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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Britain's National Health Service, the North Atlantic Treaty Organization, and the World Health Organization all cautioned against the use of debriefing as possibly harmful. In the fall of 2002, the National Institute of Mental Health (NIMH), in collaboration with the Red Cross and the U.S. Departments of Defense, Justice, and Veterans Affairs, released a report on psychological interventions in the wake of disaster. "A sensible working principle in the immediate [aftermath] is to expect normal recovery," said the report.

How can debriefings make things worse? First, venting emotions and reviewing experiences repeatedly in the immediate aftermath of a crisis can interfere with victims' natural adaptive instinct to distance themselves emotionally. They may start ruminating about the event--fixating on why it happened, how life is now ruined, whether revenge is possible--thus intensifying intrusive memories and overall distress.

Second, debriefing might lead people to believe that they have now received "treatment" for distress and no longer need to, or should, disclose their anxieties to family and friends. This deprives victims of the comfort and reassurance that are usually best supplied through established, intimate relationships. Paradoxically, knowing that professional debriefers are involved may even cause family and friends to hang back.

Third, by warning participants of the kinds of reactions that could develop over the coming weeks, debriefers might inadvertently prime victims to interpret otherwise normal reactions as pathological or as the beginning stages of PTSD. As the psychiatrist Simon Wessely has remarked, "The toxic effect of counseling is that some people begin to see themselves as having a mental health problem when they do not."

Where Are All the Patients?

In October 2001 Sharon Kahn, a senior psychologist at Coney Island Hospital, manned the phones at a televised call-in show sponsored by PBS and called Reach Out to Heal. Experts described the symptoms of traumatic stress, and viewers were urged to phone in with questions and to get referrals for help.

Kahn took calls all evening. She referred a grand total of two people for therapy. The vast bulk of the calls were queries about the resumption of regularly scheduled programming.

Across the country, mental health professionals braced for epic caseloads after September 11. Yet in the end, the demand for their services was modest. According to the New York Academy of Medicine, which conducted numerous surveys after the terrorist attacks, roughly 19 percent of New Yorkers said they saw a mental health professional within the eight weeks after the event--but this was little more than the 17 percent who did so eight weeks before the attack. "Existing therapeutic relationships and informal sources of support were the primary mental health resources for most people within the first few months," according to Dr. Sandro Galea of the Academy.

According to an Academy study published in 2004, there was no evidence that the predicted waves of delayed PTSD were surfacing, at least within the first five months after the attacks. Mental health service use declined steadily within the first five months after attacks to virtually pre-9/11 levels. "The increase was not clinically significant," Dr. Joseph A. Boscarino, the study's lead author, told The New York Times, "We expected higher use rates."

For about a year after the attacks, star-studded public service announcements were ubiquitous in subways, buses, and newspapers around New York City. "Whatever you are struggling with, you are not alone," the actor Alan Alda intoned on radio stations serving New York City. "Now is the time to feel free to feel better." The ads were sponsored by Project Liberty, the name given to the crisis counseling program in New York City funded by the Federal Emergency Management Agency (FEMA) and run by the New York State Office of Mental Health.

Project Liberty's four thousand counselors offered reassurance and advice. They met with groups of people and with individual clients. They made house calls, arranged to meet clients on park benches or at their workplaces. When the New York State Office of Mental Health applied for its first FEMA counseling grant right after September 11, it estimated that 1.5 million New Yorkers would need counseling. A grant of $23 million came through promptly in October. As of June 2002, about 120,000 had sought assistance, not even one-tenth the projected number. Yet around that time, FEMA announced another grant, of $132 million--nearly six times as large--in response to a second request for counseling funding. This time, the Office of Mental Health projected that two million New Yorkers, or one in four, would need counseling ("to allow necessary healing to continue").

In the late spring of 2003, about a year after the second FEMA grant was awarded, $90 million remained unspent, according to the New York Daily News. Recruiting clients was a priority. "In New York City," said Rachel Yehuda of Mount Sinai School of Medicine, "the strong feeling was that if [the clients] don't come to you, you've got to go to them. The idea was to institute portable Project Liberty units of people to walk the streets looking for people to help." In the winter of 2002 Lynne Rosen, a psychotherapist in Brooklyn, got a part-time job offer in just that spirit. She was contacted by a representative of a Queens-based mental health center to "reach out" to the traumatized residents of Brooklyn and Staten Island. The center would pay her with funds obtained from Project Liberty. Rosen's assignment was to sit in the waiting room of a general practitioner's office and approach patients as they came in for their medical appointments. She was to ask them where they had been on September 11 and whether they were having any psychological problems because of it. If so, she was to refer them to a center therapist.

The center wanted Rosen to talk to the patients about PTSD, she said, "even if they responded to the question about symptoms with a definite no." So she asked the center's representative how he justified such aggressive conduct. "'We all continue to be deeply affected by September 11,' he told me indignantly," Rosen said, "and he lectured me that future psychiatric symptoms could still develop." Rosen turned down the offer because she could not picture herself "accosting these unsuspecting people and burdening them with unnecessary anxiety about an event that happened over six months ago and that they said did not have a lasting effect on their well-being."

Private charities made mental health services a priority after September 11. They "have taken perhaps the most aggressive stance ever in pushing mental health therapy for families and others affected by the attacks," noted The Washington Post. In the summer of 2002 various New York City�based charities, along with the Red Cross, announced combined grants of almost $250 million over five years (including the FEMA support) to "address the enduring problem of psychic damage--grief, stress, trauma--in the aftermath of September 11." A year later these same charities announced a collaborative effort "to encourage people affected by the 9/11 attacks to take advantage of financial assistance for confidential mental health and substance abuse assistance."

Pessimism, Pathologizing, and Profiteering