Karen Seeley: Therapists Still Need Tools to Treat Trauma
In the year and a half after 9/11, I interviewed 35 New York City therapists who were working with individuals who had been psychologically wounded in the attack. Most of the therapists—whose patients included relatives of the deceased, evacuees, first responders, witnesses to the event, and less directly exposed New Yorkers—told me that they felt woefully unprepared to help persons who had been damaged by this unprecedented act of mass violence. The few who had prior experience assisting traumatized patients had worked with with survivors of natural disasters, victims of accidents and abuse, or veterans of the Vietnam War. Only two had worked with victims of terrorism.
NEW TRAUMA RESEARCH
The events of 9/11—along with the wars in Iraq and Afghanistan—have brought the study and treatment of trauma and PTSD to the urgent attention of mental health professionals. The past decade has seen an explosion in academic centers for the study of trauma, clinical training programs in trauma therapies, and research on PTSD. Contemporary psychotherapists know more about traumatic reactions than did their counterparts ten years ago. Yet they still lack the tools they need to treat them.
Although an enormous amount of research on the psychological consequences of catastrophes, and on methods for alleviating traumatic injuries, has been published since 9/11, it has two key limitations. First, some recent studies treat disasters as a general phenomenon. Because they fail to distinguish between large-scale "natural" catastrophes and those that are inflicted deliberately, and are designed to arouse extreme fear, they cannot identify the psychological wounds that are specific to acts of mass violence, or the methods that might relieve them.
Second, numerous post-9/11 studies assess the mental health programs and services that were delivered after the attack. Many of their findings point to particular interventions and treatment approaches that were unnecessary, and perhaps harmful. For example, some studies indicate the dangers of widespread psychological debriefing. Others state that most persons who were affected by 9/11 did not require professional help, as they healed on their own or with the support of family and friends. They suggest that the formal services that were widely provided may have compromised individuals’ natural resilience.
NO BREAKTHROUGHTS ON PTSD
Certainly, it is helpful for therapists to know what they should not do in the immediate and longer-term aftermath of catastrophic events. However, they also need to know how to work effectively with persons who are psychologically injured. Unfortunately, on this score, the evidence is weaker. Despite the intense focus on trauma since 9/11, there have been no significant breakthroughs in treating PTSD. Therapists who are trained to implement evidence-based treatments following acts of mass violence remain at a loss to respond because the treatments themselves are missing.
So is useful information regarding which groups and individuals will be most at risk in the event of future attacks. Once population-based programs are deemed unnecessary, it becomes crucial to determine where to target services. The events of 9/11 challenged the conventional view that in large-scale catastrophes, those who are closest to the stressor are most at risk for psychological injury, as persons hundreds of miles away developed severe psychological problems after watching the attack on television. Post-9/11 studies have generated a laundry list of risk factors. They include being female; being between 40 and 60 years old; inhabiting an affected community; lacking prior experience with disasters; belonging to an ethnic minority group; being poor; having children at home; having a psychiatric history; lacking social supports; and having the tendency to externalize blame. It is unclear how this collection of isolated factors can be applied in making policy, or in helping therapists deliver services after the next disaster.
As central questions regarding the treatment of terror-related traumatic reactions remain unanswered, perhaps it is not surprising that new consensus is to do less to help survivors of mass violence. After 9/11, public health officials wildly overestimated the number of New York City residents who would be traumatized. Expectations of mass psychopathology have given way to expectations of mass resilience. Accordingly, there currently is less interest in offering formal mental health treatments than in providing psychological first aid--basic interventions that promote a sense of safety, foster calm and hope, encourage active coping, connect survivors with support and resources, and attend to their practical needs.
While it may seem inadequate, this approach may have some merits. Every act of terror is unique, creating novel combinations of destruction, displacement, and distress. Each produces situations we have never fathomed, images we have never seen, sensations we have never felt, and miseries we have never known; each wounds us, and our communities, in ways we never thought possible. Clearly, this has made it difficult to be prepared for future catastrophes, to extrapolate from one to the next, and to determine whether existing psychiatric categories adequately frame the ways individual and communities react to them. And after all, according to some 9/11 survivors, the best healer of all still is time.
— KAREN SEELEY teaches at Columbia University. For the RSF volume Wounded City, she contributed a chapter entitled "The Psychological Treatment of Trauma and the Trauma of Psychological Treatment: Talking to Psychotherapists About 9/11." She is also the author of Therapy After Terror: 9/11, Psychotherapists, and Mental Health.
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