When Joyce Boaz of Gift from Within requested the following article, we both hoped to find a way to assist those affected by the events of September 11. We hope that this article makes clear that it is normal to have any number of a wide range of thoughts, feelings and reactions in response to the terrorist acts of that day. In addition to the individual nature of response, people react to and recover from such experiences on different timetables. The article covers issues related to possible reactions, risk factors, intensifiers, and other issues that may arise. It presents methods of psychological first aid, self care, finding assistance, and talking to children about what happened. A brief description of traumatic grief, ptsd, and reenactment issues are provided. Joyce has added a list of resources for additional information. We hope that it will be the first of a group of helpful articles and that it will be of assistance to those who are responding in their individual ways to these events.
Kathleen Nader, D.S.W.
September 21, 2001
On September 11, 2001, terrorists hijacked four commercial airplanes. Two planes were used as missiles to destroy two towers in the World Trade Center. One plane crashed into the Pentagon. One, crashed into a field in Pennsylvania. This horrible tragedy resulted in the loss of thousands of lives, treasured structures, cherished beliefs and a valued sense of ongoing safety. As a nation, we shared shock/disbelief, horror, fear, sadness, grief, despair, anger, rage, worry, stress, and/or the need to take action. In addition, we have each been affected in an individual way by this tragedy.
Heroes have and will emerge. We can all become heroes by courteously and sensitively helping ourselves to recover, helping each other to recover, enhancing the safety of all, and, when possible, finding ways to act that make life better now and over time.
Psychological First Aid 1
- In all cases, behave responsibly
- Restore equilibrium
- Recognize the impact of this event on current functioning
- Act to restore equilibrium without overuse of avoidance or denial
- When reasonable, postpone major life decisions until stress is reduced and equilibrium restored
- Acknowledge and appropriately process grief, pain, anger, etc.
- Seek needed assistance
- Take good care of body, mind, and spirit
- Be safe; make certain that others are safe
- Take care of physical first aid and recovery needs
- Rest/soothe mind and/or body when needed
- Eat and exercise appropriately
- Enhance emotional well-being
- Find support (from friends, family, a counselor, clergy, or a therapist)
- Show support
- Find peace and quiet when needed
- Engage in uplifting activities
- If/when able, take positive action
- Do things that you know will be helpful to yourself
- When welcomed, do things that will be helpful to others
- Rally around loved ones and those who are suffering
- Restore safety
- Offer your efforts and/or resources
- Influence decision makers with sound and kindly delivered advice
- Make positive change
- When emotionally and physically able, reassess (what needs reassessing)
- Change what should and can be changed
1 Professional and nonprofessional helpers, civilian and military, individuals and families alike have reacted to the events of September 11. This paper is addressed to all of them in honor of those who died, those who survived, and those who will be called to serve. We are a nation of survivors.
We have been inundated with painful images and stories. Concerns such as those regarding the dead, the injured (physically and/or emotionally), future vulnerability, the need to strike back, business losses, costs of restoration and protection, and more fill our thoughts and are regularly discussed in the media. The stresses have been unrelenting. The danger has not ceased. We wonder about the threat of another terrorist act. In New York there is continued danger from building debris, rescuer overwork, and other aspects of the cleanup process. For a long time, we hoped that people remained alive under the debris.
Many people have experienced varying levels of overload. A sense of being overwhelmed may result and may manifest as numbness, exhaustion, confusion, irritability, ready tears, anger, withdrawal, unexplained smiles or laughter, jokes (dark humor), or immobilization. Good self-care is essential. Methods used to recover from overload will vary for different individuals: a bath/shower, nap/rest, meditation/prayer, walk/run, drive/ride, organizing things, making a mess, absorption in a movie/game/task, peaceful and/or pleasant activities, looking at beautiful sights, removing irritating images, listening to specific sounds (music/water/ocean/birds), a massage, hot beverage, singing, crying, yelling, talking to a silent listener, solitude, people… As communities we have come together to show patriotism and mutual support. Neighborhood groups have gathered to light candles, cry, sing patriotic songs, commiserate, talk about what might happen or needs to happen. On the one hand, support is important. On the other hand, recovery must be an individualized experience.
As well as restoring safety and health (physical, mental, emotional and spiritual), it will be important to restore balance and a newly defined normalcy. For most of us, some issues require immediate attention (for example, safety and emotional recovery); other issues (for example, evaluating beliefs and practices) must wait until some recovery occurs. Faulty decisions can be made when overwhelmed or emotionally distressed. When reasonable, some decision-making will need to be postponed until after stress reduction. Decisions will be made by each individual about when to watch and listen, when to take action and when to rest. Decisions must be made about when to be alone and when to be among others; whether to seek support or also to seek counseling. We must determine when and where to be more cautious. For example, airports have already increased security measures. We will be confronted with finding balance in our protective reactions. For example, recognizing the line between reacting to deter assault or oppression and becoming the oppressor; recognizing the difference between reacting wisely and reacting without assessing long-term consequences.
Accepting Varied Reactions
Specific reactions as well as stress levels, grief, and trauma will differ based upon our individual experiences of the event, associations with those directly and indirectly affected, our past histories, cultures, belief systems, biochemical and physiological make-ups, temperaments, personalities, and the potential for long-term personal impact. The directly exposed, those whose loved ones died or were endangered in these events, and individuals with particular risk factors may be experiencing trauma, grief, traumatic grief, anxiety and/or other symptoms (see “Following Traumatic Events”). For those who have had previous traumatic experiences, symptoms may be reawakened by these events. Guilt or grief may complicate reactions or increase symptoms (see “Following Traumatic Events,”).
Multiple responses are likely. Individuals are unique and will respond uniquely. Although some responses may be the same for many of us (e.g., sadness, concern), their sources and manifestations will differ. Some people will seem unaffected by this experience. Because the events happened at a distance and/or did not affect them personally, some people may feel little hindered or will feel reassured of their own safety. Some people are numb or shocked and may have a delayed response. Some individuals endure their pain silently. Some people may feel elated or relieved by having survived the worst. Some individuals will feel irritation and annoyance because of the inconveniences that have and will occur as results of these events. Some will be irritable as a part of their stress reactions. Many will, at some point, experience some form of regression (see “Regression”). Some, whether or not directly affected, will have cried and/or suffered with every new detail or every new testimonial because of sympathy, present or past experiences, current circumstances and/or personal makeup. Some will see the horrific images every time they close their eyes. Some individuals will be immobilized.
Reactions will occur in many variations and on many points of a continuum from one extreme to another. People may vary their behaviors under differing circumstances. For some, this experience has been and will be uniting. For others it engenders a sense of separateness. Some will become more faithful and spiritual. Others will become more doubtful and question spiritual beliefs. Some will use this as an opportunity to rethink their lives and beliefs. Some will better appreciate their lives. Some will become disorganized. Others will become organized. Many will have a variety of thoughts regarding children, their ongoing safety, and their growth and development. It is essential to remember that different people will react differently and on different timetables.
Recognizing Vulnerability to Traumatic Response
In general, anything that reduces emotional distance or increases emotional involvement in what happened, may increase a person’s vulnerability and reactions. Among those who are particularly at risk are people who experienced the sights, sounds and smells; who felt the horror; whose relatives, friends, coworkers or rivals were endangered, killed or injured; who were previously traumatized; who have had mental health difficulties in the past; who have had specific, now unresolvable, interactions with someone killed in this event; or who have personalities or temperaments that make them particularly sensitive to the effects of a horrific tragedy. Studies suggest that individuals exposed to a violent event are at risk of experiencing increased symptoms if their parents have been previously traumatized (Nader, 1998; Solomon, Moshe and Mikulincer, 1988).
The Previously Traumatized. Those who have had previous traumatic experiences (e.g., exposure to violence, disasters, severe accidents) may reexperience thoughts, emotions, symptoms, and arousal levels associated with their original experiences. This event may serve as one more confirmation that the world is not a safe place or that it is difficult to know whom to trust. It will often result in the need for additional therapy to process the interplay of this event and the past experience(s).
The terrorism of September 11, 2001 has affected those who were previously traumatized in a number of ways. It may have amplified or reawakened traumatic emotions (such as fear, rage, depression, helplessness, anxiety, hypervigilance, fatigue, startle, distrust, poor concentration, stress, arousal, and horror…). It may have immobilized some of the previously traumatized as well as some exposed only to this event. Although the topic of facing old demons will be discussed in more detail in another article, a few examples may demonstrate the intensity and nature of the interaction of previous trauma and this event2 . Fran had been drugged, brutally assaulted and heavily scarred physically and emotionally. She was enraged at a government that gave money to countries that housed terrorists, a government that has itself attacked innocents. She was struck with the question,” Who will protect the innocents?”. This event left her even more enraged at the police who made her feel dirty and crazy and who never found her attacker. The danger is/was still out there. She felt unprotected and unassisted by doctors and mental health professionals as well. Her adrenalin was pumping amplifying her sense of rage and fear and the need to strike out… Don recalled the pain of watching, as a child, while his sibling was beaten to death. He had undergone extensive therapy. Before the terrorism of the 11th, he had been on the road to recovery. He had finally found a kind of peace during a trip he had made to a major city. On the 11th, horrible memories and emotions flooded back. He was not sure that he would ever find that peaceful place again.
In contrast to this vulnerability, there is some evidence that individuals who have successfully resolved previous traumatic reactions fare better during subsequent events. Paula had been exposed to multiple traumatic events (e.g., molest, rape, robbery). After the successful completion of therapy with a skilled trauma specialist, she did better than her husband or her friends during an earthquake that collapsed a nearby wall. Among other things, she knew to be cautious and to protect herself from the sights and sounds of horror. Although this result may be affected by more than one factor, it suggests that a severe reaction to this current event may be an indicator that past aspects of the original event need additional resolution. A severe reaction suggests the need for therapeutic assistance regardless of past history.
2Names have been changed and stories disguised or combined in the examples provided throughout this paper.
Reacting to reminders
Reminders of the tragedy of September 11 or of a previous trauma can engender sets of memories, thought processes, emotions or symptoms related to those experiences. Reminders may include certain mental or external images, sounds, smells, tastes, physical sensations, emotions, ideas, circumstances, weather conditions, places, people, and other things associated with the experience. For those who have been previously traumatized (perhaps especially when the previous trauma was a violent event), the tragedy of September 11 is a reminder.
Different people will have varying sensitivities to different reminders of the event. Some people may be reminded by airplane sounds, by any depiction of or actual explosion, building collapse, person jumping from a high place, etc. (intentional or unintentional; actual, media or movie depiction). Other individuals will only be alerted by specific things that closely approximate what they saw or heard during the event. The grieving may be reminded of the event every time they think of the deceased. Reminders may recall any or all of the emotions and symptoms associated with the original or with this event.
Varying levels of assistance will be important for many people. For those who were saddened or who need to sort out their thinking, talking to a friend, clergy or other counselor may assist a return to a newly defined normalcy. There are a number of methods of healing that might be used individually or in combination. Efforts to reduce stress or to heal strained nerves may be the best or additional assistance for some – such as periods of turning off television or radio news shows, taking a walk, art or movement (such as painting or dance; with or without an art or movement therapist), or massage therapy (see also, “Reaching Overload”, above). Those who are experiencing grief may benefit from seeing a grief counselor.
Many people may go to one or two counseling sessions to process their reactions or to sort out their thinking. If hopelessness does not begin to become hopefulness, if fear or anger do not become attempts to find positive actions that lift spirits, then finding help may be important. When symptoms and emotions become intense and/or interfere with normal functioning, it is essential to seek an appropriately trained professional. Individuals experiencing trauma or traumatic grief; anyone immobilized by fear, anxiety or guilt; anyone whose previous trauma is overwhelming; anyone who (through action or inaction) may harm themselves or others should seek the assistance of someone trained and skilled in assisting the traumatized.
Usually, the best way to find a good therapist is through people who have been helped by a therapist. In addition, some clinicians can be found through a university library search under the topic of trauma or traumatic grief. A number of organizations have members who specialize in the treatment of trauma – such as the International Society for Traumatic Stress Studies (ISTSS); the National Center for Victims of Crime (NCVC); the Association for Traumatic Stress Specialists (ATSS); the National Organization for Victims Assistance (NOVA). There are skilled and less skilled therapists in every mental health organization. It is best to investigate the successes and skills of any therapist before entering therapy and to find the clinician and method that best suit the individual seeking support. Choosing wisely is each individual’s responsibility.
Responding to the Insensitive
Events like these bring out the best and the worst in people. We have already seen many heroic endeavors. We have also seen actions toward personal gain (such as price gouging). In times of intense stress and/or after fearful events have occurred, some will behave in insensitive ways. For example, groups of people may lessen their own discomfort by making jokes about what happened. Some of these jokes may seem to minimize the tragic nature of these events or to diminish those who have suffered or died. It is possible to understand the need for comic relief and, at the same time, excuse oneself from having to endure it.
A strong patriotism is one of the results of this experience. Some will find that they are now offended when any fellow American is insulted. It is essential that we avoid creating additional traumas or perpetuating hatred by overzealous acts.
Accepting All Thoughts and Positive Actions
This experience has unleashed a cascade of thoughts in multiple directions. All thoughts are reasonable. Actions must be responsible.
Any combination of responses is expected. For example, rage and a desire to retaliate (or bring to justice) may coexist with love for “the enemy.” Jamie was surprised by feelings of wanting to violently retaliate. She studied the face of Osama bin Laden, a known endorser of terrorism, when the media aired video footage. She wondered how he could look so calm in the videos. There seemed to be no tension in his face. At one point, to her surprise, she began to feel love while looking at him. She had always been taught to “Love your enemy.” Still, she wondered if it was okay for this involuntary feeling to arise in response to such a man. She knew that feeling love toward someone does not mean that they should be exempt from answering for their deeds. She also knew that feeling the desire to retaliate did not mean you would ever act on it. She endorsed finding well planned interventions that would not result in worse atrocities.
Reexamining ourselves may be a part of patriotic feelings. Several years ago, George, an architect, went to Saudi Arabia to design buildings for the government. He was there for one month. When he returned to the United States, he was surprised that he experienced culture shock coming home. In Saudi Arabia people covered their entire bodies with clothing. women were covered except for their eyes; they did not drive and had very little freedom. Big city congestion and very tall buildings and billboards were absent from the landscape. Five times a day a voice sang out the call to prayer. Every one stopped to cleanse themselves and pray. He had only been gone for a month, yet he experienced some shock coming home. He found himself thinking how shocking it would be for his Arabian colleagues to enter and see all of the tall buildings, the congestion, the billboards and beaches with scantily clothed women, women competing with men, and the general demeanor of big city Americans. After the tragedies of September 11, after the initial shock, some of his first thoughts were about how we must look through foreign eyes and how we could show them the best of ourselves.
Patterns of response over time will differ for different people. Susan was glued to the news after the events of September 11th. Her heart poured out to those who had been in the planes and in the buildings that were demolished. She watched even after she became exhausted, crying with every new testimonial, wishing there was something that she could do, wanting to magically turn back the clock and intervene. In contrast, Bob, a veteran of the Vietnam War, found himself having flashback images of his war experiences. He dreamed of things exploding and bodies flying. He found himself shaking with fear toward enemies who could be hiding anywhere. After a few days, when Susan reached the point of feeling overwhelmed, she decided to watch movies to rest her overloaded mind. Movies from the 1940s were particularly soothing. One channel showed a movie about going back in time to a more peaceful, simple era. When rested, she again watched and listened as events began to unfold on ongoing news shows. After a few days, she became compelled to clean and organize. Perhaps symbolically, she became obsessed with a particular stain, determined to get it out. For Bob there was no escape. In desperation, he called another vet and, later, went to see a therapist.
Methods of coping also vary. After a week, Don, a school psychologist, lamented that he was so tired of explaining evil to children. He was just so very tired. He talked to a colleague about his response. Denise realized that she had reorganized all of her dresser drawers. She felt some relief at this good outcome of her distress. Charles found himself falling asleep when he was not engaged in a task. Cindy and Richard organized fund-raising efforts. Charlotte realized that she could not resolve her feelings and reactions alone. She sought therapy.
Moving in Harmony with Change
Although much remains unknown, it is certain that there will be changes in our lives. Individual, group, and national changes are likely to occur spontaneously and by directed effort. As a nation we share some common goals. Each individual will be affected in an individual way. We will have to carefully determine how to protect our safety and how to bring the perpetrators of these horrors to justice. Some decisions can and must be made by specific experts (e.g., professional, military). Matters are not simple. The consequences of all actions must be considered.
A terrorist group has expressed hatred toward us. We reassure ourselves by a strong showing of patriotism. We praise our heroes past and present. We review a newspaper article written by a Canadian recognizing the value of America. We come together as Americans. This is both a chance to recognize our worth and also to recognize how we can make a better nation. In the process of restoring the quality of our lives, it will be necessary to reexamine our nation and ourselves. It may be important to take a close look at our beliefs and practices and at the way others look at us.
Many individuals will experience new sensitivities. For a time, we may need to be more aware of what we say and project personally and collectively. Movie makers and publishers have already begun to respond to the changes. Additionally, advertising officials may have to reevaluate ad campaigns. Reactions to collapsing buildings may elicit different responses than they did before. Saying, “We will take you boldly into the future” may be less desirable to someone who wants to proceed cautiously or to see how things have been affected before boldly going anywhere.
An experience like this one raises many questions. Our many questions will be shaped by the personal experience, emotional impact, and our individuality. Most of us want to know who is responsible for this tragedy and what will be done about it. How will we prevent horrors and improve life? When will it truly be over? The question “why?” is also a common question following catastrophic events. It too will vary. Why attack innocence? Why me/us? Why my loved ones? Why our business/building/job? Why this much hatred of us? Why such disregard for human life?
Many issues must be reconciled. For example, one issue may be to help our children recognize that they are still the person who would not actually intentionally harm another person, even if, right now, they feel the desire to annihilate the perpetrators of these horrors. Many of our youths have already expressed the desire to protect innocents while bringing terrorists to justice. In stopping additional harm, part of what must be done is to find the line between doing good (for example, protecting people) and doing evil (for example, harming innocent people); the line between effective action and action that will perpetuate terrorism.
Talking to Children
When talking to children and adolescents about traumatic events or following the death of a loved one, gentle, courtesy is important (e.g., choose an appropriate setting for the discussion). Telling the truth is a must. It is also important to give the child age appropriate information that is within her/his ability to comprehend and process. Distorting the facts or withholding information may result in future confusions and in distrust. The information may be heard from a classmate or the news. Avoid giving too much information for the child to handle at one time. Recognize age factors in the child’s understanding of the issues and of the permanence of death. Provide an atmosphere of open communication. Permit questions.
It is also important to reinstate a child’s sense of safety. For example, a three-year-old who wants to know why every one is so upset can be told that a plane crashed into some very tall buildings and many people died. An eight-year-old will have a fuller understanding of what happened. In addition, the eight year old may benefit from an opportunity to take some positive action and/or to better understand aspects of the Muslim faith. They may want to help with fundraising, find activities that help the whole family to feel better, write to a senator… Youths will need to know that actions are being taken by our government and leaders to protect all of us and to prevent terrorism. They do not need worrisome, unneeded details that increase a sense of being endangered.
Although responding to children following disastrous events must be tailored to the specific event, specific children and the specific community, there are some basic guidelines for parents and teachers that may be helpful following catastrophic events.
|AFTER SAFETY IS RESTORED|
|© Nader, 1999. Reprinted with permission.|
Shocking events may result in regression in children and adults or in precocious development for children (Nader, 2001). Regression is not always easy to recognize. Childlike behaviors are common under some normal circumstances – for example, during anger, playfulness or endearment. Additionally, regression may be as subtle as desiring a person, place, or situation that previously signified good or safe feelings. Regressions such as loss of skills may be complicated or exaggerated by other trauma symptoms such as a changed biochemistry, lack of sleep, cognitive difficulties and/or preoccupations. Regression is sometimes interpreted as laziness, sloppiness, defiance, or attention getting behavior (Nader, 1999, 2001).
Following traumatic experiences, individuals may be regressed much of the time or may regress spontaneously, for example, in response to traumatic reminders. Adolescents and adults, as well as younger children, may function at more primitive levels. For example, they may use more concrete and literal levels of processing information, be more easily distracted, or engage in activities characteristic of someone younger. Thinking may be more concrete and less imaginative. Instructions may have to be delivered simply and may need to be repeated more than once (Nader, 1999, 2001).
Each person is a unique individual. It is important to learn to identify specific regressive tendencies. It may not be enough to approach someone with age level language and expectations. In addition, 1) recognize their functioning emotional age (which may change from contact to contact) following the event; 2) speak in age appropriate language; and 3) respect chronological age while adapting to the emotional functioning age. For example, for a traumatized 8 year old, it may be necessary to use a tone or the patience normally addressed to a 2 year old while speaking in the language of the 8 year old child. It may be important to use the patience, understanding and, when needed, gentle firmness afforded a younger child (Nader, 1999, 2001).
Following Traumatic Events
The long-term effects of exposure to traumatic events may include changes in personal traits (e.g., lack of confidence; inhibitions; increased risk taking; disruptions to moral beliefs or development); disturbances in interpersonal functioning (e.g., loss of friends; irritability/bullying; withdrawal); cognitive dysfunction (e.g., memory and concentration problems; inhibited imagination; primitive thinking and processing); mental health disturbances (e.g., chronic and/or complicated PTSD; substance related disorders; conduct, mood, anxiety, somatoform, eating, sleep, impulse control, personality, and/or dissociative disorders); attempts at numbing the emotions (e.g., drug abuse; alcoholism; overuse of medication; excessive sleep); compulsive repetition of traumatic behaviors and sequences (e.g., a molest victim’s promiscuity; squeezing into small spaces after having been buried under debris; repeated roller-coaster rides years after a rollover car accident; see “Reenactments” below); attempts at self punishment or warding off (e.g., self mutilation; other rituals; placing self in punishing circumstances; scratching at the sites of physical wounds or symbolic locations); and repetitive somatic complaints or general ill health (e.g., shakes; headaches; stomach aches; deficient immune response) (Garbarino, Kostelny, & Dubrow, 1991; Herman, Perry & van der Kolk, 1989; Nader,1996, 1997, 2001; Nader & Fairbanks, 1994; Nader & Pynoos, 1993; Terr 1991; Pynoos & Nader, 1988; Pynoos et al., 1987; van der Kolk & Saporta, 1991). In addition, there is a growing body of evidence that individuals who experience traumas are more likely to have children who experience traumas (Danieli, 1998) and may be more prone to biochemical stress responses (Suomi, 1998; van der Kolk & Saporta, 1991).
Failure to resolve moderate to severe traumatic reactions may result in long term consequences that interfere with the ability to engage, over time, in productive behaviors and to function adequately socially, academically, professionally and personally (Wilson & Raphael, 1993). Unresolved traumatic exposure may perpetuate violent acts that result in trauma for others (Admundson, 1993; Nader, 1997). Individuals who commit acts that traumatize others (e.g., school shootings) have sometimes been previously traumatized or have had unresolved traumatic grief (Nader, 1997). Individual and/or intrafamilial violence have increased following violence or disaster (Ibrahim, 8-4-92; Kohly, 1994; Nader, 1997; Nader & Fairbanks, 1994). Resolving traumatic experiences can restore the quality of life and serve as a protective factor (Nader, 1998; Pynoos et al., 1987).
Bereavement after a traumatic loss is more complicated than simple bereavement (Eth & Pynoos, 1985; Nader, in press, 1997b, 1996). Because of the significant differences between sudden unexpected grief and anticipatory grief, a new diagnosis, traumatic grief, has been delineated (Burnett, Middleton, Raphael, Dunne, Moylan & Nada, 1994; Jacobs, 1999; Prigerson et al., 1996; Stamm, 1999 a and b). In addition to deaths that occur during traumatic events, traumatic grief may occur after any personally devastating loss (Jacobs, 1999). The symptoms of grief (traumatic or otherwise) are affected by the circumstances of the death, aspects of the individual (biological, historical, psychological, psychosocial and sociocultural), and facets of the relationship between the deceased and the bereaved (Nader, 2001; Pynoos & Nader, 1990; Stamm, 1999b). After a traumatic experience, individuals may suffer from grief, traumatic grief, trauma and/or other disorders. Treatment for bereavement alone following a traumatic death can be ineffective and can have harmful effects (Jacobs, 1999; Nader, 1996, 1997b; Nader and Pynoos, 1993).
The combination of trauma and grief may affect the bereavement process in a number of ways. For example: 1) Symptoms common to both grief and trauma may intensify; 2) Thoughts of the deceased may lead to traumatic recollections (of images, sounds, smells, emotions related to the event); 3) Trauma symptoms may hinder or complicate issues of bereavement such as grief dream-work, the relationship with the deceased, issues of identification, the processing of anger and rage; and 4) A post-traumatic sense of estrangement or aloneness may interfere with healing interactions (Nader, 1997b).
Post Traumatic Stress Disorder (PTSD)
After a person has been exposed to a traumatic event (an event in which they have experienced, witnessed or were confronted with life threat, serious injury or physical threat to themselves or others), and has experienced intense fear, helplessness, or horror (for children, disorganization or agitation), he or she may develop PTSD or some trauma symptoms. Symptoms include persistent reexperiencing of aspects of the event, persistent avoidance of things associated with the traumatic experience and/or numbing of responsiveness, and persistent symptoms of increased arousal (APA, 1994).
Reexperiencing symptoms may include:
- recurrent, intrusive distressing recollections of the images, thoughts or perceptions associated with the event (repeated play with trauma themes in children);
- recurrent distressing dreams;
- acting or feeling as if aspects of the event were recurring (or trauma specific reenactment);
- intense emotional distress when exposed to internal (e.g., thoughts, physical sensations, emotions) or external (e.g., sights, sounds, smells) stimuli that symbolize or resemble some aspect of the event.
Persistent numbing and avoidance include:
- efforts to avoid feelings, thoughts, or conversations associated with the event;
- efforts to avoid places people or activities that serve as reminders;
- difficulty recalling some aspect of what happened;
- markedly reduced participation or interest in significant/usual activities;
- feeling estranged or detached from others;
- reduced ability to experience the full range of emotions (e.g., diminished ability to experience love or joy);
- and a sense of a shortened future or a less full life (e.g., a life without career, marriage, children, or normal life span).
Persistent increased arousal includes:
- difficulty falling or staying asleep;
- irritability or outbursts of anger;
- difficulties with concentration (may include short term memory problems);
- hypervigilance (feeling on alert to danger); and
- exaggerated startle response.
For a diagnosis of PTSD, the disturbance must persist for more than one month and cause significant distress or impairment to social, occupational, or other important functioning. Symptoms may be delayed (APA, 1994).
As a consequence of physiological (e.g., increased pulse, elevated adrenal cortical hormones) and psychological (e.g., horror, fear, rage) phenomena during traumatic events, multiple impressions register or imprint themselves with intensity and may become interlinked (Nader, 1997b; Terr, 1991). They include sensory impressions (e.g., touch, sights, sounds, smells), strong desires (e.g., to fight, intervene, flee, hide, rescue, or find; to stop the offender or to retaliate), attempts to understand (e.g., feelings or actions of others; “Why me?”), senses of injustice (e.g., innocents are killed or injured; bad things happen to good people; bad people have success), senses of betrayal (e.g., the unwelcome actions of known others; victimization by people who pretend to be friendly or harmless or who come as students in our schools, universities or training facilities), rejection of self (e.g., disdain for the helpless or ineffectual self; feelings of it should have been me instead of…), changes of focus (e.g., prominence of ineffectual self or of negative events over positive; prominence of our collective goodness and intolerance of contrary ideas), and more. These deeply ingrained impressions, desires to act, imagined interventions, and specific role identifications become embedded into traumatic memory representations; even the smallest details may become carved solidly into the memory (Nader, 1997b; Nader & Mello, 2000; Terr, 1991).
Traumatically imprinted thoughts and images often repeat themselves until they are properly processed or become suppressed, remaining influential in life. This can result in an increase in arousal symptoms or in readiness to arousal (Dodge, Bates, Pettit & Valente, 1995; Nader & Fairbanks, 1994; van der Kolk & Sapporta, 1991) or in a variety of other troubles (Herman, 1992; Nader, 1997; Terr, 1991). When intense impressions, wishes, urges and emotions remain unresolved, strong urges to express or play out the related emotions and behaviors to some form of completion may ensue. The sense of completion can be illusive and pursuing it sometimes results in frustration, dangerous or unrewarding experiences, or repeated traumas (for the trauma victim or for others). Lack of resolution of ongoing intervention fantasies such as the fantasies during and after the event of preventing or stopping harm, of challenging the assailant, of repairing damage, of desires to act can result in major changes in behavior and personality. For example, desires for revenge or retaliation or identification with the aggressor may result in increased aggression or inhibition (Nader & Mello, 2000; Nader & Pynoos, 1991).
One possible result of trauma is a tendency to relive or reenact aspects of the experience. Aspects of a traumatic experience may be relived or reenacted through emotional or physiological reactions, thoughts (or illusions, hallucinations, flashbacks), or behaviors that replicate, depict or symbolize aspects of the traumatic experience or traumatic emotions. Initial reenactments may be readily linked to the original experience. For example, the link to the trauma is evident in the child who, after a sniper attack on her elementary school ground, began to jump behind things when she heard any popping noise; the visiting Irish adults and adolescents who jumped to the ground when a bus backfired. Repeated actions may include inhibitions related to a heightened sense of vulnerability, dangerous risk taking, physiological or emotional response configurations, and complex patterns of action or reaction (Nader, 2001). Even unresolved curiosity may become a part of reenactments; for example, after her sister’s death, curiosity about what death feels like resulted in one person’s dangerous and careless rock climbing.
Initially or over time, for adults or children, unresolved aspects, episodes or emotions from a traumatic experience may translate into repeated complexes of behavior and emotions that affect the quality of life (see also life scripts, life dramas, faulty mental equivalents…). Initially or as time passes, the link between the original event and these complex patterns of thought, action, or reaction may be unrecognized (Nader, 2001). Whenever her adult life stresses increased, a woman molested by her father and others until age 12, experienced tightness of throat, nausea, fatigue, and a sense of aloneness, being trapped and being caretaker to everyone else. This pattern was not linked to her trauma until therapy sessions much later in her life.
One traumatic episode or emotion might result in a number of different behavior complexes (Nader, 2001). Like the boy who was unable to assist an injured child across the room when debris began to fall during an earthquake, some rescue workers or others may later experience an ongoing sense that someone is in danger, the repeated need to rescue others, an ongoing depression over a sense of ineffectualness, and/or a sense of hurting others somehow. Anger may express in a number of ways initially or later after someone who minimized the danger impeded the escape of someone who was injured or killed. A girl with unresolved anger that a friend prevented her from escaping injury after part of a building collapsed had perpetual nonspecific angry feelings at those who were close to her and repeated outbursts of anger at her mother. If she had not resolved these feelings in treatment, she may have had continued angry feelings, may have later chosen friends who endanger others or may have developed a tendency to endanger friends. A person’s unrecognized intense desire to remove him or herself from harm may result in a style of running away in response to stress or in a repeated sense of inescapable endangerment. If the same person was injured in the experience, he or she may have an ongoing sense of failure or ineffectualness. One individual may go through phases of reenacting or intermittently reenact different aspects of an experience. For example, at different times an individual may become any of the following depending on his or her traumatic experience: runner, rescuer, endangered, endangerer, victim, silent or frozen witness, protestor, escaper into fantasy (or fictional character), a divided or dissociated self, self punisher, betrayed, betrayer, soother, calmer, aggravator, searcher, assistant to the perpetrator etc. (Nader, 2001).
A wide variety of thoughts, emotions, and symptoms are normal responses to traumatic events. The events of September 11 have affected us as a nation and as individuals. As a nation we will have to act and react with wisdom, recognizing the long-term effects of our actions. Our personal reactions have been shaped by our individual natures, heritages, and our past and present experiences. Reactions will occur on different timetables for different individuals whether they were in the World Trade Center, Pentagon, awaiting the arrival of individuals whose flights were hijacked, or at a physically safe distance from the direct dangers of these events. Most of us will need to engage in some or many healing endeavors such as celebrating life, soothing stressed nerves, mentally processing and reassessing relevant issues, seeking appropriate support, engaging in positive actions, and recognizing personal needs. Our efforts toward helping ourselves and toward helping others will be healing to each of us and to this nation.
My sincere thanks to Joyce Boaz and Marilee Conant for their excellent feedback and encouragement. I extend my deep appreciation to those who shared brief descriptions of their own experiences. My heart has been touched.
- Amundson, K.J. (1993). Violence in the Schools: How America’s School Boards Are Safeguarding your Children. Alexandria, VA: National School Boards Association, pages 3-11.
- American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: Author.
- Burnett, P., Middleton, W., Raphael, B., Dunne, M., Moylan, A. & Marinek, N. (1994). Concepts of Normal Bereavement, Journal of Traumatic Stress, 7, 123-134.
- Dodge, K. A., Bates, J. E., Pettit, G. S., & Valente, E. (1995). Social Information-Processing Patterns Partially Mediate the Effect of Early Physical Abuse on Later Conduct Problems. Journal of Abnormal Psychology, 104 (4), 632-643.
- Eth, S. & Pynoos, R. (1985). Interaction of Trauma and Grief in Childhood. In S. Eth & R. Pynoos (eds.), Post-Traumatic Stress Disorder in Children, (pp. 171-186). Washington, D.C.: American Psychiatric Press.
- Garbarino, J., Kostelny, K., & Dubrow, N. (1991). What children can tell us about living in danger. American Psychologist, 46, 376-383.
- Herman, J.L., Perry,J.C. and van der Kolk, B.A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146(4), 490-495.
- Ibrahim, Y.M. (1992, August 4). Iraqis left coarse scars on the psyche of Kuwait. The New York Times, p. A3.
- Jacobs, S. (1999). Traumatic grief: diagnosis, treatment, and prevention. Philadelphia: Brunner/Mazel.
- Kohly, M. (1994). Reported child abuse and neglect victims during the flood months of 1993. Missouri Department of Social Services, Division of Family Services, research and Development Unit.
- Nader, K. (1996). Children’s exposure to violence & disaster. In Corr, C.A.and Corr, D.M. (eds.), Handbook of Childhood Death and Bereavement, New York: Springer Publishing Company, pp. 201-222.
- Nader, K. (1997). Childhood traumatic loss: The interaction of trauma and grief. In C.R. Figley, B.E. Bride, and N. Mazza, (eds.), Death and Trauma: The Traumatology of Grieving, pp. 17-41. London: Taylor and Francis.
- Nader, K. (1997). Assessing Traumatic Experiences in Children. In J. P. Wilson & T. Keane (Eds.) Assessing Psychological Trauma & PTSD, pp. 291-348. New York: Guilford Press.
- Nader, K. (1998). Violence: Effects of a parents’ previous trauma on currently traumatized children. In Danieli, Y. (Ed.), An International Handbook of Multigenerational Legacies of Trauma (pp. 571-583), New York: Plenum Press.
- Nader, K. (1999). Psychological first aid for trauma, grief and traumatic grief. 3rd edition. Austin, TX: Two Suns.
- Nader, K. (2001). Treatment methods for childhood trauma. In J. P. Wilson, M. Friedman, & J. Lindy, (Eds.), Treating psychological trauma and PTSD, (pp. 278-334). New York: Guilford Press.
- Nader, K. (in press). Simple formulas best applied to simple grief. Contemporary Psychology: APA Review of Books.
- Nader, K. & Fairbanks, L. (1994). The Suppression of Reexperiencing: Impulse control and somatic symptoms in children following traumatic exposure, Anxiety, Stress and Coping: An International Journal, 7, 229-239.
- Nader, K. and Pynoos, R. (1991). Play and Drawing as tools for interviewing traumatized children. In Schaeffer, C., Gitlan, K. and Sandgrund, A., (eds.), Play, Diagnosis and Assessment. New York: John Wiley, pp. 375-389.
- Nader, K. and Pynoos, R.S. (1993). The children of Kuwait following the Gulf Crisis. In, Lewis, L. and Fox, N. (eds.), Effects of War and Violence on Children. Hillsdale, NJ: Laurence Erlbaum Publishers, 181-195.
- Prigerson, H., Bierhals, A., Kasl, S., Reynolds, C., Shear, M., Newsom, J., & Jacobs, S. (1996). Complicated grief as a disorder distinct from bereavement-related depression and anxiety: a replication study. American Journal of Psychiatry, 153, 1484-1486.
- Pynoos, R. and Nader, K. (1988). Psychological first aid and treatment approach for children exposed to community violence: research implications, Journal of Traumatic Stress, 1(4): 445-473.
- Pynoos, R. Frederick, C., Nader, K., Arroyo, W., Eth, S., Nunez, W., Steinberg, A., and Fairbanks, L. (1987). Life threat and posttraumatic stress in school age children, Archives of General Psychiatry, 44: 1057-1063.
- Stamm, B. (1999a). Empirical perspectives on contextualizing death and trauma. In Figley, C. R (ed.). Traumatology of grieving: conceptual, theoretical, and treatment foundations, pp. 23-36. Philadelphia: Brunner/Mazel.
- Stamm, B. (1999b). Conceptualizing death and trauma. In Figley, C. R (ed.). Traumatology of grieving: conceptual, theoretical, and treatment foundations, pp. 3-21. Philadelphia: Brunner/Mazel.
- Suomi, S. J. & Levine, S. (1998). Psychobiology of Intergenerational Effects of Trauma. Danieli, Y. (Ed), International Handbook of Multigenerational Legacies of Trauma. (pp. 623-637), New York: Plenum Press.
- Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148(1), 10-20.
- van der Kolk, B., & Sapporta, J. (1991). The biological response to psychic trauma: Mechanisms and treatment of intrusion and numbing. Anxiety Research, 4, 199-212.
- Brock, S. & Lazarus, P. (eds.). Best Practices in Crisis Prevention and Intervention in the Schools. National Association of School Psychologists.
- Danieli, Y. (Ed), International Handbook of Multigenerational Legacies of Trauma. New York: Plenum Press.
- LaGreca, A., Silverman, W., Vernberg, E., & Roberts, M. (Eds.). Helping Children Cope with Disasters: Integrating Research and Practice. Washington, D.C.: APA Press.
- Lehmann, P. & Coady, N. F. (Eds.). Theoretical perspectives for direct social work practice: A generalist-eclectic approach. New York: Springer Publishing Company.
- Wilson, J. P., Friedman, M. & Lindy, J. (Eds.), Treating psychological trauma and PTSD. New York: Guilford Press.
- Webb, N.B. (1991). Play Therapy with Children in Crisis, a Casebook for Practitioners. New York: Guilford Press.
© K Nader & Gift From Within, 2001.