When terrorist-controlled airliners destroyed the World Trade Center's twin towers and crashed into the Pentagon, they not only shattered the lives of thousands of people directly in the line of fire. They also attacked America's psyche. Today, people from sea to shining sea are still dealing with the emotional repercussions of the events of Sept.11, 2001.
As with the assassination of President Kennedy, nearly all Americans will forever recall where they were when the jets slammed into the towers, and how they sat transfixed, watching the horrific televised images of the unprecedented carnage. But long after the disturbing news reports faded from TV screens, some Americans are still searching for a return to psychological balance.
According to mental health experts, many men and women have shown an amazing resilience since 9/11, often buoyed by feelings of patriotism and national pride, sometimes by just the passage of time. Although national surveys reported common problems like sleeping difficulties, trouble concentrating, and feelings of vulnerability in the weeks and months after the attacks, those symptoms have gradually subsided in many individuals. Others, however, still remain anxious and fearful as they continue to cope with the lingering psychological effects of the terrorist attacks -- whether they live near Ground Zero or thousands of miles away.
The presence of protracted psychiatric symptoms should not be surprising since, as psychologist William E. Schlenger, PhD, says, the 9/11 attacks "represent an unprecedented exposure to trauma" within the borders of the U.S.
In a study at North Carolina's Research Triangle Institute (RTI), published in the August 2002 issue of The Journal of the American Medical Association, Schlenger and colleagues reported that 11% of the population of metropolitan New York developed probable posttraumatic stress disorder (PTSD), characterized by nightmares, flashbacks, and other anxiety symptoms.
"Extrapolating from existing studies of PTSD, 30-50% of cases will turn out to be chronic -- and in at least some of those cases, it will probably be a lifelong disorder," says Schlenger, director of RTI's Center for Risk Behavior and Mental Health Research.
While people in New York City and Washington have been particularly susceptible to the psychological impact of 9/11, men and women in every part of the U.S. have been affected as well. Not only did almost everyone view the televised collapse of the World Trade Center towers, but according to the RTI researchers, a startling 10 million adults in the U.S. had a friend, family member, or co-worker killed or injured in the attacks.
"Having a relative's or close friend's physical well-being challenged is considered a traumatic event sufficient for the development of PTSD," says Juesta M. Caddell, PhD, senior research clinical psychologist and a co-author of the RTI study. The RTI research found a 4% prevalence of probable PTSD in the country as a whole, translating into many millions of cases away from New York City and the nation's capital.
Reshaping Personal Lives
"Sept. 11 was a terrible loss -- not just in terms of lost life, but in terms of a lost way of life," says Yael Danieli, PhD, a New York City clinical psychologist, and a founding director of the International Society for Traumatic Stress Studies. She believes that a "new normality" must be established that incorporates uncertainty, including a greater readiness for "anything." She adds, "It means accepting that nothing will ever be the same again. This may feel bad, but it's realistic."
For many, the way they live and the decisions they make in their day-to-day life are still being influenced by 9/11. "It affects what they tell and how they raise their children, where they send them to school, their relationship to their work, and whether they want to remain in a job that's in a high-rise building, especially downtown," says Danieli. "People are also making these decisions in a poor economic atmosphere, so even though they may want to leave their jobs, they're afraid they may not find another one."
Anger and Optimism
Many Americans have reacted angrily to the events of Sept. 11, and according to recent research, these individuals tend to have a more optimistic outlook on the future than those who have responded with fear.
Baruch Fischhoff, PhD, cognitive psychologist at Carnegie Mellon University, says, "Anger in some complicated way makes people more optimistic." These angry reactions to 9/11 -- and the optimism that can accompany it -- are seen more in men than in women, while women are more likely to feel fearful, says Fischhoff.
The Carnegie Mellon researchers have also concluded that a substantial minority of Americans see themselves as vulnerable to future terrorism. The surveyed adults said they had a 21% chance of being injured in a terrorist attack within the next year, which the researchers describe as "a very gloomy view." But according to Fischhoff, people tend to see themselves as less vulnerable than the "average American," who they believe has a 48% chance of terrorism-related injuries within the next year.
The effect of the terrorist attacks on the mental health of Americans was also reflected in a study commissioned by the American Psychological Association, which surveyed 1,900 Americans in early 2002. About one in four adults said they felt more depressed or anxious than at other times in their life, with the Sept. 11 events key contributors to those symptoms (along with factors such as financial difficulties). More than three-quarters of Americans surveyed said they are reexamining and have tried simplifying their lives and are focusing more on "what really matters."
Elusive "Quick Fixes"
Especially in New York City, life seems to have changed forever in the aftermath of the events of Sept. 11, says Danieli. Americans tend to like quick fixes, she says, preferring immediate cleanup and rebuilding, then moving on. "But," she adds, "Sept. 11 is not a finished, finite event that happened and ended on that day, as though it were a natural disaster. People are still living with a great deal of uncertainty, including lingering threats of other forms of terrorism, and an ongoing and perhaps an upcoming war. There is no 'back to normal' after this kind of catastrophe."
Carol North, MD, professor of psychiatry at Washington University School of Medicine in St. Louis, concurs. "Feelings of upset tend to lessen over time," she says. But that isn't always the case. In the year following 9/11, there has been a steady stream of incidents -- from the anthrax-tainted letters to the "shoe bomber" to the warnings from government officials to remain vigilant -- that have many people in what North calls "a state of constant unrest."
When healing does occur, many psychologists acknowledge that it takes time and can't be rushed. "If you had a broken leg and I pushed you to run a marathon in two weeks, everyone would think I was mad," says Danieli. "But somehow, after such a massive trauma as Sept. 11, rapid healing is expected, even though it is unwise and detrimental."
People who still feel traumatized by the events of Sept. 11 should seek professional help, according to most experts. A number of treatments are being used for PTSD, including psychotherapy and medications (such as antidepressant drugs). But, cautions Schlenger, "for long-term cases, treatment focuses more on the management of symptoms rather than 'we're going to get over this altogether.'"