New evidence questions whether counselling really is helpful at disasters, reports Dr Raj Persaud

Tragic events such as those of september 11 have reminded us that psychiatrists and counsellors are seen as having an increasingly important role in our culture's response to disasters. But whether mental health professionals do any real good by arriving rapidly on the scene of a catastrophe is increasingly being questioned by research in the field.

It is indeed true that disasters are accompanied by a dramatic extension of psychiatric disturbance in a community averaging at 20 per cent. But whether this increase can really be prevented by early psychiatric intervention is surprisingly debatable though the US Navy is convinced enough to form Special Psychiatric Intervention Teams (SPRINT) and the US Army has a similar scheme.

Oddly enough the current view seems to be that the more terrible or complete the cataclysm, the more psychotherapy has an elevated importance, compared to other emergency workers like surgeons or trauma specialists. For example, so few people were saved from the wreckage that there was in fact little that physicians could do at the scene of the Twin Towers, and instead the focus moved to helping survivors and those who experienced the calamity cope psychologically.

One question that was particularly brought into focus by the terrorist attack on New York is whether man-made as compared to "natural" tragedy leads to more psychiatric disturbance. Because there was some early evidence that this was so - the theory being that victimisation by one's fellow man engendered a greater sense of vulnerability - this raised the disturbing implication that some man-made catastrophes were partly motivated by the psychological consequences on the affected population. It seemed psychological as well as physical casualties that should now be considered part of the grim accounting of war's winners and losers.

But the problem has always been that psychiatric problems are usually less visible than physical injury and covered by greater taboo, rendering them more difficult to measure and take account of.

Now the pendulum has swung away from the idea that man-made cataclysm is worse than natural, following an influential recent study that found Armenians exposed to either a severe earthquake or political violence exhibited no significant differences in post-traumatic stress disorder (PTSD) levels. It might be that natural destruction leads to a sense of unpredictability that balances the paranoia engendered by political violence.

The distinction between man-made and natural disaster is also sometimes difficult to appreciate on the ground - for example the 1974 Buffalo Creek dam collapse could be attributable to both heavy rains and industrial mismanagement.

The issue of the cause of a disaster appears to be important because of the prominence given to trying to make sense of the incomprehensible in the kind of therapies normally offered after a cataclysm. For example perhaps the most common treatment now offered is "psychological debriefing" - referring to a kind of group discussion that occurs within 48-72 hours after an event. These sessions encourage participants to describe and share both factual and emotional aspects of their disaster experience.

The widespread belief in the field of counselling and psychotherapy which supports the endemic use of "debriefing" is that we need to be offered as soon as possible the opportunity to "restructure" the way we think about an event, so that it will be remembered in a less traumatic way. This "restructuring" is supposed to involve a switch from "non-verbal sensory" forms of memory to more verbal kinds. If this doesn't happen this might explain why sufferers from PTSD experience flash backs and nightmares, where they keep reliving the terrible events.

It would seem that they are caught in some visual loop, unable to think about the event in a different way. For example, at the risk of giving a trite example, instead of considering themselves lucky to have escaped and therefore see recent events in a more positive light, they are preoccupied instead with how close they came to death.

The PTSD prevention theory certainly sounds plausible, but the problem is that research on debriefing is not so clearly overwhelmingly in favour of it as providing real measurable benefit to clients. Some studies have even found that those given this treatment do worse than those offered no psychological help.

One possible worry is that professional intervention delays the natural mobilisation of personal or local coping mechanisms or resources. It could even lead to a reduction in self-confidence in personal ability to cope with difficulties, creating a dependency on professionals for issues that could be dealt with just as effectively informally by friends or family.

Perhaps a more serious charge is that in the spreading "therapisation" of our society we forget that sometimes what people really need is not so much an exploration of their unconscious, but the meeting of pressing practical needs following a disaster.