Boston University psychiatrist and trauma specialist Dr. Bessel van der Kolk likes to tell the story of his trip to Puerto Rico 10 years ago after Hurricane Hugo.
The place was humming. ”Everybody was rebuilding houses. I came into this devastated island scene of human resiliency,” he says. Then the feds swooped in, telling people how to get reimbursed and go about recovery. ”All the rebuilding stopped. People sat in homeless shelters. It interrupted the natural healing process.”
Van der Kolk has no grudge against federal assistance, or any organized mental health intervention in the wake of disasters such as hurricanes, plane crashes or the recent school shootings in Littleton, Colo., and Conyers, Ga.
What he and other skeptics do have, however, is a healthy respect for the capacity of individuals and communities to heal themselves – and a wariness about the value of sending hordes of strangers, albeit professionals, to help.
The notion that people who’ve witnessed a natural or manmade disaster need expert counseling, and fast, runs deep in America. Somehow, we’ve come to assume that without planeloads of specialists to help us get a grip, our fragile psyches would crumble in the face of the tragedies we witness.
Last year, through the Center for Mental Health Services, a federal agency, the US government spent $10 million to help states provide emergency mental health services to people in disaster areas. Private groups, like the International Critical Incident Stress Foundation in Ellicott City, Md., are also on call with ”debriefers” to zoom wherever they might be needed.
But are they needed? Is there evidence that professional intervention helps bystanders get over traumas any better than they would without it? For that matter, isn’t it possible that intervention might make some people worse, perhaps those who need time and quiet rather than venting of feelings to heal?
Psychologist Raymond Flannery, Jr., director of training at the Massachusetts Department of Mental Health, has reviewed the last 30 years’ worth of published data on crisis intervention, about 90 studies. Of these, he says, 13 found no benefit or potential harm, and the rest suggested there is a benefit.
But many of the studies are methodologically flawed. It’s rare, for instance, for researchers to randomly divide people into those who get instant help and those who don’t, partly because counselors usually assume it would be unethical to deprive people in the control group of their services.
Beyond that, there’s no unanimity on what to study: group counselling for all bystanders of a disaster or one-on-one debriefing? And what outcomes should be measured – distress a month after the intervention? Three months later? A year?
Even proponents of a kind of intervention called group debriefing concede that, as trauma specialist Robert Macy of the Trauma Center in Brookline puts it, there are no randomized, controlled trials of the technique, though some are underway.
And while crisis intervention probably does help many people – indeed, the anecdotal evidence is overwhelming – it doesn’t help everybody. Seven years ago, for instance, an El Al plane crashed into an apartment building in Amsterdam, providing researchers a chance to study crisis intervention.
Everyone participated in ”intense communal activity – dancing, singing, funerals, a lot of good holding,” and half got individual debriefing as well, says BU’s van der Kolk. Those who got the debriefing were more likely than those who didn’t to get post-traumatic stress disorder, in which one’s life becomes centered on the trauma for months or years afterwards.
”This may seem surprising,” says van der Kolk, but for some people, ”plunging into your feelings may actually interfere with the natural healing process. Biologically, stirring up the emotions will keep the body in a state of hyperarousal.
”The critical thing after exposure to trauma is to get the body to calm down…Religious ceremonies get it: sit down, hold each other, mourn with each other,” he says. ”But don’t immediately go into all the details of how painful it is.”
George Bonanno, a psychologist at the Catholic University of America in Washington, D.C., agrees. He has studied personal losses – the death of a loved one – not communal disasters. He believes that after a tragedy, ”most people are just trying to figure out what hit them and the last thing they need is a bunch of therapists arriving and telling them what has happened to them and what they need to do.”
But mere venting is not all that crisis intervention specialists actually do. A key goal, in fact, is not just emotional release but restoring a sense of community, control and safety – usually in groups, not individual sessions, though group sessions do provide the debriefers with a chance to screen people and refer those who may need more help.
”A lot of good counseling isn’t just catharsis, it’s to see what resources they have to get back to normal,” says Peter Sheras, a clinical psychologist at the University of Virginia.
People often think ”there’s something wrong with them, that they’re losing their mind,” after a disaster, says Elizabeth Carll, a Centerport, N.Y. trauma psychologist. What crisis experts do is ”reduce the impact of the crisis” by teaching people it’s normal to be stressed after an abnormal event.
Historically, the rationale for quick intervention goes back to World War II and army efforts to get combat-fatigued soldiers to feel better – and get back to the trenches. Over the years, that led to programs for firefighters and police officers.
Fifteen years ago, Maryland psychologist Jeffrey Mitchell developed what he calls critical incident stress debriefing – and later, critical incident stress management, which includes more services, including family and individual counseling.
The basic debriefing is a 7-step, 2-hour group session, usually within 10 days of the disaster, says psychologist George S. Everly, chairman of the board emeritus at the critical incident foundation in Maryland. The debriefer first asks people to recount the facts – what they saw or heard, then asks about thoughts and emotions, then about physical symptoms like insomnia and rapid heart beat.
Then comes the key, he says – ”expectancy,” the lesson that it’s normal to have intense reactions to an abnormal event.
Indeed, a 1986 study of combat-stressed Israeli soldiers during the Lebanon war showed that those who fared best were the ones who got intervention close to the front, close in time to the trauma, and who were taught that stress reactions are normal.
That basic strategy certainly helped a Boston man in his 40’s. A little over a year ago, a former employee walked into the office where this man, who wants to remain anonymous, works. The intruder assaulted one person and terrified co-workers. Three days later, Boston trauma specialist Macy ran a debriefing for those most affected.
”It definitely helped,” the man says, not just in making people feel better in the moment, but in spurring co-workers to institute a better security system.
That kind of pulling together is probably the best therapy of all, says van der Kolk. ”Trauma makes people feel helpless, so if you can do something where you feel you’ve changed the world a little so it won’t happen again, that is very helpful.”