The ‘skeptical inquirer’ of modern medicine, Dr. Jerome Groopman, investigates how much crisis counseling after a trauma helps… or hurts in The New Yorker. (As usual, I advise anyone interested in this article to read it soon, as it is my experience that New Yorker articles go into the bit bucket in relatively short order…) He gives a good overview and history of the prevailing paradigm, ‘critical incident stress debriefing (CISD),’ in which I am trained and have practiced. He rightly points out the ways in which the process was misused in the aftermath of the Sept. 11, 2001 attacks — among them mandatory rather than voluntary debriefing, the inclusion of people with little or no direct traumatization, and corporate (public relations, do-goodism, preventing absenteeism and avoiding liability) rather than compassionate motives. Recently, the first systematic research has shown that rapid crisis interventions are ‘inert’ in terms of preventing the development of PTSD in those exposed to massive traumas. Indeed, by encouraging sufferers to open up instead of seal over, it may promote PTSD sxs. The question is whether, as the paramedic-turned–psychologist developer of CISD suggests, these botched results arise only from misapplication of his paradigm.
I personally think, and the data supports this notion, that most people exposed to trauma are resilient and recover over time with their own strengths, and that misguided attempts to keep their wounds open and raw can indeed do harm rather than good. A smaller percentage of people do not recover and will eventually need extended psychological support because they develop the post-traumatic stress syndrome. It is doubtful whether these people can be identified in advance and singled out for early intervention, and even more doubtful whether preemptive intervention works.
To understand this issue, one has to understand the current concept of ‘trauma’ and the psychiatric politics behind it. (Groopman does not, or chooses not to discuss any insights he may have in this area, perhaps because of their ‘political incorrectness’. Groopman is a hematologist/oncologist; I have considered writing to him suggesting that he collaborate with a well-versed psychiatrist if his medical musings turn to issues in mental health treatment in the future…) The modern notion of trauma is much obliged to the historical coalescence of the women’s movement and the exposure of the ugly secret of rampant sexual abuse with the interests of a small number of psychiatrists working with the mental health issues of returning Vietnam veterans. Because treatment and study of these two populations is of necessity retrospective (the trauma has long since passed by the time the suffer annoounces her/himself), a third stream of data was fused into this notion of trauma, the prospective study of the course of post-traumatic reactions in those exposed to overwhelming solitary traumatic events such as natural disasters, plane crashes and crimes ranging from rapes to genocide. (One of the most famous trauma researchers made her name by getting in only months after they were freed to study a group of 23 schoolchildren in Chowchilla, California, who had been the victims of a 1976 hijacking, kidnapping and imprisonment.) Although, by and large, the research has supported the notion that trauma symptoms and resiliency depend on one’s prior constitution and resources, this has been obscured by lumping so many heterogeneous types of experience together as trauma. It has further been obscured by the feminist-inspired political correctness of insisting that all inappropriate sexual contact is victimization and that victimization explains mental health symptoms in many women. The idea that sexual victimization is not the fault of the victim turns inexorably (and wrongly) into the notion that the sufferer’s personal characteristics are irrelevant to the development of the post-traumatic symptoms.
Thus, in some clinical circles, patients are diagnosed as trauma victims (or ‘survivors’) at the drop of a hat, all trauma victims are said to have PTSD (regardless of whether they demonstrate the symptoms which define the syndrome or not), and careers of victimhood and chronicity are rationalized and excused zealously. And this is without even even talking about the induction of ‘false memories’, in which so-called ‘suppressed memories of trauma’ which may never have happened are ‘uncovered’ enthusiastically by mental health practitioners on the trauma bandwagon, shaping and explaining everything.
So two of the covert, probably erroneous foundations on which the CISD gospel has rested is are a vague, imprecise notion of what constitutes traumatic exposure and the politically correct notion that all those exposed to trauma will go on to develop symptoms. Thus relatively little attention has been paid until very recently to the notion that it may only be the particularly vulnerable who will succumb to their traumatic stress.
The wastebasket notion of trauma is so maddeningly imprecise that it obscures many clinically crucial distinctions among ‘trauma sufferers’. Let me highlight just a few:
- There are probably profound physiological as well as cognitive differences between the reactions to sudden, acute trauma and chronic or repetitive traumatization; think of a single rape by a stranger vs. being kept imprisoned and regularly sexually abused. This is related as well to whether it is expectable or unexpected.
- Human-perpetrated abuses cause a disturbance in ability for basic trust in others that exposure to an accident or natural disaster does not.
- Different ‘traumas’ are perceived as more or less avoidable or inevitable. How escapable a trauma seems in retrospect has effects on one’s sense of responsibility for one’s victimhood and sense of efficacy for the future.
- Socially-shaped expectations of what is within the realm of expectable human experience vs. outside cultural norms of human experience have an effect. Think about the impact different attitudes about the acceptability of warfare and combat will have on shaping combat trauma or ‘shellshock’.
- Sexual abuse, physical brutality, and psychological/emotional abuse cause different reactions. Likewise undergoing victimization as opposed to merely observing it, even at close range.
Despite the influx of counselors into New York after Sept. 11th (from personal experience, I know that many of them were employed ministering to so-called “secondary victimization” suffered by the first wave of helping professionals!), most New Yorkers received no psychological attention. And, contrary to predictions, there really was no phenomenon of massive psychological distress, Groopman observes and, as I have above, concludes “that the debriefing industry is predicated on a false notion: that we are all at high risk for P.T.S.D. after exposure to a traumatic event.” More useful is immediate “psychological first aid”, Groopman says. A number of my CISD-trained colleagues, in fact, went to New York as part of the ‘post-trauma industry’. Those who found themselves most useful, according to discussions I have had with them, did not however do CISD, but rather other kinds of mental health intervention such as grief counseling for those who had lost family members, and assisting and empowering those entitled to relief benefits to navigate through the red tape of securing these entitlements. Similarly, Groopman cites examples of proponents of CISD who, in the wake of their experiences after Sept. 11th, have turned away from that paradigm.
The psychotherapy of those who have complicated PTSD in earnest (with a legitimate traumatic antecedent, usually a protracted period of exposure to inescapable brutalization by others; and the scientifically described symptom complex) is painstaking, complicated and protracted. An early stage is giving the sufferer a name and a description for what they are undergoing. I do believe that counseling those exposed, truly exposed (and participating of their own accord), to traumatic events to recognize the symptoms of PTSD they might develop or may already have developed — by which time they would have declared their vulnerability, and it would be too late to depend on preemption — is a more useful model for early intervention, predicated neither on the notion that we are all vulnerable nor on the mistaken belief in its preventive efficacy.
Groopman turns later in the article to the very important and often-neglected topic of the neuroscience of the trauma reaction. In vulnerable individuals, evidence suggests that the physiology of their stress causes the memories of the trauma to actually be encoded differently in the brain, so that they are both less accessible and cause more enduring distress. Classical ‘talking therapy’, especially long after the fact, is not very useful in undoing these neurally encoded trauma residues. Groopman describes work being done in very different, promising, neuroscientifically informed trauma treatment.