This article first appeared in the St. Louis Beacon, Sept. 7, 2011 - Time has turned out to be the best therapy for many who were traumatized by the sight of jetliners crashing into the twin towers of the World Trade Center in New York during a terrorist attack a decade ago, mental health experts say.
While post-traumatic stress disorder was common among eyewitnesses in New York's Manhattan to the horrors of Sept. 11, 2011, many experts say there has been no long-term emotional effect on those who watched the events unfold on television.
This view is in contrast to predictions a decade ago that both groups would experience strong emotional crises requiring lots of therapy.
"What we learned from that incident was that we had a lot more resilience than we've given ourselves credit for," said Steven Bruce, director of the Trauma Recovery Center at the University of Missouri at St. Louis.
"I'm trying to walk a fine line here in saying that people weren't affected. I'm not downplaying anybody's experience. It certainly was a horrific event."
But he added that predictions of widespread post-traumatic stress disorder were overstated. Symptoms of the disorder include depression, substance abuse, anxiety and/or "lots of hyperventilation, being kind of jumpy, being on edge," Bruce said. To be diagnosed with the disorder, the symptoms must persist for at least a month.
Bruce conceded that after the attack, many people experienced elevated levels of anxiety, nightmares and a lot of other symptoms associated with PTSD, "but by and large, most of those symptoms went away after a period of time."
In addition to showing that "we are a resilient bunch," the attack changed the way professionals respond to disaster, Bruce said. Before 9/11, the response to a tornado or hurricane would include going out and giving "mass treatment" to everybody who was exposed. That's the equivalent of passing out pills for physical ailments without first making a diagnosis to determine who really needs the medicine.
"That actually could be harmful," he said.
The aftermath of the attack turned out to be a watershed event. At least one article in the journal American Psychologist suggests that some post-9/11 interventions were inappropriate. The article, "Postdisaster Psychological Intervention Since 9/11," points out that psychological debriefing -- the practice of gathering facts, thoughts and reactions from trauma survivors -- used to be widely accepted. In the aftermath of 9/11, the authors say, respondents have learned that the initial goal of early intervention should simply focus on promoting safety, stabilizing survivors and connecting them with additional resources.
"There is a growing current consensus that this type of approach (known as Psychological First Aid) is the most appropriate" following disasters and mass violence, the article says.
This new thinking about the appropriate response to mental health needs during a disaster was followed in the wake of the tornado in Joplin. Vicky Mieseler, clinical director at the Ozark Mental Health Center in Joplin, said experts didn't rush in with treatment. She said mental health workers like herself were pleased by the way many victims bounced back from the trauma on their own. Even more impressive to her was the fact that some staff members from the Ozark Center who suffered personal losses during the storm were able to cope well enough to show up for work in spite of their own hardships.
This example points once again to the human resilience that Bruce mentioned. There also seems to be a consensus that children generally coped well with what they heard and saw related to the attacks. Another article in American Psychologist concludes that the psychological consequences among youngsters were relatively transient, particularly among those who watched the events unfold on TV. The article gives parents credit for playing an important role in shaping their children's responses.
Jerry Jacobs, director of the Disaster Mental Health Institute at the University of South Dakota, has much experience in working with victims of disasters. His work dates back to 1992 when United Airlines Flight 232 crashed in Sioux City, Iowa, claiming the lives of 100. Jacobs and another psychologist, Randy Quevillon, partnered with the Red Cross in treating trauma among the victims. While the response to the 9/11 attacks is regarded by some as a turning point in treating widespread trauma, others say the Sioux City crash was the start of a move by the Red Cross to restructure disaster-related mental health services.
That incident prompted Jacobs to establish a new academic program: The University of South Dakota became the first school in the country to offer a full curriculum in disaster psychology. The University of Denver and the University of Kansas are among the schools now offering graduate-level disaster psychology programs. Jacobs was inspired, he said, by the nation's limited research surrounding psychological support for survivors and families such as those in Sioux City.
"We felt bad because we thought we'd have a big chunk of literature," he said. "At that point I proposed to come up with a plan for disaster with the Red Cross and the American Psychological Association."
What has been learned, he said, is that some of the good intentions behind mental health interventions can cause problems.
"In the immediate aftermath of most major events, we have thousands of people who come forward to volunteer, and they have no training, no preparation and they really aren't very helpful," Jacobs said.
People can help best by gaining know-how before a disaster occurs from groups such as the American Red Cross. The agency offers disaster training "in virtually every field you can imagine. They can make use of any expertise that you bring to the table," Jacobs said.
Like UMSL's Bruce, Jacobs doubts that most people will experience emotional problems during the coming anniversary of 9/11.
"Some in the field have maintained that the bombing of the Murrah Federal Building in Oklahoma City was more difficult" for the public, Jacobs said. "The number of children who were involved could lead to that (bombing) being a more stressful experience. The event on Sept. 11 was certainly more dramatic and tragic on a mass scale. But I don't think it's any different from other mass casualty events we've experienced."
He said 9/11 showed that "it is really profitable to be prepared in advance."
The preparedness or lack of it is a worry of Greg Evans, director of the Institute for Bio-Security at the Saint Louis University School of Public Health.
"People who were not in New York City were affected by 9/11 and experienced a certain level of psychological stress," he said. "I think they have been able to go on with their lives."
But the public's emotional health remains at risk because the nation seems to be dropping its guard and investing less in preparedness programs, Evans said.
"I just got off the phone with some people from other states who indicate that their preparedness budgets have been slashed substantially," he said last month. In addition, he argued that the public health workforce has been aging in the past 10 to 15 years, and that many of those who received training in preparedness after 9/11 have retired or are no longer working in that area. He said heightened preparedness persisted for five or six years after 9/11, but he said it has fallen off.
Although Bruce is confident that time has helped heal many psychological wounds growing out of 9/11, he added that the victims also have to do their part in learning to cope. He said avoidance can be a stumbling block to recuperating.
""Not avoiding (the issue) is one of the strongest things we advocate," he said. "That's part of the treatment."
Funding for the Beacon's health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization that aims to improve the health of the people in the communities it serves.
