A Message of Caution

The issue of appropriate – and especially less appropriate- crisis intervention is receiving all kinds of serious attention and concern right now, and it is important that it should. We must keep a focus on the critical importance of meeting people’s needs as they define them in ways we can be confident will help . . . in some cases, this will mean protecting them from the convergence of “trauma tourists” who come to offer untested and ill-conceived fringe therapies for trauma to the desperately frightened and grieving. But we must also be aware that some approaches that seem intuitively reasonable and have been widely embraced have proven ineffective and even harmful.

The temptation to offer what tools we feel we know best may seem compelling in so severe a crisis, but we must especially work to discourage yielding to the desperate need to do something by acquiescing to the compulsion to use anything. Tools like the ubiquitous “debriefing” techniques are especially suspect at this juncture and should be approached with caution if approached at all. Available evidence shows this approach to be inert at its best, and it has been demonstrated in some studies to have yielded paradoxically negative responses with respect to later symptoms.

Though this caution is now widely disseminated in everything from Cochrane Reviews to the British National Health Service’s decision to list it as a contraindicated procedure, its practitioners- most well removed from the world of evidence based practice and serious empirical research-have responded to the rapidly mounting evidence with denial, deflection, and ad hominem. They have been in great and growing numbers at any disaster large and small, and are already part of the smokey landscape of Manhattan.

As important as this message may be, we must be very, very cautious not to state the case in any way that might be taken as a callous disregard for the pain and anguish people are experiencing. We are extremely concerned for that agony, and this must ring through very loudly. Consider, for example, that FDNY lost in a heartbeat more firefighters than were on duty in Kansas City that morning, even after we had increased staff in the wake of the event. Indeed, that single agency lost, at current estimates, more than thrice the number of firefighters that the nation as a whole loses to duty-related deaths in an average year. Their friends and colleagues continue digging desperately through the rubble for them, knowing with every passing hour that whatever probability of finding any alive may have existed – agonizingly slight even since the beginning – is fading forever from their grasp. The shift they must soon make from focused if frantic rescue to accepted loss and protracted recovery will be more difficult than anyone outside the enterprise can imagine. Even the thought of resolution and recovery remains to address somewhere well into the future.

These quiet heroes – long our stalwart guardians against the misfortunes of community life and now among the most vulnerable soldiers in a war that all realize has likely but begun – will need all the help a grateful nation, including its psychologists, can offer throughout this horrendous ordeal. But we do them no service to thrust at them interventions, no matter how well intended, that cannot stand to the mettle of solid evidence of benefit, much less ones that have been shown repeatedly in a range of independent examinations to carry the possibility of delaying or impeding the recovery they will need and have certainly earned. We owe them much, much more.

Many recent tragedies – Columbine, Oklahoma City, TWA 800 – became encampments for legions of well intentioned but often underprepared and undercredentialed mental health providers whose ministrations and machinations have led to moves on a number of levels to reconsider how these services are orchestrated, choreographed, and delivered in times of high impact. This event is unlike any this nation has ever experienced, not only in its magnitude but also in its nature and its intent. Competent and ethical providers must set aside all our various preconceptions and search the very breadth and depth of our understanding for suggestions that can help us all to help one another through these tragic and treacherous times. We must begin, though, with a thorough and honest assessment of what we know and what we do not know.

We know now that many of the “one-off” interventions* we once touted have proven inert at best and dangerous for some. No matter how well those approaches may have fit with our views of what our clients should need, or even how warmly received our good intentions, expressed in those forms, may have been by many, we must remember our pledge that first, we shall do no harm. Hungry people will flock for a warm doughnut, relish its flavor and its ability to quiet their appetite, and thank its purveyor, but all that doesn’t make it a nutritious meal. We know now that describing the inescapable angst, sorrow, and even rage that most of us cycle through hourly at this juncture as if those are symptoms of a disorder we are apt to acquire only increases the likelihood that the most vulnerable will make dangerous misattributions regarding the nature of their discomfort. And we must be careful about our belief that talking about our feelings is always of help: if we warn folks with understated but evident alarm that they have stood near a precipice and then walk them again to its edge in the name of aid, we should not be too surprised that some may stumble and fall as a result of that trip.

We also know that the palliative ingredient in most all these encounters comes from commonwealth, community, courage, and concern, and we are not even remotely the best or the only vehicle to convey these crucial commodities. These cannot be taught in structured group sessions or told through informational handouts and media bites; they are elements of our deepest character that we must struggle together to find and to forge. Friends and family, teachers and clergy, neighbors and colleagues near and far are all essential components of our resolution, and psychologists often do our best work when we fade into the background and labor with quiet humility to help bolster those resources to do their best.

It’s here that a simple allusion to the Wizard of Oz applies best: It was only when the Wizard gave up his pretense that he did any good – this by showing Dorothy and her pals that they had always carried within them everything they needed to survive their crisis. What they sought and learned they held were heart, brains, and courage; those are the things we all need in the wake of this atrocity. Too often, we’ve wanted to come in like the messiah when the Maytag repairman would have been a much better role to play. Let us try to help as we can, but let us leave any hubris behind.

*an intervention done once, without subsequent intervention to follow