Bread and Shelter, Yes. Psychiatrists, No.

The New York Times, March 25, 2005

By Sally Satel

Sally Satel is a psychiatrist and resident scholar at the American Enterprise Institute and a co-author of a new book, “One Nation Under Therapy: How the Helping Culture Is Eroding Self-Reliance.”

Days after the tsunami struck South Asia, American mental health workers flew to Sri Lanka to offer counseling services to grief-stricken victims.

“Psychological scarring needs to be dealt with as quickly as possible,” one psychologist told The Washington Post in January. “The longer we wait, the more danger.”

Sri Lankan health officials saw things slightly differently. They discouraged aid agencies that offered to send counselors to their country.

“We believe the most important thing is to strengthen local coping mechanisms rather than imposing counseling,” Dr. Athula Sumathipala, chief of the psychosocial desk at the Sri Lankan government’s Center for National Operations, told The New York Times the same month.

I found the contrast between the two men particularly striking because I had recently gone to Rome to attend an international conference on trauma. The conference, titled “Project One Billion,” was organized by Dr. Richard Mollica, a psychiatrist at Harvard, under the auspices of the World Bank, the World Health Organization, and humanitarian nonprofit organizations. The United States also provided support.

“One billion” signified the number of people worldwide, roughly one in six, suffering the psychological consequences of war, torture and terrorism. And though these people suffered human-caused horror rather than natural disaster, the question still applies: can outsiders bearing therapy provide meaningful help in times of crisis?

One thing is clear. Even before strife ripped these societies apart, many of them had pitiful mental health systems. According to the W.H.O., most developing countries have fewer than 1 psychiatrist per 100,000 people; in rural areas, the gap is even larger. The entire country of Rwanda has only one psychiatrist. (The United States has about 14 psychiatrists per every 100,000 people; England has about 4 per 100,000.)

Experts at the conference emphasized four undertreated mental conditions: psychoses (mainly schizophrenia), major depression, drug and alcohol abuse, and epilepsy (a neurological disorder often treated by psychiatrists). They noted that depression and drug and alcohol abuse increased in the aftermath of violence and destabilization. When they spoke of post-traumatic stress disorder, on the other hand, it was more as a nod to the organizing theme of the meeting.

True, suffering was abundant — “We cannot dry our tears,” said one African representative — but psychiatry was not the obvious answer.

It would not be the first time that psychological aid was regarded by non-Western recipients as a kind gesture but a bad fit. For the last 15 years or so, humanitarian workers have been exporting the concept of post-traumatic stress disorder and trauma counseling around the globe.

They have rushed in to impose Western “debriefing” — a group therapy technique intended to get victims to express their feelings about a horrific event and to relive it as vividly as they can — without regard to the needs of the victims, their natural healing systems or their very conception of what mental illness might be.

Indeed, as literature from CARE International put it during the Balkan conflict: “Almost everyone in Kosovo will consider her- or himself traumatized.”

But is this true?

Several years ago, a resettlement project run by the United States government for Albanian Kosovars at Fort Dix, N.J., was staffed with mental health specialists prepared to treat high rates of post-traumatic stress disorder among the refugees. Those expectations were not met, observed Elzbieta Gozdziak, an anthropologist at Georgetown University who was part of the team. “Only 7 of the 3,000 refugees were found to need psychiatric care,” Dr. Gozdziak said.

Indeed, many program evaluations reveal that actual use of specialized psychological help is typically low.

Kenneth Miller, a psychologist in the Bosnian Mental Health Program in Chicago, saw much suffering among his clients — they had been placed in concentration camps before migrating to the United States — yet the most successful feature of his program was not therapy, which most clients rejected anyway. It was practical help like education and job training.

Dr. Elie Karam, a psychiatrist at the Institute for Development, Research and Applied Care in Beirut, who attended Project One Billion, similarly concluded that post-traumatic stress disorder was not a major issue.

“What we found was that the violence served as a catalyst for the destabilizing effects of pre-existing problems in people’s lives such as poverty, marital discord, physical illness,” Dr. Karam said.

Project One Billion reflected this philosophy. Debriefing, Dr. Mollica stated, has been discredited in clinical trials.

In its place, he strongly urged that Western mental health workers collaborate with indigenous healers. The W.H.O. now instructs aid workers to “listen, convey compassion, assure basic physical needs, not force talking, and provide or mobilize company preferably from family or significant others.”

Notably, mental health advisers acknowledge that local economic and social recovery is a prerequisite for improved psychology, not a consequence of it. As Dr. Mollica put it, “the best antidepressant is a job.”

The very same week that Project One Billion took place, a “Dare to Act” conference was held in Baltimore. Supported by federal tax dollars, the conference promoted an inward-looking “trauma paradigm,” holding that childhood and adult traumatic experiences lie at the root of most psychopathology.

A colleague of mine who works with Bosnians, Hmong and Somali refugees told me he was asked by organizers of the conference to provide a refugee woman to talk about “her trauma” at the conference.

He asked around but couldn’t find one. “They don’t want to think of themselves as victims,” he said.