Journal of Traumatic Stress, Vol. 19, No. 5, October 2006, pp.

583595 (

C 2006)

Disseminating Early Interventions

Following Trauma
Jonathan I. Bisson
Department of Psychological Medicine, University Hospital of Wales, Cardiff University,
Cardiff, United Kingdom

Judith A. Cohen
Center for Traumatic Stress in Children and Adolescents, Allegheny General Hospital,
Pittsburgh, PA

Dissemination of effective early interventions following trauma is necessary to ensure the provision of the
best possible care in a timely manner. To achieve this, agreement from all key stakeholders is required
regarding the messages to be disseminated and the means of dissemination. This article is based on a
National Institute of Mental Health sponsored symposium on the dissemination of early interventions at
the 21st annual meeting of the International Society for Traumatic Stress Studies in Toronto in 2005.
The current knowledge base regarding the effectiveness and dissemination of early interventions (dened
here as those that are begun within the rst 3 months after exposure) following trauma for children,
adolescents, and adults is considered.

The level of knowledge regarding the effectiveness of
early interventions for children and adolescents is not
currently as developed as the evidence base for adults.
The key issues are therefore somewhat different at present,
which is reected in the different focus of the two sec-
tions of this article. The rst section considers children
and adolescents. The limited evidence base on screening
and early interventions is reviewed and the implications
this raises regarding planned responses and future research
is discussed. Dissemination is considered by drawing on
work around the dissemination of effective interventions
for more established PTSD that is likely to inform what
will be required to disseminate effective early interven-
tions for children and adolescents in the future. The nal
part of this section raises a series of questions that need
to be answered to improve the current evidence base and
to develop effective interventions. Given the more devel-
oped evidence base, the second section on adults provides
a greater focus on dissemination itself with an overview
of the issues surrounding this process and a description of
the dissemination of early interventions. Throughout the
article, early interventions are dened as those that are be-
gun within the rst 3 months after exposure to a traumatic
event.
DISSEMINATING EARLY INTERVENTIONS
FOLLOWING TRAUMA IN CHILDREN AND
ADOLESCENTS
Almost no randomized clinical trials exist to inform us
about optimal treatments for trauma-specic symptoms in
children provided within the rst month after trauma expo-
sure. The few studies we have specically in this regard are,
not surprisingly, for children experiencing serious medical

Correspondence concerning this article should be addressed to: Jonathan I. Bisson, Monmouth House, University Hospital of Wales, Cardiff University, Heath Park, Cardiff, CF14
4XN, United Kingdom. E-mail: BissonJI@cf.ac.uk.


C 2006 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20175

583
584
traumas (e.g., Robert, Blakeney, Villarreal, Rosenberg, &
Meyer, 1999) or car accidents, since these are the types of
traumas for which children are brought for immediate care.
We have growing information about what factors put chil-
dren at greatest risk for developing serious psychological
difculties following exposure to mass disasters (Pine &
Cohen, 2002) and how to conduct large-scale screening for
children and adolescents in the acute aftermath of such sit-
uations (Pfefferbaum et al., 1999). We also have empirical
information about effective treatments commenced within
3 months of the trauma for children and adolescents who
develop posttraumatic stress disorder (PTSD) and other
stress-related symptoms (Cohen, Deblinger, Mannarino,
& Steer, 2004). We are only beginning to learn about how
to disseminate information about effective early treatments
for traumatized children and adolescents. These issues are
addressed in the following sections.
Screening
Epidemiological studies after community level traumas
such as natural disasters, terrorist attacks, war, and indus-
trial accidents have consistently indicated that the strongest
risk factors for children developing acute PTSD and other
psychological difculties are the following: female gen-
der (Green, Korol, & Grace, 1991, Pynoos et al., 1993);
past trauma history (LaGreca, Silverman, & Wasserstein,
1998); how immediate and life threatening the exposure
to the index trauma was for them and their immediate
family members (Brown, Cohen, Johnson, & Smailes,
1999; Fergusson, Lynskey, & Horwood, 1996a, 1996b;
Laor et al., 1996; Nader, Pynoos, Fairbanks, & Frederick,
1990; Smith, Perrin, Yule, & Rabe-Hesketth, 2001; Yule &
Bolton, 2000); preexisting psychiatric problems, especially
anxiety disorders (LaGreca et al., 1998; Tyano et al., 1996;
Udwin, Boyle, Yule, Bolton, & ORyan, 2000); and lack
of parental or other support, including parents PTSD or
other psychiatric problems (Fergusson & Lynskey, 1997;
Laor et al., 1996, 1997; Laor, Wolmer, & Cohen, 2001;
Smith et al., 2001; Udwin et al., 2000). High levels of
PTSD symptoms immediately after the trauma predict on-
going problems, but most children seem to have transient
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Bisson and Cohen
levels of some anxiety symptoms following trauma expo-
sure (Pfefferbaum, Stuber, Galea, & Fairbrother, 2006;
Tyano et al., 1996). Early dissociative symptoms have of-
ten predicted later PTSD in medically injured children
(Kassem-Adams & Winston, 2004; Meiser-Stedman, Yule,
Smith, Glucksman, & Dalgleish, 2005) but not always
(Daviss et al., 2000).
It is important to be realistic in recognizing what early
screening means with regard to children. Systematic screen-
ing is almost never instituted for children in the rst month
following a community-level trauma. (One example of very
early school screening occurred 7 weeks after the Oklahoma
City bombing; Pfefferbaum et al., 1999). This is due to
a variety of systemic factors that typify this type of event,
including (a) the disruption of normal services that may
occur following a large-scale traumatic event, (b) appropri-
ate efforts by community and school personnel to protect
children from intrusion by outsiders, and (c) the necessity
of obtaining approval for cooperative activities between the
school district and those providing the expertise in screen-
ing. Thus, because screening typically occurs not within
days, but at least 1 month later, it is usually appropriate to
screen for PTSD symptoms in children. Given the infor-
mation above, we should ideally screen not only for PTSD
symptoms, but also for past trauma history, exposure vari-
ables to the index trauma, family support, and preexisting
anxiety disorders.
Untreated PTSD is a documented risk (Warshaw et al.,
1993); therefore, it would be optimal for children who
meet criteria for PTSD for past traumatic events as well
as those with PTSD related to the current trauma, to re-
ceive treatment. Children with signicant but subsyndro-
mal PTSD symptoms (either with or without the above risk
factors) should also be offered evidence-supported treat-
ment, because it has also been documented that children
with subsyndromal PTSD symptoms do not differ signi-
cantly from those with full PTSD in terms of impairment
or distress (Carrion, Weems, Ray, & Reiss, 2002). Despite
the fact that many children experience natural recovery,
others do not. Although natural recovery (i.e., gradual de-
cline in PTSD symptoms with no intervention) occurs in
many children, it is not clear that waiting for this process to
 Early Intervention
occur is completely benign. A bigger question is what to do
with those who have only mild symptoms but none of the
risk factors. Even what we currently know about risk and
protective factors does not allow us to identify individuals
who are at risk for persistent PTSD accurately. Parents and
children should be given the option of receiving versus not
seeking treatment for these children, after receiving appro-
priate information about risks and benets of both courses
of action.
Evidence Base for Effective Early Interventions
Because children rarely receive psychological treatment
(other than supportive interventions such as psychological
rst aid) within the rst month of non-medical traumatic
events, it is important to recognize that early interventions
for children may be indistinguishable from other forms
of psychological treatment. This is because unlike adults,
children are rarely able to seek treatment on their own, but
rather are dependent upon their parents, teachers, or other
adults to recognize that they are in distress and seek mental
health interventions on their behalf. Parents, who are trau-
matized themselves, may be less able to recognize the im-
pact of trauma on the child. Legal (e.g., obtaining consent
from a noncustodial parent for psychological treatment;
completing legal investigations in the case of child abuse
allegations), economic (e.g., lack of health insurance), and
logistical (e.g., lack of babysitting for siblings, lack of trans-
portation, parents having to work during clinic hours, etc.)
barriers may also delay or prevent children from receiving
mental health interventions. Thus, we only have empirical
randomized clinical trial (RCT) data from a few studies,
following medical trauma and road accidents, respectively,
about the efcacy of providing psychological interventions
to children within the rst few weeks following traumatic
events, because other than in these situations, children
are rarely brought for psychological care within that
period.
One small, randomized controlled pharmacological
study was conducted for severely burned children imme-
diately after their injuries, comparing a tricyclic antide-
pressant, imipramine, to a sedative, chloral hydrate. This
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
585
study demonstrated that imipramine was superior to chlo-
ral hydrate in treating acute stress disorder in these children
(Robert et al., 1999). Because of the recent FDA warnings
associated with using these medications in children, they
cannot be considered a rst line treatment at this time.
A single RCT for children experiencing PTSD symp-
toms following road accidents compared psychological de-
brieng to a no treatment comparison condition (Stallard
et al., 2006). This study found that children in both groups
experienced signicant improvement in PTSD symptoms
and that the group receiving psychological debrieng was
neither better nor worse at 8-month follow-up than were
the children experiencing natural recovery.
At the time of this writing the strongest evidence
for treating PTSD symptoms in children supports the
efcacy of trauma-focused cognitivebehavioral therapy
(TF-CBT). Trauma-focused cognitivebehavioral therapy
has been tested in six RCTs, including a large multisite
study of over 200 children (Cohen et al., 2004). In this
study more than 50% of the children started treatment
within 3 months of the most recent episode of the in-
dex trauma (sexual abuse). As in previous RCTs, TF-CBT
was shown to be superior to the comparison treatment (in
this case, child centered therapy [CCT], another treatment
commonly provided in community settings), in improving
childrens PTSD symptoms, as well as depressive, anxi-
ety, shame, and behavioral symptoms in children. Trauma-
focused cognitivebehavioral therapy was also superior to
CCT in improving depression, parenting skills, parent-
ing support, and emotional distress among parents who
participated in their childrens treatment. These ndings
held true even for those children who started treatment
within one month of the abuse and thus were receiving
intervention quite early. Other children in the study were
experiencing chronic PTSD; there were no differences in
response to TF-CBT based on the time elapsed since the
most recent trauma exposure. The key components of TF-
CBT are summarized by the acronym PRACTICE: psy-
choeducation, parenting skills, relaxation skills, affective
modulation, cognitive processing of the trauma, trauma
narrative development, in vivo desensitization, conjoint
childparent sessions, and enhancing safety and future
586
developmental trajectory (Cohen, Mannarino, &
Deblinger, 2006).
It is also important to remember that although we usu-
ally focus on PTSD when considering trauma, many chil-
dren exposed to trauma and abuse do not develop this
disorder, and evidence-based treatments (EBTs) are avail-
able for those children who more typically develop other
types of symptoms. For example, two treatments, abuse-
focused CBT (Kolko & Swenson, 2002) and parentchild
interaction therapy (Chafn et al., 2003) have been rec-
ognized as effective treatments for physically abused chil-
dren. These treatments are most appropriate for children
with a predominance of observable behavioral problems
and primary caretakers who are willing to be actively in-
volved in therapy because a primary focus of both treat-
ments is optimizing interactions between children and par-
ents through actively changing parenting behaviors and
attitudes.
Guidelines and Dissemination Strategies
and Examples of Models
The typical manner used to disseminate EBTs is to have
single-day didactic trainings by treatment developers and
hope that community therapists will then use the EBTs.
However, this does not allow for ongoing communication
between the community therapists and treatment develop-
ers. When problems in using and implementing the model
in the community setting arise, if the developers are not
available for guidance and consultation, community thera-
pists may drift back to their previous practices or abandon
the EBT altogether (Berwick, 2003). Two initiatives have
attempted to address this issue with specic attention to
disseminating EBTs for traumatized children.
After the September 11, 2001, terrorist attacks, the
Child and Adolescent Trauma Treatment and Services
(CATS) Project utilized evidence-informed engagement
strategies, monthly consultation calls with TF-CBT de-
velopers, and a strong focus on local therapist adaptation
to disseminate and implement TF-CBT among 80 ther-
apists at nine sites for more than 500 traumatized chil-
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Bisson and Cohen
dren in greater New York. Data from the CATS Project
demonstrated that therapists successfully adopted the
TF-CBT model and that childrens PTSD symptoms
signicantly improved through these methods (Hoagwood
et al., 2006).
The National Child Traumatic Stress Network
(NCTSN) funded by the Substance Abuse and Mental
Health Services Administration has been collaborating for
the past 4 years to disseminate EBTs for traumatized chil-
dren across the United States. The NCTSN has explored
a variety of dissemination and implementation strategies,
including providing community therapists with ongoing
consultation calls with EBT developers. The NCTSN
has sponsored several regional learning collaboratives and
a National TF-CBT Breakthrough Series Collaborative
(Institute for Healthcare Improvement, 2003). The Break-
through Series Collaborative is a national learning collab-
orative implementing TF-CBT in 12 states in the United
States. It incorporates a strategy of all participants initiating
changes in current practices in their communities through
PlanDoStudyAct cycles. Data analyses are currently
underway to assess the impact of the National TF-CBT
Breakthrough Series Collaborative.
It is also important to nd innovative ways to reach
community providers who may not have the ways or
means to receive personal training in EBTs. One of the
NCTSN centers has developed a Web-based learning
course, TF-CBTWeb (www.musc.edu/TF-CBT), which
includes streaming video demonstrations of each TF-CBT
PRACTICE component, allowing learners to proceed at
their own pace and return to the Web site as often as
desired to review components. It also provides printable
scripts that can be used in treatment, includes handout
suggestions, and discusses cultural considerations and com-
mon clinical challenges. Free precourse and postcourse self-
assessment evaluation questions and continuing education
credits are included. In the rst 9 months of its public
availability more than 6,000 providers from 40 countries
registered for TF-CBTWeb. Preliminary data from the rst
150 completers indicate signicant gains in TF-CBT con-
tent knowledge after completing TF-CBTWeb (Saunders
& Smith, 2005), suggesting not only the appeal but
 Early Intervention
also the potential efcacy of this alternative dissemination
methodology. The developers are planning to expand TF-
CBTWeb to include a traumatic grief component. Direct
comparisons between Web-based and in-person training
are also planned to assess the effectiveness of Web-based
learning.
Future Needs
Obviously, there are large gaps in our knowledge regard-
ing optimal early interventions for traumatized children.
First, what do we do for those children who have moderate
symptoms in the time after trauma exposure in the absence
of any obvious risk factors? We know that statistically many
of these children will spontaneously recover without inter-
vention, but we do not know which ones those are. If we
had unlimited resources, it might be helpful to provide
each of them with prophylactic coping interventions, in-
dividualized to each childs needs. Randomized controlled
trials would be helpful to ascertain long-term risks and
benets of such a strategy. Because resources are always
limited, we need better empirical information regarding
how to evaluate or treat these children. At the least, we
should be educating their parents and teachers about what
warning signs to look for and following up with them a
month later to see how they are doing.
The second question is whether there is potential or real
harm being done when children are offered well meaning
but possibly detrimental early interventions that are cur-
rently available. Grief counselors and other helpers often ar-
rive after community disasters, offering psychological sup-
port and other interventions shortly after tragedy strikes.
There is no evidence that in the very acute aftermath of
these types of events, children need psychotherapy as a
rst priority. What most children need is to be reunited
with their family or other supportive adults, to receive
food, water, clothing, shelter, accurate and age-appropriate
information about what has happened, and reassurance
regarding their safety to the extent that is warranted
given the reality of the situation. Psychological rst-aid
(Terrorism and Disaster Branch, National Child Traumatic
Stress Network, 2005) is an example of this type of non-
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587
psychotherapeutic support that is probably most helpful
to children and families in the immediate aftermath of
community-level traumas.
Children also need reassurance that their parents or
caregivers can handle the stress of the situation and will
take care of them (Laor et al., 1996). These measures will
likely go further to reduce most childrens symptoms in the
acute aftermath than any acute psychological intervention.
The problem with some acute psychological interventions
is that children are asked to talk about what happened
(i.e., include some exposure or trauma narrative compo-
nent) when there is no evidence that either screening for
distress or risk factors has occurred. In the absence of se-
vere distress or signicant risk factors, there is no current
evidence that cognitive processing, trauma narrative, and
in vivo desensitization should be provided. If any interven-
tion at all is offered universally to children, that is, without
systematic screening, we should be very cautious about ask-
ing asymptomatic or low-risk children to talk about what
happened in the immediate aftermath of trauma exposure.
It is our clinical impression that it would be more useful
to build such childrens resilience through the use of less
trauma-specic stress management skills in this setting,
or through nontherapy relaxing, affective modulating and
stabilizing activities (e.g., song, art, storytelling, and play
activities), which may normalize childrens situations, en-
hance their social skills and strengthen their natural coping
abilities.
DISSEMINATING EARLY INTERVENTIONS
FOLLOWING TRAUMA IN ADULTS
During the 1980s and 1990s, calls for the routine provi-
sion of specic early interventions following adult trauma,
such as critical incident stress debrieng (Mitchell, 1983)
became widespread. However, an appraisal of the scientic
evidence led to the wisdom of such an approach being ques-
tioned (e.g., Bisson & Deahl, 1994; Raphael, Meldrum, &
McFarlane, 1995). Hence, several randomized controlled
trials emerged that have considered debrieng techniques
and more complex early interventions such as multiple
588
session TF-CBT within 3 months of a traumatic event
(see National Collaborating Centre for Mental Health
[NCCMH], 2005, for review). This work along with
research into predictors of PTSD has made it possible to
produce evidence-based guidelines on how best to manage
adults following traumatic events.
Screening
Two large meta-analyses of over 60 studies each have helped
determine the commonly measured factors that are most as-
sociated with the development of PTSD. Peritraumatic and
posttraumatic variables including trauma severity, trau-
matic stress symptoms, perceived life threat, dissociation,
reported lack of social support after the traumatic event,
and subsequent life events had the strongest association
with PTSD (Brewin, Andrews, & Valentine, 2000; Ozer,
Best, Lipsey, & Weiss, 2003). Preexisting vulnerability fac-
tors such as personal or family history of psychiatric disor-
der and gender were shown to be weaker predictive factors.
Most screening tools have focused on eliciting traumatic
stress symptoms several months or years after a traumatic
event. Brewin (2005) in a comprehensive review of screen-
ing tools for PTSD found that the Trauma Screening Ques-
tionnaire (TSQ; Brewin et al., 2002), the Impact of Event
Scale (Horowitz, Wilner, & Alvarez, 1979), and the SPAN
(Chen, Shen, Tan, Chou, & Lu, 2003; Meltzer-Brody et al.,
2004) were as good as any at detecting it.
A recent UK study (Walters, Bisson, & Shepherd, in
press) found that the TSQ (Trauma Screening Ques-
tionare), a 10-item yes/no questionnaire based on the in-
trusion and hyperarousal questions of the PTSD Symp-
tom Scale (Foa, Cashman, Jaycox, & Perry, 1997), when
completed within 3 weeks of a physical assault could
detect most individuals who would develop PTSD at
1 month and 6 months after trauma. However, it also
had a relatively low positive predictive value. At present,
there is no predictive screening method for PTSD that
would fulll the United Kingdom National Screening
Committees criteria for recommending implementation
(www.nsc.nhs.uk/pdfs/criteria.pdf ).
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Bisson and Cohen
Effective Early Interventions
In considering the effectiveness of early interventions, it
is very important to understand the natural course of
traumatic stress reactions. Rothbaum and Foa (1993) de-
scribed the natural resolution of traumatic stress reactions
in women following rape or nonsexual assaults. Although
94% of rape victims fullled the PTSD symptom criteria 1
week after their assault, at 3 months the level was less than
50%. In nonsexual assault victims, the reduction in rates
of PTSD was even more marked. This and similar research
emphasizes the fact that the majority of individuals will
not go on to develop chronic PTSD and that spontaneous
recovery is a normal response to a traumatic event.
Systematic reviews of randomized controlled trials have
found no certain clinical effects for any brief one-time
intervention delivered within 1 month of a traumatic
event and a possibility that single-session psychological de-
brieng of individuals may cause harm (NCCMH, 2005;
Rose, Bisson, Wessely, & Churchill, 2005; Van Emmerick,
Kamphuis, Hulsbosch, & Emmelkamp, 2002). There is
also no evidence emerging for the effectiveness of group
debrieng (Litz & Adler, 2004). The routine provision of
education has produced neutral results in general (e.g., Litz
& Adler, 2004; Rose, Brewin, Andrews, & Kirk, 1999)
although worryingly written information was associated
with worse outcome in one study (Turpin, Downs, &
Mason, 2002). A recent dismantling study of psycho-
logical debrieng found psychoeducational debrieng to
have a neutral effect but emotional debrieng to be as-
sociated with worse outcome in individuals with signif-
icant hyperarousal symptoms (Sijbrandij, Olff, Ratsma,
Carlier, & Gersons, in press). Alternative strategies such
as case management (e.g., Zatzick et al., 2001) have pro-
duced neutral results overall and there is no evidence that
any pharmacological agent including propranolol prevents
PTSD after traumatic events (NCCMH, 2005).
The lack of evidence for interventions provided to ev-
eryone involved in traumatic events has led to the devel-
opment of more complex interventions for symptomatic
individuals. There is some evidence for the effective-
ness of multisession TF-CBT targeted at individuals with
 Early Intervention
signicant traumatic stress symptoms within 3 months of
the traumatic event (e.g., Bisson, Shepherd, Joy, Probert,
& Newcombe, 2004; Bryant et al., 1998; Ehlers et al.,
2003). These randomized controlled trials provided be-
tween 4 and 17 hours of therapy using a combination
of techniques, including education, relaxation, imaginal
exposure, image habituation training, thought stopping,
distraction, cognitive restructuring, and in vivo exposure.
With the current evidence, it is hard to disagree with
the recommendations of the United Kingdoms National
Institute of Health and Clinical Excellence (NICE;
London, UK): Individual psychological debrieng should
not be offered after traumatic events and TF-CBT should
be offered within 1 month if an individual is suffering from
severe PTSD symptoms or within 3 months for anyone
with PTSD (NCCMH, 2005).
Models of care have now been developed based on the
results of randomized controlled trials when they exist,
although they continue to incorporate lower levels of evi-
dence such as nonrandomized trials, case series, and con-
sensus opinion when they do not. The Cardiff and Vale of
Glamorgan Traumatic Stress Service (University Hospital
of Wales, Cardiff, Wales) have developed a stepped or
stratied care model following trauma that is consistent
with the current evidence base (Bisson et al., 2003) as
shown in Table 1. In the absence of an effective formal in-
tervention for all individuals involved in a traumatic event,
early social and practical support provided in an empathic,
sympathetic, and usually informal manner forms the main-
stay of the initial response. Family and friends will often
provide this but social services, employers, and voluntary
Table 1. Stepped/Stratied Care Model
Following Trauma Exposure
Social and practical support
Education
Detection of high-risk groups
Assessment
Symptom monitoring
Early intervention
Reassessment
Posttraumatic stress disorder (PTSD) treatment
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589
agencies will also often have a role. An educational infor-
mation leaet is made available to those involved but as
described above, there remains uncertainty regarding the
effectiveness of education about traumatic stress reactions
and how to deal with them. Such information is widely
available but if to, how to, and when best to deliver it
requires further evaluation.
An assessment would occur if an individual is identied
as symptomatic 1 month after a traumatic event, or sooner
if the reaction is severe. Thorough assessment is key to de-
termining an individuals exact needs and any intervention
should be based on these. Options will include interven-
tions for grief, substance abuse, depression, or PTSD. If an
individual is felt to be suffering from acute PTSD, then a
period of watchful waiting is considered, whereby an in-
dividual is asked to monitor their symptoms for 2 weeks.
This is consistent with the ndings of Ehlers et al. (2003),
who noted that 12% of individuals no longer fullled the
criteria for acute PTSD after 3 weeks of monitoring symp-
toms. For those individuals with persisting PTSD, brief
TF-CBT would be offered followed by reassessment and
further intervention as indicated.
Guidelines
Guidelines provide evidence-based management recom-
mendations and standards to assess practice. They often
provide recommendations regarding education and train-
ing of professionals, and assist patients and care givers in
making decisions about their treatment and care. They
should also help to improve communication between na-
tional and international bodies, commissioners, providers,
and users of services. In recent years, various guidelines
concerning early interventions following traumatic events
have been prepared (e.g., practice guidelines from the
American Psychiatric Association, [APA] 2004; the Inter-
national Society for Traumatic Stress Studies [ISTSS], Foa,
Keane, & Friedman, 2000; and NICE, NCCMH, 2005).
Such documents are an appropriate source on which to
base dissemination messages although given the rapidly in-
creasing level of knowledge it is important that guidelines
are regularly updated. They are also probably not a very
590
effective means of dissemination on their own (Berwick,
2003).
The United Kingdoms NICE Clinical Guideline 26
concerns the management of PTSD (NCCMH, 2005). It
was developed by systematically reviewing the literature,
collating the information, addressing feedback, compil-
ing two drafts and then publishing the guidelines in vari-
ous formats. Well-conducted, replicated randomized con-
trolled trials were considered the gold standard of evidence,
but many recommendations were based on lower levels of
evidence as no appropriate randomized controlled trials
existed. The full guideline is 160 pages long accompanied
by a CD-ROM providing information of all the studies
evaluated, and the evidence base for early intervention,
psychological and pharmacological treatments, predictors
and screening, and children. The quick reference guide,
which is aimed at clinicians working in primary care, is
17 pages long and contains the key recommendations of the
guideline. A third publication covers the key recommen-
dations in a way that is designed to (a) help traumatized
individuals know what help they should be offered, and
(b) offer instruction on how to discuss their needs in an
informed manner.
The guideline, in common with other NICE guidelines,
was launched through the media with a separate one-day
conference for mental health professionals and others in-
volved in providing services to PTSD sufferers. Since the
launch, there have been various presentations and work-
shops to disseminate the messages contained within the
guideline to a wide variety of audiences. A set of slides has
also been developed by NICE to help with dissemination,
available from www.nice.org.uk.
Dissemination
Effective dissemination is labor intensive but increasingly
recognized as vital to improve health and functioning
(McCannon, Schall, Calkins, & Nazem, 2006). Dissemi-
nation is required at various levels (see Table 2). The ability
to provide concise, meaningful messages is a challenge that
needs to be addressed for effective dissemination to occur.
Ideally, dissemination would increase awareness of trau-
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Bisson and Cohen
Table 2. A Multi Level Dissemi-
nation Strategy
Society
International Organizations
United Nations
Nongovernmental organizations
Governments
Health and social care commissioners
Health and social care providers
Statutory
Nonstatutory
Individual practitioners
matic stress reactions, the fact that routine intervention for
everybody is not indicated, that some individuals will need
more specialist input, and that there are effective treat-
ments available. Media involvement, for example through
newspapers, television, radio, and Web sites, is important
and the work of the Dart Foundation (www.dartcenter.org)
in this area has been very valuable in promoting this
message. Other methods of dissemination to society as
a whole include leaets, the Internet, and presentations,
for example, to schools and communities.
The United Nations and nongovernmental organiza-
tions play a key role in the planning and delivery of re-
sponses following major traumatic events throughout the
world. Traumatic stress experts should develop partner-
ships with them. There are many examples of positive work
in this area including that of the ISTSS committee that li-
aises directly with the United Nations. However, there is
some evidence that a clear message is not being dissemi-
nated. This was highlighted in a plenary talk at the 2005
Annual ISTSS meeting in Toronto when a senior mem-
ber of a nonstatutory organization described the confused
messages coming from trauma professionals regarding early
intervention (Schaar, 2005).
Governments are key entities in providing funding and
encouraging appropriate recognition of national and global
traumatic events. At present, there are often only partially
formed plans regarding specic services following trau-
matic events; however, the disaster technical assistance
center in the United States (http://www.mentalhealth.
samhsa.gov/dtac/default.asp) and the dissemination of
 Early Intervention
information about the psychological rst aid manual
following Hurricane Katrina (http://www.ncptsd.va.gov/
pfa/PFA.html) are examples of good practice. Traumatic
stress experts should be involved in government planning,
developing contacts at various levels, and trying to raise the
prole of the traumatic stress eld through publications,
presentations, and involvement with the media. Sadly, such
lobbying is usually much easier to do following major dis-
asters and traumatic events than it is before they occur. The
traumatic events over the last few years have raised aware-
ness throughout the world; hence, governments are likely
to be more sympathetic to discussing enhanced traumatic
stress services than they were in the past.
Without an awareness of the issues, health and social
care commissioners are unlikely to adequately fund im-
proved services in the future. It is important that traumatic
stress specialists exert an inuence on the various commit-
tees and groups responsible for these decisions. This can
be achieved by adopting a whole systems approach, i.e., by
developing effective partnerships with providers of other
services, such as emergency planning ofcers (Bisson et al.,
2003), emergency units (Shepherd & Bisson, 2004), pri-
mary care workers, and physical trauma specialists (Zatzick
et al., 2001). Most non-mental health professionals with
responsibility for providing care for individuals following
traumatic events are keen to adopt a holistic approach and
welcome the opportunity to work with somebody who is
passionate about the psychological and social needs of those
they care for, providing fertile ground for the development
of healthy partnerships.
Example of Dissemination
One of the main vehicles used to disseminate a
stepped/stratied care approach in Cardiff & the Vale of
Glamorgan following traumatic events is involvement with
the local emergency planning department. As a result, a
social and psychological care steering group has been de-
veloped, chaired by a traumatic stress specialist. This is
a multiagency group including traumatic stress sufferers
and representatives from emergency planning, social ser-
vices, physical healthcare, emergency services, the non-
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
591
statutory sector, faith organizations, and journalism. The
group meets three times a year, has prepared a psychosocial
guidelines document, which has been incorporated into the
areas emergency plan and also has a remit to implement it.
The responsibility of the local authority to maintain an ad-
equate emergency plan provides a source of funding for the
training of providers from various backgrounds, including
trauma counselors.
Training Trauma Counselors
Given the shortage of traumatic stress specialists, the dis-
semination of evidence-based treatments such as TF-CBT
relies on the training of less-experienced therapists such as
trauma counselors to deliver them. It is possible to provide
individuals who are not working solely with traumatic
stress sufferers with a good basic grounding in TF-CBT
(e.g., Foa et al., 2005; Gillespie, Duffy, & Hackmann,
2002). In Cardiff, a cognitivebehavioral therapist, who
works with the traumatic stress service provides trauma
counselor training. Groups of six to eight individuals
from a variety of backgrounds, including medical,
nursing, and counseling, with limited previous training
in cognitivebehavioral therapy have been formed. They
meet weekly for 1 12 hours during which they receive six
weeks of training in TF-CBT assisted by a prolonged
exposure manual (Foa, Dancu, & Hembree, 2002) and
a video-training package (Creamer, Forbes, Phelps, &
Humphreys, 2004). Individuals are also provided with
relevant background reading, which is discussed during
the sessions. Role-playing of various cognitivebehavioral
techniques within the group enhance the development
of members skills. Following the 6-weeks training, the
individuals continue to attend the weekly groups and
once the trainer and trainee agree the time is right, they
are allocated an individual with PTSD of mild severity to
treat with TF-CBT. During this treatment, they continue
to attend the weekly supervision group and receive audio
or in vivo supervision during some of the sessions.
The trauma counselors speak positively about the new
skills they have acquired, as well as the fact that they
are able to use them in other areas of their work. The
592
PTSD sufferers who have been treated with TF-CBT
by trainees have achieved similar rates of recovery to
those treated by the traumatic stress specialists (Kitchiner,
Phillips, Roberts, & Bisson, in press). The training has
been seen as a key component of individuals personal
development plans and is well received by their em-
ployers. In terms of cost, the traumatic stress service
is able to see and treat more PTSD sufferers than it
would without this initiative and maintains a group
of trained trauma counselors who could be deployed
should a disaster occur. The cognitivebehavioral therapist
who runs the initiative dedicates time to training and
supervision that he would have spent treating individuals,
allowing more individuals to be treated in total.
SUMMARY
In this article, we have considered the issues facing those
attempting to disseminate early interventions following
traumatic events. Despite the limited evidence base for
children and adolescents, TF-CBT for acute PTSD has
been shown to be effective in one randomized controlled
trial. There remain many unanswered questions including
how best to intervene, when to intervene, and whether or
not early interventions can cause harm. The current prior-
ity should be to address these questions and with ongoing
research over the next few years, we should be able to pro-
vide the answers with much more condence. For adults,
further research is also required particularly into the de-
velopment of more-effective early interventions, how best
to provide early support, and the role, if any, of specic
education. There is stronger evidence for adults than chil-
dren that an appropriate approach is to aim to detect those
with signicant symptoms within 3 months and if acute
PTSD is present to offer TF-CBT. To achieve a global dis-
semination of this message, it is important that we are able
to agree on guidelines that can be adopted worldwide and
on a dissemination strategy to disseminate the guidelines
to the various levels as described above. Finally, we need to
prioritize dissemination and recognize it as the best way to
provide more people with effective management for their
trauma-related mental health difculties.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Bisson and Cohen
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