Letters

Psychology helps a nation heal

I WAS IMPRESSED by what was presented in the November Monitor but something was missing, and I wonder if it might be the reluctance of psychologists to step beyond psychology to recognize that we exist in a much broader context of societal and cultural realities. The Monitor was concerned with terrorism and what has occurred in the last few months. President-elect Zimbardo wrote eloquently of the psychological problems we confront. He asks about "the root causes of the hatred against America," but nowhere makes an effort to provide specifics for such a search. Edward Dunbar says "these people are very troubled, very disturbed." Placing the World Trade Center tragedy under the rubric of hate crimes is simple nominalism. Zimbardo properly refers to "the ideological, political and social bases of the next generation of potential terrorists," but what are these bases? I would like to know what those who lead us think they are.

Surely, we have access to such information both from within and outside of APA. Let us hear what others who are well-informed have to say about "root causes." Hopefully, the Monitor will provide such possibilities for us. Obviously, these get transformed into perceptions, cognitions and motivations, but let us get to basics, broaden our perspectives and understand what we are really up against.

BERNARD SPILKA, PHD

University of Denver

IN "HELPING A NATION HEAL" you quoted a Red Cross psychologist, who said: "Being present is one of the best things we do--that and an awful lot of listening." This is, of course, the very premise of existential and client-centered therapies--modalities we don't hear a lot about in these days of managed care and prescription drug protocols. What is interesting is that nowhere in your comprehensive coverage of mental health professionals helping people heal in the aftermath of the terrorist attack did we find anyone running around dispensing tranquilizers or SSRIs. Instead, as your article so beautifully demonstrated, people were doing something remarkable: They were listening to one another.

I am glad to see, even if only for a fleeting moment, the affirmation of the therapeutic power of listening-to, being-with and fellow-feeling. It would be nice if psychology as a profession could recognize this and think twice about what it means to the profession that we are now seeking prescription privileges, instead of preparing ourselves for the challenge of listening empathetically to the people we serve.

SCOTT D. CHURCHILL, PHD

University of Dallas

THE LETTER LABELED PRIMUM non nocere published in the November Monitor encouraged psychologists not to do bad things when responding to people's needs after disasters. Certainly, that is a position with which it would be hard for any responsible provider to disagree. Licensed providers need to work within their scope of knowledge and to carefully choose procedures and interventions that respond to the needs of the clients to be served.

Unfortunately, the letter also makes what I would consider carelessly broad references to unspecified evidence that "certain forms of postdisaster psychological debriefing treatment" are ineffective, and criticizes "certain therapists...descending on disaster scenes." It isn't at all clear to whom these barbed comments were directed. Some of APA's members, however, have interpreted this letter as attacking the American Red Cross (ARC) Disaster Mental Health Services (DMHS), while others have felt that the references refer to the APA's Disaster Response Network (DRN).

In most cases, DRN members respond as ARC Disaster Mental Health Services volunteers. Like the DRN, the ARC also requires that mental health professionals be authorized to practice independently in their own state if they are responding in that state, or be licensed or certified if they are crossing state lines. The ARC also advises each professional to adhere to the ethical and professional standards of his or her profession. The ARC provides a two-day training for mental health professionals who wish to work in Disaster Mental Health Services. This training focuses on how mental health professionals can use their skills within the context of ARC disaster services.

While the ARC disaster mental health interventions include the use of debriefing procedures, there are numerous models for debriefing. The ARC debriefing model is flexible and recognizes the needs of individuals. No one is coerced to speak. Follow up services and referrals are provided wherever appropriate. The primary participants in these debriefings are ARC disaster relief personnel. Occasionally ARC disaster mental health professionals may also offer debriefing to other disaster response personnel. Across disasters, debriefing and defusing procedures constitute only about 12 percent of the activities in disaster mental health. Crisis intervention, problem-solving, education and advocacy are the primary procedures used. As one of the original volunteer ARC Disaster Mental Health Services instructors, and volunteer ARC National Consultant for Disaster Mental Health from 1992 through 1999, I can tell you that from the beginning the ARC has emphasized that the workers be visible and available to those who have been affected by the disaster. DMHS staff are encouraged to explain to those they serve what services they can provide to those affected, and how those affected can request support. Typically, an appropriate educational brochure is also provided to the person being served. There is no agenda to force-feed psychology to anyone. The role of the ARC disaster mental health provider is to be present to those affected when and if they are ready to be served.

If the authors of the Primum non nocere letter have specific individuals whom they feel have acted in an illegal or unethical manner, I encourage them to specify their concerns to the appropriate licensing board or professional ethics review board. There are constructive procedures for responsibly pursuing such valid concerns and protecting the public. But these vague accusations cast aspersions on the thousands of psychologists and other mental health professionals who provided support through the DRN and/or the ARC in the aftermath of the Sept. 11 terrorist attacks. The professionals who have volunteered in this time of national emergency gave of their time, their character and their professional expertise in very difficult circumstances to try to make a difference for those affected.

GERARD A. JACOBS, PHD

Disaster Mental Health Institute University of South

Dakota

THE "RESPONSE FROM APA" TO the thoughtful letter in the November Monitor about post-crisis debriefing was strangely defensive, evasive and anonymous. As an APA member, I would like to know who wrote that on my behalf. The "response" assumes that the original letter was directed at APA efforts in New York following the Sept. 11 attack. However, it does not say what the APA program actually is and how those efforts differ from the post-incident debriefing techniques cogently critiqued. The published "response" appears to be an attempt at refutation without relevant facts or accountability.

TIMOTHY R. TUMLIN, PHD

Oak Forest, Ill.

Editor's note: APA's response to the Herbert et al. letter was written by the Monitor's executive editor in consultation with APA senior staff.

IN THESE DIFFICULT TIMES, IT ill-becomes anyone to poison public discourse with carping based on inaccurate, misleading or incomplete information. This criticism unfortunately applies not only to the letter by James D. Herbert et al., but also to APA's response, both of which appeared in the November "Letters."

The authors of the Herbert et al. letter criticize "certain therapists" for "descending on disaster scenes with well-intentioned but misguided efforts." As one of those who "descended," I would like to inform Herbert et al. that I was called by a national organization that in turn was contacted by local employee-assistance programs.

To anyone engaged in a significant amount of psychological practice, it is self-evident that employee-assistance programs are "community structures that people naturally call upon in times of grief and suffering." I do not know of anyone who "descended" there simply because they thought it was a good idea to go there on their own. We were therefore responding precisely as Herbert et al. suggested.

Meanwhile, APA stated: "The APA/Red Cross program is not based in debriefing techniques." If it isn't, it would have to be very different from the Disaster Mental Health Training program that the Red Cross provides. I state that from the standpoint of being a card-carrying graduate of that program. This attempt to "separate what psychologists, under the auspices of the APA/American Red Cross Disaster Response Network, are actually doing and what is suggested is happening at the New York and Pentagon disaster sites" is, therefore, misleading. No doubt Herbert et al. really did want to prevent people from being harmed. No doubt APA did want to state that professionals in its own program were not guilty of what Herbert et al. allege. However, the way both groups went about doing so only are too "well-intentioned but misguided efforts" that create more heat and throw up more dust when we all need more light.

CHARLES WHEATON, PHD

Clearwater, Fla.

IT IS DISTURBING TO READ THE recent letter from Herbert et al. in the November issue. It harkens back to the New York Times article, by Erica Goode ("Some therapists do more harm than good") shortly after Sept. 11, in which Ms. Goode similarly referred to the "dangers" in "forcing" victims to talk about their experiences. In both that article and the doctors' letter, an issue is raised where none appears to exist.

As someone who has worked at "ground zero" under the auspices of the Red Cross since early on in this crisis, I am well aware of the psychic toll that rescue and recovery workers have paid and continue to pay for their efforts. But nowhere have I seen "therapists...descending on disaster scenes with well-intentioned but misguided efforts." We have offered conversation, Krispy Kremes, and I think clinically astute and sensitive responses when firefighters, EMTs, police or other workers talk about their ordeal.

Debriefing is used by CISM-trained clinicians in circumstances that are specifically defined for that kind of intervention and not at all improvised by freelancing therapists, at least not to my knowledge or experience. The debate about what are the most effective treatments for those who have themselves survived grave danger is best done in scientific journals and meetings, not in the popular media or even a letter to the editor. It hardly serves to advance considered scientific examination of the many factors that define good treatment.

NINA K. THOMAS, PHD

New York City

APA RESPONDED TO HERBERT et al.'s admonition primum non nocere with a non sequitur. The Herbert letter, signed by a number of experts in the field of trauma research, attempted to warn well-meaning psychologists in the aftermath of the Sept. 11 terrorist attacks against using interventions that may be harmful to victims. Psychological debriefing, in its various forms, has been gaining in popularity lately as an intervention that can help prevent the development of post-traumatic stress disorder in trauma victims. Although a noble goal, research has demonstrated that this treatment is ineffective for this purpose, with some studies actually showing a worsening of symptoms in those who underwent the treatment (see Cochrane review: Rose, Wessely, & Bisson, 1998). APA responded by denying that the APA/Red Cross program used debriefing techniques (although this was never mentioned or implied in the letter) and suggested that the authors were misdirecting criticism and misapplying labels.

APA chose to respond defensively and dodge the issues at hand, instead of using the space to educate clinicians so that research can inform practice. Such practices can contribute only to the widening of the scientist-practitioner gap and are counterproductive to helping victims cope with tragedy.

BRANDON GAUDIANO

MCP Hahnemann University

AS A MEMBER OF THE DISASTER Mental Health team of the Nassau County (New York) Chapter of the American Red Cross, I should like to comment on APA's response to the letter from James D. Herbert and 18 other psychologists in which they warn that there are times when our well-intentioned interventions may have iatrogenic effects.

APA's response reminds me of the press releases issued by the Pentagon during the war in Vietnam: The relationship between the reality of what was happening on the ground and what was being said in Washington was, to be generous, casual at best. APA's reply states, in part, that the licensed professionals who responded to the Sept. 11 tragedy were "experienced clinicians with specific disaster mental health training...." Not only can I attest from personal experience that that statement is false, but what must be the height of irony, one of the psychologists whose experiences you highlight was quoted in another publication to the effect that she had no experience or training in disaster mental health prior to Sept. 11; she then went on to note that she quickly learned that much of what was appropriate in a private practice setting was inappropriate in a disaster. While I am willing to believe that she performed admirably, we cannot depend on quick learners. What we must do is incorporate empirically validated disaster mental health training into our graduate school clinical curricula and our continuing education programs.

NORMAN C. WEISSBERG, PHD

Wantagh, N.Y.

AFTER READING THE NOVEMBER Monitor, I am prouder than ever to be a practicing psychologist. My colleagues around the country have given so much of themselves to the people in need in their communities. What they have brought to their efforts is their skill, their training and their understanding that each survivor or witness of disaster reacts in his/her own way and needs to be treated accordingly. Any implication that we are just well-intentioned do-gooders who create iatrogenic symptoms in those with whom we work is condescending and disrespectful of the profession.

DOROTHY W. CANTOR, PSYD

Westfield, N.J.

WHILE IT IS LAUDABLE FOR APA to strike a helpful pose in response to the terrorist attack on our country, it is some of the sociopolitical stances taken by APA that have contributed to the atmosphere that has allowed these attacks to occur.

If APA really wants to assist with the threats terrorism poses to this nation, I suggest it do the following:

  • Purge from its agenda the perverse and misguided notions of multiculturism and diversity which imply that American culture is not superior to other cultures (since, under this philosophy, no one culture is superior to another), and hence not worth defending.

  • Promote a view of what the United States of America is and what this country stands for. Stop presenting a revisionist approach to American history and culture.

  • Support the introduction and teaching in the public schools of the values and philosophies that have allowed this country to become the nation it is. Let us do this with the same fervor that we have observed with children in Islamic countries being indoctrinated to hate our country and what it stands for.

  • Disavow and repudiate the extreme political correctness that pervades many of APA's positions.

  • Present the field of clinical psychology as one that emphasizes individual responsibility and freedom to choose.

If we truly believe psychology has something to offer, the time for such an effort is now.

ALAN J. LEWIS, PHD

Tampa, Fla.

Suicide                                                                                                                                                     THE THREE NOVEMBER ARTICLES on suicide underscored the alarming prevalence of suicide-related behaviors as well as the limitations in our ability to assess, predict and treat such behaviors. Although the author cogently argued for more psychological research on suicide, I was disappointed by the lack of attention to psychological research already available in this area. For instance, the first article in this series focused on "surviving a patient's suicide"; however, there was no reference to recent research on this exact topic that I think would be of interest to most psychologists (Hendin et al., 2000). In addition, the list of "statistical risk factors for suicide" included in the first article contained several variables that have not been independently linked with completed suicide in the research literature (e.g., sexual orientation and occupation), and excluded several key variables that have (e.g., hopelessness and suicidal ideation). Moreover, no mention was made of recent psychological research demonstrating the effect of some psychosocial interventions in reducing suicide-related behavior (e.g., Rudd, Joiner & Rajab, 2001).

I know that APA fully supports and attends to psychological research and plays a prominent role in providing psychologists worldwide with access to the fruits of psychological science. Indeed, the Monitor can be an excellent vehicle for providing scientifically informed information to APA members, and I hope to see a more careful and thorough integration of research findings in future issues.

MATTHEW K. NOCK

Yale University

I CAN ATTEST FROM MY OWN experience to the positive impact of an internship's willingness to deal with a patient's suicide openly, making it into a learning opportunity as well as a supportive endeavor on the part of faculty and supervisors. As the intern who survived the patient's suicide, the support, understanding and opportunity for discussion and learning in every one of our seminars following the event was an enormous surprise to me as well as a huge relief. Professors shared their own personal experiences and my fellow interns could not have been more supportive. While the whole experience was extremely trying for me personally, and even little things seemed almost insurmountable for a while, I never forgot the learning that took place, and surprisingly, I felt that the reality of dealing with a suicide made me more able to deal with the suicidal feelings of patients in the following years.

When, in late August, I lost a patient in my own private practice, the internship experience enabled me, I am certain, to deal more openly and honestly with every aspect of the suicide. Even now I am still dealing with the aftermath of this event, but I was so conscious of the fact that the earlier experience had taught me to talk and talk and talk and not to be ashamed of reaching out for help. To be sure, the experience will never really leave me, but again and again I have thought back to that internship experience with enormous gratitude. I cannot emphasize this enough.

MARY ANN BENAVIDES, PHD

Milwaukee, Wis.