The Mental Health Crisis That Wasn't

How the trauma industry exploited 9/11.

Sally Satel & Christina Hoff Sommers from the August/September 2005 issue

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All manner of setbacks qualify a worker for psychological help. According to Psychotherapy Finances, a newsletter for entrepreneurial therapists, "workplace trauma isn't just about bank robberies or shooting sprees...for every high-profile incident there are thousands you never hear about." When a tasteless cartoon about firemen appeared in the New York Post two years after the attacks, the Fire Department of New York City sent counselors to a company that had lost men on 9/11. "We wanted to make sure the guys were all right," a FDNY official told the New York Daily News.

Business and corporate managers have jumped on the psychological debriefing bandwagon, persuaded by its purveyors that without their help productivity will suffer and mental health costs will soar. Organizations that do not offer debriefing for workers exposed to on-the-job trauma "may put themselves in medical-legal jeopardy," warns Landy Sparr, a psychiatrist at Oregon Health and Sciences University. Some psychologists even tell employers that they have 48 hours to act after a disaster, otherwise employees may "jump ship" or "come down against the company."

Trauma Tourism?

The International Critical Incident Stress Foundation (ICISF), based near Baltimore, is the largest psychological debriefing training outfit in the world. With a virtual monopoly on debriefing training, ICISF appears to be prospering both at home and abroad. Its clients include the FBI, the Coast Guard, the American Red Cross, and U.S. Air Force bases worldwide. It has training programs in Canada, Europe, the Caribbean, Central and South America, and Australia.

Anyone with a high school diploma is eligible for the foundation's course. In some circumstances, an ICISF certificate grants the bearer access to disaster sites that an advanced clinical degree does not. For example, in 1995 a group of psychiatrists from Yale that included respected experts in traumatic stress offered to help with victims of the Oklahoma City bombing. Emergency officials turned them away because they lacked certification from the International Critical Incident Stress Foundation.

The certificate, then, doubles as a coveted passport to disaster sites--even though it is awarded to anyone who has paid the $190 course fee and shown up for the lectures. Is it any coincidence that critics of the crisis management business have taken, tongue-in-cheek, to calling volunteer crisis counselors "trauma tourists"? There is no doubt that the volunteers are well meaning, but neither is it any secret that some of them have a voyeuristic urge to be part of a historic moment or a media event.

"Disaster vultures" was the name given to overly enthusiastic mental health professionals who rushed into the scene at the Oklahoma City bombing in 1995. "Their credibility in the future would be their claim to have worked in Oklahoma City," a dismayed local psychologist observed.

Psychological debriefing is an enterprise that has operated outside of conventional clinical boundaries and oversight. Richard Gist, a psychologist with the Kansas City, Missouri, fire department and an outspoken critic of the trauma industry, describes it as a prolific and parochial subculture of providers whose understanding of these highly complex issues is often limited to proprietary instruction in the form of traveling seminars, trade magazines, and paperback books, rather than the refereed venues of empirically guided professional practice.

In the summer of 2002, one of us (Satel) spent two days in a frigid hotel ballroom outside Baltimore with about 200 men and women--nurses, social workers, rescue volunteers--seeking ICISF certification in the basics of crisis counseling. Much of what the instructor said was obvious: that routines should be preserved after a crisis,
that too much alcohol is bad, that depriving yourself of sleep is unhealthy, and so on. The "experts" had appropriated common sense as if it were their own special province.

Then came a session on psychological debriefing, also known as critical-incident stress debriefing--the centerpiece of trauma counseling. Our instructor acknowledged that debriefing had come under attack, but promptly dismissed the critics, maintaining that psychological debriefing was proven to thwart the development of PTSD.

The instructor peppered us with a series of half-truths and outright misstatements. We were told, for example, that PTSD "rarely goes away by itself," that there are no factors that predispose a person to develop PTSD, and that people who "hold it in do worse"--all untrue statements. The course manual stated that debriefing compensates for "the failure of the [victim's] usual coping strategies." Moreover, unless psychological debriefing took place soon after the crisis, a "trauma membrane" would form around the victim and "thicken" so that he would no longer be receptive to help. (Ironically, the psychiatrist Jacob Lindy, who treated survivors of the devastating Beverly Hills Supper Club fire outside Cincinnati in 1977, coined the term trauma membrane to describe not a debriefing-resistant cocoon but a small network of trusted friends who buffer the victim from additional stress. A properly functioning trauma membrane, in Lindy's sense, might well act to keep debriefers away.)

We also learned how to conduct a psychological debriefing by breaking up into groups of eight. Each group was provided its own tragic scenario. In ours, we were supposed to be telemarketers busy on the phones one morning when an employee's drunk and jealous ex-husband burst into the work area with a gun and shot one of us in the shoulder. After the injured worker was taken away in an ambulance, the rest of us gathered to be debriefed by our eighth colleague, who was assigned the role of an outside debriefer. Following the directions in our course manual, the role-playing debriefer encouraged us to talk about how scared we were, rehashing in the most graphic language how the blood had spurted from our colleague's wound, how we had panicked and had thought we would all be killed. This was our "opportunity for catharsis, an opportunity to verbalize trauma," said the manual.

First, Do No Harm

Such opportunities are precisely what the 19 psychologists' open letter warned about when it spoke of therapists "descending on disaster scenes with well-intentioned but misguided efforts." And with good reason. Research shows these efforts at debriefing to be ineffective in preventing the development of PTSD or related symptoms, and, at times, to actually be harmful.

Most random-assignment studies of individuals who have suffered accidents, assaults, or burns show the same degree of improvement, whether patients were debriefed in a one-on-one session by a therapist or instead received general support or no intervention at all. Two such studies, however, found that debriefing actually impeded recovery. In one, debriefed burn victims were three times as likely as the control group to develop PTSD after one year. In the other study, a three-year follow-up of car accident victims, anxiety, level of functioning, physical pain, and degree of preoccupation with the accident improved more slowly in the debriefed patients than in the control group.