Five days after the attacks on September 11, 2001, Vickie Taylor led a group of firefighters from Pennsylvania into the pile at Ground Zero. By this time, it was clear that there were no survivors in the rubble. But families in mourning wanted the remains of their loved ones, and firefighters wanted to bring their brothers home, so that was the job.
The site was cluttered with signs and stations — places to get fitted for gas masks to filter out the particulate matter still heavy in the air, a table where workers could stop for some soup donated by Campbell's. Church groups, Scientologists and every type of grief counselor had set up shop. Some firefighters had told Taylor to avoid areas of the wreckage where well-meaning but unthinking people would grab them for forcible therapy sessions.
In the previous 120 hours, as bodies were recovered, funeral services had been conducted continuously. Many of the victims were Roman Catholic, and the priests there were exhausted. One called Taylor's command post, requesting help to spread the word about an upcoming Mass. "I've had a hard day and I've done a number of funerals," he told her.
So now Taylor and the firefighters were hanging laminated signs announcing that a service — not a funeral but an opportunity for people to pray together if they needed to — would be held later that day. They had just finished hanging a new sign when Taylor felt someone take hold of her hand.
Before she knew what was happening, Taylor and her crew were holding hands in a circle with a group of strangers. Taylor only half-listened to the words, which sounded like a sermon, because she was busy watching the firefighters who were all standing in silence, looking at one another with expressions of confusion. Then the clipboards appeared, and the sermonizers started asking questions from a checklist of psychological trauma symptoms.
"They started putting these pamphlets into our hands — something about our grief and how to deal with it, I think. I think it was religious," says Taylor, a social worker who deals with first responders such as firefighters and paramedics in Prince William County, Virginia. "Later on, I saw a lot of those brochures lying on the ground. People threw them away as soon as they were left alone. If I hadn't experienced being grabbed like that, I don't think I would've believed it."
As Taylor continued her work at Ground Zero, she would come to appreciate the counselors who carried broad placards announcing themselves or the long pieces of plywood with the words "Trauma Counseling" lettered roughly in red paint.
"Those at least you could see coming and avoid," she says.
On the day that Taylor was forced into a prayer circle, a psychologist in Kansas City named Richard Gist was dealing with the fallout here. People were stranded at the airport as planes were grounded, and requests for assistance were still coming in from all over the country. In the middle of the night, he found time to grab a laptop and send an e-mail to members of the Society of Clinical Psychology, warning that the practice Taylor had been seeing was more than a benign annoyance.
It was important to stay focused on meeting people's needs in ways that would help, Gist wrote. "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."
And, he warned, "We must also be aware that some approaches that seem intuitively reasonable and have been widely embraced have proven ineffective and even harmful."
At the time, Gist was an adjunct professor of psychology at the University of Missouri-Kansas City and principal assistant to the director of the Kansas City, Missouri, Fire Department. Today, he lives in Old Briarcliff. A modestly built man with a bristling mustache, he has an expression that tends to make him look a little incredulous and he has a way of talking that takes long, scenic detours.
When Gist talks about trauma counseling before 9/11 — when disaster response and community mental health were considered far less sexy fields of study — he compares it with the monster that Mary Shelley created in Frankenstein, and he brings up the old Irish saying about good intentions paving the road to hell.
Other researchers have also grown suspicious about the effectiveness of treating post-traumatic stress with a technique that has come to be known as "debriefing": forcing the victims or witnesses of a traumatic situation to talk about it with counselors.
Over the last 20 years, grief counseling has become a big business. Almost anyone can say he or she is a grief counselor — it doesn't take a medical degree or a background in psychology. Pop culture has exploded with daytime-talk-show psychology and what Gist calls "touchy-feely" books. So the idea of bringing in an expert — even if the expert was only a self-proclaimed one — to help workers who have seen horrific things seemed reasonable. Most fire departments around the country eventually adopted some system of mandatory group debriefings.
This move to crisis counseling had its roots in the work of Jeffrey Mitchell, a paramedic who invented the techniques while studying for a graduate degree in psychology in 1974. Calling his methods Critical Incident Stress Management (CISM), Mitchell advocated putting first responders who had been exposed to trauma in groups to talk about their feelings, also advising that they eat right, get exercise and rest, and list their behavioral red flags. Today, International Critical Incident Stress Foundation Inc., which trains people in CISM and puts together counseling teams, offers year-round courses in counseling and trauma response for corporations, first responders, pastors, school officials, social workers and therapists, among others. The company's Web site boasts more than 1,000 trainees who have been approved to offer courses on CISM, and the four- to five-day workshops draw an estimated 40,000 people a year. CISM also has foundations in Canada and Australia.
With the market booming, companies that use methods similar to Mitchell's started popping up, offering their services not only to the public sector but also to corporations, claiming that their techniques helped employees cope after on-the-job fatalities or workplace shootings. (Donald Howell, executive director of International Critical Incident Stress Foundation Inc. and press liaison, did not respond to interview requests for this story.)
Among those who embraced trauma debriefings in the beginning but now questions them is Bryan Bledsoe, a clinical professor of emergency medicine at the University of Nevada School of Medicine. Bledsoe started his career as a paramedic before going to medical school. In the late 1980s, he began writing textbooks for paramedics. Like almost everyone else at the time who was trying to find ways to help first responders through difficult situations, Bledsoe included information on trauma debriefing methods.
"We put it in [the textbooks] without looking too much into it," Bledsoe says. "At the time, it was just the best science you could find."
Bledsoe didn't actually see a debriefing in practice until 1991 while working in Maryland. A car had crashed and caught fire, burning four people to death, including two children. As an experienced paramedic, he was familiar with such scenes.
"It didn't bother me," he says of the accident. "But the policy was that for anything like that you do a debriefing." As he sat through his first session, he says he thought, "This is really inappropriate." The counselors, he says, "were trying to draw feelings out of people without much regard for how they'd react to it or how they wanted to deal with it."
After that, Bledsoe started researching trauma on his own. He began publishing a series of articles critical of CISM in EMS Magazine, a periodical for first responders. In response, he says, people started sending him death threats. You're trying to hurt people by saying this, a typical one would begin. If people listen to you, paramedics will suffer, read another.
"The World Health Organization had already taken a stand against CISM," Bledsoe says. "And I wrote a CISM article for the journal Prehospital Emergency Care, doing a systematic review of the research, pro and con. The thing was that there wasn't much pro except for articles in journals published by people who invented the practice. But the idea that this is what we're supposed to do — it takes such a hold that it's like killing a vampire."
Bledsoe's research led him to Gist, who had similar interests and concerns. In Virginia, Vickie Taylor was having doubts about trauma debriefings, too.
During the early '90s, when Prince William County used large-group debriefings, it was common for those involved to have performance issues later. For police, that could mean use of excessive force and sporadic attendance.
Many of the counselors were offering services that they didn't have experience in, Taylor says, and it was becoming less clear that the methods actually delivered on their claimed benefits.
The problem with something like the group prayer circle at Ground Zero, she explains, is that it disrupts the emergency responder's mental focus. "You're in this state of mind: 'I'm going to work,' and you don't need this [people butting in]. What we needed to have in place down there was every skill for distancing instead of bringing it all in close." Taylor says that workers in the middle of such situations have to "reframe the event" so that they believe what they're doing has meaning. Stopping work to talk about how bad they're feeling interrupts that necessary focus.
On April 16, 2007 — the same day as the Virginia Tech shootings — a firefighter in Vickie Taylor's county was killed in the line of duty. Just as she had seen during her team's 9/11 cleanup, a swarm of people wanted an opportunity to round up the firefighters and force them to talk about their feelings.
"They came out of the woodwork. We had many, many calls from people who wanted to come and help us. They find out about these deaths because they'll watch the message boards on firehouse.com, or they'll troll community Web sites. It was our first line-of-duty death, and the people calling to help had never been involved in a line-of-duty death. So they would've shown up to do — what?"
Back then, Taylor says, the fire department would have allowed the counselors. "It was the best we knew to do at the time," she says. "Now I just say, 'No, thanks.'"
Gist's trepidation with trendy trauma counseling has roots in one of the worst disasters in Kansas City history.
At 7:05 p.m. Friday, July 17, 1981, two aerial walkways collapsed into the lobby of the Hyatt Regency Hotel during a "tea dance." Such dances had been weekly events for a couple of months, hosted by the hotel and attracting revelers from all across the metro. It's estimated that 2,000 people were present when the walkways fell. Of those, 111 were killed, and more than 200 were injured. Victims were trapped for more than 10 hours beneath 90 tons of steel and concrete. The rescue effort eventually involved perhaps a thousand responders, including firefighters, police, paramedics, physicians, nurses and volunteers.
Gist was a junior administrator at a mental-health center in Independence and a doctoral student in community psychology. He had a grant from the National Science Foundation to study treatment philosophies and advocacy.
"I was looking at what we now think of as behavioral health issues, and I'd encountered some things about community reactions as part of that. So I just happened to have some background when the Hyatt happened."
Even then, Gist was not the type of psychologist to be enamored with the then-popular self-esteem movement or the idea that therapy necessitated the unfiltered disgorge of one's inner thoughts. "Lots of people think if you're a doctor in psychology, you're Dr. Phil," he says. "I don't do huggy-buddy, touchy-feely, kissy face. And if you hug me, I'll probably hit you."
In the months after the Hyatt collapse, local media outlets went out of their way to inform victims of how they could get help.
All of that attention slowly dissipated. But Gist and his fellow UMKC researchers kept following the psychological recovery of those affected. It was an unusual event to study, in that a large, traceable mass of the community had the same precursor for the trauma occurring at the same time. Often, people who are considered trauma victims are those with personal tragedies that isolate them in some way. A rape victim, for instance, embodies the scene of the crime. A combat veteran faces prolonged and constant threats, with a heightened sense of danger that's difficult to shake even when one is clearly safe. In the case of the Hyatt, however, people could distance themselves physically from the event; at the same time, almost all of the victims lived in the area, and it was rare to find a metro resident who didn't know a victim personally or know someone who did.
"That was seminal work in many ways," says Krys Kaniasty, a professor of psychology at the Indiana University of Pennsylvania, who researches community responses to disasters and has collaborated with Gist on books. "Before 9/11, there was little interest in community trauma. The field existed, but it wasn't a major interest," he says.
Gist wasn't alone in his research. Studies involving English and Israeli soldiers would come to many of the same conclusions about the way people process traumatic events. In Australia, work had been done with people who suffered through brush fires.
But because events like the Hyatt had almost never been studied, no one knew exactly what a normal psychological response really was. Gist found that all of the standard symptoms of post-traumatic stress disorder — shock and disbelief, exhaustion and a long period of assessment and integration, during which the person who experienced the event finally feels its full weight — were all normal reactions to the most abnormal situations imaginable.
"People deal with things in different ways. Maybe you ruminate on something, maybe you feel depressed, but does that make you sick? Does it mean you've been injured or just that life is full of stuff you have to grow from? What we found was that people who dealt with trauma by not dealing with it, by compartmentalizing it and distancing themselves from it until they could handle it in their own way — those people actually recovered just as well as anyone else. But others who were told that they had to go through some kind of counseling or who were forced to go through debriefing had their natural processes interrupted, and it actually hurt them."
To put it in nonacademic terms, Gist uses an example from landscape architects who design college campuses: "You don't put down sidewalks. You leave raw grass for a semester or two, and then you look at where the students have worn a path and you pave it. You assume people already know where they're going, and then you just try to make it possible for them to get there. Unfortunately, in contemporary pop psychology, we got to a place where we figured people didn't know where they were going, and we started leading them places they didn't need to be."
Gist edited two books on community disaster responses, one published in 1989 and the other in 1999. He thought that would be the end of it.
"Reality has a way of catching up with you," he says. "Following September 11, myself and many other researchers were just getting inundated with reporters. All of a sudden, all this minor academic debate became a huge concern to a lot of people."
It turns out that, from his work on the Hyatt, Gist had helped create a singular way of dealing with community disasters.
In the wake of disasters like 9/11 and hurricanes Katrina and Andrew, the long-term effects of post-traumatic stress disorder have been scrutinized at an unprecedented level. With the rest of the country catching up to lessons already learned from the Hyatt, mental-health providers are now less likely to bombard people with intrusive help.
Betsy Vander Velde is president and CEO of the Family Conservancy in Kansas City, Kansas, which represents mental-health workers across the metro's counties. She calls Gist's work "an amazing evolution of not just what post-traumatic stress really is, but how to be helpful and how to intervene and how not to intervene."
The country's firefighters now seem poised to move away from surveys and strangers asking them about their feelings. The National Fallen Firefighters Foundation — an organization for creating standards and requirements for fire prevention and suppression, training, equipment, codes and standards — removed any recommendation for using CISM from its 2009 standards.
Even with the official protocol turning away from CISM, it may take awhile for fire departments that have used it for decades to adopt a new model.
"There was just a suicide in Texas [this October], and the first thing that fire department did was run a debriefing," Bledsoe says. "A lot of police departments are still into it, and I think most of the debriefers are moving into the public-school setting. Guys like this just move to a different market. You see it all the time. There's a school disaster, and counselors are on hand."
Now, the National Center for Post Traumatic Stress Disorder is trying to provide a better option.
"We're developing combat and operation stress aid for the military, Marine Corps and Navy that's informed by research that came from Kansas City, among other places," says Patricia Watson, an educational specialist with the center, which is part of the U.S. Department of Veterans Affairs.
"We're also creating a model with the same basis for the National Fallen Firefighters Foundation. The first responders have started saying they don't want to sit and talk with this stranger about how they feel, and there've been red flags raised."
Watson's mode is based at least partially on the idea that nothing can be mandatory or coercive, so the challenge becomes how to make sure people get the help they need without getting in their way. That means not intervening with any kind of psychological first aid unless a person shows problems functioning.
The center's guide, still in preliminary drafts, establishes a framework for early interventions that rely on a person's peers rather than outside agencies and counselors; peers would help connect traumatized colleagues to outside agencies if necessary. The loose structure will be tested over the next year at 14 military bases.
"I'm very cautious now about what we do," Watson says. "You look back 100 years, and it's like, 'Oh my God, they're drilling holes in people's heads!' But that's what they thought was best. We want this to be a living model that'll keep improving over time."
In Kansas City, the silver lining to the Hyatt has been that the mental-health sector learned the benefits of allowing people to heal in their own ways.
In May 2008, when tornados swept through the Northland, grief counselors — some trained in CISM, others just self-made specialists from disparate religious groups — reacted in typical fashion. Workers on-site took their information but didn't give them direct access to the people involved.
"What's unique here is that we've developed a very controlled system," Betsy Vander Velde says. "There's a mechanism in place to be sure that people who aren't supposed to be in these recovery areas aren't there being counterproductive."
As Vander Velde helped with the tornado recovery effort, she regularly saw people who she expected would need ongoing counseling. She recalls one elderly couple who was isolated from nearby neighbors and had little family. They refused to leave their home because it was all they had, and they wanted to start repairing damage as soon as possible. As it turned out, they were fine.
"We've learned we can't assume everyone is going to be horribly hurt for the rest of their lives," she says. "It seems now like the best predictor we might have of how you'll do in a crisis is how you handled the bad things that happened in your life before, on your own."
Gist suggests that counselors stop trying to be saviors.
"I tell students, if you want to be the messiah, you don't understand the story," Gist says.
"Messiah looks like a great job on Palm Sunday, but working conditions deteriorate remarkably over the week, and by Friday they suck." Instead, he tells students, "Be the Maytag repairman. Build a system that doesn't break down, and if it does, it can be fixed easily. Build something that can sustain itself and look for ways to help people where they are, without you getting in the way."Click here to write a letter to the editor.