Treating survivors of the World Trade Center terrorist attacks of September 11, 2001

As part of an established traumatic stress research and treatment program located in New York City, we experienced the September 11, 2001, terrorist attacks on the World Trade Center first as New Yorkers, but also as professionals with an interest in both treating the survivors and furthering scientific knowledge regarding the neurobiology and treatment of traumatic stress. This paper gives vignettes of calls to our program and the treatment of World Trade Center terrorist attack survivors.     

September 11th,an attack at the limits of thought

The paper deals with imagination and its failures from a psychoanalytic perspective. We offer a definition of imagination failures and suggest how they can be interpreted as an opportunity to learn from experience. In order to show that the topic has a concrete and not only speculative significance we consider the public report on September 11 as a case study. The report was published by the National Commission on Terrorist Attacks Upon the United States after a long investigation of the facts and circumstances relating to the September 11 attacks. The document has been the object of strong criticisms, as we argue in the paper. Both the document and some of the critiques that it received focus, however, on significant aspects of the debate about imagination, such us the fragility of imaginative thought, its dependence on unconscious desires and its plurality of outcomes: a plethora of imaginaries can in fact be developed at any time, from the same set of information about reality. We comment on these aspects and reinterpret them from a Bionian perspective. The concepts of ‘unthinkability’, ‘imagination failure’ and ‘depressive position’ are used to inform the necessity of dealing with an evolving and conflictual geopolitical scenario. Particular attention is paid to the proposal of ‘routinizing, even bureaucratizing, the exercise of imagination’ within the institutions that deal with National Defense. This possibility is discussed in depth in order to suggest how it may be concretely implemented. In conclusion, a strong case is made for the usefulness of psychoanalytic reflection in the arena of relationships among countries, with particular emphasis on the new terrorist challenges.     

Psychological effects of attack on the World Trade Center: analysis before and after

Four different studies using a total sample of 711 from the same New York City student population tested a model that has emerged from previous research on disasters. The model suggests that postdisaster psychological distress is a function of exposure to the disaster, predisaster psychological distress, acute distress following the disaster, time elapsed between disaster and observation of distress, and additional traumatic experiences since the disaster. Although findings replicate those of previous cross-sectional studies regarding association of exposure and distress after the disaster, before and after studies did not detect an effect on postdisaster psychological distress of the World Trade Center attack. Great caution must be used in attributing elevated psychological distress observed postdisaster to the effects of the disaster.     

The flexible application of a manualized treatment for PTSD symptoms and functional impairment related to the 9/11 World Trade Center attack

The purpose of this treatment effectiveness study was to evaluate the flexible application of a manualized cognitive behavioral treatment (CBT) for PTSD and related symptoms in survivors of the 9/11 terrorist attack on the World Trade Center. Treatment delivery ranged from 12 to 25 sessions; therapist experience ranged from no prior training to extensive training in CBT; and training and supervision of clinicians in the treatment manual was considerably less than that required in a randomized clinical trial (RCT). Paired t-tests demonstrated significant pre-post reductions in symptoms of PTSD and depression for the flexible application of the treatment. A benchmarking analysis revealed that the moderate-to-large effect sizes found for these variables were similar to those obtained in an RCT of the same treatment. Furthermore, effect sizes on measures of outcomes particularly relevant to this population of mass violence survivors such as functional impairment, use of alcohol and drugs to cope, and use of social support to cope, were also medium to large.     

Psychological resilience after disaster: New York City in the aftermath of the September 11th terrorist attack

Research on adult reactions to potentially traumatic events has focused almost exclusively on posttraumatic stress disorder (PTSD). Although there has been relatively little research on the absence of trauma symptoms, the available evidence suggests that resilience following such events may be more prevalent than previously believed. This study examined the prevalence of resilience, defined as having either no PTSD symptoms or one symptom, among a large (n= 2,752) probability sample of New York area residents during the 6 months following the September 11th terrorist attack. Although many respondents met criteria for PTSD, particularly when exposure was high, resilience was observed in 65.1% of the sample. Resilience was less prevalent among more highly exposed individuals, but the frequency of resilience never fell below one third even among the exposure groups with the most dramatic elevations in PTSD.     

Forgiving the September 11th terrorists: associations with coping, psychological distress, and religiosity

Two studies examined how non-interpersonal forgiveness (when there is no social relationship between the transgressor and forgiver) related to coping and involuntary responses to stress, psychological distress, and religiosity. Three to six weeks after September 11th, 2001, forgiveness had non-linear associations with other responses to the terrorist attacks. Among college students (N=488), those who were trying or had forgiven (pro-forgiveness) the terrorists reported less involuntary engagement, more primary and secondary control coping, and more meaning finding than those who were unsure about forgiveness (ambivalent) and those who did not believe the perpetrators should be forgiven (anti-forgiveness). Ambivalent students reported the most distress, even after controlling for religion. Anti-forgiveness students reported less religiosity than ambivalent and pro-forgiveness students. Most findings were consistent among middle schoolers (N=154), particularly regarding psychological distress and responses to stress. Also, forgiveness of strangers for acts against one's community functioned separately from religion.     

The World Trade Center Disaster and the Apocalyptic

A discussion of the apocalyptic dimensions of the World Trade Center disaster, this paper considers some first-hand reports of the towers burning and collapsing, as well as the author's own experience that day watching events unfold and discussing these horrors with his patients. Several conceptual ideas are developed, including the varied ways people experienced the disaster in terms of “zones of sadness”; the organic nature of the way the disaster unfolded; the language of the victims in terms of underlying rhetorical structures of response; and psycho-historical considerations that suggest, in part, why the disaster was such a collective trauma.     

Psychological sequelae of remote exposure to the September 11th terrorist attacks in Canadians with and without panic

The purpose of the present investigation was to examine the psychological impact of remote exposure to the events and aftermath of the terrorist attacks in the USA on September 11th, 2001, and to assess what differences, if any, exist between individuals classified with probable panic disorder and those without. Telephone interviews were conducted with 122 residents of the capital city of the Canadian prairie province of Saskatchewan in spring 2002 in order to gather information regarding current mood, fears and avoidance behaviours as well as current post-traumatic stress disorder symptoms specific to September 11th. Consistent with previous findings and despite the remote nature of exposure, results indicated that the psychological well-being and behaviour of participants with probable panic disorder was more adversely affected by the events and aftermath of September 11th than those without panic disorder. These results suggest that remote viewing of traumatic events can have a significant and lingering impact on psychological well-being and behaviour and that these effects are more pronounced in those with panic disorder. Implications of the findings and future research directions are discussed.     

Psychological sequelae of remote exposure to the September 11th terrorist attacks in Canadians with and without panic

The purpose of the present investigation was to examine the psychological impact of remote exposure to the events and aftermath of the terrorist attacks in the USA on September 11th, 2001, and to assess what differences, if any, exist between individuals classified with probable panic disorder and those without. Telephone interviews were conducted with 122 residents of the capital city of the Canadian prairie province of Saskatchewan in spring 2002 in order to gather information regarding current mood, fears and avoidance behaviours as well as current post‐traumatic stress disorder symptoms specific to September 11th. Consistent with previous findings and despite the remote nature of exposure, results indicated that the psychological well‐being and behaviour of participants with probable panic disorder was more adversely affected by the events and aftermath of September 11th than those without panic disorder. These results suggest that remote viewing of traumatic events can have a significant and lingering impact on psychological well‐being and behaviour and that these effects are more pronounced in those with panic disorder. Implications of the findings and future research directions are discussed.     

The Effect of September 11th on Job Attribute Preferences and Recruitment

This paper considers the effects of the September 11^th attacks on job attribute preferences and recruiting strategies. A survey was conducted with firms (n = 46) and college students (n = 138) in the New York, New Jersey, and Pennsylvania area. Results indicate 91% of firms believe the attack changed the job attribute preferences of students. The corresponding survey given to college students indicates that 60% of the students say the attacks would not have an impact on their preferred job attributes.     

Recognizing Anxiety Disorders in the Aftermath of the World Trade Center Crisis

This article seeks to educate the reader on how to recognize the presence of anxiety disorders as they occur in the church community. The author uses medical information, Scriptural wisdom and a case illustration to help concerned Christians to assist sufferers in getting appropriate care. Anxiety disorders in the aftermath of the World Trade Center trajedy will be on the rise and the paper addresses this matter particularly for clergy, caregivers and professional counselors.     

Coping and anxiety in college students after the September 11th terrorist attacks

This study investigated the presence of a stress response after the September 11^th terrorist attacks in a sample of indirectly affected college students living in Boston, Massachusetts. Anxiety was examined at two time intervals, approximately 2 and 4 months after the attacks. Methods of coping with the stress of the attacks (assessed using the COPE Inventory) and their impact on initial and longer-term anxiety were also examined. Results demonstrated that the majority of college students in the study were severely psychologically impacted initially by the terrorist attacks. However, this initial impact appears to decay over time for most people. Several potentially maladaptive coping strategies were found to be predictive of initial anxiety, including denial, behavioral disengagement, mental disengagement, and focus on and venting of emotions. However, only focus on and venting of emotions was found to be uniquely predictive of longer-term anxiety.     

Studies of the vicarious traumatization of college students by the September 11th attacks: effects of proximity, exposure and connectedness

From mid-October 2001 through the end of November 2001, we collected fairly large sets of questionnaires from undergraduates at three public universities (Albany, NY, n = 507, Augusta, GA, n = 336, Fargo, ND, n = 526 ) to assess rate of acute stress disorder (ASD) and level of ASD symptoms following the September 11th attacks, rate of current posttraumatic stress disorder (PTSD) and level of PTSD symptoms, and current level of depressive symptoms resulting from the September 11th attacks. We also gathered information on exposure to media coverage of the attacks, connectedness to the World Trade Center (WTC) and personnel there, and degree of engagement in reparative acts such as giving blood, attending vigils. We found higher levels of ASD, ASD symptoms, PTSD and PTSD symptoms as a function of geographical proximity to New York City (and within the Albany site, proximity of students' homes) and gender. Exposure (hours of TV watched) was a predictor in some instances as was connectedness to WTC victims. ASD symptoms were the strongest predictor of subsequent PTSD symptoms. Path models accounted for over 60% of the variance in PTSD symptoms.     

Social categorization and fear reactions to the September 11th terrorist attacks

Two experiments were run in The Netherlands and Belgium 1 week after the terrorist attacks against the World Trade Center in New York on September 11, 2001. The aim was to investigate whether social categorization affected emotional reactions, behavioral tendencies, and actual behaviors. Results showed that focusing participants' attention on an identity that included American victims into a common ingroup led them to report more fear and stronger fear-related behavioral tendencies and to engage more often in fear-related behaviors than when victims were categorized as outgroup members. Results are discussed with respect to appraisal theories of emotion and E. R. Smith's model of group-based emotions.     

The Treatment of Children Impacted by the World Trade Center Attack

Abstract

This article presents, from a developmental perspective, the authors' experiences treating children and families who were traumatized by and who lost relatives in the World Trade Center attack. The treatments took place within the Trauma Treatment Development Center, National Child Traumatic Stress Network (NCTSN) of the Division of Child and Adolescent Psychiatry, North Shore University Hospital, Manhasset, New York, of the North Shore-Long Island Jewish Health System. Case vignettes address treatments for toddlers, preschool, and school-age children and adolescents. Family, individual cognitive-behavioral, school, social, and parenting treatment strategies utilized are discussed.     

Follow-up of a cross-national comparison on flashbulb and event memory for the September 11th attacks

Flashbulb memories are defined as vivid and long-lasting memories for the reception context of an important public event (Brown & Kulik, 1977). They are supposed to be triggered by both emotional reactions to the original event and rehearsal processes (Brown & Kulik, 1977; Finkenauer, Luminet, Gisle, El-Ahmadi, van der Linden, & Philippot, 1998; Neisser & Harsch, 1992). A test-retest design (21 vs 524 days after the event on average) was employed to assess flashbulb memory and event memory for the September 11th attacks and the impact of their emotional and rehearsal predictors in a sample of 985 respondents coming from six countries (i.e., Belgium, Italy, the Netherlands, Romania, Japan, and the USA). Results showed that national membership had a significant impact on event memory, and the emotional and rehearsal variables, but flashbulb memories for the September 11th attacks were found to be high and consistent across different countries. The implications of these findings for the debate about the nature and maintenance of flashbulb memories are discussed.