Sunday, April 14, 2013

SHIELD OF GOLD, WTC 9/11 Attack and PTSD

The Anguish of Attack: Postmortem Post Traumatic Stress Disorder (PTSD) A Qualitative Situational Analysis: World Trade Center Attacks 9/11/01

Dr. Lois P. Tannenbaum, Psy.D

The experience of death of those we care about is always difficult to assimilate into our lives. A life force so deeply intertwined within our own is now physically gone forever. We go through the stages of grieving as we move towards acceptance to a greater or lesser degree, and at a divergent pace, depending on such variables as age, illness, relationship, and the circumstances of death.

When the causal factor surrounding death is trauma, there are residual effects that affect those involved in the aftermath of that trauma which evidence as Post Traumatic Stress Disorder (PTSD). PTSD is a psychological wound sustained when a person is exposed to an overwhelming stressful event. The magnitude of that occurrence threatens and violates that person's pre-trauma reality. The response/s will be experienced and expressed in a manner unique to each individual; however, all are considered normal responses by normal people to abnormal situations. Reactions may include:

-event re-experiencing
- anxiety
- avoidance

- depression

- isolation

- arousal

- hyperarousal

- social disconnect

- occupational dysfunction

- substance abuse

In sudden-onset emergencies, such as in war, natural disasters, and/or exposure to attack, there is no warning, no retreat, and no predictability of either the experience or the outcome. Such was the reality of the World Trade Center 9/11 First Responders in 2001. The intensity of being in the epicenter of such a massive, collective death experience was beyond assimilation by any human being. The responsibility assigned to Detective Golino, and countless other officers, was to sort and sift through "The Pile" (as they termed it) of debris searching for human remains. Each responder had no choice but to detach to whatever degree possible just to push through that horrific task moment by moment. Yet, the deep scarring of the incomprehensible degree of loss literally experienced through all senses by innumerable bone fragments that were once thousands of people can only result in a shockwave to the mind and soul. Once the "shield" of responsibility is surrendered, the impact of its life-long effect may be fully, devastatingly absorbed.

Following the terrorist attack on the World Trade Center, each person's pre-trauma belief system in their view of the world, and their safety, had been radically altered forever. We had been attacked on our own soil, and thousands were brutally, instantly gone forever. The total lives lost in the attacks were 3,497 people with 3,332 at the World Trade Center alone. The responsibility to identify their remains and provide any sense of closure to the grieving families lay literally in the hands of these dedicated responders.

In total 3,497 people died in the attacks on September 11, 2001.

- 2,735 civilians in the World Trade Center died

- 87 passengers and crew members aboard American Airlines Flight 11 that hit the North Tower

- 60 passengers and crew aboard United Flight 175 that hit the South Tower

- 343 New York City firefighters and rescue workers and 23 New York City law enforcement officers, 47 Port Authority workers and 37 Port Authority Police Officers, lost their lives when they rushed in to save the victims in the World Trade Center

36 passengers and crew aboard United Flight 93, who gave their lives stopping four hijackers over Pennsylvania

64 passengers and crew aboard American Airlines Flight 77 that crashed into the Pentagon, killing them and 125 people in the building.

- Also there were the 19 terrorists who hijacked four airliners & murdered 3,497 people who died.

According to Alexander & Klein (2009), there has been research focused on major statutory bodies such as fire, police, and emergency services personnel as well as recent research involving other agencies all of whom are first responders. Palm and colleagues (2004) identified key concepts affecting these demographics that include: vicarious traumatization; compassion fatigue; and burn-out. The research states that although these terms require increased delineation, they reflect the principle that providing help for victims of major trauma has the potential to be "psycho noxious" to those who provide it.

Many of the factors explored in previous research are consistent with those experienced by the WTC Search & Recovery Responders including viewing and handling bodies and mutilated remains, family members desperate for answers, and risks to their own safety including exposure to toxic materials. They were further impacted by lack of sleep, poor diet, inadequate equipment, excessive noise, and work overload. Moreover, as reported by Klein and Alexander (2009) first responders may not only be "secondary victims" due to the distasteful nature of their duties, they may also be "primary victims" due to the personal loss of friends and loved ones. These very real experiences may result in one or more of the aforementioned psychological effects related to PTSD.

Post Traumatic Stress Disorder is not an inherent weakness in facing difficulty, nor is it a flaw in an individual's personality, belief system, or values. The development and intensity of PTSD symptoms is concordant with the intensity and duration of the stressful event. Why is it then that some individuals involved in the same traumatic event, to the same or similar degrees, either experience decreased symptomology, or adapt to and resolve adverse reactions more effectively? There are multi-variant factors that contribute to individual outcomes of healing and recovery.



Pre-determinant risk factors in family history

Negative risk factors:

- Child abuse that is likely to reactivate past traumas
- Under-developed protective skills, problem-solving skills, self-esteem, resilience,

- Personality & habitually negative thought patterns (pessimism, depression, introversion)

- Biology related to overactive nervous systems/heredity/and history of drug abuse

Negative family characteristics:

-Children of divorce might feel that the world is not safe, people abandon you, so don’t trust.
- Children of parents with poor coping skills inadvertently learn to blame others, to take out anger on others, to use illegal drugs to self-medicate, or to just avoid emotions completely.

Parents with PTSD can indirectly transmit their wounds:

Combat veterans

- Destroy your enemies lest they destroy you.

- Don’t show feelings such as grief or tenderness.

- Do whatever it takes to protect yourself.

- It is safer to disguise your intentions.

Children of such vets learn to keep quiet, to feel unsafe, and out of control because parental angry outbursts are fearful, sudden and unpredictable. A child’s self-esteem is disrupted if they feel they are to blame due to lack of understanding.

Police officers

- May protect their family but be emotionally disengaged.

- They worry so much about the danger during outings, that they do not experience or allow their children to experience the joy of the time together.
- They may also be suspicious and distrusting of others, emotions that teach children to be anxious and distrustful.

Abusive and/or alcoholic parents

Children learn to be secretive and ashamed, to appear “normal” at all times to keep family intact

On the opposite end of the PTSD spectrum are the positive risk factors & characteristics.

Positive risk factors:

- Creativity
- Humor
- Discipline
- Ability to express emotion to others
- Ability to tolerate distress

Positive family characteristics:

- When adults have a childhood history of growing up in a secure, predictable setting with warm, loving adults they learn to trust others and themselves.
- They learn to express emotions appropriately and safely.
- They discover that the world is predictable and that they can cope.
- Another important lesson learned in this type of environment is that when there are difficulties, they can share their burdens with people who support them.

In-Trauma Experiences

During a trauma experience, an individual’s recent life stressors; negative perceptions related to the event; or positive paradigm shifts they are able to mentally convert; all contribute to the eventual outcome/s related to PTSD.

Recent life stressors:

In addition to underlying factors in a person’s past, in an adult life there are the added stressors: divorce, illness, financial difficulties, loss of a job, and/or death of a friend or loved one.


Negative Perceptions vs. Positive Paradigm Shift

- Purposeful act - Pre-disaster training (military comparable)

- Feeling unsafe in location - Focus on the greater good

- Empathetic to survivors - Challenge vs. threat

- Helplessness in disaster zone - Meaningful not pointless

- Intensity of exposure - Personal growth/resilience

- Developing acute stress - Clear definition of duties

- Becoming dissociative - Teamwork & sense of being appreciated




Post-Trauma Experiences

History reveals how a person’s post trauma experiences influence both mental status and reintegration into his/her home and community. One crystal example is the parallel opposite receptions received by veterans in the United States following the Viet Nam War vs. the more recent wars in Iraq and Afghanistan.

In all three wars, there was death, destruction, and devastation. However, added to the psychological dilemma of the veterans returning home from Viet Nam was finding themselves targets of verbal and physical abuse by fellow countrymen. This point is not raised as a question of political viewpoint of war, it speaks to the personal experience of one who has faced unfathomable trauma, and desperately needs support.

The experience of First Responders in the World Trade Center attacks was analogous to military personnel returning home, each having faced horrific tragedy etched in their minds and hearts forever. The recovery and resumption of “normalcy” was highly dependent upon the nature and degrees of supports they did or did not have upon their return.


Negative aftermath Positive healing

- Lack of network supports - Accepting the reality of the experience

- Feelings of aloneness - Psychological debriefing

- Emotional unavailability - Recognition and expression of feelings

- Disbelief, stigmatizing, shame, - Revealing not

shunned concealing

- Secondary victimization - Rediscovering self, family, & friends

- Conspiracy of silence - Allowing network acceptance & support

- Lack of treatment - Being of service to others

- Ineffective coping skills - Rejoining & reinvesting in life



The Road to Recovery


Cognitive Behavior Therapy – integrating emotionally disassociated/distorted thoughts

Acceptance & Commitment – recognition and moving forward

Stress Inoculation Training (SIT) – exposure to lesser stressors to build or regain resiliency

Breathing & Relaxation Techniques – focused breathing/activities to decrease anxiety

Cognitive Processing Therapy (CPT) – reinforcing strengths and teaching strategies

Review/revisit/restructure – confront, challenge, and control (from victim to survivor)

Autogenic training – a form of self hypnosis that relaxes and utilizes imagery

Meditation – learning to free the mind of thought for increasing periods of time

Anger Management – developing internal controls and coping mechanisms


In summary, it is imperative to reinforce that all survivors will cope with a traumatic experience and resultant after-shocks in a way that is unique to them based on past, present, and future supports and resources. It is “normal” to feel “abnormal” about the magnitude of an event that one is trying to integrate into a life system for which there is no prior frame of reference.

Even those trained to respond to trauma, and perform as they must, come away with healing work to do. Too often, individuals and the media may represent the remarkable recovery of a trauma survivor in a way that seems to say that life for that person has returned to “normal”. This portrayal may cause others who are not faring as well in similar circumstances to feel even more distraught or incapable of healing. Normalcy does not resume it reconstructs!

In the horrific tragedy of 9/11, the global impact was internalized and absorbed by every living human being old enough to process the violation of security which was forever compromised; the assault and grief related to the massive loss of life; and the significantly permanent change in each person’s viewpoint regarding trust, boundaries and the future stability of the world in general. This attack was perpetrated on humanity as a whole, and as such left an open wound which healed and scarred to greater or lesser degrees within each affected person, community, and country. Simultaneously, it also created an appreciation for life and a unified purpose to stand together and support one another. Such is the wisdom of tragedy!

Each person who lived through the 9/11 nightmare will relive and retell it differently. Every first responder left “The Pile” with post traumatic stress, and many were not able to move beyond it resulting in a disorder that would require treatment. Thankfully, there were also many who survived and assimilated this tragedy as one experience in the sum total of their lives in order to move forward in a purposeful manner for themselves and others. Detective Golino, and others like him, returned to their families and their duties with heavy hearts but renewed commitment to protect and serve in every sense of the word.



David A. Alexander and Susan Klein (2009). First Responders after Disasters: A Review of Stress Reactions, At-Risk, Vulnerability, and Resilience Factors. Prehospital and Disaster Medicine, 24, pp 87-94 doi:10.1017/S1049023X00006610

Matsakis, Aphrodite, 1992. I Can’t Get Over It: A Handbook for Trauma Survivors. Oakland, CA: New Harbinger Publications

Matsakis, Aphrodite, 1994. Post-Traumatic Stress Disorder A Complete Treatment Guide. Oakland, CA: New Harbinger Publications.

Schiraldi, Glenn R., 2000. The Post-Traumatic Stress Disorder Sourcebook: A Guide to Healing, Recovery, and Growth. Lincolnwood, IL: Lowell House

           Parkinson, Frank, 2000. Post-Trauma Stress.     Tucson, AZ: Fisher Books


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