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Coping Mechanisms and Post-traumatic Stress Reactions: Life after September 11, 2001
From: Columbia University
| By:
Randall D. Marshall |
EDITOR'S INTRODUCTION |
The September 11, 2001, events were the largest terrorist attacks to have occurred on US soil to date. Mental health workers around the world responded by increasing support services for  affected individuals in the aftermath of these attacks. Researchers will use these events to learn more about long-term effects that this form of large-scale trauma can have on local, national and international communities.
There is a wide range of reactions to traumatic events, according to Dr. Randall D. Marshall. Sorrow, grief, fear, confusion and anger are all natural feelings for adults and children alike. In this interview conducted on September 22, 2001, Marshall, associate professor of clinical psychiatry at Columbia University's College of Physicians and Surgeons, discusses the differences between manageable, acute and chronic stress reactions and reflects on the natural healing abilities of local communities. |
Fathom: Is it possible to predict the impact that the September 11 terrorist attacks will have in the US and around the world? |
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| Colored flags that lined the streets around the Armory, a family center for relatives of people missing in the terror attack on the World Trade Center. | |
Dr. Randall D. Marshall: On September 11, 2001, New York City was changed irrevocably. I was out of town at the time and awoke to the horrific scene on television. Like many New Yorkers both in and away from the city, I kept watching the television while immediately trying to reach family, friends and colleagues. There were hours of mounting fear for many of us because cell phone services and telephone lines were down or jammed. As we all know, thousands never saw their family member, friend or colleague again. |
The mental health field knows quite a lot about psychological responses to devastating events from research in other countries and on different kinds of catastrophic events, including the Oklahoma City bombing. But we do not know enough about the effects that this scale of terror in the United States will have on local, national and international communities. |
The destruction and the numbers of deaths from the September 11 events are orders of magnitude larger than any other terrorist incident that has happened in the United States. In the Oklahoma City bombing, for example, 168 people were killed. Estimates of those killed in New York City are upwards of 6,000. In addition, tens of thousands more have been affected through loss of colleagues, loss of friends and through witnessing the events from near or from afar. In Hoboken, New Jersey--located just across the Hudson River--crowds of people watched the World Trade Center towers collapse while fighter jets flew overhead. These levels of exposure to a disastrous and traumatic event are unprecedented in the US. |
Fathom: Can mental health workers and stress counselors draw lessons from research that focused on reactions to the 1995 Oklahoma City bombings? |
Marshall: The Oklahoma City bombings offered opportunities for some of the most sophisticated studies to date on the consequences that a terrorist attack within the US can have on the general public, rescue workers, children, affected families and individuals. Many of the lessons learned from the Oklahoma City studies can be used to estimate the effects that the September 11 terrorist attacks will have, such as rates of PTSD and depression in those directly exposed. There are many other studies as well conducted both within and outside the US. |
Fathom: Is it natural for people who were not directly exposed to a traumatic event, such as the attacks on September 11, to feel grief or a sense of loss? |
Marshall: Most people in New York City, around the US and around the world are having an understandable, human reaction to these horrificevents. This is a very important public health message, so that individuals are not frightened by the intensity of their reactions. No one could have been prepared to cope with something like this. If one feels overwhelmed, it isn't necessarily a bad sign. These feelings can still pass, in the same way that one can be temporarily overwhelmed by grief over the loss of a close friend or relative, but then gradually return to daily life over time. |
Fathom: People around the world are impacted both directly and indirectly by the events that occurred on September 11. What is the range of reactions to this event? |
Marshall: Typical reactions for people who were not directly involved or exposed can include: insomnia, heightened levels of anxiety, increased vigilance, a concern for the welfare of people they know and love, a need to feel more connected with and in closer contact with their core community, emotional lability or instability and difficulty concentrating. |
People also are experiencing all kinds of fears related to going back to work, to flying, to being in tall buildings and to being in large crowds of people. These particular fears are fed by awareness of the kinds of places that are often targeted in terrorist attacks around the world. |
For those people who were directly exposed--meaning the tens of thousands of people who escaped the Pentagon or the World Trade Center, those who were working nearby, and especially the emergency, fire, police and construction workers involved in the rescue and recovery efforts, the range of reactions can be much more severe. These more acute reactions can include: re-experiencing of images, intrusive thoughts and images of what was seen or heard, nightmares, an impulse to avoid being reminded of the events, and sometimes a compulsion to repeatedly talk over and ruminate on what has been experienced. |
Emotional numbness and shock, difficulty concentrating, irritability, a dramatically-heightened startle response and, of course, tremendous grief are also known to be reactions to severe trauma that can pass over time. It is also important to note that the stronger the initial reaction, the greater the risk for developing longer-term problems. Many factors are involved though, so we cannot predict with certainty who will recover with the help of friends and family and who will need more help. |
In the same way that a grief reaction or mourning period over the loss of a loved one is overwhelming at first but then gradually passes--not that you forget about the loss; you don't forget what happened but you do somehow find a way to live with the memory--in ideal circumstances people will gradually be able to adapt and move on with their lives. In fact, trying to return to a normal routine after a traumatic event is a positive coping strategy. |
Fathom: What are some examples of community responses to the September 11 events, and can local discussions and initiatives help facilitate a natural healing process? |
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| Flowers, photos and candles were placed in Union Square, New York City, as a temporary memorial to those lost in the September 11 terrorist attacks. | |
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Marshall: It has been profoundly moving to see so many diverse communities come together the way they have in New York City. And it isn't restricted to local communities, it's the whole nation. This is the ideal response to a catastrophe. |
At the New York State Office of Mental Health, there were calls coming in from all over the country and the world. For example, a clinician called to say, "My department has pulled together some money to send me out there to help. Where can I go and what should I do?" Hundreds of people, including mental health professionals, worked long hours volunteering in whatever way was needed. |
In the city itself, there are marches, groups of people gathering for vigils, for memorials, for debates and for discussion, which I think is very important. In Union Square, there are memorials, hundreds of candles, at least a thousand origami cranes built up into a tower, and hundreds of pictures of the missing. But there was also great music: slow jazz like at a New Orleans wake, and people dancing solemnly, like in ritual dance. These reactions are quite remarkable and show the whole human range of a community's response to catastrophic events. |
These types of local events, we think, encourage the process of natural healing and emphasize that there are many different coping styles. For example, some individuals cannot watch news coverage with graphic pictures because at this point they find it damaging. Others are following the stories avidly as a way of coping. |
I also have patients who have histories of depression and anxiety and psychotic reactions, and I have advised them that if they find themselves dwelling on the traumatic events, they should stop watching the television coverage and talk about the events only as they feel able. These individuals were totally overwhelmed with the symptoms that were being evoked by the images of the tragedy. |
Fathom: Are children affected by these events? |
Marshall: After the Oklahoma City bombing, children who directly witnessed the events or were directly affected showed very high rates of post-traumatic stress disorder (PTSD) several months later. In addition, children were also more likely to develop PTSD if they had a friend or knew a child who was killed or who was profoundly psychologically affected by the events. What was most remarkable however was the finding by Betty Pfefferbaum and others, reported in the November 1999 Journal of the American Academy of Child and Adolescent Psychiatry, that even among children with no direct loss at all, 58 percent reported worry about self or family seven weeks later. |
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| A young girl lights a candle at the temporary memorial in Union Square, New York City (September 2001). | |
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Controlling for all the other factors, we learned that the more graphic television children watched, the worse they did. The other important factor to know is that children who were most affected by the trauma actually were more likely to be exposed to or to repeatedly watch news footage, as Pfefferbaum noted in an article in The American Journal of Psychiatry in 1999. This should be a cautionary note to parents, I think, as part of screening appropriate and inappropriate television viewing. |
Fathom: Should adults try to talk to children about the September 11 attacks? |
Marshall: There are divergent views on this, and again there is no "one size fits all" piece of advice. Many child psychiatrists have said it is important to discuss your child's thoughts and reactions to the event because this is an opportunity for parents to have a positive influence on their child's coping mechanisms. I doubt if it has been possible to shield any child from knowledge of what has happened if the child has any interaction with peers, for example. So the first step is to ask your child what he or she is thinking and feeling about what happened. Have a talk about your child's perspective on the event. Any kind of discussion should come with the message that the child is loved, as this is a primary source of security. |
If close loved ones and family members are safe, you can remind your child of that. "This is a terrible thing that has happened, but we are safe and you are safe and we are going to get through this." |
If the parents are deeply affected or upset by the events, they should not feel badly about revealing their emotions or sadness in front of their children. It is simply human. Dr. Robert Pynoos recommends that parents should be straightforward with their children while trying to manage their own reactions, but they should not be alarmist. For example, a father could say, "Daddy is upset about this event, too, but we are going to get through this together. I am going to be okay, it is just going to take some time." Telling a child that "everything is fine" when the child can plainly see this is not true can be particularly upsetting and confusing. |
Fathom: Should people be encouraged to talk about the September 11 events and the effects that those events have had and will have on their lives? |
Marshall: This is very important. Each individual needs to recover at his or her own pace. There was a well-meaning approach that had been developed called Critical Incident Stress Debriefing that has been practiced for a few years. We now know that this is not effective for preventing PTSD and can, in fact, be harmful after a traumatic event, although it can be helpful in many other situations. The debriefing involves an extremely intense, structured, detailed review immediately after an individual's exposure to trauma in which the individual is encouraged to talk about what he or she saw and experienced. |
A more flexible approach in which people can talk or not, attend sessions if they want to and go at their own pace, is considered a much better approach by many experts in the field. It is important that someone's reaction is not being protracted by forcing a style of coping onto them that doesn't suit their personality and culture. I talked to an individual who was coping fairly well until he went through a rigid debriefing session, after which full-blown PTSD symptoms emerged. |
There are important cultural differences in how people cope with stress and trauma. For example, there are some languages with very few words for negative emotion, and cultures in which negative expressions are strongly discouraged. In some cultures there is the belief, perhaps superstition, that talking about bad things can actually make more bad things happen. Even in Western cultures, the literature is unclear as to whether talking about the events actually is protective, so we are advocating that individuals use whatever coping method seems right to them. |
From the mental health perspective, the question is at what point does avoiding talking become psychological avoidance, which has been a predictor of developing chronic PTSD. Avoiding dealing with a trauma rather than processing it can lead to long-term problems. |
Fathom: Are certain people at greater risk for developing long-term, acute stress reactions to traumatic events? |
Marshall: We are not able to identify with certainty those individuals who are going to develop a chronic problem and those individuals who are likely to recover on their own with the support of friends, families and their communities. There are risk factors, however. It is important to remember that these risk factors are part of a statistical model, because someone can have several of these risk factors and still manage to cope well. |
Somebody with a history of mental health problems, such as anxiety, depression, substance abuse or psychotic illness, is potentially at risk for relapse and for PTSD. Someone with a family history of mental health problems can also be at risk. In addition, individuals who do not have a strong support network may be at risk. |
There is also an increased rate of suicide among individuals with depression and PTSD. Our recent study published in the September 2001 American Journal of Psychiatry found that there was increased risk of suicidal thoughts with each additional PTSD symptom, even if the individual did not meet full criteria. |
It is important that professional and local communities are aware of these risk factors. Lay people also want to know when a friend or family member may need professional help or counseling. I spoke to someone who said, "My friend is devastated by what happened in New York City, and she feels guilty for being so upset. How can I help my friend?" |
The overall intensity of someone's reactions--anxiety, fear, dissociation (meaning such experiences as feeling numb, outside one's body, experiencing reality as altered or distorted in some way) and depressive reactions--are predictors of whether that individual may need professional help. |
Fathom: Can you say more about how professionals can know when an individual's post-traumatic symptoms are chronic? |
Marshall: In addition to the above, the most important factor in predicting chronic problems is how severe the individual's exposure was. In the September 11 case, witnessing the events, the loss of a loved one or colleague, or being involved, somehow, in the rescue crisis or crisis-counseling efforts could greatly heighten an individual's reaction to the events. On this last point, mental health workers should also be mindful of their need for support as they go about the business of helping others. |
Post-traumatic stress reactions are divided into three categories. The first is acute stress reactions. When this reaction is very severe it is called acute stress disorder, which is similar to severe PTSD but with dissociative symptoms as well. After 30 days the diagnosis changes and it officially becomes acute PTSD. |
Three months later the symptoms are diagnosed as chronic PTSD. After three months, the symptoms can begin to consolidate into a chronic problem. This time period is a useful measure of the need for intervention because several longitudinal studies have shown that if someone meets criteria for PTSD after three months, that individual is at very high risk for having PTSD at one year. |
It is very important to realize, however, that we are not just expecting increased rates of PTSD. Traumatic bereavement, major depression, relapses of anxiety and depression, as well as relapse of substance abuse, are all associated with large-scale disasters. |
Fathom: Do individuals who suffer from an acute stress disorder always develop acute or chronic PTSD? Are there specific interventions that help improve an individual's ability to cope with acute stress? |
Marshall: There are new counseling techniques that have been shown to accelerate the process of normal recovery, as well as prevent long-term PTSD. Dr. Edna B. Foa at the University of Pennsylvania and Dr. Richard A. Bryant at the University of New South Wales in Australia head up two major research centers that have studied these successful interventions. |
These studies show that if you can intervene with people who are having very severe reactions to trauma early on, you can greatly accelerate the rate of recovery by several months. For the most severe stress reactions, some studies show that early intervention programs can actually reduce an individual's risk for developing PTSD by a considerable percentage. |
Typical interventions include four sessions of fairly intensive treatments that are focused on normalizing the reaction to the trauma, teaching coping skills to affected individuals and helping the individual tell the story of what was actually experienced. |
In fact, when analyzing differing reactions to trauma, it is important that people are not labeled as either symptomatic or "fine." Intervention programs attempt to facilitate the body and mind's natural healing processes. |
One analogy is the use of antibiotics: most individuals would recover from a bacterial infection without an antibiotic, but an antibiotic can reduce the length of illness from, say, three weeks to four days, as well as decrease the risk of a worse outcome. In our study, mentioned above, with a very large sample of approximately 9,000 people who attended National Anxiety Disorders Screening Day, we showed that sub-threshold PTSD symptoms were also associated with high rates of suicide, depression, disability and other psychiatric problems. So PTSD should probably be considered a dimensional disorder, rather than a binary category. Previous research also supports this view. |
Fathom: What are some of the available treatment options for those individual's who do develop acute or chronic PTSD? |
Marshall: We know a lot more about chronic PTSD treatments than we do about acute PTSD treatments and reactions, because historically that is how the research was focused: the first studies were focused on people who had experienced PTSD for many years, of which there are millions in the US. |
In terms of psychotherapy, there are several validated brief-term psychotherapies that are a mix of psycho-education, anxiety coping skills, and supportive and cognitive behavioral models. These are difficult treatments to conduct. Because of the intensity of the emotions involved and the structure of the treatment, these treatments are best conducted by a well-trained professional. The literature on these treatments is well-established, although not many clinicians are well-trained, yet, in these techniques. The research and services community hope to rectify this situation as quickly as possible in NYC. |
There are also several medications available to treat PTSD. Zoloft has been officially approved by the Federal Drug Administration (FDA) in the US. That in itself was a remarkable effort because up until very recently, PTSD was really considered a quintessential psychological disorder. We now know, however, that PTSD is associated with a range of biochemical alterations in the body and brain, so that it is rational to consider a medication to stabilize or correct those alterations. Other large studies with similar medications such as Prozac and, most recently, Paxil, have also been positive. And other types of medications were previously shown helpful. |
Fathom: Are psychiatrists preparing for the long-term impacts that the September 11 events will have on the New York City community? |
Marshall: Mental health professionals in New York know that there are going to be long-term consequences in the aftermath of this problem and we are preparing to handle those. Collaborations and relief efforts are already in progress at the federal, state, city, local hospital and community levels. |
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