TERRORISM and PTSD

Resources for Clinicians

It was a few minutes before 9 AM on September 11, 2001, and like many typical days I was in my office returning calls and completing paperwork prior to the arrival of my 10 AM patient, when I received a call from my husband informing me that a airplane had crashed into one of the towers of the World Trade Center (WTC). While he was describing the incident to me, he saw on TV the live newscast of the second airliner crashing into the other tower. At this point we both realized the horrible implications of this disaster. Within minutes all television networks were reporting the shocking breaking news. When I conceived and established the New York State Psychological Association Disaster/Crisis Response Network in 1990, I had no idea that we would be responding to such a terrible tragedy on our own home grounds, but felt gratified that we had a database of over 250 trained psychologists in NY State alone to respond to this tragedy.

New York has certainly had its share of disasters including the Persian Gulf crisis which impacted many New York families for nearly nine months, the 1993 WTC bombing, the Long Island Railroad shooting, the ripple effect of the Oklahoma City bombing, TWA 800, the many bomb scares following the school shootings across the country, and now the WTC disaster, the largest terrorist attack in the history of the Unites States.

It was not unusual in the last few years when a disaster/crisis occurred, especially in the wake of TWA 800, for some of my patients to call me to see if they should keep their appointments, with some even offering not to come in that week, as they felt others who were in crisis were more in need of my support. However, this was not the case with the WTC tragedy as all my patients kept their appointments that day. In fact, in the week following the tragedy all but two patients kept their appointments. With each session I heard updates from my patients about the horrific news of the collapse of the Twin Towers that day. Some of my patients had friends or spouses who worked in or near the WTC. It was a very difficult day and while much was uncertain, the death toll was sure to be in the thousands and the survivor victims would be many times that amount.

In the long weeks following the tragedy, I listened to many personal versions of this enormous tragedy. I listened to horrific details recounted by some, including one patient who barely escaped from the 88th floor of the WTC, just making it out of the building minutes before it collapsed. She was running down the street just ahead of the mushroom explosion of glass and debris and fortunately was pulled into a store seconds before the black debris filled cloud hurled down the street. My patient lost many co-workers and also recalled passing the firefighters running up the tower as she and others were running down. She can still recall the face of a firefighter who was advising women to take off there shoes when running down the stairs, but to be sure to take them with them due to the glass and the metal shards on the lower floors. She knew the firefighters never made it out of the building.

She also described the horrific sight of a woman running down the corridor screaming, whose skin was burned off and charred black. The sight of bodies along the way and the remains of those who jumped from the upper floors, whose bodies were only identifiable as people by their tattered clothing, will stay with her indefinitely.

Therapy sessions were punctuated by calls from other therapists for advice, consulting, and support. Being both at the front-line in Manhattan, as well as, the home-line for my patients was a unique experience, which is probably only shared by mental health professionals who had victims of the Oklahoma City or the 1st WTC bombing already in their practice at the time of these tragedies. My specialty in trauma was eerily apropos, and as one patient described it, perhaps, it was destiny that she had previously been referred to me.

My experiences in responding to the 1st WTC bombing, the Long Island Railroad shooting, the TWA 800 explosion, and many natural disasters have vividly shown me the dramatic changes in the public’s perception of the impact of trauma and the value of psychological intervention. The recognition of the psychological impact of trauma on “normal” people has, in part, been the basis for a rapidly growing acceptance of psychology in everyday life.

The mental health response to disasters and crises has undergone enormous change in last decade. Initially, when I first suggested (1990) the need for intervention for the public (as police, fire, an emergency personnel had already some form of psychological debriefing and intervention) even my colleagues were skeptical. The recommendation for a statewide volunteer disaster response network passed the NYSPA Council with a lukewarm reception and support. However, in the wake of the Persian Gulf crisis, APA was sending brochures to communities and psychologists to help the families of service personnel. Having recognized the need for trained psychologists, I proposed the formation of a national disaster response task force to the head of Special Projects at the Practice Directorate (PD) in 1991. Six weeks later I was informed that the PD was forming a task force and recruiting representatives for each of the regions across the nation. I was invited to serve as the northeast representative.

At that time very few psychologists had training in trauma and even fewer had on-site experience in responding to acute stress. At that time, in New York, we were developing and conducting many disaster/crisis response trainings. I developed various training programs, including one on Trauma Psychology. It should be kept in mind that acute stress disorder was not included as a classification until the DSM-IV. This only came about due to those involved in crisis intervention repeatedly pointing out the need for a conceptual classification that addressed the first few weeks of stress, not just PTSD after the first month. The classification also served the practical purpose of providing insurance coverage in this early stage.

Linking acute stress and early intervention along a continuum that recognized the need for ongoing and even long-term intervention for those individuals who did develop PTSD, was the purpose of my beginning to use the term “trauma psychology” as an umbrella term to describe this evolving specialty.

Trauma psychology includes short-term crisis intervention, sometimes referred to as critical incident stress management, based on a psycho-educational model to provide psychological first aid. The goals of critical incident stress management are education and assessment, reduction of the impact of the critical event, and accelerating the recovery of normal people experiencing painful but normal reactions to an abnormal event.

Recognizing the need to educate the public about short and long-term trauma was the basis for my long-standing work with the news/mass media. I believe that mass media is one of the most effective ways to reach large segments of the public and society. I am privileged to have had the opportunity to participate in the first live news coverage following former President Clinton’s radio talk with children following the Oklahoma City bombing. The telecast included a segment on psychological coping, and highlighted the importance of addressing the emotional well-being of all people.

I had the opportunity to collaborate and participate in the first news segment (Dateline NBC) on long-term trauma following the Jonesboro school shootings. This news program demonstrated the ability to convey sophisticated psychological concepts to the public through the news media. I believe that the on-going communication of helpful information to the public demonstrated the benefits of intervention and has contributed to the rapid evolution of the specialty of trauma psychology.

The communication of this information to large segments of the population has resulted in the development of crisis response teams by many organizations such as hospitals, schools, EAP’s, etc., which on the positive side is very helpful to the public. On the negative side, crisis intervention has become very trendy with some mental health professionals responding without adequate training. The need for extensive psychological intervention in the wake of the WTC disaster will create a great challenge in balancing the need of providing sufficient psychological intervention, while maintaining high standards of training. Reports of inappropriate psychological intervention, no matter how well-intentioned, will serve to undermine our credibility and the public’s perception of the value of psychological services.

In the years to come the interrelationship between public education and the public perception of psychology’s value, and the growing specialty in trauma psychology will continue to impact the future direction of our discipline.