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P1: GCE Psychiatric Quarterly [psaq]

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Style file version June 4th, 2002

C 2003) Psychiatric Quarterly, Vol. 74, No. 4, Winter 2003 (°

CONTEXTUALIZING TRAUMA: USING EVIDENCE-BASED TREATMENTS IN A MULTICULTURAL COMMUNITY AFTER 9/11 Randall D. Marshall, M.D., and Eun Jung Suh, Ph.D.

The mental health community was caught unaware after 9/11 with respect to treatment of survivors of terrorist attacks. Because this form of trauma was quite rare in the U.S., few trauma specialists had extensive experience, or taught regularly on this subject. Since the primary objective of terrorism is the creation of demoralization, fear, and uncertainty in the general population, a focus on mental health from therapeutic and public health perspectives is critically important to successful resolution of the crisis. Surveys after 9/11 showed unequivocally that symptomatology related to the attacks were found in hundreds of thousands of people, most of whom were not escapees or the families of the deceased. Soon after 9/11, our center formed a collaboration with other academic sites in Manhattan to rapidly increase capacity for providing stateof-the-art training and treatment for trauma-related psychiatric problems. Our experience suggests that evidence-based treatments such as Prolonged Exposure Therapy have proven successful in treating 9/11-related PTSD. However, Randall D. Marshall, M.D., is the Director of Trauma Studies and Services, New York State Psychiatric Institute; Associate Director, Anxiety Disorders Clinic, New York State Psychiatric Institute; and Associate Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, New York. Eun Jung Suh, Ph.D., is an Instructor of Clinical Psychology, Columbia University College of Physicians and Surgeons, New York. Address correspondence to Randall D. Marshall, M.D., Director of Trauma Studies and Services, New York State Psychiatric Institute Unit 69, 1051 Riverside Drive, New York, NY 10032; e-mail: [email protected]. 401 C 2003 Human Sciences Press, Inc. 0033-2720/03/1200-0401/0 °


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RANDALL D. MARSHALL AND EUN JUNG SUH

special clinical issues have arisen, such as the influence of culture on clinical presentation and treatment expectations in a multiethnic community; the need to focus on more subtle aspects of relative risk appraisal in examining traumarelated avoidance; the range of changes in daily life that constitute adaptation to ongoing threat; the difficulties in working as a therapist who is also a member of the traumatized community; and grappling with multiple secondary consequences of 9/11 such as unemployment, work relocation, grief, and apocalyptic fears leading to a dramatically foreshortened vision of the future. KEY WORDS: September 11th terrorist attacks; PTSD; culture; treatment; disaster mental health.

INTRODUCTION On September 11th, 2001, the terrorist attacks on the World Trade Center Towers and the Pentagon shocked America and the world. The loss of human life, the crippling of a major economic center and the nonstop live media coverage all obfuscated early attempts to predict the scale of mental health ramifications and needs. The mental health community in the New York area was taken by surprise, unprepared to respond to a disaster of such magnitude. While most mental health professionals are trained to see through the lens of psychopathology, which is usually focused on the individual’s inner psyche, this event had broad social, cultural, political and economic consequences which profoundly affect our patients’ well-being and ramify through an everwidening circle of relationships, communities, and social structures. For these reasons, it is important to draw upon a multiplicity of perspectives when working with those affected by the events of 9/11. One important lesson from our work with these patients is the importance of addressing the social, cultural, political and economic aspects of this event in therapy, and not restricting the therapeutic discourse to traditional “psychological” issues. Investigators (e.g. (1)) have pointed out that most human-made and natural disasters go through several, sometimes overlapping, stages of recovery: there is the “heroic stage” characterized by altruistic actions directed at saving lives and property shortly after the disaster; the “honeymoon period,” usually lasting for several months and characterized by solidarity and expectations of massive assistance; the “disillusionment” phase, lasting from several months to several years in which people become disillusioned over subsequent delays in hoped for and promised aid; and the “reconstruction” period during which victims


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assume a role in, and responsibility for, their own recovery and new programs, including the physical construction of new environments. We need to recognize the specific challenges and stressors faced by the victims of 9/11 as they try to cope with their lives during the current “disillusionment” and “restoration” phases. This paper aims to describe the professional response of a team of clinicians and researchers at Columbia University and the NYSPI Trauma Studies and Services program, with a special focus on the unique clinical issues arising from our work with those individuals seeking treatment following the events of 9/11. This team tried to do our part in meeting the anticipated mental health needs of the community in the wake of the September 11th disaster by providing trauma education and training to health care providers, and treatment to traumatized individuals. In the days and weeks following the World Trade Center attack, we turned our attention to the possible psychological consequences of large-scale disasters. This paper therefore begins with an overview of the findings from the epidemiological surveys conducted in New York City and nationally since September 11th, 2001. Then we describe the mobilization of our local mental health community, including clinicians, researchers, and educators to help meet the psychosocial needs of the city. Finally, we focus on the valuable clinical lessons learned thus far from our therapeutic work. We will discuss why we believe the attack posed a profound challenge to existing models of disaster-related mental health assessment and treatment, and we will review how emerging models of the sociocultural context of trauma help guide the clinical treatment of persons in treatment for terrorist-related events.

REVIEW OF THE 9/11 LITERATURE Since September 11th of 2001, a number of general population surveys have been conducted in New York City (NYC) and across the country. Galea and colleagues (2) conducted a random-digit-dial telephone survey of 988 adults residing below 110th Street in Manhattan, 4–8 weeks after the attacks. The study assessed the relationship between severity of exposure and PTSD and depression. Among respondents, 7.5% reported symptoms consistent with a diagnosis of current PTSD related to the attacks, and 9.7% reported symptoms consistent with current depression. Criteria for either disorder were met by 13.6% of those surveyed, while 3.7% met criteria for both. Within the surveyed area,


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it was estimated that 67,000 people met criteria for PTSD and 87,000 met criteria for depression at the time of the study. Predictors for PTSD in a multivariate model were Hispanic ethnicity (Odds Ratio [OR] = 2.6); history of two or more stressors preceding 9/11 (OR = 5.5); experience of a panic attack during or immediately after the event (OR = 7.6); residence below Canal Street (in lower Manhattan, OR = 2.9); and loss of possessions (OR = 5.6). Predictors for depression in multivariate analysis were Hispanic ethnicity, two or more prior stressors, a panic attack during or immediately postattack, a low level of social support, the death of a friend or relative during the attacks, and loss of a job due to the attacks. Ten percent of the respondents reported an increase in frequency of visits to a mental health professional in the month following 9/11 (compared to the month before) and 3.4% reported using new psychiatric medications during that time period (3). 28.8% of respondents reported an increase in tobacco, alcohol, or marijuana use (4). Current PTSD was more prevalent in individuals who reported increased cigarette smoking (24.2 vs. 5.6 percent, p = 0.001) and marijuana use (36.6 vs. 6.6 percent, p = 0.05). Depression was also more frequent in people who increased use of cigarettes (22.1 vs. 8.2 percent, p = 0.004), marijuana (22.3 vs. 9.4 percent, p = 0.05), and alcohol (15.5 vs. 8.3 percent, p = 0.01). In multivariate models, an increase in cigarette smoking was found to be strongly related to proximity to the site of the attacks, previous life stressors, and panic attacks in the first few hours after the attacks. Alcohol consumption was found to be related to high media exposure, while increased marijuana smoking was related to younger age, low household income, being single or divorced, and having a panic attack close to the time of the attack (4). Vlahov and his colleagues predicted that the ongoing threats of terrorist attacks, high rates of unemployment, as well as on-going clean-up efforts at the WTC area would contribute to both severity and persistence of symptomatology. A second survey was conducted about four months after 9/11 (3) with oversampling of Manhattan residents living south of 110th street to allow for comparison with the initial study. Response rate for the second study was 60%. The prevalence of current PTSD and depression had dropped to 2.9% and 4.3%, respectively, a decrease of 66% for PTSD and 60% for depression since the initial survey. Such decline in prevalence is consistent with findings from previous studies (5,6). A national web-based survey (N = 2733) (7) conducted 1–2 months after the September 11th attacks found that prevalence of current PTSD was higher in the NYC metropolitan area (11.2%) than in Washington,


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DC (4.0%), and the rest of the country (4.0%). Being in the NYC area on the day of the attacks was associated with a 2.9 fold increase in the likelihood of PTSD. Schlenger and colleagues also found that PTSD was strongly related to number of hours of TV coverage of the attacks viewed on and in the days following September 11th. Among New Yorkers (N = 691), younger age, female gender, being at the WTC on 9/11, and media exposure were all found to be related to PTSD. The authors suggest that the lower prevalence of PTSD in Washington DC might be accounted for by differences in the nature of the attacks. The WTC attack was viewed directly by more people, was a civilian target, and received much broader media coverage; the Pentagon site was more isolated and perceived as a military base by citizens. The relationship between number of daily hours of TV exposure and PTSD symptomatology is intriguing. DSM-IV does not explicitly mention media exposure (DSM-IV, 1994), but insofar as it evokes fear, helplessness, or horror, media exposure can theoretically fulfill criterion A (8). Various competing explanations for this association have been suggested: TV exposure may have contributed to symptoms by retraumatizing viewers, or alternatively, persons who already were experiencing 9/11-related symptoms may have been watching more television in an effort to make sense of their experience. Yet another possible explanation is that individuals who are more vulnerable to PTSD are more likely to be high consumers of television. The only published prospective nationwide study to date investigated a wide range of mental health consequences of the 9/11 attacks (9). The researchers examined the degree to which various demographic and clinical factors could predict psychological outcomes over time. Similar to Schlenger’s study, the sample was also assembled by means of a web-based survey. Two months after the attack, 17% of the population outside NYC reported experiencing posttraumatic stress symptoms. Six months after the attacks, prevalence had declined to 5.8%. As can be seen, the studies are somewhat inconsistent, although well within expected confidence intervals. Each used different instruments with different psychometric properties to measure PTSD, and somewhat different time frames. In addition, study instruments were administered differently. The validity of a telephone interview may be limited by social expectation bias and by level of training of the interviewers. A web-based study ensures anonymity, but may be limited by other sources of invalidity, which have yet to be systematically examined in this relatively new technology. Notwithstanding, these surveys clearly indicate the presence of significant stress reactions and psychopathology following the terrorist


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attacks of 9/11, both among residents of NYC and nationwide. Clearly, there was a significant need for treatment intervention in the community, especially in the NYC area. It was necessary to prepare to serve as many as possible, especially vulnerable populations such as those with comorbid disorders, those in close proximity to the disaster, and those who suffered the loss of a loved one. Conducting clinical and epidemiological studies with state-of-the-art methodology is a difficult challenge, since the study site is almost always chaotic (see also (10,11)). Similarly, the provision of well-studied therapeutic interventions in the acute phase attempting to address the initial post trauma and grief responses, although highly recommended (12), is very rare due to funding shortage, (13); technical difficulties, feasibility barriers, and ethical concerns. However, reliable and credible findings based on strong study design, with pre-, during-, and followup evaluation and with scientifically sound comparison methodology, are essential for programming this field. Reasonable response rates, eligible comparison groups, gold standard measures, and especially longitudinal data collection can support generalization of findings, help reconcile results from different studies, and guide the community of clinicians who seeks for trauma education (11,14).

RESPONSE TO MENTAL HEALTH NEEDS AFTER 9/11 The National Center for PTSD, located within the Department of Veterans Affairs (National Center for PTSD website, accessed 2002), advises that interventions conducted after a community disaster are best understood within the context of when, where, and with whom interventions take place. With this in mind, the New York City Consortium for Effective Trauma Treatment was created to use existing expertise and resources available to the mental health professionals in the New York City area to meet the needs of New Yorkers suffering from post trauma sequelae. The NYC Consortium, funded initially by The New York Times Foundation and the Surdna Foundation, was a collaboration between four directors at trauma centers in Manhattan: New York State Psychiatric Institute, Columbia University (Randall Marshall, MD), Mount Sinai Hospital (Rachel Yehuda, PhD), Weill Medical College, Cornell University (Marylene Cloitre, PhD), and Saint Vincent Medical Center (Spencer Eth, MD). The overarching goal of the NYC Consortium was to organize the deployment of well-trained clinicians by creating an infrastructure for ongoing training, provision of


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evidence-based treatment, and quality control. The Consortium mobilized in time to respond during the 8th–12th week following the disaster, typically referred to as the restoration phase, during which long-term recovery programs are generally implemented. The study and provision of evidence-based treatment for adults with PTSD is a relatively new and highly specialized area in mental health. Immediately after the 9/11 attacks, The New York State Psychiatric Institute was inundated with requests for education and training from clinicians. In order to meet this demand, the NYC Consortium for Effective Trauma Treatment held a series of intensive training seminars conducted by experts from around the world for a group of experienced clinicians who would, in turn, be providing treatment at no cost to victims of 9/11. The directors and clinicians would also provide lectures and trainings for the community in the year following September 11th (2001–2002).

PSYCHOLOGICAL ADJUSTMENT AFTER 9/11 Clinical Presentations Patients who came to our clinic presented with a myriad of symptoms and problems as well as a wide range in their impairment of functioning following 9/11. Some exhibited the classic symptoms of reexperiencing, arousal, and avoidance/numbing as defined by the DSM-IV criteria for PTSD. Others presented with subsyndromal psychological problems, yet were nevertheless deeply troubled and suffered many difficulties in functioning during their everyday lives. Many of our patients presented with diverse problems influenced by their particular ethnic and cultural backgrounds. If we were to truly help these patients, the social, cultural, political and economic aspects of the events of 9/11 could not be ignored by the mental health profession. This is one of the lessons emerging from the enormous breadth and range of problems that have arisen in our work with 9/11 related patients. Far from restricting their discussion to traditionally classified “psychological” issues, these individuals have presented with a myriad of problems that necessitates considerations well beyond a symptom-based model. Since many of the clinical issues raised following 9/11 have not traditionally been the focus of treatment in either cognitive-behavior or psychodynamic psychotherapy, our challenge has been to understand in the broadest possible


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way how to help these patients adapt to their particular post-9/11 world. The Trauma of Terrorism The breadth of these presenting clinical problems should not come as a surprise, as they are not responses to ordinary traumas, horrific enough in themselves, but rather are responses to a highly sophisticated and psychologically engineered terrorist attack. As the epidemiologist Ezra Susser has pointed out, terrorism is fundamentally psychological warfare (15). Unlike conventional warfare, the targets are not the military or industrial assets of a country, but rather its psychological wellbeing. This is not a side effect of terrorism; terrorism aims to maximize psychological damage to the population being targeted. One aspect of this was clearly manifest in what we call the iconography of terrorism (16). Some of its component elements on 9/11 were the following: the element of surprise; the attack on major symbols of American power, military, economic, and international influence; the targeting of random civilians going about their ordinary daily routine; the execution of a highly visible and dramatic attack that garnered maximum television coverage and extensive broadcast repetition in a city in which worldwide coverage was guaranteed. The collapse of both towers, whether intended or not, magnified the impact even further, as it symbolized the helplessness of victims and rescue workers alike. Perhaps most frightening and appalling was the grim reality that the attackers had no qualms about the murder of thousands of people. While the strategy of terrorism aims at disrupting the aforementioned social structures, disaster research predicts that it also has the potential to create reactions that can lead to positive social consequences. Mobilization after the attack can create a new social cohesiveness within an otherwise highly diverse and often contentious society. As a nation, we are more aware of the culture and diversity existing within the Islamic community. Many previously unaware Americans have achieved a new awareness and concern about the role of the US in international relations and a greater understanding of the sources of antipathy toward the U.S. At the same time, many have a newfound moral outrage at the targeting of civilians to achieve political ends and a new commitment to opposing terrorism around the world. How, then, do we conceptualize the breadth of responses to this complex event, and how do we help our patients and ourselves achieve a healthy integration while living with a different reality?


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Clinical Considerations in the Treatment of Victims of 9/11: The Role of Relative Risk Appraisal in Living with the Dread of Further Attacks In order to accommodate these broad clinical issues we have drawn from a theoretical framework based on Shalev’s observation that a number of the early responses to trauma are healthy and reparative, but if they persist these same responses become symptoms. In sum, PTSD resembles an impaired recovery process (17). We begin with the commonplace observation that the hallmark of life is adaptation to a physical environment, and the hallmark of healthy psychological life is flexibility of adaptability. The goal of treatment, then, is to facilitate adaptation to the new reality. This is presumably impeded by both distortions in perception of the new reality and by barriers to making this transition. This framework encompasses many important aspects of what is known about responses to trauma. Edna Foa (1992) noted that a defining characteristic of a traumatizing event is that it is unexpected, uncontrollable and inescapable. In other words, trauma is usually a stressor that requires a response outside the usual range of adaptation. It should be noted that this conceptualization encompasses both the objective nature of the event and the subjective response to it. What is needed to successfully navigate this transition is a change in the environment, in the person’s usual adaptive strategy, or in the relationship between them that is beyond the adjustment ability of the current adaptive state. Those who witnessed the WTC collapse on television but were in no personal immediate danger may nonetheless have experienced a change in their internal representation of the environment as safe. For many this change was so profound that it simply could not be accommodated by their previous cognitive schema and belief structures, and required a readaptation. This readaptation process may produce a great deal of psychological discomfort accounting for Shalev’s observation of the near universal experience of “symptoms” in the immediate post traumatic period, and confirmed by longitudinal studies after severe trauma and after 9/11 (9,18). If one’s capacity for readaptation is adequate these “symptoms” aid in the achievement of a readaptation and subside as that readaptation coalesces. Given this framework, our therapeutic approach has been to facilitate functional readaptation. To do this we first identify those psychological functions that have been adversely affected and bring to bear appropriate therapeutic tools. For example, many patients present with a failure in the cognitive function of risk appraisal, which is common after a new


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threat is introduced into awareness. We refer to this important clinical issue as the problem of relative risk appraisal. The theoretical basis of exposure therapy for posttraumatic symptoms derives from the observation that, in these patients, potentially new threats are appraised as exaggeratedly likely based on confounding of the vivid memory of the prior trauma with the expectations of future experience. This is viewed by therapists as a cognitive distortion, and the problem often responds to cognitive restructuring. At some point in the therapy, for example, the therapist might point out that approximately 115 persons are killed every day in automobile accidents (15), and yet the patient feels no anxiety about driving to work everyday. In 30 days as many die on U.S. highways as died in the WTC attack. Moreover, air travel, given the thousands that fly every day, is no more dangerous than it was before 9/11. When presented in a calm and factual manner at the appropriate time, most patients find such observations reassuring. This approach places more emphasis on the capacity for rational thinking than the traditional psychodynamic approach—or in theoretical terms, it emphasizes the use of mature coping strategies as a way of overcoming fear. But what of the problem we face as contemporaries under the uncertain threat of war and retaliation from terrorists? All our therapists are also members of the community, and any dialogue with the patient will activate therapist concerns as well. If the therapist avoids public transportation in New York City, will she be able to help a patient take the subway again if necessary to daily life? In other words, the therapist’s assessment of what constitutes realistic risk plays a critical role in the construction of interventions with the patient. Moreover, the current uncertainty requires a more subtle perspective than that of simply framing the dangers as exaggerated. We believe that it is important for the therapist to have arrived at a conscious and deliberate decision as to what the risks are for himself in the community, so as to avoid barriers to working with the patient. This must be viewed as a personal decision that involves the rational weighing of risks and benefits and of various courses of action based on available information. Once the therapist has gone through this process, he will be able to assist the patient through the same kinds of considerations, and remain comfortable with individual differences to these outcomes. Cognitive interventions aimed at relative risk appraisal are informed by the concept of overgeneralization (19). That is, this cognitive distortion is characterized by an exaggerated, often unconscious influence which the traumatic memory exerts on views of the whole self, the whole world, or most of humanity. An extreme example is found in the many persons we have encountered who did not leave their apartments


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for weeks or months after 9/11 out of fear. The whole world became dangerous, except for the apparently magically protected interior of their living space. In formal terms, the patient expects that key aspects of the prior trauma will necessarily occur again. When exploring such issues, the Socratic method is usually more effective than a didactic approach. As in psychodynamic therapy, we assume that insight into the nature of a cognitive distortion will have greater emotional impact if the patient arrives at it herself. Unlike longterm psychotherapy, however, the therapist does not hesitate to use gently leading questions or statements if the patient does not quickly arrive at such insight. In helping the patient overcome avoidance, which can be the source of severe impairment, cognitive and psychodynamic approaches alone may not suffice. Exposure techniques involving in vivo exposure (out of session exercises) and sometimes medication are considered integral to most validated psychotherapies for PTSD. Because therapists who did not receive early training in behavioral techniques are often particularly uncomfortable using structured interventions, we provide some examples of using in vivo exposure below. –A 55 year old artist who was working in her studio located near the WTC on the morning of 9/11 developed PTSD symptoms and was unable to return to her studio to continue her work. She would frequently have nightmares about burning bodies falling from the WTC buildings and have intrusive memories of the smell of burning flesh and the screams of the victims. She was unable to go near the WTC or back to her studio where her paintings and personal possessions were covered in ashes. In PE, the patient’s primary goal was to return to her studio and continue working on several projects which she had been commissioned to complete in the very near future. First, an in vivo hierarchy was constructed such that she could gradually approach her studio, and then clean-up her space and begin to work on her paintings. The SUDS scale ranging from 0–100 was used to monitor her level of anxiety before, during, and after in vivo exercises. The first in vivo situation was to walk by her studio with a friend who would act as her “coach.” This situation was rated by the patient as provoking a SUDS level of about 50, whereas walking by the studio alone would be about a 70. She rated her actual SUDS level at 85 for entering her studio and 95 for cleaning off the ashes from the paintings. With gradual exposure, the patient was able to successfully overcome each of these situations return to continue working in the studio.


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–A 28 year old man who was working as a financial analyst in a building next to the WTC developed severe PTSD symptoms which were interfering with his functioning at work following 9/11. On the morning of 9/11, he was on duty as the floor representative for guiding the evacuation of his colleagues. He was burdened by tremendous feelings of guilt and shame over his “failure” to perform his duty successfully. He witnessed the terrorist attacks on the WTC at very close proximity from his office window and was haunted by witnessing people jumping to their deaths. He began to avoid any contact with colleagues and friends as well as avoided attending important meetings because he felt ashamed, feared that they would talk about the WTC disaster, and also feared they would confront him about his failure to guide people out of the building effectively. He also was unable to work in his office, and was using a spare room which did not have a window to avoid looking at ground zero. Through gradual in vivo exposure exercises, he was eventually able to return to his normal state of functioning. For example, the first in vivo exposure exercise was to set up a lunch date with a friend/colleague. He was also assigned to work in his office, which had large windows, first for one hour, and then gradually greater lengths of time until he was able to fully move back. –A 40 year old male who completed his overnight work shift as a systems engineer at the WTC was just leaving the building when the airplanes crashed into the WTC. He witnessed the destruction of the WTC buildings that for which he felt such pride, and lost several colleagues whom he cherished on 9/11. Following 9/11, he was overcome by fear that New York City would be the target of another severe attack. He was unable to take public transportation. He would only take taxis from his home on Coney Island into Manhattan to attend his job, although he could not afford the cab fares. He was also close to losing this new job because he was unable to perform certain duties that required taking the elevator up to the roof. His wife was becoming impatient with his avoidant behaviors and also feared he would lose his job during this time of high unemployment. In vivo exposure techniques were successful in his treatment. The following are examples of some of the situations on his in vivo hierarchy: taking the bus with a friend–40 SUDS; taking the subway with a friend—50 SUDS; taking the bus by himself—60 SUDS; taking the subway by himself—75 SUDS; taking the elevator with a


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colleague to the top floor—70 SUDS; taking the elevator to the top floor by himself—80 SUDS; walking out onto the roof—90 SUDS. With much practice, the patient was eventually able to master the avoided situations. As a final point on therapeutic technique, many patients we have seen have prior trauma histories. This is not surprising since psychological trauma is extremely common. 60.7% of men and 51.2% of women interviewed reported having experienced at least one major (criterion A) traumatic event in their lifetime in the National Comorbidity Study, establishing such experiences as relatively common in the U.S. (5). It is a normal function of memory that associative networks would be activated by strong affect, and when an individual is preoccupied by fear and anxiety, previously frightening experiences will be brought to consciousness. The important question then becomes how to address these in psychotherapy. Previous beliefs in the mental health field, now discredited, were that the prior trauma explained the current response to trauma, particularly if the trauma occurred at critical points in development. Although prior trauma often seems to play a powerful role in shaping the individuals current responses, we believe it is important to give equal emphasis, or even primary emphasis, to the adult’s response. Otherwise there is the potential pitfall of seeming to minimize the person’s often very vivid emotional engagement with the adult experience. In summary we have seen how terrorism is engineered to cause maximal psychological and interpersonal disruptions in a society and results in a broad range of clinical responses. By thinking of our patients as adapted individuals with a capacity to readapt to new realities we can bring to bear specific therapies and thereby hope to attain a new and comfortable integration. We think of this process as a form of metaadaptation.

CONTEMPORARY PSYCHOLOGICAL MODELS OF POSTTRAUMATIC STRESS REACTIONS The characteristic intrusive and avoidance symptoms of PTSD can be understood as evidence of the victim’s search for a new sense of meaning and order in the world in the wake of the traumatic experience (20). Cognitive theorists have suggested that trauma produces its effects by undermining unconscious schemata which serve to organize an


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individual experience of reality. The most influential early model of posttraumatic stress disorder was the “information processing” model of trauma developed by Horowitz (21), a crucial advance in integrating psychodynamic theory with advances in cognitive science. Psychodynamic theory offers much in the way of deepening therapist understanding of the whole experience of the patient, and is a useful complement to evidence-based cognitive-behavioral treatments (22). Horowitz (21) argues that traumatic experiences create an obstacle in cognitive and emotional processing by presenting information which conflicts with preexisting schemas. This incongruity gives rise to distress, provoking a “stress response” which involves reappraisal of the event and revision of the schemas. If the event is highly traumatic, the event remains stored in “active memory,” and is replayed over and over again in an attempt to assimilate the meaning of the event, each time causing distress for the individual. In order to avert emotional exhaustion, inhibition and facilitation processes become involved and act as a feedback system which modulates the flow of information. Horowitz argues that individuals’ response to trauma has a phasic nature which entails periods of active memory alternating with periods of inhibition. Although the importance of social, cultural and personality factors in relation to trauma is acknowledged, Horowitz emphasizes cognitive processes that occur in individuals as innate response to stressful events. Intrusive symptoms such as nightmares and flashbacks are present if there is a failure of inhibition. However, symptoms of withdrawal and avoidance are present if there is too much inihibition. Technological metaphors are copiously applied to explain cognitive processes. Analogous to computer programs, cognitive schemas encounter new information from a particular perspective and process it in particular ways. Schemas filter information to either reject the new data as anomalous and remain unchanged, or changes to integrate the information. In this model, traumatic experience overwhelms individual’s capacity to process and integrate new information which contradict the existing “meta-schemata.” Bolton and Hill (23) emphasize that posttraumatic stress reactions are accompanied by a failure to integrate the trauma into the system of belief about the self and reality. Reexperiencing symptoms result from this disintegration and avoidance symptoms represent the individual’s innate attempts to escape triggers for these intrusive symptoms. Janoff-Bulman (24) speaks about “shattered assumptions” in the wake of trauma, assumptions about the self and about the meaning of the world which provide the essential background for individuals to


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understand the self, others, and the world. Thus, when the inner world of the victim is abruptly ruptured and becomes fragmented, trauma results as their “conceptual system” becomes disrupted and disintegrated. Posttraumatic stress symptoms represent an individual’s conscious and unconscious efforts to cope with the loss of meaning as their fundamental assumptions which provided security, coherence an order are shattered (24). COGNITION AND CULTURE Traditionally, psychologists and cognitive theorists have in general viewed loss of meaning as something which happens predominately within the individual mind, with little influence from external sociocultural factors. Although culture may be considered to contribute peripherally as the backdrop in which cognition functions, our sense of the world and our processing of traumatic experiences occur independently of culture. Kleinman (25) argued that culture cannot be regarded as a decorative surface to reality. Instead, he suggested that very basic aspects of our reality are culturally constructed. The basic mechanism of internalization also suggests that both the cultural and social milieu has influenced adult psychology in a formative way. The neurobiological underpinning of this mechanism is the considerable plasticity known to be present in the developing human brain. Cross-cultural studies of emotion have recently challenged the idea that emotional states have the same representation universally and that these representations are independent of culture. These findings have increased the acceptance that culture significantly mediates the experience and expression of emotion. This cross-cultural understanding of emotional responses has intriguing implications regarding responses to traumatic and stressful experiences. Bracken (20) argues that if culture shapes emotional experience in a pervasive and profound way, the current discourse on trauma based on the “emotional processing” theories of cognitive psychology, may need to be reconsidered. Jenkens (26) questioned the validity of using the individual trauma model in cross-cultural situations, based on her work with Salvadorean women refugees living in North America. She recommended the examination of the “collective trauma,” suggesting that investigations conducted only at an individual level are inadequate in the comprehensive understanding of traumatized cultures. Summerfield (27) argues that the individualistic concept of PTSD cannot encompass the cultural dimension of suffering in times of war,


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particularly in non-Western settings, and that social context often determines the outcome after wartime suffering and loss. He believes that recovery from trauma does not occur without the rebuilding of social worlds. This position is supported by the work of Eastmond (28), who compared two groups of Bosnian refugees relocated to Sweden. The refugees were from the same town and had been detained in the same concentration camp in Bosnia. Refugees who settled in a location where they were offered temporary jobs fared better than those who were offered psychological interventions but no work. Most of the adults who were not offered work were on indefinite sick leave one year after arrival. These data constitute empirical validation of Maslow’s classic construct that need is organized in a hierarchy such that more basic needs such as those for security or stability must be satisfied before more abstract needs, such as interpersonal connectedness and self-respect (29). Models of posttraumatic stress reactions have generally been constructed by cognitive researchers with the premise that a psychological process is the essential element of the reaction. The central focus of the model is on an individual mind reacting to a specific event or series of events. While preexisting personality traits and cognitive schemas of the individual are acknowledged as operating within a given and specific social environment, the cognitive model is developed mostly independent of culture. Bracken (20,30) argues that the experience of trauma and reactions to it are understood to be structured by the everyday social and cultural world of the individual. He suggests that the first step in understanding the impact of an event or series of events, on an individual or community, is the generation of an account of the social world which existed before and after the events. Then, the second step is to understand the meaningful world of any particular individual. This perspective usually begins with a social and anthropological focus and then moves towards psychology, with the sequence of inquiry flowing from the cultural context to the individual cognition (20,31). It is notable that both these perspectives are deterministic in their purest form: the former locates the explanation of the perceived meaning of trauma in the psychology of the individual, and the latter, from the sociocultural context of the individual. The challenge for anthropology and psychology alike is the design of strategies to test competing or complementary models that can contribute to our understanding of both the universal aspects of human trauma, and the unique contributions of individual psychology and culture.


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FUTURE DIRECTIONS Following September 11, 2001, there was an unprecedented need for the mental health community to mobilize and collectively respond to the psychosocial needs of those suffering from the terrorist attacks. Many mental health professionals put forth their time and expertise in an effort to best meet the needs of people across the nation. Now, over a year later, it is necessary and timely to reflect on how we have responded and, assess our response critically to determine what more needs to be done, and how to prepare resources and improve resilience for the future. Coordination, collaboration, and communication among various professional communities are essential elements of disaster preparedness. Different service groups such as mental health providers, primary healthcare physicians, rescue workers, and other professionals who are most likely to have initial contact with victims of disasters need to integrate their efforts to maximize efficiency and effectiveness. Healthcare professionals also need to coordinate their efforts with local religious and community leaders to best meet the specific needs of the community, by providing assessments and interventions appropriately adapted for each individual. Through these integrative approaches, we hope to not only discern the most effective trauma interventions but also to discover how best to strengthen resilience and coping in the community. The disaster research literature suggests that the primary and secondary consequences of a disaster of this scale will continue over a period of several years. The main objectives of our trauma center are to continue providing evidence-based treatments for trauma and traumatic loss for the community and education training and supervision for mental health clinicians in the greater NYC area. We will also advance our knowledge in the area of trauma-related interventions and refine our ability to effectively educate clinicians in the community through rigorous research studies. The terrorist attacks of 9/11 were not only destructive to the physical integrity of our cities, but also to the psychological infrastructure of individuals, families, and communities. Terrorism resulted in a broad range of clinical responses from our patients as they struggled to adapt to the many changes and losses in their lives. In the wake of 9/11, we were challenged by our patients to assist them in their search for a new sense of meaning and order in the world, just as we, the clinicians, battled our own altered assumptions about ourselves, others, and the world. One invaluable clinical lesson we learned from working with the culturally


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and ethnically diverse clients in NYC who presented to our clinic following 9/11 was the importance of the social and cultural context in shaping posttraumatic stress reactions. In emphasizing contextual issues as a significant determinant of how trauma is experienced for each patient, we have been deeply enriched in our efforts to comprehensively treat individuals within their environment.

ACKNOWLEDGMENTS This work was supported in part by The New York Times Foundation, The Surdna Foundation, and The Atlantic Philanthropies.

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