On September 11, 2001, the United States was brutally thrust into a new and dangerous world. As the twin towers of the World Trade Center collapsed and the Pentagon burned, the horrible reality of terrorism seared the American consciousness. For those directly affected, of course, the loss can never be measured. But in this age of mass media, the tragedy has reached far beyond the victims and their families. As people across the nation watched the catastrophes unfold on their TV sets—and as they sat transfixed before the endless reruns—they all participated in the trauma. In a sense, we were all eyewitnesses, and we all have to cope with the feelings of anger, stress, and anxiety that such events produce.
That clearly poses a huge challenge for business, because it is largely in the workplace—where we spend so many of our waking hours—that we will confront these emotions. Restoring people’s confidence in the safety of the workplace is an immediate priority for managers. Nearly every business is developing new procedures for guarding against the threat of bioterrorism in mailrooms and offices. But many companies are doing much more; they’re asking their HR departments to organize stress reduction programs to help employees deal with the emotional strains engendered by the attacks.
While the immediate logic of launching these initiatives is incontestable, doing so raises a much larger question: What responsibility does a company bear for the mental well-being of its workforce? After all, depression and anxiety have always been with us. If companies feel that they should help employees cope with these emotions in the wake of terrorist outbreaks, doesn’t that put mental health care on the business agenda? Arguably, the tragedy of September 11 may come to be seen as a tipping point, the moment when managers started to think about dealing with mental health issues on a regular basis.
To gain insight into these questions, HBR senior editor Diane L. Coutu visited Dr. Steven E. Hyman, who served as the director of the National Institute of Mental Health (NIMH) from 1996 through 2001. There, he oversaw the work of more than 1,000 scientists and a budget of nearly $1.2 billion, which is largely devoted to basic brain and clinical research. A summa cum laude graduate of Yale University, Hyman studied philosophy at Cambridge University in England before he graduated from Harvard Medical School in 1980. After completing a residency in psychiatry at Harvard, he worked as a research fellow in molecular biology in the Harvard department of genetics. He later became a professor at Harvard Medical School and the first faculty director of Harvard University’s initiative in mind, brain, and behavior. He became the provost of Harvard University in December 2001.
In a two-hour conversation in the NIMH offices in Rockville, Maryland, Hyman talked about the immediate psychological fallout of September 11 and offered guidance on coping strategies. He also discussed the longer-term implications for mental health care in the workplace, suggesting ways that businesses can provide mental health support to employees.
Terrorism has rocked this nation. When will we be back to business as usual?
We have never been this traumatized before, so I can’t say how long it will take before people start living and working with full effectiveness again. But to get a sense of the scale of the trauma, consider this finding from studies of the 1995 Oklahoma City bombing. A year after that act of terrorism, one in six children who lived 100 miles from the city—and whose only exposure was through media outlets—still suffered from anxiety symptoms that impaired their school performance.
The psychic toll of September 11 will be much greater than that. Millions of people saw the second plane hit the south tower of the World Trade Center, they saw the towers collapse, they saw people leaping to their deaths. If they didn’t see the events in real time, then they saw the pictures repeated again and again until the networks themselves realized, I think, that the images were traumatizing. The result is, as a recent Pew survey has shown, that about 70% of Americans have developed significant psychological symptoms—for instance, feelings of depression and intrusive thoughts of the disaster. They mentally replay those devastating images, or they have repetitive thoughts about what they could have done to prevent the tragedy. Many people are sleeping poorly; many startle easily. They feel that they are not in control and that their world is no longer safe. A good piece of evidence that people don’t feel safe is that air travel is still way down.
Will most Americans develop serious psychological problems because of the terrorist attacks?
Most people will have at least transient trouble concentrating, and many will be irritable or depressed. Some people may feel that normal tasks are not meaningful anymore, so they may lose their motivation. These symptoms can obviously affect interactions among colleagues at work, and they can negatively affect productivity. For most individuals, these symptoms will recede with time.
Some people, though, will develop a chronic and disabling disorder, either post-traumatic stress disorder (PTSD) or major depression. The people most at risk for these conditions are those who were closest to ground zero in New York or to the Pentagon disaster. This includes, of course, not only those who were wounded or who lost a close relative or colleague but also firefighters and police officers. A second major risk factor for developing PTSD or major depression is a history of prior trauma or mental illness, such as earlier bouts of depression—a common illness that affects more than 10% of Americans at some time in their lives. In fact, a substantial number of people right now come to work but cannot concentrate; they feel edgy and they experience intrusive thoughts. For instance, someone might hear a normal commercial flight passing overhead and, all of a sudden, she will visualize the terrible images of September 11. People who have persistent and pervasive symptoms that cause impairment would benefit from professional help.
Yet it’s important to remember that people are very resilient. Research shows that with time, the majority of people living in Oklahoma City returned to normal functioning. Even 55% of those who were directly affected by the blast did not develop a mental disorder. That’s a testament to the amazing resilience of the human spirit.
Unfortunately, to a far greater degree than Oklahoma City, the current situation is one of continuing uncertainty, and the fear of new attacks is a rational one. It’s impossible to escape this reality, but we should not panic. Like most emotions, fear is highly contagious. The infectious quality of fear and anxiety is part of our species’s warning system for shared dangers; but when anxiety becomes chronic, it is no longer adaptive. That’s why we need to develop strategies for coping.
Can you identify some of the coping strategies that may be particularly helpful for businesses at a time like this?
Corporate leaders must speak and act calmly, despite their own concern. They must provide honest, accurate information insofar as that is possible. Leaders should say what they know—and what they don’t know—and then relate the steps they are taking to control the situation. It is critical that managers not mix their attempts to provide information with efforts to reassure employees. Confusing the two calls into question the reliability of the information at hand.
At the individual level, employees can take steps to improve how they cope. They should stay connected to their social networks because isolation heightens the risk for anxiety and depression. Within their social networks, both at home and at work, people should be solicitous of one another. They should offer to listen if someone needs to unload, or make a concerted effort to keep plans. At the same time, they must be wary of becoming intrusive. Some people want to tell their stories and discuss their concerns, but others do not. Pushing someone who isn’t ready to talk about his anxieties is not helpful. In fact, forcing people to face their raw emotions can retraumatize them, unless they have a safe setting and appropriate coping strategies in place. Parenthetically, this is why poorly trained stress debriefers or grief counselors can actually do harm.
People should also take care of themselves physically. The activation of our bodies’ fight or flight response—with the accompanying release of stress hormones—may actually strengthen traumatic memories in the brain, prolonging or worsening symptoms. And so it is terribly important to get rest, even though sleeping may be difficult. Eating well and getting exercise are also important, as is avoiding excessive alcohol or caffeine. Sleeping pills may be helpful for a few days, but their use should not become long-term. An overreliance on sleeping pills may create more problems than it solves—including the risk of dependence.
Finally, we must try to re-create a sense of control over our destinies and restore a sense of meaning to our lives. The terrorism we experienced on September 11 seriously undercuts both. So we have to make real efforts to return to life’s routines. Work is a vital aspect of that: People feel healthy when they think they’re contributing to society. Indeed, finding significance in life is crucial for mental health. I think one reason President Bush’s address to Congress on September 20, 2001, was so effective was that he covered all these points. Without falsely denying danger, he calmly told the nation what he knew, what he didn’t know, and what steps he was taking to regain control of events. He also provided a larger sense of purpose by describing America’s fight for civilization against the forces of evil. I think this is ultimately very healing.
Will terrorism—and the deep anxiety it has stirred up—create a greater awareness of depression and other mental illnesses in the workplace?
Almost inevitably. In recent years, business has been taking a much greater interest in mental health issues. That’s largely because a number of studies by the World Health Organization and other institutions have shown that mental illness is a disproportionately large source of disability in the workplace. Indeed, in any given year, 19 million Americans are affected by depression. I realize that health professionals and businesspeople don’t always agree on the criteria for disability. But for many U.S. companies, major depression is among the top three causes of absence from work. That’s without taking into account the effect depression has on the performance of employees who aren’t taking time off. An employee may be at work but staring out the window all day because of a serious depression. In cases like that, the impact on productivity is hard to quantify—but depression clearly affects the bottom line, and something needs to be done.
What can managers do to help employees deal effectively with depression?
While this is hard for smaller businesses, many larger businesses have invested in well-publicized employee assistance programs. These programs have been very effective in helping employees resolve personal problems that affect their job performance and their personal well-being. But the critical thing is to make sure that your EAP staff and referral network know what they’re doing. It’s great that companies are making interventions with employees—especially at a time like this—but the interventions have got to be the right ones. It should be well understood that EAP professionals are generally not physicians or clinical psychologists; their job is to offer referrals, not to make diagnoses. It’s also essential for EAPs to maintain confidentiality so that the company’s employees feel safe using them.
How well do people respond to treatment?
People differ greatly in their responses to any illness, whether it’s cancer or major depression. Some get back to work in a couple of weeks and function at a remarkably high level. The characteristics of resilience are hard to define: a positive attitude, family support, intelligence, a good education—anything that gives you a leg up can play a part in your recovery. But treatment plays the largest role. It’s almost always true that if someone with a serious mental illness such as schizophrenia or manic depression is employed, it is because he or she is getting good treatment. Speaking more generally, there is quantitative evidence that about 70% to 80% of the people suffering from major depression who get proper treatment return to full productivity. Those kinds of findings are very reassuring, given the scale of depression we’re likely to see in the aftermath of September 11 and the anthrax attacks.
“The characteristics of resilience are hard to define: a positive attitude, family support, intelligence…anything that gives you a leg up.”
But don’t companies risk great financial liability if they open themselves up to dealing with illnesses such as depression and stress?
There is a widespread concern among businesspeople that the costs of health care will escalate if employees are covered for mental illnesses. Specifically, companies fear that given the lack of objective diagnostic tests for mental illnesses, it will be hard to know where to draw the line. A cholesterol problem, for instance, is real and measurable; depression is real, but it can’t be objectively measured. So businesspeople wonder, “If stress is first, won’t shyness be next?” But I think their concerns are overblown. Doctors have been able to distinguish between a cold and pneumonia for a very long time—even without expensive laboratory tests. Similarly, trained professionals are able to tell the difference between the distresses of ordinary life and clinical depression or post-traumatic stress disorder. Of course there’s a gray zone in psychiatry. But there’s a gray zone in all of medicine. The fact is that mental illnesses are real, diagnosable, and treatable.
Another source of concern for businesspeople comes from the false but widespread belief that mental illness is treated primarily through long-term, exploratory therapy. I don’t want to decry the value of exploratory therapy, but I must point out that most modern treatments involve medication or brief, symptom-focused psychotherapy or both. The pharmaceutical treatments developed during the last decade are quite effective for mood and anxiety disorders, and they have much milder side effects than older medications. At the same time, in clinical trials, the short-term, symptom-targeted therapies such as cognitive-behavioral therapy have proven to be efficacious for illnesses like PTSD, panic attacks, major depression, and obsessive-compulsive disorder. Maybe in the wake of the attacks, we will see businesses looking to these solutions more often.
Are there risks for business to get involved in pharmaceutical solutions?
Unfortunately, there is always some risk—as there is in any performance-sensitive situation: Kids use illicit anabolic steroids to improve their performance at sports, or they take stimulants before exams. Similarly, there are dangers that in some competitive situations, some people will feel coerced into taking psychotropic medications. Consider the executive whose excessive shyness or irritability has hampered his career development.
This situation is further complicated by the fact that the goal in medicine is increasingly prevention rather than treatment. This means that we are going to be treating illness earlier and earlier. So the real question becomes, Why would we think differently about treating an executive for very mild depression than we would think about giving medication to a manager who has only slightly elevated levels of cholesterol? Clearly, there is much for us to discuss collectively—and thoughtfully—as a society. But I want to stress that the far more serious problem is not the overuse of medications but rather the failure to diagnose and treat serious mental disorders that contribute to distress and impairment in the workplace.
We seem to be assuming that a mental disorder is always a bad thing. Is that necessarily so?
There’s no cookie-cutter answer to this question; compelling articles have been written about the relationship between creativity and bipolar disorder, for example. During periods of mild mania, people often feel very creative, energetic, and unfettered. If I could speculate, I would say that it’s possible that the creativity, energy, and engagement that occur with mild forms of mania are an advantage. The problem, however, is that as mania worsens, which is most often the case, the person lacks the focus and discipline to turn creative ideas into something that can be implemented—whether that’s a business plan or a work of art. So the possible advantages that the illness may confer are not easily tapped.
Some people have observed that the qualities seen in a mild manic episode are reflected in the temperaments of many successful CEOs. But here, too, I would warn that despite some obvious similarities, it’s very important not to confuse energy and engagement—and the ability to go without a lot of sleep—with the disease of manic depression. Clinical episodes of mania can be terribly impairing. Because the very hallmark of a successful executive is his or her ability to execute, the difference between the high-energy manager and one with even mild mania is generally quite pronounced. Naturally, we may wonder whether the optimistic, energetic, extroverted temperament of many entrepreneurs comes from sharing a few genes that contribute to a mood disorder. That’s an interesting question, but there’s no data. In time, though, science will find the answer.
Did the nation’s reaction to the recent acts of terrorism shape your theories on mental illness in any way?
It reinforced them. When I reflect on the events of September 11, I’m reminded of just how complex the determinants of mental illness are. For instance, a large number of behavioral genetic studies show that for important personal characteristics—including vulnerability to mental illness—genes do have a lot to say. But so do specific environmental factors, such as family and peers. There is also the element of chance. Think of the World Trade Center: It wasn’t a matter of genes or upbringing that brought people into proximity with this horrible tragedy; it was random chance.
Yet when it comes to personality or mental illness, our society exhibits a moralizing and determinist streak. Some people still see depression and anxiety disorders as evidence of character weakness: If only depressed people were strong enough or resolute enough, they would shake off their illness. Besides being inappropriate and incorrect, the statement shows that society ascribes much more responsibility to people whose illnesses have mental symptoms than to those whose illnesses have physical symptoms. Underlying this criticism is the flawed idea, based fundamentally in ignorance, that the mental is somehow less physical and therefore less “real.” But September 11 brought home to me just how real mental illness is—it reminds us that genes, prior experience, and yes, even chance, may conspire to trigger it.