New Yorkers Don’t Need Therapy

The Wall Street Journal, July 26, 2002

By Sally Satel

This week, two New York City-based charities and the Red Cross announced a combined grant of over $100 million to “address the enduring problem of psychic damage — grief, stress, trauma — after September 11th.” Such largesse implies a substantial continuing need for professional help 10 months after the terrorist attacks. But the mental-health crisis in New York City, if it ever existed, is well over by now.

Right after Sept. 11, hospital and clinic directors in New York City braced themselves for epic caseloads of depressed and traumatized residents. In the shock of the moment, these frantic preparations made sense. Yet the flood of “psychically damaged” patients never arrived.

Joseph Boscarino, a researcher with the New York Academy of Medicine, found no major jump in visits to city mental-health clinics. “I expected to see much higher rates of utilization,” he says. Writing in the journal Psychiatric Services, John Markowitz of Weill Medical Center reports most patients he saw who were affected by Sept. 11 had a history of mental instability.

Among veterans with combat-related psychiatric problems, a group expected to react strongly to 9/11, clinic visits and hospital admissions barely rose, according to Robert Rosenheck of the Veterans Affairs Northeast Program Evaluation Center. His results, published in February in the New England Journal of Medicine, show that daily visits to Veterans Affairs mental-health clinics in New York City increased 5% in the 19 days after the attacks compared to the 19 days before. In 2000, however, there was a larger increase of 12% over the same time period.

Last October, Sharon Kahn, a senior psychologist at Coney Island Hospital, manned the phones at a televised call-in show sponsored by PBS called “Reach Out to Heal.” Experts described the symptoms of traumatic stress and viewers were urged to call in with questions and to get referrals for help. Ms. Kahn took calls all evening. She referred two people for therapy. The vast bulk of calls were queries about the resumption of regularly scheduled programming.

Consistent with previously published research on human response to disaster, we saw symptoms of stress decline naturally in time. The New York Academy of Medicine found that within two months of the World Trade Center collapse, about 7% of Manhattan residents had symptoms suggestive of post-traumatic stress disorder. By midwinter, the rate had dropped by half. People who lived closer to Ground Zero had higher rates but they also waned with time.

Where were the patients? Mental-health experts may have extrapolated too closely from the psychological fallout from the Oklahoma City bombing to New York City. About one-third of people in or close to the Alfred P. Murrah Building, most of whom suffered injuries in the blast, developed post-traumatic-stress disorder. Viewing the fiery towers on television or from a safe distance was surely horrendous, but the psychological impact cannot compare to actually surviving a harrowing conflagration.

What if many people have yet to manifest symptoms? The delayed onset phenomenon is more lore than clinical reality. Roxane Cohen Silver, a bereavement expert at the University of California, Irvine, has studied grief reactions for over two decades and says that her research “shows minimal evidence for delayed grief.”

But none of this has staunched the flow of federal money for counseling. Last month, the Federal Emergency Management Agency gave New York an extra $132 million for the supposed counseling needs of 2 million city residents. This in addition to a donation immediately following 9/11. At that time, city officials estimated 1.5 million people would need counseling. According to the New York Times, only 120,000 residents actually sought assistance between September and June. So the additional grant is quite puzzling.

And now the Red Cross, the Sept. 11 fund (sponsored by the New York Times) and the Robin Hood Foundation are planning to spend even more. Why?

Many mental-health professionals cannot comprehend that people are making an informed choice to forego their services. They blame the low show rate on the fear of being stigmatized or their inability to recognize they need professional help in the first place. True, this may explain some missed opportunities for assistance. But there is yet another reason for the modest clinical turn out: Most New Yorkers do not need therapy.

The vast majority of people — especially those whose lives are not endangered and who do not suffer profound losses in the wake of catastrophe — get better on their own. The ethos of the mental-health profession overstates people’s psychological fragility and too readily confuses pathos with pathology. A professor of epidemiology at Columbia University recently pressed for a “determined effort to help the population withstand such attacks on the psyche.” But such sentiments imply we must rely on professionals to prop up our psyches. They raise doubt when confidence is what we need.

Instead of spending millions of dollars on unnecessary counseling, the charities should bestow the money on the truly psychically damaged. Some of this could pay psychiatric costs for people genuinely undone by Sept. 11 and much of it could patch the frayed safety net for the city’s severely mentally ill, who would be suffering even if the Twin Towers still stood.

As the anniversary of Sept. 11 looms we will be barraged with warnings of a resurgence of angst; counselors will be standing by. Fortunately, our natural resilience, so profoundly underestimated by many experts, will serve us once again.

Dr. Satel is a psychiatrist and a fellow at the American Enterprise Institute. She and Christina Hoff Sommers are writing a book, “One Nation Under Therapy.”