Talk About Trauma!

The Wall Street Journal, May 2, 2003

By Sally Satel

The World Health Organization and other relief agencies worry that “half a million” Iraqi children are now mentally scarred for life — damaged by the war in a way that calls for professional intervention. It is hard to predict exactly how many psychological casualties the recent war has caused, but one thing is fairly certain. We can expect to see a second army enter Iraq: the trauma therapists.

In the past decade relief agencies — such as UNICEF, the U.N. High Commission on Refugees and the U.S. Agency for International Development — have sent Western-trained therapists around the war-torn globe. Typically they urge “patients” to open up and talk about their traumatic memories — an approach developed for Western populations. The common expectation is that “almost everyone will consider himself ‘traumatized'” — and thus in need of intervention. That is the way CARE International’s Psychosocial Training and Support Program manual put it (in this case referring to Kosovo).

The Iraqi people have surely suffered terribly. But whether the war has rendered many of them in need of therapy is another matter entirely. What have we learned from the earlier interventions?

The first lesson is that diagnosis is an inexact science. At a resettlement project for Albanian Kosovars in Fort Dix, N.J., medical personnel who were prepared to treat high rates of post-traumatic stress disorder (PTSD) found that only three of the 3,000 refugees needed psychiatric care. Other researchers have found high rates of the disorder among refugees — sometimes almost 100%. (PTSD is marked by intense re-experiencing of the event through nightmares or intrusive memories, high anxiety and social withdrawal.)

Why these differences? Symptom checklists give a limited picture. A study of Rwandan adults who saw relatives and friends hacked to death found that up to 90% said they had trouble sleeping, poor concentration and bad memories — symptoms of PTSD. Yet more than half were optimistic about the future and their ability to care for their families. Harvey Weinstein, director of the Human Rights Center at the University of California at Berkeley, cautions his colleagues not to look at symptoms only: “At the extreme, if we think about these symptoms as a manifestation of psychiatric disturbance, then we are left with diagnosing the people of an entire nation with a psychiatric disorder.”

The second lesson is that survivors often reject therapy — for good reasons. “Many resent the implication by mental-health providers that they are emotionally abnormal in any way,” Dr. Weinstein says. What’s more, talking about painful experiences with a stranger is alien to them culturally and off-putting as well. Consider the experience of Kenneth Miller of the Bosnian Mental Health Program in Chicago. The psychologist’s patients were in concentration camps before emigrating to the U.S., yet most of them welcomed efforts to relieve their day-to-day loneliness and worry over economic survival as much as, if not more than, efforts to deal with war-related trauma.

Similarly, when Joan Giller, a physician with the London-based Medical Foundation for Caring for Victims of Torture, offered counseling to Ugandan rape victims near Kampala, none took her up on it. “They wanted advice, medication, practical and financial assistance and reassurance,” she reports. At Fort Dix, the Albanian Kosovars politely declined to tell their “trauma stories” to the mental-health workers. They wanted, instead, to talk to Amnesty International and the State Department about their ordeals. Political testimony was important to them, not “sharing” in therapy.

Don’t get me wrong. Some civilian survivors of war — in Iraq and elsewhere — will undoubtedly slip into a pathological state and require psychiatric care. But the rush to “treat” psychological reactions — most normal, if deeply anguished — often happens too quickly.

Herein lies lesson three: The basics matter to mental health. Food, medicine, sanitation and civil order are essential, along with routines, schools and employment. This social infrastructure enables people to rely on the institutions that have always supported them — houses of worship, communities, families.

Alas, these lessons are too often lost on members of the therapeutic community, who have too much invested in “traumatology,” a discipline that has flourished ever since post-traumatic stress disorder found its way into the official handbook of the mental-health profession, the Diagnostic and Statistical Manual, two decades ago. At first PTSD could be diagnosed only in the context of mortal threats. Gradually, however, trauma was defined downward. By the time the manual was updated in 1994, one could qualify for PTSD simply by learning of the death of a loved one or watching the 9/11 terrorist attacks on television.

Indeed, 9/11 was a watershed moment in the trauma industry. Roughly 9,000 trauma counselors raced to lower Manhattan, advocating, as one observer put it, “intervention for any person even remotely connected to the tragedy.” A media blitz informed New Yorkers of free counseling services funded by the Federal Emergency Management Agency.

This is just a homegrown example of what Monica Schoch-Spana, a medical anthropologist at Johns Hopkins, calls the “pathological model.” Often, she says, officials and mental-health planners neglect the positive human traits that crisis elicits, such as “reasoned caution, resourcefulness, adaptability, resiliency, hopefulness, and humanitarianism.”

A half-century of disaster research yields a largely sanguine picture of human response in the face of uncertainty, calamity and fear. The Center for Disaster Research at the University of Delaware has conducted hundreds of studies of natural disasters, chemical emergencies and building collapses. Over and over, researchers have found that people rarely panic or lapse into passivity.

Lee Clarke, a Rutgers University sociologist, has observed: “The rules of behavior in extreme situations are not much different from rules of ordinary life. . . . The most consistent pattern in disasters is that people connect in the aftermath and work to rebuild their physical and cultural environments.” Most people are resilient and adapt well. They prefer to cope — and can cope — on their own. But the very idea that a potent stress could pose an ennobling challenge to the human spirit is the minority view among trauma professionals.

Right now the people of Iraq need material resources and tangible aid, not trauma therapy. A reflexive invocation of Western mental-health practices may do more harm than good. At the very least, it is irrelevant. At worst, it erodes confidence in local knowledge, siphons off money that could be used for material repair and distracts from engagement with everyday life, the best prescription for easing the trauma of war.

Dr. Satel is a scholar at the American Enterprise Institute and the author of “PC, M.D.: How Political Correctness Is Corrupting Medicine.”