The Mental Health Crisis That Wasn't

How the trauma industry exploited 9/11.

On September 14, 2001, three days after the terrorist attacks on the World Trade Center and the Pentagon, a group of psychologists sent an open letter to the American Psychological Association. The 19 signatories, all established experts in trauma research and treatment, were concerned that thousands of people in New York City and elsewhere would receive dubious, even damaging, counseling. "In times like these," the letter said, "it is imperative that we refrain from the urge to intervene in ways that--however well-intentioned--have the potential to make matters worse....Unfortunately, this has not prevented certain therapists from descending on disaster scenes with well-intentioned but misguided efforts. Psychologists can be of most help by supporting the community structures that people naturally call upon in times of grief and suffering. Let us do whatever we can, while being careful not to get in the way."

The letter voiced a second powerful warning: not to mistake normal reactions--intense sadness or sleeplessness, jumpiness, and so on--for mental abnormality. The letter was posted online and picked up by a New York Times science reporter who fast-tracked the controversy into Sunday's paper, five days after the attacks. As Gerald Rosen, a Seattle psychologist and one of the letter's authors told the reporter, "The public should be very concerned about medicalizing what are human reactions."

By then, though, the trauma industry had shifted into high gear. Roughly 9,000 counselors raced to lower Manhattan, advocating, in the words of one observer, "intervention for any person even remotely connected to the tragedy."

Spencer Eth, a psychiatrist at St. Vincent's Catholic Medical Centers in New York City, foretold "huge increases in the prevalence of traumatic grief, depression, post-traumatic stress disorder [PTSD], and substance abuse in the New York City metropolitan area at the least...[the] psychiatric toll will be enormous." Richard Mollica, a Harvard psychiatrist, forecast that "starting around the Thanksgiving holiday and through the New Year, a major mental health crisis will emerge in the city and surrounding area." The president of the New York State Psychiatric Association predicted that psychiatric problems would continue to emerge over several years, including among those who were watching television coverage of the attack.

Granted, these urgent statements were made soon after the attacks, while our collective nervous system was still reverberating from the shock. Yet weeks and months later, when cooler heads might have prevailed, the warnings remained frantic and grim. In June 2002, for example, the Office of Mental Health projected that two million New Yorkers, or one in four, would need counseling. And one year after the attack, the president of the Washington, D.C., Psychiatric Society was still worried about mental health manpower: "There are not enough psychiatrists, psychologists, social workers, or other crisis counselors to treat the fallout from a massive, unimaginable horror."

The dire predictions of psychological injury prompted a Washington Post reporter to correct the misimpression: "Even though it is commonly believed that post-traumatic stress disorder is universal among trauma victims--a fallacy that some mental health counselors are perpetuating in the aftermath of this tragedy--epidemiological studies show otherwise." In response to the apprehension about whether people could cope, a skeptical reporter with USA Today was finally forced to ask, "Does everyone who goes through trauma need a therapist?"

The answer, of course, is no.

The Trauma Industry

Therapism is a worldview that valorizes openness and emotional self-absorption; it assumes that vulnerability, rather than strength, characterizes the American psyche, and that a diffident, anguished, and emotionally apprehensive public requires a vast array of therapists, self-esteem educators, grief counselors, workshoppers, healers, and traumatologists to lead it through the trials of everyday life.

In fact, there is no evidence that large segments of the population are in psychological free fall. On the contrary, researchers who follow the protocols of social science find most Americans--young and old--faring quite well. If they're crashing and burning, they don't seem to know it. This has proven true even in the wake of terrible disasters.

Trauma counseling flowered with the Oklahoma City bombing of 1995--where counselors reportedly fought over patients "because there were simply not enough to go around"--and the TWA Flight 800 air disaster of 1996. After the Columbine High School massacre in 1999, counselors logged 1,500 hours talking to students in the first week alone, according to Time. This "psychological debriefing" involves a counselor--who has never before met any of his victim-clients--conducting group-therapy with those individuals for a few hours, encouraging them to emote. Typical questions include "What were the first thoughts that raced through your mind at the time of the crisis?" and "What was the worst moment for you?"

This bears little resemblance to its precursor: military operational debriefing. After a significant battle in World War II, soldiers were "debriefed" by their superiors. The aim was to establish what happened for historical purposes, identify plans that had gone awry or well, share experiences, boost morale, and facilitate troops' rapid return to duty. The mitigation of distress was a welcome byproduct, but operational debriefing was not designed as a psychological aid.

In the 1960s and 1970s these frontline principles were translated into peer-to-peer support activities for rescue workers. Firefighters, paramedics, and other emergency workers who routinely witnessed horrible scenes of carnage and risked their lives in the line of duty would gather to review the logistics of an operation and talk about their experiences.

Over time, the debriefing process was extended to civilians. As a form of psychological first aid, it joined--and sometimes displaced--traditional crisis work, which had grown out of crisis theory elaborated in the 1960s. The basic tenets of crisis theory are that people who have endured a life-threatening event are not sick and that crisis intervention is not necessarily a mental health service. The main job of a crisis worker or counselor is to help the client find concrete, realistic solutions to the problems created by the event.

This perspective differs fundamentally from the more recent model created by Jeffrey T. Mitchell, a former paramedic and firefighter. In the late 1980s Mitchell began to market his crisis philosophy that virtually all victims are at risk for trauma-induced mental illness. If crisis workers shore up people who are basically sound though temporarily in disarray, psychological debriefers give a mixed message. On one hand, they tell victims that stress reactions are normal, and yet warn that without their intervention such reactions can easily blossom into PTSD.

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