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Crisis Counseling

By Peter D. Kramer
Posted Friday, Sept. 21, 2001, at 3:00 AM ET
Illustration by Robert Neubecker

Does crisis counseling work? This past weekend, the New York Times ran contradictory articles. The first profiled Dr. Manuel Trujillo, the chief of psychiatry at Bellevue Hospital. According to the Times, Trujillo appeared to have spent the whole of his professional life preparing for a crisis like the World Trade Center catastrophe. He has blanketed the city with counselors, sending teams to high schools, emergency rooms, and family centers. The piece ended on an oddly wry note, depicting a chaotic group of mental health workers hovering behind bereaved family members but rarely finding anyone who wanted to talk.

The next day, Erica Goode, a respected medical writer, let the other shoe drop. Goode noted that a group of psychologists had circulated a document warning against quick attempts to intervene. Anxious and depressive symptoms are so common after exposure to frightening events, or in the face of loss, that it is unclear who needs treatment. And forcing people to confront a disaster immediately may actually be harmful.

A third article, appearing Tuesday, split the difference. Goode said that a high proportion of people who encounter severe trauma—perhaps 25 percent—go on to develop long-term stress disorders and that intervention is called for.

This back-and-forth response by the Times reflects the state of the field. Trauma services appear to be necessary, but any particular intervention is difficult to justify. In this respect, psychiatry is not different from the rest of medicine. If you ask whether obstetrical care improves outcomes in ordinary pregnancy, the answer is probably yes; but the closer in you focus—is this or that particular intervention useful?—the harder answers are to come by.

Crisis management—whatever its applicability to the aftermath of Sept. 11—has a distinguished history in psychiatry. The model ailment is "shell shock," World War I's version of post-traumatic stress disorder (PTSD). British psychiatrists had tried to prevent nervous ailments by screening soldiers. But even quite healthy recruits, and large numbers of them, returned home psychologically scarred. Doctors tried various interventions and found that location is important. If you hospitalized soldiers, they did poorly, and if you let them go home—which on the face of it seemed like a good idea—they did worse. What worked was treating them at the front, in the context of the injury.

That lesson was forgotten at the start of World War II, but by the middle of that war on-the-scene treatment once again proved effective. America's community mental health system, a Great Society program, imitated the military. It emphasized prompt treatment where people live rather than hospitalization. Many studies show this model to be effective at home and at war.

Acute psychological trauma does cause lasting harm. The Times articles imply that it is difficult to predict just who will suffer (again, the problem of screening), but some things are known. People with past histories of depression or anxiety are vulnerable to recurrence. And after a disaster, people who early on look like they have frank PTSD—ones with intrusive flashbacks and a sense that they themselves are somehow unreal—are at very high risk for developing the long-term disorder. This sequence makes sense. Animal research shows that stress causes predisposed mice or monkeys to develop syndromes that resemble depression or anxiety disorders in humans. The new behavior patterns are accompanied by corresponding persistent chemical and anatomical changes in the brain that predict worse trouble down the road.

But outside the lab, in the community, things get messy. PTSD has become suspect, not because of doubts about war injuries, but because of the controversy over recovered memories and multiple-personality disorder. The trauma referred to in popular discussions of PTSD is often a remembered injury from childhood. Some experts fear the diagnosis is multiplying in a way that reflects fad or politics rather than science.

As for intervention, treatments have a grass-roots feel that makes professionals uneasy, and many branded versions come without conclusive evidence of their therapeutic value. One of these treatments, "critical stress incident debriefing," is at the heart of the confusion reflected in the Times. Debriefing was developed 20 years ago, as a means of helping firefighters cope with the horrors they witness. In a typical session, a counselor encourages patients to recall a traumatic event and attach emotion to memory.

The claim that debriefing causes harm rests on an overview in the journal Cochrane Library in which individual studies are drawn together and summarized mathematically. But this meta-analysis looked only at research on one-shot debriefings—in some cases, a 20- or 30-minute conversation. And the Cochrane group uses high standards for admitting research into its analyses. It found 11 worthy studies. Three were of normal postpartum women, who bear scant resemblance to trauma victims. Some studies excluded subjects with prior mental illness, No study involved groups exposed to a common mass trauma.

The Cochrane summary has virtually no relevance to the World Trade Center catastrophe or the Bellevue group's response to it. Another Cochrane analysis—which found that psychiatric medications do have a role in the treatment of PTSD—is more to the point. It makes sense to identify people in need if you have help to offer, and it is likely that both medication and psychotherapy have roles in the treatment of trauma survivors with symptoms.

The crux is who should offer help and where. On-the-scene intervention makes sense in wartime, when soldiers are forced into strange and frightening settings. It makes sense in response to natural disasters where local resources are destroyed. Whether it is useful in the face of a discrete, urban terrorist attack is less certain.

Imagine members of a suburban family who travel to Lower Manhattan in search of a lost loved one. Perhaps crisis counselors should advise them to seek help if they display obvious psychiatric symptoms. But if individuals need treatment, the context of their lives, even the context of their trauma, is not the World Trade Center. It is the town where they live, the family doctor they know, the psychologist who counseled a relative in the past.

Taken simply, the lesson of trauma research is that people should be comforted, in a context that makes sense to them. A brief screening interview is not likely to be harmful. It should identify those who already have worrisome symptoms and let everyone else know that care is available, should they or those around them think they need it.

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Peter D. Kramer's novel, Spectacular Happiness, was published in 2001. His blog In Practice considers matters of brain and mind.
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Reader Comments From The Fray:


I've stayed out of The Fray lately as a personal measure for my own well being…Not that I've had time to post anyway...my 13 to 15 hour work days since the 11th have been spent coordinating onsite support (i.e. Critical Incident Stress Debriefings or CISD's) for the people we cover in the area (several banking and technology companies). Any breaks from that task have been spent on the phone with people who worked in the WTC or across the street. Hence, this article seemed the perfect re-entry point for me into The Fray.

All respect to Dr. Kramer. At the same time, I'd like to say that it is significant that he is a psychiatrist. By and large, the psychiatric profession (medical doctors) are not the ones most involved with crisis counseling. Psychiatrists have plenty of demands when it comes to managing medications for mental health, something that people without an MD can't do. It is the master's and Ph.D. level counselors who are out there, meeting with the folks, and doing the PTSD-prevention activities.

And here's how it went. We had people on site on the 11th, 12th, 13th...and the feedback we got from counselors was consistently this; "We feel useless. Nobody wants to talk." It was too soon: you can't deal with emotional reactions until you have them, and you don't have them until you come out of shock. This Monday was a different story...in many places, we couldn't get enough counselors on site. So, both sides of the issue are in a sense correct, but a lot of it has to do with timing.

Now let's talk about CISD's themselves. The particular method laid out for these interventions is called the Mitchell Model. The Mitchell Model calls for group sessions in which participants spend up to three hours discussing the details of the events, and then de-escalating back into a more rational framework for the event. The participants are limited to those who were first-hand witnesses to the trauma. So, when a counselor tries to spend 20 to 30 minutes with someone, and tries to debrief people who weren't even there, it's not a knock on crisis counseling itself--the model is being misapplied.

Bonus nitpick: PTSD. In order to suffer from PTSD, the person must have "experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others", and they must respond with "intense fear, helplessness, or horror". (from DSM-IV). So, being yelled at or neglected or scared of the dark doesn't count. Being spanked doesn't count, being sent to bed without dinner doesn't count. For the record, seeing body parts fall from the sky (as my clients have reported) definitely does count. So, it sounds like in the cases where "The trauma referred to in popular discussions of PTSD is often a remembered injury from childhood", the diagnosis is also often misapplied.

--Mangar

(To reply, click here.)

 (9/21)

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