Feature

A year after the terrorist attacks, early research is beginning to shed light on how the attacks have affected Americans. Some research suggests many people are still experiencing post-traumatic stress. Other studies find that people's reactions differ depending on their proximity to the disaster, their gender and their particular coping mechanisms.

But other key questions remain unanswered. Among them: What psychological interventions are most effective in a traumatic event of this magnitude? How can we prepare to meet the challenge of possible future tragedies?

The Monitor asked several psychologists who were involved in relief efforts after Sept. 11 as well as those who devote their professional time to trauma treatment and research to share what they believe psychology has learned since the attacks last year. Here's what they said.

JERRY JACOBS, PHD
Director, The Disaster Mental Health Institute and a founder of APA's Disaster Response Network
University of South Dakota

Part of the things we've learned so far in other mass casualties worked even in a disaster of this scale. When we provided the level of service and care that we've provided in other settings and theorized it would work in tragedies such as these, it was very well-received by people.

I think it's time for us to teach the general citizenry how to cope with trauma in their lives--as opposed to going in each time and going from scratch. The International Federation of Red Cross and Red Cross Crescent Societies has been endorsing and promoting the development of psychological first aid in many countries. The time has come to develop such a program in the United States.

If we have a large-scale event that affects more parts of the country, we'd see a very different scenario than the responses to Sept. 11. We wouldn't have sufficient resources to help respond in the same way. If you look at the bioterrorism exercises that have been done, they're not encouraging. It would be more effective if all people in the community understand how to take care of each other.

We talk about physical first aid, we've done a good job of training for that. But psychological first aid is not a common thing in our country. We need a systematic training that's employed nationwide. We don't have enough psychologists to take care of everyone, but if we teach people to recognize problems that need professional help, they can make better use of our resources.

PATRICIA RESICK, PHD
Director, Center for Trauma Recovery
University of Missouri-St. Louis

People's expectations about the impact of the event on the country's mental health were wrong but exactly as might be expected if one looks at [the past century's] history.

In the days and weeks after Sept. 11, mental health professionals had an urge to rush in and do something, to provide services for everyone who was distressed. The media asked and many "experts" predicted that people would be traumatized by witnessing the attack on television. Although there are a substantial number of people in New York who were personally affected and who may have extended trauma reactions, the rest of the country had a transient reaction.

Lesson? Strong emotions do not equal psychopathology. Even in our trauma clinic with highly distressed victims of multiple traumas, we did not witness an increase in symptoms as a result of the attack. All of England did not develop psychopathology following the blitz, nor did Japan following Hiroshima. Mental health professionals will need to take the long view in helping those in New York. The quick fix did not work in Oklahoma City and there will be no quick fix in New York.

Among those who developed PTSD, years may pass before they become desperate enough to seek out mental health services. Half of the symptoms of PTSD are avoidance symptoms. On top of that, housing, jobs and other instrumental needs will take priority over mental health needs. Ongoing psychological problems will emerge slowly as other more pressing needs are met.

Maslow was a smart man.

BRETT LITZ, PHD
Associate Director, National Center for Post-Traumatic Stress Disorder
Boston Department of Veterans Affairs Medical Center

We've learned the need to expand our models of how people suffer acutely and chronically as a result of malicious acts of violence. It is not just "PTSD." For example, traumatic loss as a result of mass violence is a particularly pernicious psychological experience, which complicates direct trauma exposure considerably.

Although there is a profound need for effective secondary prevention strategies in the wake of mass violence, we need to expand awareness in the mental health field about the limited evidence for early intervention strategies and the grave need for more rigorous research. Since most people are astoundingly resourceful and resilient over time, randomized controlled trials are essential.

The horror of Sept. 11 also should force the field to conceptualize the lasting psychological effects of indirect exposure to mass violence (for example, seeing it in real time on TV or knowing someone indirectly who was lost or who suffered) in nonpathologizing ways. The goal here would be to identify an invariant pattern of thought, feeling and behavior that poses a threat to well-being or produces a negative influence on important life-course trajectories.

On the other hand, it's important to appreciate the possibility that indirect exposure and its psychological sequelae could lead to positive transformations, such as a greater sense of connectedness to humanity, greater volunteerism and charity, and more tolerance. Those who have made these profoundly positive alterations in beliefs and values as a result of 9/11 have a lot to teach psychologists about the individual differences and contextual factors that produce such growth.

ROSEMARY SCHWARTZBARD, PHD
Private practitioner, Arlington, Va., and APA Disaster Response Network member

In this ever-changing world, we have learned that bad things can happen anywhere, anytime. In working with victims, survivors, relief workers and the general population in and around the Pentagon and Washington, D.C., I have observed that there is an increase in anxiety over issues of safety and security, although many people do not connect their anxiety with the terrorist attacks. Emotions were quite intense for several weeks after the attacks and then the anthrax scare but, generally, that seems to have subsided.

I have been impressed with the remarkable adaptability and resilience of so many people who were directly affected by the attacks. Many people have made changes that they have talked about for years and many seem to be connecting more with friends and family. Just as the Pentagon has been rebuilt in such a short period of time, people are also rebuilding their lives.

Mental health professionals were called on to assist in many roles following the terrorist attacks, from being at the disaster sites to working with families and survivors, to covering hotlines and just being available in their communities to help calm and educate people about the effects of trauma and how to take care of themselves. We, in the Disaster Response Network, continue to work in our communities to try to prepare for future incidents or attacks while, at the same time, trying to learn from our experiences of the past year.

BARBARA ROTHBAUM, PHD
Director, Trauma and Anxiety Recovery Program
Emory University School of Medicine

We went to New York to train therapists in treatment for post-traumatic stress disorder (PTSD) in November and were struck that the therapists were dealing with their own feelings of vulnerability. They wanted to know how to reassure their patients that they were safe when they didn't think they were safe. From our point of view, the similarities of what people were going through following Sept. 11 to what other people with PTSD go through were more important than the differences. People feel very vulnerable. In New York City, people were worried about another terrorist attack and were experiencing what we refer to as exaggerated probabilities of danger. That's part of PTSD. If people have survived a sexual assault, they fear that they will not survive another. The sentiments are similar--the settings are different, and in fact, what they were experiencing was more similar than different.

I think Sept. 11 has made us question what is the proper intervention immediately following trauma, and there have been many discussions about this. This is controversial, and we need more controlled research. There is some evidence from controlled studies that psychological debriefing soon after a traumatic event can impede recovery. People who didn't get it did better years later than those who did, and we want to learn what to do and what not to do.

One good thing that has come out of it is there is more awareness of PTSD and post-trauma reactions now, and education and recognition are good.