From the July/August 1997 issue
People in North Dakota insist that the land is so flat, they can spot an anthill a half mile away. Local lore says that when it snows at night, by morning the wind has blown it all into South Dakota. But there was too much snow to blow away this year–74.6 inches of it, the fourth heaviest snowfall on record. Then the spring thaw, usually welcome, came rushing in too fast, and on April 19, when the melting waters breached the dam and roared over the makeshift dikes, at a record 22 feet above flood stage, they created an instant Dead Sea filled with floating furniture, automobiles and thousands of memories. The vast flooding destroyed so many homes that the people of Grand Forks and surrounding areas sought shelter with relatives and friends in more than 40 states, and weeks later, families were still trying to figure out how to get reunited and where to live. Three months have passed, and according to psychologist Rilla Anderson of Mayville State University, one of the Grand Forks evacuation centers, “If you look at Maslow’s hierarchy of needs, we’re still at the basic level of survival.”
North Dakota remains one part of the country where therapists are generally thought of with some skepticism. “We’re a kind of buckle up and do-what-you’ve-got-to-do state,” says Bob Sanderson, director of the Northeast Human Service Center. The most frequent term used to describe the mental health care services being provided in the weeks following the disaster “was coffee klatch therapy”–going around to the shelters and later, as residents slowly returned to their homes, visiting door-to-door, informally checking in with people too frantic to stop and look inside themselves. “We’re just letting people know we’re here,” says one therapist. “Later, when the other symptoms start, hopefully we can build on that initial contact.” This kind of initial numbing happens after any disaster, but experts see something different in the Fargo/Grand Forks flooding. Unlike recent disasters–Hurricane Andrew, the Oklahoma bombing, the Northridge, California, earthquake, the Arkansas tornadoes–the flooding took weeks to unfold, so that by the time the waters finally inundated the community, everyone was already worn out, and the numbing is taking longer to dissipate. Psychologist Ann Looby, mental health coordinator for the American Red Cross’s disaster services, came to North Dakota directly from the Arkansas tornadoes. “In Arkansas 1,128 homes were immediately destroyed,” she says, “but the people began bouncing back almost immediately. People here were already suffering from weeks of chronic stress before they got hit by the acute stress, and they haven’t started recovering yet.”
The citizens of Grand Forks had spent weeks sandbagging, trying to stave off the flood, first in warm weather, then in blizzards and sleet, and even as the struggle sapped their strength, it reinforced their sense of community. Playing off the cynicism so prevalent in other parts of the country, a local newspaper ran a caption underneath a photo of a brigade of sandbagging kids, which asked, “What Are Teenagers Good For?” Community spirit ran high. Psychologist Myron Veenstra, unit director for Adult and Family Services of Fargo’s Northeast Human Service Center, after futilely trying to get exhausted sandbaggers and rescue workers to take a rest, finally decided to pass out stamped postcards, so that they would at least take a quick break and write to their families, many of whom had moved far away to safety. (The postcard that was requested most often had a picture of the river in normal times.) Then the Red River surged five feet above the predicted level, and in an instant, the weeks-long battle was lost, suddenly calling into question the Midwestern and Scandinavian ethic that hard work and community spirit can always save the day. How does it affect youngsters’ view of the world when the best efforts of their neighbors and authority figures–and their own hopes and work as well–reap such a payoff of misery? In the first days of the flooding, kids began reporting stomach problems and vomiting. How can an event that contradicts one of their community’s fundamental beliefs be recast to offer some hope? “That’s one of the big things we’ve got to help the young children face,” says Veenstra.
Other strains on the sense of community began to appear as the waters slowly receded. Calls started coming in to hotlines from people in the surrounding towns who had enthusiastically opened their homes to flood victims. Now they were beginning to feel impatient and irritable at the loss of privacy–and their guests were calling in with the same complaint. Exhausted parents were torn between spending their time getting their homes back in order and driving four to five hours daily to visit their kids who were staying in temporary quarters (275 licensed day care centers in the Grand Forks area were under water). Ultimately, the numbness gave way to frustration and anger and, as the avalanche of help and supplies that had poured in from the rest of the country subsided, people’s grief overcame their natural reticence. Says Sanderson, “There’s a dawning sense that our history’s been swept away.” By now, therapists have learned the mechanics and stages of trauma relief all too well. First there’s the numbing and shock, along with the fatigue and trauma of the rescuers and healers themselves, and then the heroism and generosity of the community and outsiders, which help keep spirits alive. After that comes the long-term task of rebuilding. This is the most difficult period, during which the delayed symptoms of post-traumatic stress–increases in domestic violence and depression, nightmares, a rise in the divorce rate, kids acting out–begin to appear.
“We know there’ll be a lot of PTSD the first time the snow begins to fly,” says John Collins, program administrator for regional intervention services for the Southeast Human Service Center in Fargo. “But there’s so much work to do before then, and what’s happened is so enormous and so unprecedented, that we can’t even begin planning for it. We just hope that winter doesn’t come too early, and that it’s a mild one. A lot of people are really scared.”
At the invitation of Harold Eist, president of the American Psychiatric Association (APA), psychologist Ivan Miller of Boulder, Colorado, held a press conference at APA’s annual convention in May to challenge the scientific validity of the research supporting the massive mental health managed care industry. For years, managed care has cited a group of research studies that purportedly prove the superiority of time-limited therapy (TLT)–therapy with a predetermined limit of sessions–over clinically determined therapy (CDT)–in which the length of treatment is more fluid, being determined by the client and therapist. Claiming that TLT is more effective than CDT, managed care marshaled the authority of empirical findings in mandating strict controls on the duration of therapy, leading to cuts in at least 75 percent of outpatient mental health services. But when Miller, vice president of the National Coalition of Mental Health Professionals and Consumers, the nation’s largest anti-managed care, grass-roots organization, scrutinized the research cited by managed care to support its position, he claims to have discovered serious design flaws in the original studies and mistakes in the reviews of the studies, as well as misinterpretations of the research by the managed care industry.
According to Miller, many of the classic studies cited actually shed no light on the relative merits of TLT and CDT. Several studies lack comparison groups, and two others compare completed TLT cases to partially completed CDT cases. Another study, amazingly enough, does not even include a TLT or a CDT group. In addition, Miller discovered that in one study the researcher unaccountably took out some statistics indicating that CDT might occasionally be more effective than TLT.
Miller also examined the reviews of the studies and found that reviewers occasionally used the conclusions of misleading abstracts of the studies, failing to evaluate the actual studies themselves. Noted psychotherapy researcher Lester Luborsky’s influential 1975 metanalysis of several early studies favorably comparing TLT to CDT repeated one researcher’s unjustified conclusion about the superiority of TLT and then compounded the problem by not realizing that, contrary to research protocol, the researcher had reported three times on the same study. Luborsky himself acknowledges that Miller is “probably correct” in his detective work. Further, he points out that there is no valid research showing a statistically significant correlation between number of sessions and treatment outcome. In other words, he believes the claim that TLT is superior to CDT remains unproven.
Miller is not disputing that short-term therapy can be an appropriate clinical approach. He believes that the issue is whether a predetermined limit on the number of sessions should be mandated from the outset of therapy through a decision determined by cost, not by clinical judgment. The most definitive conclusion from the research that can be drawn concerning TLT and CDT, according to Northwestern University researcher Kenneth Howard, is that, for problems such as phobias and depressions, “Time-limited therapy is by and large effective for the average person.” But there is no evidence that it is the only, or best, therapy; neither is there any evidence that CDT doesn’t work for these same conditions.
A confusing or inconclusive research landscape can easily become fertile ground for facile and erroneous conclusions. “Trusting managed care’s research and interpretations about therapy,” says Miller, “is like trusting the tobacco companies’ research on tobacco and health.” He claims that setting stringent limits on the number of sessions without regard to variables, such as patients’ individual personalities or larger systemic influences, is ultimately unjustified by anything other than short-term profit.
Because the issues that he raises affect, literally, millions of Americans, Miller was disappointed that his press conference received no national press coverage. But this really comes as no surprise; academic research doesn’t usually attract the press. However, feature a mother whose son, denied adequate care by his HMO, committed suicide, juxtaposed with a health care CEO expounding upon cost-effectiveness, as 60 Minutes did recently, and you draw an audience. Nonetheless, says Miller, Americans ought to know what they’re getting, or not getting, from their mental health managed care plan, and why. “Thousands of people each month are being fooled into giving up on mental health treatment,” he says, “just because managed care wants to give up paying for it.”
For more information about Miller’s findings, consult the December 1996 issue of Professional Psychology: Research and Practice.