Adverse events, such as rapid ascents, entanglements, boating incidents, or situations necessitating rescue and first aid/CPR, can occur, posing significant challenges and raising important questions for those involved. This page is part of a wider resource that aims to offer relevant, practical guidance to anyone in the diving community who has experienced, witnessed, or been affected by an adverse event in diving.

Whether you are a recreational diver, an instructor, a buddy, a rescuer, or a bystander during a diving incident, this resource is designed to provide you with essential information and support.  The purpose is to help you understand your options and make informed decisions that contribute to your/your divers well-being and recovery. 

After an adverse event, the question of how to support those involves often raises the questions relating to debriefing. The focus of this page is to consider the practice of "trauma-focused debriefs". If you are an organisation or club whose customers/members/staff have been involved in such an event, you may be wondering whether you should provide such a debrief.  If you are a diver who has been invited to attend a debrief after an adverse event, you may be looking for information to help you decide whether or not to attend. 

The following information is  based on current healthcare guidance and recommendations from research. The main guidance referenced is from the United Kingdom, and there are regional differences in practice.  However, the stance presented is also consistent with international guidance from the World Health Organisation. 


Some definitions

  • Trauma-Focused Debrief / Psychologically-Focused Debrief:

    A structured intervention shortly after a traumatic event, aimed at reducing distress and preventing the development of post-traumatic stress symptoms. It encourages individuals to recount the traumatic event and express their feelings.

  • Operational Debrief:

    A structured review conducted after an operation or event, focusing on evaluating actions, decisions, and outcomes related to the operation. It is usually led within the team and is primarily aimed at performance and learning.

  • Learning Review

    A review conducted following an adverse event that aims to understand the organisational and systematic factors that led to the event occurring.

  • Peer Support:

    A supportive relationship between people who have a lived experience in common. It may involve individuals with shared experiences of traumatic events providing emotional and practical support to each other. Peer support can also mean trained members of the wider community supporting people affected by an event.

  • Active Monitoring:

    Observing and assessing an individual’s psychological well-being following exposure to a traumatic event, with the aim of identifying any emerging mental health conditions and referring for further assessment and support if required.

What is a trauma-focused debrief?

Understanding Trauma-Focused Debriefs

A Trauma-Focused Debrief, also interchangeably referred to as a Psychological Debrief or Psychologically-Focused Debrief, is a structured intervention conducted shortly after an individual or group of people has experienced a traumatic or distressing event. The primary objective of this debrief is to mitigate the impact of the traumatic experience and prevent the onset of subsequent psychological complications, such as post-traumatic stress disorder (PTSD), anxiety, and depression.

Core Components:

  1. Recounting the Event: Participants are encouraged to narrate the details of the traumatic event, providing a chronological account of their experiences, perceptions, and reactions during the incident.

  2. Expression of Emotions: The debriefing process facilitates the expression of thoughts and emotions associated with the traumatic event, allowing individuals to articulate their feelings, fears, and concerns.

  3. Cognitive Processing: The intervention aims to aid individuals in making sense of the traumatic experience, assisting in the cognitive processing of the event and helping to construct a coherent narrative.

  4. Information and Education: Participants receive information about common reactions to trauma and are educated about potential psychological responses, coping mechanisms, and available support resources.

Timing of Trauma-Focused Debriefs

Trauma-focused debriefs, when utilized, are typically conducted shortly after the occurrence of a traumatic event. The intention behind this timing is to provide immediate support and intervention to individuals who have experienced trauma, with the aim of mitigating acute distress and preventing the development of subsequent psychological complications, such as PTSD, anxiety, and depression.


"There is no evidence that debriefing reduces the risk of developing PTSD. At no time does any study suggest a significant reduction in [trauma symptoms] in those receiving the intervention. On the other hand, the trials with the longest follow up (Hobbs 1996; Bisson 1997) both reported adverse effects. ... in the only 2 long‐term studies identified to date, debriefing would appear to have increased long term traumatic distress. There is also no evidence that debriefing has any effect on any other psychological outcome, including depression, anxiety or general functioning"

- Rose et al., (2002) Psychological debriefing for preventing post traumatic stress disorder (PTSD).  A systematic review by the Cochrane Library: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7032695/

Do trauma-focused debriefs work?

Efficacy of Trauma-Focused Debriefs

The efficacy of trauma-focused debriefs has been scrutinized and challenged by various health organizations and research studies. A study published by the NCBI indicated that single-session debriefing may not prevent, and could potentially increase, the risk of PTSD and depression. The research, which involved a systematic review of 11 studies with a total of 1,305 participants, found that individuals who received trauma-focused debriefing were not less likely to develop PTSD compared to those who did not receive debriefing. 

The studies involved in this review varied in their approach to examining the effectiveness of debriefing. Some studies compared the outcomes of individuals who received debriefing to those who received no intervention, while others compared trauma-focused debriefing to alternative interventions. The methodologies included randomized controlled trials, which are considered a gold standard in evaluating intervention efficacy. The findings consistently indicated that trauma-focused debriefing did not prevent the onset of PTSD and, in some instances, was associated with higher incidences of PTSD and depression among participants. There are several sources like this that raise substantial questions about the actual effectiveness of trauma-focused debriefs in mitigating psychological complications following trauma.

Risks of trauma-focused debrief

Here is a summary of the concerns found within research and guidance.

  • Potential to Increase Symptoms: Trauma-focused debriefs may not only fail to prevent post-trauma conditions, but there is some evidence that they could increase the risk of PTSD and other mental health conditions.

  • Possibility of (Re-)traumatization: Engaging in a detailed discussion of the traumatic event shortly after its occurrence might inadvertently re-traumatize individuals who were there. There is also a risk of vicarious trauma.

  • Inadequate Addressing of Individual Needs: Single-session debriefs may not adequately address the varied and potentially complex psychological needs of each individual involved.

  • Potential for Misinterpretation: There is a risk that individuals may misinterpret the information or emotional responses shared during the debrief, which could negatively exceximpact their psychological recovery.

  • Lack of Long-term Support: Trauma-focused debriefs, often being single-session interventions, may not provide the sustained support that individuals might need following a traumatic event.

  • Potential to Inhibit Natural Recovery: Engaging in debriefing might interfere with the natural psychological recovery processes that some individuals may experience following trauma.

  • Risk of Stigmatization: Participants might perceive their reactions to the trauma as abnormal or pathological, potentially leading to feelings of isolation or stigmatization.

  • Privacy Concerns: Sharing detailed accounts of traumatic experiences in a group setting might raise concerns about privacy and confidentiality among participants.

  • Inconsistent Application: The varied methodologies and inconsistent application of trauma-focused debriefs might not align with the specific needs and contexts of all traumatic events.

Vicarious trauma

You do not have to be there to be affected

Vicarious trauma refers to the emotional and psychological impact experienced by individuals who are exposed to the traumatic experiences of others, even without being directly involved in the traumatic event itself. In the context of diving, vicarious trauma might affect individuals such as diving instructors, buddies, or rescuers who witness or are exposed to adverse events like rapid ascents, entanglements, or incidents requiring emergency rescue and CPR. 

Vicarious trauma can also manifest from hearing about or being indirectly exposed to traumatic events, without witnessing them firsthand. This form of trauma can affect individuals who listen to or read about the distressing experiences of divers involved in adverse events, such as rapid ascents, equipment malfunctions, or dangerous marine life encounters. The emotional and psychological impact can be significant, potentially influencing one’s mental well-being, diving practices, and perceptions of diving risks, even without direct involvement in the traumatic event.

Trauma-focused debriefs encourage participants to describe their experience in detail.  Such debriefs may be carried out with a group of the people involved in the incident,  and possibly connected individuals such as buddies, or loved ones who were not present.  First of all there is a risk to those who were not there in hearing graphic accounts and witnessing the raw emotion of those who were there.  Although people will often be willing to do this in support, it is important to take into account the supporter's current capacity and the extent of participation.  Secondly, there is a risk of further traumatisation to those who were there.  Where people have experienced a traumatic event, there may be a level of vulnerability and overload of information to be processed about what happened. If someone is already struggling with what they saw, hearing more vivid accounts of aspects they were unaware may have an additional impact. Asking everyone to listen to all the other perspectives risks adding more to the backlog of information to be processed and more emotional content.  

Should we do trauma-focused debriefs?

Guidance and recommendations

When something traumatic happens while diving, it can be tough to know what to do afterward. Some people might suggest having a trauma-focused debrief. But is this the right step to take?

International guidance from the World Health Organization (WHO),  says no. They do not recommend trauma-focused debriefs because the practice has not been shown to help prevent stress or other mental health issues after a traumatic event.

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) directs healthcare professionals on various conditions.  In their guidance on the prevention and management of post-traumatic stress, their recommendation is in line with the WHO.  NICE explicitly state that trauma-focused debriefs should not be offered.

Other national guidance may differ. 

Both WHO and NICE make these suggestions because they want to make sure that what we do after a traumatic event helps and does not cause any more harm or stress. Based on the national and international professional guidance, it might be best to skip the trauma-focused debrief and look for other ways to support people after a tough time underwater.

Alternatives to Trauma-Focused Debriefs

What is recommended?

Operational Debriefing/Learning Review

  • Focused on reviewing the factual occurrences of the event, learning review aims to understand the sequence of events and identify any learnings or improvements in practice, without delving into emotional or psychological aspects.
  • This is particularly relevant for teams (clubs, instructors, businesses) responsible for organizing diving activities.
  • There is some useful information about operational debriefs for professional responder here that may be relevant for professional divers providing rescue and resuscitation: https://www.resus.org.uk/responder-wellbeing 
  • See below for more details.


Psychological First Aid:

  •  A supportive response aimed at addressing basic needs, providing comfort, and promoting adaptive functioning in the immediate aftermath of a traumatic event. 
  • Psychological first aid does not delve into detailed discussions about the event but focuses on providing a supportive presence, helping individuals feel safe, connected, and able to access physical and emotional support.


Peer Support:

  • Engaging with peers who have shared similar experiences can provide a safe and understanding space to express feelings and share coping strategies without the formal structure of a debrief.
  • There are also structured programs that train people in peer support and provision of psychological first aid. 


Talking with Friends and Family, Buddies or Co-workers:

  • Sometimes, simply talking with, sharing experiences, and being heard can provide a level of comfort and support that facilitates coping in the aftermath of a traumatic event.
  • Depending on relationships within the team, it may be helpful to allow some space for talking.  Or perhaps short check-ins during team dive briefs.  There are some important things to consider, see below


Cognitive-Behavioral Therapy (CBT):

  • A structured, goal-oriented therapy that helps individuals understand and change their patterns of thought and behavior. CBT, particularly trauma-focused CBT, has been recognized for its efficacy in treating PTSD and other trauma-related psychological issues.


Eye Movement Desensitization and Reprocessing (EMDR):

  • A psychotherapy approach that helps individuals process distressing memories of traumatic events. EMDR involves recalling the traumatic event while receiving bilateral sensory input, such as side-to-side eye movements, which can help to reduce the emotional charge of the memory.
  • There is some evidence that early intervention EMDR can reduce the incidence of diagnosable PTSD.


Watchful Waiting:

  • Recognizing that some individuals may naturally recover from traumatic stress without intervention, watchful waiting involves monitoring and providing support as needed, intervening therapeutically only if symptoms persist or escalate.


Mindfulness and Stress Reduction Techniques:

  • Engaging in mindfulness exercises and utilizing stress reduction techniques, such as meditation and yoga, can also be supportive in managing stress and anxiety following a traumatic event.


Support Groups:

  • Participating in support groups, where experiences can be shared in a safe and confidential environment, and where mutual support can be provided, can also be a valuable resource.


Professional Support/Therapy:

  • Engaging with a professional counselor or therapist, who can provide a safe space to explore and understand feelings and develop coping strategies, can be beneficial.


Educational Resources:

Debriefing as standard

Consider a practice of debriefing diving activities

The practice of talking through diving activities does not need to be only for when dives go badly wrong. Using debriefs as standard practice after dives helps in learning from less severe events as well as shared reelections on current process.  Often people are aware of issues long before those issues actually result in a significant adverse event.  Picking these up in debriefs and changing what we do can reduce the risk of experiencing the traumatic event in the first place.

Routine  operational debriefs, whether things went well or not, also means being ready to talk and learn more effectively should the worst occur

You can find information about the practice of debriefing on the Human Diver website: https://www.thehumandiver.com/blog/debriefing 

Learning Reviews

When the focus of the debrief is to review what happened and learn from an adverse event , this would not be a trauma-focused/psychological debrief. But it may help with psychological recovery nevertheless!

Although a learning review does not aim to process trauma, it can contribute to recovery indirectly.  Traumatic events lead to feelings of powerlessness, and difficult emotions such as guilt, anger and shame.  Knowing there is something that you can do to make things safer in future, to prevent others experiencing the same or to contribute to wider changes can often help in recovering.  At the individual level, asking "what did I learn?" can help improve control, a way to take responsibility or reconnect with others. Where these actions are identified collaboratively within a team, weight is added to their significance, as well as the opportunity for validation, connection and repair/building of trust.  

Often the changes needed are beyond the individual, such as improved safety measures or changes to procedures.  This can also indirectly impact recovery for the individuals involved.  If the organisation implements lessons from the learning review, individuals may feel safer, be consoled that others are less likely to suffer the same or feel valued.  All of which can help in the healing process.

If you would like to learn more there is a comprehensive guide to learning reviews available to download here: https://www.thehumandiver.com/blog/learning-reviews-in-diving

Want to be safer when diving?

Problems in diving arise from a complex array of factors. Most of the contribution comes from the humans. Human factors is the foundation for improving the safety of diving. Check out ways you can learn about and apply human factors.

Resources for safer diving

References

National and International Recommendations

  1. Psychological Debriefing in People Exposed to a Recent Traumatic Event - World Health Organization (WHO) https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme/evidence-centre/other-significant-emotional-and-medical-unexplained-somatic-complaints/psychological-debriefing-in-people-exposed-to-a-recent-traumatic-event

  2. Post-Traumatic Stress Disorder - National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/guidance/ng116/resources/posttraumatic-stress-disorder-pdf-66141601777861

  3. Guidelines for the Management of Conditions Specifically Related to Stress - World Health Organization (WHO) https://www.ncbi.nlm.nih.gov/books/NBK159725/pdf/Bookshelf_NBK159725.pdf





Things to consider

If your team/club/business is taking time to talk through an adverse event in diving, here are a few things to consider.

  • Return to safety - diving-related accidents and incidents can involve objective psychological trauma such as experiencing injury or threats to survival. Even witnessing such events can disturb basic human needs for safety. Before any sort of debrief, check these needs are met. Returning to safety allows the body to move out of survival mode. This can mean moving to a more physically safe place, rest, food and water.

  • Different perspectives - in such an event there can be a lot going on, and everyone there will have had different experiences. In addition, to that, people have different life history and skills, so perspectives on what happened can differ considerably.

  • Psychological Safety - talking through a difficult experience in a setting where there is high psychological safety can be effective in processing what happened and beginning healing. Where there is low psychological safety, the opposite can be the case.

  • Timing - immediately after a traumatic event, people are likely to be physically and mentally tired, possibly exhausted. There are benefits to talking, but it may be that rest and space is needed first. This could be a few hours or days., depending on what happened and what people need.

  • Protecting people - where an event was traumatic or distressing, everyone involved will have thoughts, images and emotions left over. Expressing these by talking can be an important part of processing what happened. However, just hearing about an event second hand can be distressing, particularly when the memory is fresh and unprocessed. Consider who is involved in the conversation.

  • Boundaries - a clear purpose and expectation for the discussion reduces pressure and uncertainty. Placing limits on what can be discussed may help increase safety. For instance, directing away from detailed and graphic memories towards factual steps of what happened, or how people are feeling now.

INDEX

List of all resource pages to support divers after an adverse event