Sonali Garg
The morning of September 11, 2001 (9/11). Nearly 3,000 people died that day. Millions more watched the planes hit the Twin Towers and the Pentagon, the two symbols of American power swiftly disappearing into an enormous plume of black smoke. Many saw the attacks on live TV. And two decades later, those images remained seared in the nation's memory. It was one of the greatest memorialisations of mass trauma experienced by the United States, which was obliviously embarking upon a new era of history.The intense media coverage of the terrorist attacks and that of the rescue operations till weeks after, had a potent effect on people's psychological and physical health over time. A plethora of research was conducted on the mental health repercussions of the 9/11 terror attacks in the two decades after they took place, marking a major climacteric in the psychiatric understanding of Acute and Chronic Trauma, Post-Traumatic Stress Disorder (PTSD) and disaster psychiatry practice (Moran et al., 2021). In this article, I will discuss the dramatic innovations in the treatment of Post-Traumatic Stress Disorder in the wake of 9/11, and discuss the lessons we learned from this catastrophic event.
It wasn't until 1980 that PTSD was given its present designation in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Under the DSM-5, PTSD is defined as an anxiety disorder that develops in reaction to an incident that causes psychological trauma, such as natural disasters, a serious accident, a terrorist act, war/combat, rape or other violent personal assault. This includes the direct experience of the event, witnessing the event in person, knowing of the actual or impending death of a close family member or friend, or repeated first-hand, intense exposure to the facts of the event (Leon et al.). Even those individuals who experienced vicarious exposure to the traumatic events of 9/11, that is, those who were not physically present at or around the struck buildings had been both negatively and positively impacted by the events of 9/11 and met the criteria for probable PTSD (Linley et al., 2003). A disorder that was thought to have affected only soldiers in faraway war zones was now having indelible effects on innocent civilians, posing an unprecedented mental health crisis and resulting in a trajectory shift of focus to mitigating the mental health consequences of the attack. In the aftermath of this event, courses on trauma therapy have become more common in counselling and psychology degrees (Matchar, 2021).
In the New England Journal of Medicine, Sandro Galea and colleagues reported that 7.5 per cent of Manhattan residents fulfilled the criteria for PTSD, a few weeks after the attacks. . This percentage increased to 20% in lower Manhattan, near the World Trade Center, and to roughly 30% for individuals who were most directly impacted by the assault i.e. were in the towers when the aircraft hit (Bonanno, 2021). Statistical evidence also shows that over 21% of those enrolled in the World Trade Center Health Registry (which provides free health treatment and monitoring to individuals immediately affected by the tragedy) reported new PTSD symptoms, 5 to 6 years after the events of 9/11 (Brackbill et al., 2009). These figures eventually plummeted to the ground. Renowned PTSD researcher Patricia Resick said, “Lesson? Strong emotions do not equal psychopathology.” (Brackbill et al., 2009).
Albeit grim, prior to the events that took place on September 11, (apart from Americans thinking that their country was invincible), there was a paucity of well-developed and established crisis protocols in the aftermath of disasters. It was only after 9/11 took place, that a number of institutions devised protocols that could be used in a crisis situation, like “psychological first aid” (PFA), which involves carefully listening to persons who have experienced trauma and analysing their needs – similar to how an emergency room nurse triages injuries (Matchar, 2021). PFA was introduced to fill the gaps created by the 1970s first-aid model of “critical incident stress debriefing”, which involves gathering people in groups to talk immediately about their experience (Matchar, 2021). Though it was used after 9/11, research suggested that it would not be an ideal model for the post-disaster or post-terrorism situation, as it is not tailored to the individual needs of the victims, who may need downtime before they can forge ahead and have a discourse about their experiences (Flatlow, 2011). Patricia J. Watson said, “If they choose to talk and they want to talk, absolutely, the person should be supportive and listen, but not to impose that they should talk before they're ready to talk.” (Flatlow, 2011). Similarly, despite the popularity of PFA and its endorsement by expert consensus, there remains a dearth of evidence for its effectiveness (Shultz & Forbes, 2013).
Since 9/11, a slew of new treatments have been brought to the fore. Some evidence-based treatments include antidepressants like Zoloft and Paxil, as well as talk therapies like Cognitive Behavioural Therapy (CBT) or extended exposure therapy, which include talking about the traumatic events and attempting to perform things that the person has avoided since the trauma. (Chatterjee, 2021). Researchers have also made tremendous progress in understanding the significance of genetic variables in the development of PTSD. Imaging, biomarkers, and brain-related studies have all exploded in popularity. Many biomarkers have been linked to PTSD, such as an increase in specific hormones or inflammation, and there is now a greater focus on finding the correct ones, in the proper combinations, for diagnosing and treating the mental disease (Jovial, 2021). Additionally, a variety of brain imaging tools to better understand PTSD as a unique brain disorder marked by a variety of brain signatures were also introduced (“Remembering 9/11,” 2021).
To conclude, there is a lot that we have learned from the mental health response to this mass tragedy. The fact that the incidence of PTSD dissipated with time, taught us that exposure to life-threatening situations does not always result in the acquisition of trauma-related illnesses. It instead enhances resilience and is indicative of a stable trajectory of good mental health beginning soon after the event (Bonanno, 2021). Owing to the developments of PTSD treatments in the wake of 9/11, the general public had a much greater understanding of trauma amidst the state of affairs that we found ourselves in during the first half of 2020- The Covid-19 Pandemic. Though the initial months following the covid-19 outbreak were marked with increasing rates of anxiety, depression and distress these numbers reduced with time.
Even in the dark cloud of the 9/11 terror attacks, there was a silver lining.
It wasn't until 1980 that PTSD was given its present designation in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Under the DSM-5, PTSD is defined as an anxiety disorder that develops in reaction to an incident that causes psychological trauma, such as natural disasters, a serious accident, a terrorist act, war/combat, rape or other violent personal assault. This includes the direct experience of the event, witnessing the event in person, knowing of the actual or impending death of a close family member or friend, or repeated first-hand, intense exposure to the facts of the event (Leon et al.). Even those individuals who experienced vicarious exposure to the traumatic events of 9/11, that is, those who were not physically present at or around the struck buildings had been both negatively and positively impacted by the events of 9/11 and met the criteria for probable PTSD (Linley et al., 2003). A disorder that was thought to have affected only soldiers in faraway war zones was now having indelible effects on innocent civilians, posing an unprecedented mental health crisis and resulting in a trajectory shift of focus to mitigating the mental health consequences of the attack. In the aftermath of this event, courses on trauma therapy have become more common in counselling and psychology degrees (Matchar, 2021).
In the New England Journal of Medicine, Sandro Galea and colleagues reported that 7.5 per cent of Manhattan residents fulfilled the criteria for PTSD, a few weeks after the attacks. . This percentage increased to 20% in lower Manhattan, near the World Trade Center, and to roughly 30% for individuals who were most directly impacted by the assault i.e. were in the towers when the aircraft hit (Bonanno, 2021). Statistical evidence also shows that over 21% of those enrolled in the World Trade Center Health Registry (which provides free health treatment and monitoring to individuals immediately affected by the tragedy) reported new PTSD symptoms, 5 to 6 years after the events of 9/11 (Brackbill et al., 2009). These figures eventually plummeted to the ground. Renowned PTSD researcher Patricia Resick said, “Lesson? Strong emotions do not equal psychopathology.” (Brackbill et al., 2009).
Albeit grim, prior to the events that took place on September 11, (apart from Americans thinking that their country was invincible), there was a paucity of well-developed and established crisis protocols in the aftermath of disasters. It was only after 9/11 took place, that a number of institutions devised protocols that could be used in a crisis situation, like “psychological first aid” (PFA), which involves carefully listening to persons who have experienced trauma and analysing their needs – similar to how an emergency room nurse triages injuries (Matchar, 2021). PFA was introduced to fill the gaps created by the 1970s first-aid model of “critical incident stress debriefing”, which involves gathering people in groups to talk immediately about their experience (Matchar, 2021). Though it was used after 9/11, research suggested that it would not be an ideal model for the post-disaster or post-terrorism situation, as it is not tailored to the individual needs of the victims, who may need downtime before they can forge ahead and have a discourse about their experiences (Flatlow, 2011). Patricia J. Watson said, “If they choose to talk and they want to talk, absolutely, the person should be supportive and listen, but not to impose that they should talk before they're ready to talk.” (Flatlow, 2011). Similarly, despite the popularity of PFA and its endorsement by expert consensus, there remains a dearth of evidence for its effectiveness (Shultz & Forbes, 2013).
Since 9/11, a slew of new treatments have been brought to the fore. Some evidence-based treatments include antidepressants like Zoloft and Paxil, as well as talk therapies like Cognitive Behavioural Therapy (CBT) or extended exposure therapy, which include talking about the traumatic events and attempting to perform things that the person has avoided since the trauma. (Chatterjee, 2021). Researchers have also made tremendous progress in understanding the significance of genetic variables in the development of PTSD. Imaging, biomarkers, and brain-related studies have all exploded in popularity. Many biomarkers have been linked to PTSD, such as an increase in specific hormones or inflammation, and there is now a greater focus on finding the correct ones, in the proper combinations, for diagnosing and treating the mental disease (Jovial, 2021). Additionally, a variety of brain imaging tools to better understand PTSD as a unique brain disorder marked by a variety of brain signatures were also introduced (“Remembering 9/11,” 2021).
To conclude, there is a lot that we have learned from the mental health response to this mass tragedy. The fact that the incidence of PTSD dissipated with time, taught us that exposure to life-threatening situations does not always result in the acquisition of trauma-related illnesses. It instead enhances resilience and is indicative of a stable trajectory of good mental health beginning soon after the event (Bonanno, 2021). Owing to the developments of PTSD treatments in the wake of 9/11, the general public had a much greater understanding of trauma amidst the state of affairs that we found ourselves in during the first half of 2020- The Covid-19 Pandemic. Though the initial months following the covid-19 outbreak were marked with increasing rates of anxiety, depression and distress these numbers reduced with time.
Even in the dark cloud of the 9/11 terror attacks, there was a silver lining.
References
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Bonanno, G. A. (2021, September 4). What 9/11 taught us about trauma and resilience. The Wall Street Journal. Retrieved March 6, 2022, from https://www.wsj.com/articles/what-9-11-taught-us-about-trauma-and-resilience-11630728061
Chatterjee, R. (2021, September 10). For many who were present, the 9/11 attacks have had a lasting mental health impact. NPR. Retrieved March 6, 2022, from https://www.npr.org/sections/health-shots/2021/09/08/1035224815/for-many-there-that-day-the-attacks-on-9-11-have-had-lasting-mental-health-impac
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Leon, C. L., & Hunter, C. J. (n.d.). Posttraumatic stress disorder (PTSD) DSM-5 309.81 (F43.10). Theravive Counseling. Retrieved March 5, 2022, from https://www.theravive.com/therapedia/posttraumatic-stress-disorder-(ptsd)-dsm--5-309.81-(f43.10)
Linley, P. A., Joseph, S., Cooper, R., Harris, S., & Meyer, C. (2003). Positive and negative changes following vicarious exposure to the September 11 terrorist attacks. Journal of traumatic stress, 16(5), 481–485. https://doi.org/10.1023/A:1025710528209
Matchar, E. (2021, September 9). 9/11 changed how doctors treat PTSD. Smithsonian Magazine. Retrieved March 6, 2022, from https://www.smithsonianmag.com/innovation/911-changed-how-doctors-treat-ptsd-180978573/
Moran, M., Search for more papers by this author, & O'Connor, K. (2021, August 17). 9/11 attacks changed understanding of trauma, elevated disaster psychiatry. Psychiatric News. Retrieved March 4, 2022, from https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2021.9.18
Remembering 9/11 and what we've learned about its impact on Mental Health. Columbia University Irving Medical Center. (2021, September 5). Retrieved March 7, 2022, from https://www.cuimc.columbia.edu/news/remembering-9-11-and-what-weve-learned-about-its-impact-mental-healthShultz, J. M., & Forbes, D. (2013). Psychological first aid: : Rapid proliferation and the search for evidence. Disaster Health, 2(1), 3–12. https://doi.org/10.4161/dish.26006
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