COLLIDING WITH REALITY—POST-TRAUMATICALLY
If I were to tell you that the incidence of stress-related disorders among war veterans, civilians in war zones, Israeli children subject to bombardments, and Holocaust survivors is not significantly higher than in comparable populations which have not been exposed to these stressors, would you believe me? I'll go one better: Clinicians warned that the cataclysmic events of September 11 would coincide with an increase in the use and need for mental health services. Yet it didn't happen. The specter of the ubiquitous crisis-intervention team descending on a community following a tragedy doesn't help my case—my claim that these services are unnecessary if not downright harmful is at odds with their popularity.
On September 11, agents from Crisis Management International (CMI) galvanized a nationwide network consisting of 1402 therapists and psychologists to tend to the New York workforce. Charles Fishman, editor of Fast Company, reported that it was not unusual on any given day to find a corporation employing dozens of these agents to administer a protocol known as "critical-incident stress debriefing." "Even after two weeks," marveled Fishman, one firm "was still using between 10 and 20 CMI counselors a day" to administer both group and individual sessions. At a cost of $250 an hour per counselor, some companies were spending upwards of $35,000 daily on stress-debriefing services.
The common perception that there exists a direct connection between extreme events and disordered behavior is firmly ensconced across our communities. All told, the incidence of "toxic" events in the lives of people in western democracies is very high. In Third World countries it is virtually universal. Yet paradoxically, the lifetime prevalence of Posttraumatic Stress Disorder (PTSD) is very low. "Very few directly exposed individuals develop distress disorders," writes Marilyn Bowman, professor of psychology at Simon Fraser University, British Columbia, and an expert on the subject of PTSD.
Still, the crisis-debriefing protocol, administered by intrusive strangers, now routinely accompanies any upheaval in the workplace, in schools and elsewhere. With the psychiatric profession's Diagnostic and Statistical Manual of Mental Disorders stipulating that merely hearing about a "toxic" event may cause mental damage, is there any wonder that such intervention has become an imperative?
Yet most of the data supporting these flawed assumptions are derived from biased clinical samples and rely on controversial self-reports. A patient presenting for treatment is already unrepresentative of the general population. She will typically tell of an event and implicate the incident in her symptoms. The clinician then erroneously concludes that there is a causal relationship between the event and the patient's symptoms. This post hoc or backward reasoning contaminates most studies on PTSD. Controlled studies though, show that well-functioning individuals tend to report as many pathological experiences as do people who don't function well. The same faulty reasoning must lead us to conclude that their trauma caused their successes.
The findings of Robert Rosenheck of Veterans Affairs certainly confirm that the deluge of dispatched therapists following September 11 was likely redundant. In a paper in the American Journal of Psychiatry, Rosenheck documented only small increases in mental health service use in New York among veterans with PTSD following the attacks of September 11. These increases differed only slightly from those of previous years, and were, in fact, slightly smaller than the increases observed in other large American cities. This led Rosenheck to conclude that, "Although the events of September 11 were profoundly traumatic for those directly involved and clearly distressing for others, they are not necessarily medically significant."
So what am I missing here? Toxic events are rife in people's lives, yet stress-attributed disorders are not common? Clearly the toxic event in and of itself doesn't cause PTSD. In her book on individual differences in PTSD, and in a 1999 paper in the Canadian Journal of Psychiatry, Bowman demonstrates that whether those exposed to traumatic events will suffer mental repercussions is determined by certain stable temperamental styles. Intelligence confers a protective benefit, as does an individual's belief system. The relatively unchanging tendencies to feel helpless and to attribute responsibility to others are predisposing personality traits. Another good predictor of PTSD is a history of psychiatric and personality disorders.
Despite such evidence, mental health professionals continue to expand their jurisdiction. Tooled up with Freudian constructs like "denial" and "repression," they insist that if you are not "venting," you are "in denial"; if you are stoical, you are likely "repressing." Evidence that contradicts the clinician's theory is enlisted as evidence for the theory's correctness—every behavior the post-trauma individual shows—adaptive or not—is said to be a consequence of the trauma and proof of it.
Therapy itself is based on the premise that "expression of negative feelings is essential," to quote Bowman. Venting, moreover, is regarded as a moral virtue, helping to explain not only the camera-friendly grief chic cultivated by people many times removed from a tragedy but also the pressure to undertake counseling. But the evidence indicates that denial more often provides an adaptive benefit. Individuals given to emotionality fare worse than people with a stiff upper lip. And when therapy is undertaken, clinical outcomes are in fact improved when it focuses on problem-solving strategies instead of on the excavation of emotional agony.
The pressure from many PTSD-advocacy groups notwithstanding, the American Psychological Association's clinical division reports that zero out of 255 treatments for PTSD meet criteria that are well established. Evidence for the efficacy of treatments is indeed scant if non-existent. No surprise here. The faulty assumptions underlying this clinical diagnosis dovetail with a general emphasis on subjectivity and relativism in psychological research and the culture at large. It's all part of our contemporary aversion to objective inquiry and a fascination with the emotional and the histrionic. Bowman contends that we have regressed to an unenlightened, premodern—not postmodern—era, paralleled in some of history's less evolved periods.
Chimeras such as repressed memory therapy and multiple personality disorder, which not so long ago received the nod from many mainstream mental health professionals, bear this out. Sustaining the adversity-distress model, however, requires the willing collusion between "professional guild interests" and groups of individuals who prefer to attribute their difficulties to anything but themselves.