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.
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."
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.
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
This money was pouring forth even as evidence consistently showed that most people were improving with time. Polls taken by the Pew Research Center, the Marist Institute for Public Opinion, ABC/Washington Post, and RAND within six months of the attacks all showed declines in problems such as sleeplessness, trouble concentrating, and intense worry about future attacks. Volumes of data on traumatic response confirm that rates of stress and PTSD decline with time.
Why did the money keep flowing? Partly because mental health planners, lacking data on nonpathological responses to terrorist attacks, relied on models that were inappropriate–chiefly from the Oklahoma City bombing and other mass disasters where death or injury was widespread. The victims of such events bore little resemblance to the vast majority of New Yorkers, who, while deeply shaken, even devastated, were never in mortal peril.
In addition, officials believed more people would use trauma services in the future. "Based on our experience, we know that thousands more need these services but have not come forward," the administrator of the American Red Cross's September 11 Recovery Program announced. Once they recognized that they needed help or got over their fear of being criticized for seeking it, the assumption was, many more New Yorkers would be getting therapy. Fully three years after the attacks, the Mental Health Association of New York City was still advertising counseling services for reactions to 9/11.
Continued funding was also justified by the expectation that symptoms had yet to manifest themselves. Joshua Gotbaum, the chief executive of the September 11th Fund, informed the public that "many people affected by September 11 will need some form of counseling and that many of them will not realize it for months or even for years." Dr. Paul Ofman, chairman of emergency services at the Red Cross in Greater New York, also expected to see delayed reactions: "While for some people, the impact on their mental health is evident right away," he told The New York Times, "for a noteworthy minority of individuals, the impact won't become evident until months or even years after the disaster."
Finally, money flowed because service providers were eager to take it. Daryl Regier of the American Psychiatric Association issued a canny prediction when he told the Times, "There are going to be people coming out of the woodwork to capitalize on this large amount of money that's available, some of whom will be completely legitimate." And, Regier added, some of whom will not be. As Reuters reported, "A whole new era of mental health services could be opening up for longer-term care [for stress relating to the terrorist attacks] in what could be a boon for individual counselors and the companies who act as industry middlemen."
Ending an Ethos of Therapism
In New York City on September 11 there was a strong, spontaneous show of collective resolve and organization. Near Ground Zero, members of one tenant association helped direct the streams of people running from the World Trade Center; they formed an "urgent needs" team to check on homebound residents; they acted as volunteer cashiers in stores when paid employees could not get to the area. The calm and orderly behavior of workers evacuating the World Trade Center towers themselves surely kept the death and injury tolls from rising. In the largest waterborne evacuation in our history, half a million people left lower Manhattan. Barges, sailboats, and ferries, with no instructions, put into the port as the towers burned. "If you're out in the water in a pleasure craft and you see those buildings on fire," the Rutgers sociologist Lee Clarke said to The New York Times, "in a strictly rational sense, you should head to New Jersey. Instead people went into potential danger and rescued strangers."
According to the sociologist Henry Quarantelli, a pioneer in the field of disaster research, such constructive responses are typical. "Mythical beliefs to the contrary," he writes, "disaster victims do not panic, they are not passive, they do not become caught up in [selfish and] antisocial behavior, and they are not behaviorally traumatized." Monica Schoch-Spana, a medical anthropologist with the Johns Hopkins Center for Civilian Biodefense Strategies, laments the predominance of the "pathological model." So often, she says, officials and mental health planners neglect the positive human elements that crisis elicits, such as "reasoned caution, resourcefulness, adaptability, resiliency, hopefulness, and humanitarianism."
In our trauma-conscious society, many mental health professionals seem eager to take charge of managing the collective anxiety surrounding terrorism and its aftermath. But perhaps one of the lessons from September 11 is that the clinician's role in a shocked and heartbroken world is actually quite limited.
Consider what we know about human response to crisis. Under threat, citizens are ravenous for information and require practical resources. They need a social scaffolding in the form of civic order and some minimal infrastructure to support the bedrock institutions and relationships–families, communities, and houses of worship–that have always served them in times of uncertainty and immense sorrow.
One of the lessons of 9/11 is that therapists must find a balance between offering their services and promoting them too eagerly, between letting people know help is available and suggesting that they need help when they do not. On September 11 the helpers toiled in good faith, powered by genuine concern. But they also endorsed one of the mistaken tenets of therapism: that people are fragile. In their zeal to help, they underestimated our natural fortitude.?