Psychiatry 67(2) Summer 2004 153

WesselyCommentary on “Terrorism: Reactions, Impairment, and Help-Seeking”

Commentary on “A National Study of the Psychological Consequences of the September 11, 2001 Terrorist Attacks: Reactions, Impairment, and Help-Seeking”

When Being Upset Is Not A Problem

Simon Wessely

I live in Central London under the pre-arranged conference on psychological re- Heathrow flightpath. As I write this editorial, sponses to trauma (NIMH 2002), I observed my house has just been shaken by the final something else. Sept 11th had also brought flight of the last three Concordes. Just over about positive changes in the society that I two years ago, on Sept 11th, we experienced had visited so many times. Was it my imagi- the opposite, a strange week of silence, when nation, or were people genuinely more talk- all overflights were banned for a week. And ative, more likely to engage with me in bars, when they resumed, for a while I looked out waiting rooms, and queues that are the staple of my window as each plane came past, and of travel these days? No, on everyone’s lips experienced a frisson of anxiety. And like vir- was the observation that adversity had tually everyone I know, it took some time to brought us together, and indeed that upsurge shake off the hypnotic images imprinted in in communitarean feelings for once even in- my memory from those hours glued to our volved myself as a Britisher, finally forgiven television screens throughout the horrors of for George III. that first day. Should we be surprised by this? It was But I never considered that I had a the great Durkheim who suggested that dur- problem, let alone sought help for it. And af- ing periods of external threat group cohesion ter a few weeks these emotions disappeared. increases, and suicide rates decrease. Indeed, Yes, my world view had changed—and my tentative evidence of a lowering of the suicide appraisal of the society we live in and the rate in the United Kingdom after Sept 11th threats we face. The world seemed, and prob- has been presented (Salib 2003), and it would ably was, a riskier place (Halpern-Felsher and be interesting to know if the same will be ob- Millstein 2002). But emotionally and physi- served in the United States. We are robust na- cally I felt the same as I had been before, for tions, and our citizens repeatedly surprise us better or worse. by their resilience in the face of adversity—in And when I visited America only a few the past (Jones, Woolven, Durodic, and weeks later, to take part, ironically, in a Wessely, in press), and during the terrible

Professor Simon Wessely is affiliated with the Institute of , Department of Psychological Medicine, King’s College London. Address correspondence to Professor Simon Wessely, M. D., Institute of Psychiatry, Kings College London, Weston Education Centre, Cutcombe Road, London SE59RJ, United Kingdom; E-mail: [email protected] 154 Commentary on “Terrorism: Reactions, Impairment, and Help-Seeking” events of September 11th, when panic was normal and abnormal in psychiatry. In gen- noticable by its absence (Glass and eral, we strive to treat the abnormal (clinical Schoch-Spana 2002). depression, for example), and not the normal Sept 11th did bring about changes in (sadness after the death of a loved one). After most of us. These were a complex mixture of exposure to traumatic events, we often ex- both negative and positive. But were these ab- pend considerable efforts to remind people normal? Did I need treatment for my compul- that it is normal to feel upset or shaken or to sive checking of the sky over my house, or the have difficulty sleeping, and that this is not dreams I experienced? Was any of this any- psychiatric disorder or the inevitable precur- thingtodowiththementalhealthsor to it. Indeed, the inherent ambiguity of professional? post-disaster interventions—which simulta- It is a general principle that profession- neously proclaim that it is normal to feel upset als should refrain from treating ailments that when bad things happen and then to suggest a are going to get better fairly quickly anyway, variety of therapeutic interventions—points since to do so wastes resources, and exposes to the importance of non-therapeutic factors patients to the risks of side effects of unneces- underlying many institutional and profes- sary treatment. What do we know about the sional responses to trauma. So, deciding on emotional responses that were indeed so com- the boundaries between the normal and ab- mon after September 11th? normal will always be a matter of discretion. In their original paper, the Rand team And as sociologist Frank Furedi has recently reported that 44% of Americans had “sub- argued, there is a danger that we are now get- stantial stress” in the wake of Sept 11th ting these boundaries wrong (Furedi 2003), (Schuster et al. 2001). One or two critics did and actively professionalizing or wonder if scoring “having trouble falling or pathologizing normal feelings with staying sleep” or “having difficulty concen- consequences that can be unforseen and trating” at the “quite a bit” level as being suf- undesirable. ficient to qualify for “substantial stress” was One increasingly recognized boundary really compatible with the word “substan- is that between symptoms and disorder. In our tial,” but never mind. The current paper work on members of the United Kingdom shows that this figure had halved at Wave 2, Armed Forces after the 1991 , we taken during November, only a few weeks found elevated rates of every symptom that later. we inquired after, including those indicative We can compare this with the recent pa- of possible posttraumatic stress disorder per from Sandro Galea and colleagues, who (Unwin et al. 1999). And yet when we inter- conducted an equally elegant follow-up study viewed these service personnel using stan- carried out solely in New York City at one, dardized psychiatric instruments the rate of four, and six months after the atrocities (Ga- PTSD was elevated, but only from 1% in the lea et al. 2003). Probable PTSD declined from well veterans to 3% in the sick (Ismail et al. 7.5% to 0.6% at six months, the latter figure 2002). Many veterans had symptoms; fewer comfortably within expected population had discrete disorders mandating treatment. norms. Thus we can expect that the Rand Symptoms alone are a poor guide to disorder, study, if it had been repeated six months after and what we should be concerned about is dis- the outrages would show further decline, and I order—people who are unable to earn a living suspect would likewise return to the baseline or look after their families, not those who feel level of psychological distress in the commu- transiently alarmed or anxious in a world nity. That is high enough, but that is another growing increasingly alarming. non-September 11th story. Symptoms might indicate disorder, but Just how serious or abnormal where then again they might not. It is a dilemna ex- these manifestations anyway? We all know emplified in the paper from the Rand team in that there are no clear cut-offs between the this issue. On the one hand, the authors repeat Wessely 155 the warning about the importance of recog- committed to post-Sept 11th—in New York nizing significant distress that does not reach City in particular. One reads of hotels occu- levels that qualify for a diagnosis. Yet on the pied by teams of counsellors, but this may rep- other, they also point out that the responses in resent modern mythology. Approximately this study (i.e., individuals who were still $21 million was allocated in federal funds to bothered by their emotional reactions to Sept provide free counselling for New Yorkers 11th) should not be viewed “in any way to be (“Project Liberty”) (Kadet 2002), with an ad- indicative or predictive of a clinical disorder.” ditional $131 million requested for therapist Which is it to be? If symptoms are neither in- salaries. Predictions were made that one in dicative nor predictive of psychiatric disorder, four New Yorkers would require mental then why as clinical and/or psy- health assistance, and emergency workers ap- chologists should we pay attention to them or pear to have received obligatory counselling. ask others to pay attention? Another survey suggested that 28% of work- Instead, is it not our duty to make it ing Americans had been offered work place clear that these do not constitute a psychiatric counselling after Sept 11th. disorder? That is exactly the view espoused by Some have questioned the assumption many professionals who become involved in that even this was not enough, and that more the immediate psychological management of could and should have been done. Few have those exposed to trauma. Most of the inter- questioned the wisdom of what actually was ventions with which I am familiar involve done. Leaving aside those directly affected, by some form of education to the effect that we which I mean direct survivors and the be- all feel like this, that this does not mean you reaved, were increased resources needed for are going mad, and that it is all perfectly the rest of population? And what should those understandable. resources have consisted of? When we strip away the current paper, The answer is that we don’t know. It beautifully and indeed rapidly executed by the Rand team (and am I alone in envying the would be fair to say that a consensus was not alacrity with which they managed to cut reached at the conference on early psychologi- through the research-stifling bureaucracies of cal interventions after trauma (NIMH 2002). our overblown Institutional Review Board The weight of opinion was against giving systems to actually get into the field only days blanket interventions to normal people, most after Sept 11th?), what do we have? We have a of whom were either not distressed or, if so, large sample of people like myself, people who were going to get better anyway—although felt both emotional distress and greater social the corridor conversations indicated that this involvement in the days after Sept 11th, peo- was precisely what was happening on the ple who did indeed experience emotional ground even as we debated. Some (this author change, and sometimes visible distress, but included) worried about the possibilty of whose emotions were understandable, not ab- causing more harm than good, and remain normal, and did not indicate a lifetime of psy- troubled by the proliferation of interventions, chiatric illness. Indeed, such emotions began high in enthusiasm and charisma, but low in to disappear in a matter of weeks. And as these evidence of effectiveness. Our past should papers tell us, they did so largely without the leave us in no doubt that as mental health pro- benefit of help from a mental health fessionals we do have the power to create dis- professional. order as well as treat it (Dineen 1996; And yet the leitmotif of so much of the McHugh 1999). Likewise, we have a rather Sept 11th literature emerging in the mental better record in treatment than prevention. So health field is the call for more and better in- for us, the mental health professional’s role in terventions and resources that need to be de- the immediate aftermath of disaster was to be ployed more quickly. I have yet to see a supportive and advisory to those making the complete audit of exactly what resources were decisions and managing the consequences, 156 Commentary on “Terrorism: Reactions, Impairment, and Help-Seeking” but otherwise to be there only when called must be good neighbors, loving parents, loyal upon, which would be infrequently. colleagues, and sensitive employers. But be- Others preferred to target scarce re- yond this good citizenship, is there a role for sources on the immediate minority who really us as psychiatrists, psychologists, or other needed help, rather than the majority who mental health professionals? In our increas- didn’t. A recent scholarly review echoes this ingly disconnected world, what is needed is conclusion (McNally, Bryant, and Ehlers encouragement for people to develop the so- 2003), highlighting a rapidly developing liter- cial networks that are known to decrease dis- ature which is starting to suggest that the tress and increase relience. Do our blanket strategy with the most promise is to target interventions assist or detract from this? Is this only the minority with acute stress reac- one reason why some controlled studies have tions—acute stress disorder (ASD) in civilian shown an apparently paradoxical effect after practice, combat stress reaction (CSR) in mili- psychological debriefing—an increase, not a tary practice. And successful intervention in- decrease, in psychological distress (Gist 2002; volves not a single-session stress debriefing, Emmerick, Kamphuls, Hulsbosch, and but a more focussed and lengthy cognitive be- Emmelkamp 2002)? havioral intervention, which not everyone is We now have evidence-based treat- qualified to deliver (McNally et al. 2003). ments to help those minority of citizens who This is not, and is not meant to be, an do go on to develop serious psychiatric disor- intervention to be implemented on a popula- ders, including, but not restricted to, PTSD, tion level. So what do we do for the rest? after trauma. And yet we also know that Here’s the hard part. Speaking now as a men- many, perhaps most, of these people still do tal health professional, why do we need to do not receive the best available treatments. This anything at all? Yes, there is a desire to “do reviewer feels that we should not expend re- something.” None of us like to see people in sources for those who probably don’t need distress. The desire to help our fellow human our help, but instead concentrate on those beings is one of the more attractive aspects of who would benefit from our modern interven- human . Of course, in times of crisis we tions, but are most likely not receiving them.

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