred and thirty-three adult burn trauma victims.^3.1 After completing an initial questionnaire, the team randomly allocated participants to a PD group or a control group receiving no intervention. At 3 and 13 months following a traumatic incident an assessor, who was blind to their PD status, interviewed 110 individuals (83%). The PD group had higher initial questionnaire scores and more severe burn trauma than the control group, both of which were associated with a poorer outcome. However, results showed that sixteen (26%) of the PD group had PTSD at their 13-month follow-up compared with four (9%) of the control group. Bisson's research therefore provided strong evidence against the (then) common approach of advocating one-off interventions post-trauma, and stimulated further research into more effective initiatives.

Two later studies by independent teams have confirmed negative outcomes associated with individual PD.^{3.2, 3.3} Similarly, systematic reviews and meta-analyses carried out by the Cardiff research team and wider associated groups have found no evidence of a positive effect and positive evidence to suggest that PD has the potential to do harm to some individuals.^{3.4, 5.8}

The Bisson et al. (1997) study^3.1 has been widely cited [167 Web of Science, 475 Google Scholar] and underpins recommendations against individual PD, for example by the National Institute for Health and Care Excellence (NICE).^5.8

References to the research

Key publications (Cardiff)

Background publications (non-Cardiff, evidencing research quality)

Key grant (Cardiff)

1994-7 - £32,000 to J. Bisson & P. Jenkins from the Welsh Scheme for the Development of Health and Social Research for "A randomised controlled trial of the effectiveness of psychological debriefing following acute burn trauma."

Details of the impact

Prior to the publication of the Cardiff University trial, worldwide policy and practice included routine debrief following traumatic events. This recommendation and practice has been changed worldwide as a result of Cardiff University research.^5.1-5.10 Despite being difficult to quantify, the public, patients and healthcare institutes will also have benefited as a result of better treatment management and a reduction in associated costs of health and social care and loss to the economy.

Linking Cardiff's underpinning research to REF period impact
Recognised for the findings from his underpinning research, Bisson was asked to co-chair the NICE Guideline Development Group. Cardiff research and expertise played a major role in the evidence base used to assess the efficacy of PD and contributed significantly to the widely cited Cochrane^3.4 and NICE^5.8 reviews. For example, in its clinical summary leading to recommendation against the provision of systematic, brief, single session interventions after traumatic events (p.84), the NICE guideline^5.8 specifically cites Bisson et al. (1997)^3.1 as providing evidence of harmful effects. Since publication, extensive citation of these reviews has led to the global dissemination of the key message not to provide PD following traumatic events.

Qualifying global dissemination and impact on public policy
Since 2008, underpinning findings published in either the Cochrane review or NICE guidelines have impacted upon the following policy documents:

• In the UK, the Department of Health's NHS Emergency planning Guidance (DoH, 2009) recommends against the provision of single session interventions that focus on people's emotional reactions (p. 93), stating that this risks re-traumatisation.
• In Europe, a European Union funded project, The European Network for Traumatic Stress (TENTS, 2008) created guidelines^5.3 that recommend against formal interventions such as single session individual PD (p. 5). The guidelines are now being implemented through a Train the Trainer programme across Europe with 35 participating countries (www.tentsproject.eu); 31 workshops and 462 potential new trainers have been trained.
• In the USA, the Departments of Veterans' Affairs and Defense 2010 guideline^5.2 states that, "Routine debriefing or formal psychotherapy is not beneficial for asymptomatic individuals and may be harmful" (p. 26). Bisson et al. (1997)^3.1 is cited (along with Mayou et al., 2000) on page 105 as one of "two well-controlled studies with longer-term follow-up of individual patients [that] have suggested that this intervention may be related to a poorer outcome compared to controls".
• The Australian guidelines (ACPMH, 2013)^5.1 updated the systematic reviews used for NICE and an earlier version of the Australian guidelines (ACPMH, 2007) and recommend "For adults exposed to a potentially traumatic event, a one-session, structured, psychological intervention in the acute phase, such as psychological debriefing, should not be offered on a routine basis" (p. 3 of Full Guidelines).
• The International Society for Traumatic Stress Studies (ISTSS, 2008) produced treatment guidelines^5.4 recommending that individual PD should not be used following traumatic events (p. 2).
• The North Atlantic Treaty Organisation's (NATO's) Joint Medical Committee produced non- binding guidance^5.9 for its members and partner nations in 2008 (NATO, 2008). The document concludes that it is "not advisable to provide a single session intervention that focuses on people's emotional reactions" (p. 93).
• The Inter-Agency Standing Committee (IASC) comprises a large number of UN and non-UN humanitarian organisations working together to strengthen coordination of humanitarian assistance (www.humanitarianinfo.org/iasc). IASC has produced a series of documents that are widely followed throughout the world. Based on its own guidelines (IASC, 2007)^5.6, IASC produced a document^5.7 in 2010 to provide an overview of "essential knowledge that humanitarian health actors should have about mental health and psychosocial support in humanitarian emergencies". On page 11 it states that PD is "...at best ineffective and should not be implemented".
• The Sphere Project (www.sphereproject.org) comprises a group of NGOs and the Red Cross and Red Crescent Movement. It has produced a widely followed handbook^5.10 that details universal minimum standards in core areas of humanitarian response. The latest Sphere handbook (2011) states that, "Psychological debriefing is ineffective and should not be provided" (p. 73).

The IASC and Sphere documents have both been translated into numerous languages and are available to download from the respective websites.

Bisson's original research^3.1 and the impact it has had was included in the submission of Cardiff University's Violence Research Group, which was independently audited before winning a 2009 Queen's Anniversary Prize.

Patient impact
According to www.healmyptsd.com, 70% of adults (223.4 million people) in the U.S. alone experience some type of traumatic event at least once in their lives and, of those victims, 60- 80% will develop PTSD. Additionally, people with PTSD have among the highest rates of healthcare service use, resulting in significant costs to society. These figures therefore suggest that during the REF assessment period (2008-2013), the widespread dissemination of the research finding and strong recommendations against the use of PD in the major international guidelines must have benefited many tens of thousands of patients and hundreds of healthcare institutes around the world.

Sources to corroborate the impact

1. Guidelines used in Australia, based on Cardiff research can be found in: Australian Centre for Post Traumatic Mental Health (2013), Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne: ACPMH. See `The full guidelines' at
   http://www.ncptsd.unimelb.edu.au/resources/resources-guidelines.html. [Copy of guidelines downloaded from website on 19 November 2013 and available from HEI on request].
2. Guidelines used in USA, based on Cardiff research can be found in Department of Veterans' Affairs and Department of Defense (2010). VA/DoD clinical practice guideline for management of post-traumatic stress. Washington DC: VA/DoD. See PTSD Full Guideline (2010) link at
   http://www.healthquality.va.gov/post_traumatic_stress_disorder_ptsd.asp [Copy of guideline downloaded from website on November 19 2013 and available from HEI on request].
3. Guidelines used in Europe, based on Cardiff research can be found in: The European Network for Traumatic Stress (TENTS) (2010). The TENTS guidelines for psychosocial care following disasters and major incidents.
   http://www.tentsproject.eu/_site1264/dbfiles/document/_~57~__7E64_7ETENTS_Full_guideli nes_booklet_A5_FINAL_24-04.pdf [pdf saved from website on 26 July 2013 and available from HEI on request].
4. Guidelines used internationally, based on Cardiff research, can be found in: Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. (Eds.). (2008). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd edn.). New York: Guilford Press [available from HEI on request].
5. Guidelines used internationally, based on Cardiff research can be found in: Forbes, D., Creamer, M., Bisson, J. I., Cohen, J. A., Crow, B. E., Foa, E. B., Friedman, M. J., Keane, T. M., Kudler, H. S., & Ursano, R. J. (2010). A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress, 23, 537-552.
   http://dx.doi.org/10.1002/jts.20565 [pdf available from HEI on request].
6. Guidelines used internationally, based on Cardiff research can be found in: Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC. (Japanese, Chinese and Nepali versions published since 2008).
   http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psych osocial_june_2007.pdf [available from HEI on request].
7. Guidelines used internationally, based on Cardiff research can be found in: IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings (2010). Mental Health and Psychosocial Support in Humanitarian Emergencies: What Should Humanitarian Health Actors Know? Geneva: IASC.
   http://www.who.int/mental_health/emergencies/what_humanitarian_health_actors_should_kn ow.pdf [pdf saved from website on 26 July 2013 and available from HEI on request].
8. UK NICE guidelines for managing PTSD during REF period can be found at National Collaborating Centre for Mental Health (2005). Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London/Leicester: Gaskell and BPS. http://guidance.nice.org.uk/CG26/Guidance/pdf/English [pdf saved from website on 26 July 2013 and available from HEI on request].
9. Guidelines used by NATO, based on Cardiff research can be found in: NATO Joint Medical Committee (2008). Designing, delivering and managing psychosocial services for people involved in major incidents, conflict, disasters and terrorism. Non-binding Guidance.
   http://www.coe.int/t/dg4/majorhazards/ressources/virtuallibrary/materials/Others/NATO_Guida nce_Psychosocial_Care_for_People_Affected_by_Disasters_and_Major_Incidents.pdf [pdf saved from website on 26 July 2013 and available from HEI on request].
10. Guidelines used internationally, based on Cardiff research can be found in: The Sphere Project (2011). The Sphere Project: Humanitarian Charter and Minimum Standards in Humanitarian Response. Rugby: Practical Action Publishing.
    http://www.ifrc.org/PageFiles/95530/The-Sphere-Project-Handbook-20111.pdf [pdf saved from website on 26 July 2013 and available from HEI on request].