When words fail

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When words

fail 40 | NewScientist | 3 February 2007

You’ve been through hell. That doesn’t mean you need counselling, finds Laura Spinney

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After the 2006 tsunami in Java, Indonesia, yet more western counsellors rushed in

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AFTER a tsunami struck the rim countries of the Indian Ocean on 26 December 2004, hundreds of western aid organisations flocked to the region to help. As well as providing practical and financial support, many focused on the disaster’s psychological toll. In Sri Lanka, the job of liaising with the foreign counsellors fell to Athula Sumathipala, psychiatrist and director of the Forum for Research and Development in New Town. Things didn’t always go smoothly. For a start, many of the foreigners spoke neither the local languages nor English. Some advocated a www.newscientist.com

controversial form of therapy called eye movement desensitisation and reprocessing (EMDR), which involves asking the patient to focus on the therapist’s moving finger as they recall the unpleasant memories. The evidence for the efficacy of EMDR is debated, and while Sumathipala was not opposed to its use in principle, he drew the line when some of the therapists argued that Sri Lankan cricket umpires should be recruited because they were experienced at wagging their fingers . Some of the outsiders argued for compulsory counselling. “Most had no knowledge of Sri Lankan culture,” says Sumathipala. These days few can be unaware that people who undergo highly stressful experiences risk long-term mental trauma, in particular post-traumatic stress disorder (PTSD). After disasters ranging from a school shooting to a terrorist attack, ranks of counsellors rush in to mitigate the psychological fallout. A small number of doctors are starting to question this orthodoxy, however. They are sceptical of the received wisdom that a quarter of those exposed to a traumatic event generally go on to develop PTSD. And they oppose offering counselling to almost everyone who has experienced the event in the hope of preventing future trauma. They claim that at best it wastes resources and at worst it does more harm than good. It is nothing new to find social commentators expressing misgivings about today’s therapy culture, but this is a fight between the professionals themselves, and it is turning nasty. Psychiatrists who are sceptical of the orthodoxy face accusations that they are ignoring suffering. The sceptics question the impartiality of commercial organisations that provide preventive counselling. “This is not your ordinary debate,” says Richard Gist, a public health psychologist with the Kansas City Fire Department, Missouri. “If words were weapons, there would be bodies.” So what do the experts agree on about PTSD? The condition became widely known during the first world war, when it was called shell shock, but it was not until 1980 that the American Psychiatric Association added PTSD to its list of recognised mental disorders. Beyond battlefield horrors, other potential triggers are now thought to include incidents such as rape or natural disasters – even events as commonplace as a mugging or difficult childbirth. PTSD is characterised by vivid flashbacks, and people can also suffer sleeplessness, anxiety and emotional numbness, to the

extent that they cannot hold down a job or maintain a relationship. It is still not known why and how PTSD develops, and why only some people are susceptible. A working hypothesis is that something goes awry with the brain’s normal mechanism for initially paying extra attention to frightening memories and then allowing them to fade if the threat does not recur. Some experimental approaches to treating the disorder involve using drugs to erase those memories at the molecular level (New Scientist, 3 December 2005, p 32), but if this method does prove useful it is probably many years from reaching the clinic. Established treatments include antidepressants and counselling, in particular cognitive behavioural therapy (CBT), tailored to trauma survivors. Most psychiatrists agree that counselling can help people who are already suffering from PTSD. It is when counselling is put forth as a preventive against the condition that some become sceptical.

Force-fed therapy The notion of trying to prevent PTSD took off in the 1980s, with the growth of single-session psychological debriefing. This is not the kind of debriefing soldiers and emergency workers receive after an operation, which is essentially information gathering. The psychological variety generally involves a specially trained person carrying out a therapy session soon after a traumatic event, either with groups or individuals. Participants tell their story, are asked about their feelings and taught about PTSD symptoms to watch out for. The trend fed easily into today’s litigation culture. Some commercial debriefing services promoted the idea that if a firm’s employees experienced some trauma (such as a hold-up), the company might later be held negligent if it did not provide counselling. Some emergency workers have even been compelled to undergo debriefing against their wishes. This happened after the Oklahoma City bombing of 1995, for example. After the attacks on the World Trade Center and the Pentagon on 11 September 2001, debriefing was part of the range of counselling services on offer. The events of 9/11 brought trauma psychology into the public consciousness as never before. Numerous experts warned of an impending mental health epidemic, with claims that as many as 1 in 4 New Yorkers would suffer PTSD or other psychological trauma. An army of mental health professionals was mobilised through the government-funded Project Liberty. Eager for work, some even stopped people in the street to offer counselling. Randall Marshall, a psychiatrist at the New York 3 February 2007 | NewScientist | 41

was ineffective emerged in the late 1990s. By 2002, a formal review of 15 randomised controlled trials found that not only does this therapy not do any good, it might even raise people’s risk of PTSD. Debriefing is now a dirty word in academic circles, although there are still plenty of firms that market debriefing services, sometimes under different names – for example, critical incident stress management. Whatever it is called, some question whether the forms of preventive counselling that are used in its place differ significantly. “It’s still early emotional ventilation after trauma, and education about symptoms,” says Simon Wessely, director of the King’s Centre for Military Health Research at King’s College London. According to Gist, the school of preventive counselling that grew out of debriefing is about more than mere therapy – it is a social movement with an evangelical undercurrent. “Debriefing and its conceptual cousins are

“It is not your usual debate. If words were weapons, there would be bodies” 42 | NewScientist | 3 February 2007

seductive,” he says. “It is very satisfying to parachute in and help people.” After the London bombings on 7 July 2005, in which four suicide bombers killed 52 people, the official response was on a smaller scale than it had been in New York four years earlier. While experts still predicted a PTSD rate of 25 per cent, they applied this to the estimated 4000 people who had been directly caught up in the bombings – not to the whole city, as some did after 9/11. Peter Scragg, a clinical psychologist at University College London who coordinated the response, is no fan of immediate counselling for all. “In the first month to six weeks, let people use their own natural ways of coping,” he says, “The strange face of a psychologist is not going to be helpful.” Wessely believes that in the crucial four to six weeks after a disaster, people’s best support comes from their existing social networks – their family, friends and neighbours. These people can provide a GILLES PERESS/MAGNUM

State Psychiatric Institution and one of the architects of Project Liberty, acknowledges that some of the counsellors went too far. He says: “The city was crawling with our types, many of whom were perceived as pushing their services or ideologies onto people.” The events of 9/11 also gave researchers a chance to study disaster psychology on a huge scale. Five years on, the epidemiological data from that period are still being debated. One telephone survey, led by Sandro Galea of the University of Michigan School of Public Health in Ann Arbor, indicated that one month after the disaster around 8 per cent of the population of Manhattan had probable PTSD. Those figures, says Marshall, show that the initial predictions of an epidemic were borne out. Others disagree. A follow-up study found that six months after 9/11, the rate of probable PTSD in Manhattan had dropped to 0.8 per cent. “This is an unprecedented rate of recovery,” says Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute for Public Policy Research, a conservative think tank in Washington DC. “True PTSD resolves much more slowly, suggesting that the vast bulk of what was measured was in fact rational distress.” Now the debate has been further inflamed by a book co-edited by Marshall, 9/11: Mental health in the wake of terrorist attacks, published last September by Cambridge University Press. Richard McNally, a psychologist at Harvard University, had been invited to write a chapter. When the editors learned that he planned to mention Satel’s reference to 9/11 as “the mental health crisis that wasn’t”, they threatened to cancel his chapter. “They went ballistic on us,” he recalls. Indeed, Marshall makes scathing reference in his own chapter to McNally and his coauthor’s “denial of human suffering”. In turn, McNally is sceptical about the motives of those who promote early preventive counselling: “They can say: ‘We are doing something, see how much we care.’” The first studies suggesting that debriefing

friendly ear and may also be willing to help with the practical demands that a disaster imposes, such as finding food and shelter, and dealing with physical injury and bureaucracy. “Although we do not think these are mental health measures, they are,” he says. After the Asian tsunami, Sumathipala found that local religious bodies – mainly Buddhist, but also Hindu and Catholic – provided the most effective help. It came in the form of age-old rituals for collective grieving, as well as more practical support: turning temples into refugee camps, for example. Wessely fears that debriefing or other www.newscientist.com

six weeks afterwards. This involved asking people 10 questions about their mental health, such as whether they had had upsetting dreams or difficulty sleeping. Those identified with potential problems were referred for a full clinical interview and if necessary, counselling.

U-turn Even this low-key approach is controversial, though. That’s because numerous screening programmes for various types of medical problems have been introduced over the years, only for questions to be raised later over whether they do more harm than good (New Scientist, 22 June 2002, p 34). The case for women checking their breasts for lumps every month, for example, is now widely discredited. Most doctors now agree that any medical screening programme must meet several criteria before it is widely used. Arguably the most important is that the programme has

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forms of preventive counselling could interfere with these natural coping mechanisms. In the 9/11 book he cites the example of a British school (which shall remain anonymous), where one of the pupils died under particularly distressing circumstances. The headteacher asked counsellors to come into school the next morning and help the children “come to terms with the tragedy”. Another teacher told Wessely that although he had initially felt it was part of his role to discuss the child’s death with his class, once the counsellors were called in he assumed this activity required professional skills that he did not possess. Another possible downside of early counselling is to make people focus on symptoms to which they previously hadn’t given any thought, making such symptoms more likely to emerge and persist. Alternatively, in some people, it could reinforce their memories of the event, when forgetting would be better. A 2002 study by Karni

As survivors of hurricane Katrina (above) and 9/11 (left) have shown, patterns of mental trauma can vary hugely and defy simplistic analyses

Ginzburg of Tel Aviv University, Israel, and colleagues showed that among heart attack survivors, those who suppressed memories of their brush with death were less likely to develop PTSD than those who talked about them (Psychosomatic Medicine, vol 64, p 748). After the London bombings, rather than promoting universal counselling, the official response was to offer “screening” to anyone who had been caught up in the attacks, from www.newscientist.com

been tested in a large randomised controlled trial, in which the overall health of people who take the test is compared with that of people who haven’t. Only that way can all the possible problems be assessed. Screening for PTSD has never been tested in this way. What possible problems might we be missing? Perhaps screening is not very cost-effective because most people with symptoms of post-traumatic stress and anxiety might improve over time without counselling – as suggested by Galea’s 9/11 research. Worse, all screening programmes carry the risk of harm to the healthy

population. Asking trauma survivors a list of questions about possible symptoms could conceivably make them more likely to occur. On the other hand, fans of screening, such as Chris Brewin, a clinical psychologist at UCL who devised the questionnaire used after the London bombings, counter that there is plenty of evidence showing that cognitive behavioural therapy can be effective if PTSD is identified early, and screening is the only way to do that. The chaotic aftermath of a major disaster must be one of the hardest environments in which to conduct a clinical trial. It is unlikely a definitive answer on screening will emerge any time soon. In the meantime, the sceptics argue that it is wisest to confine any screening efforts to those at most risk of developing PTSD. Different psychiatric services, however, seem to have set different cut-off levels for deciding who should be screened. Sandy McFarlane, head of the University of Adelaide node of the Centre for Military and Veterans’ Health in Australia, helped set up a screening programme for Australian troops returning from combat in 1998. “What you don’t do is screen thousands of people with a low probability of developing PTSD,” he acknowledges. “Judging this takes a good degree of common sense.” McFarlane believes people should be screened if it is estimated they have more than a 1 in 20 risk of PTSD. Wessely, on the other hand, has mixed feelings even about the screening after the London bombings, despite accepting that those affected by these attacks were probably at the high end of PTSD risk – about 1 in 4. Wessely says he supported the screening, but had reservations because of the lack of evidence. “It’s very sad that they didn’t do it as a clinical trial,” he adds. Among the minority who do experience psychological distress, each new disaster reveals how variable their responses can be. Since hurricane Katrina struck Louisiana in 2005, for example, PTSD proper has not been the main mental disorder diagnosed in the disaster zone. “The common problems are more non-specific anxiety spectrum disorders and cognitive impairment that locals called ‘Katrina brain’,” says psychiatrist Kenneth Sakauye of Louisiana State University in New Orleans. In the face of a condition about which so little is really understood, McNally believes mental health professionals should show more humility. The debriefing saga should have been a wake-up call warning the profession to stick to evidence-based practice, he says, but the lesson was only partially learned. Perhaps, says McNally, the take-home message is that when disaster strikes, “Don’t just do something, stand there.” ● Laura Spinney is a journalist based in London 3 February 2007 | NewScientist | 43