September 9, 2021 – Karestan Koenen, professor of psychiatric epidemiology at Harvard T.H. Chan School of Public Health, recounts how 9/11 affected her career and transformed how professionals address the emotional impact of large-scale disasters.
Q: How have the 9/11 terrorist attacks affected you personally or professionally?
A: On Sept 11, 2001, I was living in Manhattan as a post-doctoral fellow at Columbia’s Mailman School of Public Health. In fact, I saw the planes hit the Twin Towers. Personally, I knew people who died in the attacks and others who were displaced from their homes or their jobs. A close friend whose apartment building was impacted slept on my couch until he could go home.
Professionally, the attacks made my work on post-traumatic stress disorder (PTSD) suddenly widely relevant. I was trained in evidence-based trauma treatment. My research focused on why, when exposed to trauma, some people develop PTSD and other mental health problems while others do not. In a matter of moments, my work had the potential to have important, immediate impact.
My mentor, Dr. Marylene Cloitre, was involved in organizing services for persons directly affected by 9/11—family members of those who died for example—and asked me to help. She organized a service where family members of those lost in the attacks could sign up to speak with a counselor (my colleagues or me). We would speak with family members in the acute stages of grief, who were trying to comprehend what happened and reconcile themselves to loss. (Some remains have taken years to be identified.) We organized visits for families to Ground Zero where we would tour the site with a firefighter and an engineer who would explain the impact and damage, in order to help families process the fact their loved ones were dead as well as have a chance to see the site where they died. Colleagues and I also organized talks and workshops around New York City on trauma, stress, and coping. Longer term, the attacks renewed federal interest in PTSD research—both because of soldiers being sent to war and because of the impact on first responders, direct civilian victims, and the families of those lost. This increased attention and funding fueled the next two decades of PTSD research and greatly advanced our knowledge of the pathophysiology of the disorder as well as accelerated treatment development.
Q: When trauma happens or anything bad happens, it’s normal to feel upset. So what is the difference between normal upset from trauma and PTSD?
A: Something we have learned in the past 30 years from psychiatric epidemiology is that trauma is common. Most people, whether they live in the U.S. or somewhere else, will experience at least one trauma in their lifetime. Many people will experience more than one trauma. Furthermore, we have learned that most people have PTSD-like symptoms after a trauma. It’s common to feel anxious and on guard, look over your shoulder expecting something bad to happen. It’s normal to keep playing over what happened in your mind, to have trouble sleeping or concentrating, and even to try to avoid thinking about or distract yourself from what happened. But for most people, as time passes over weeks or months, these PTSD-like symptoms naturally diminish without treatment or intervention. They diminish through talking with friends, doing things that give you pleasure even if you don’t feel like it, exercising and taking care of yourself, engaging in meaningful work, or praying. PTSD occurs when symptoms persist over time instead of diminishing and these symptoms interfere with functioning, for example being able to go to work or school or enjoy time with friends or family.
I am often asked how does someone know if they need professional help after a traumatic event? I would say to get help if you don’t feel like you are getting better over time, if you feel worse, or if your thoughts and feeling about the trauma are making it hard for you to live your life. Another sign is if you find yourself drinking more or using drugs to make yourself feel better. These are signs that you might have PTSD and require professional treatment. The good news is that there are many effective treatments for PTSD and you can feel better.
Q: What’s a healthy strategy for learning to live with the reality that disasters will happen? What’s a happy medium between complete denial and crumpling into a ball of despair?
A: Mass traumatic events—whether the 9/11 terrorist attacks or the COVID-19 pandemic—shake the foundations of our lives. We are suddenly confronted with the truth about our vulnerability as humans—life is unpredictable and our control is limited. At the same time, many basic aspects of our lives may be disrupted —for example, after 9/11 subway service in Manhattan was suspended and flights grounded. And yet somehow, facing this truth and managing these disruptions, we still have to get up in the morning, feed our kids, walk the dog, do our jobs. I don’t have a magic answer on how to do this; greater minds than mine have struggled with finding meaning and purpose in life while facing difficult circumstances. I remember doing a workshop on trauma in Manhattan after the 9/11 terrorist attacks, and a parent said she found herself feeling afraid all the time of another attack—how could she reassure her children that they were safe when she felt so afraid herself? I was reminded of something that Nelson Mandela said:
“I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.”
That is, the goal I think is not to live our lives in denial but to acknowledge the fear and our vulnerability and live our lives despite these realities.
On a practical note, there are some concrete actions I find helpful. First, I limit my consumption of news. So much news is fear-based; fear sells. My news consumption is limited to an email summary daily. I find written news less stress-inducing than television or radio. I then will read more on specific stories that are important to me. I also almost never watch cable news. Second, I have found taking breaks from social media helpful. I have deleted the Twitter and Facebook apps from my phone which has helped a lot. Third, I try to be mindful of when I take in news and social media. For example, I protect my sleep. Watching a lot of news is probably not the best thing to do before going to bed! Fourth, I consciously practice gratitude for the good aspects of my life and seek out people and stories that inspire me.
Q: How has the field of evidence-based treatment for trauma evolved in the last 20 years? What would we do differently now to help the first responders, those directly affected, and the families of those who died than we did back then?
A: The experience of 9/11 dramatically changed how we in trauma and public health address the emotional impact of large-scale disasters in several ways. After 9/11 many providers and organizations descended on New York City and conducted a treatment called Critical Incident Stress Debriefing (CISD), which was widely used in the field at the time for psychological intervention following large scale trauma. There were different versions of CISD, but most involved having those exposed to the trauma share their experience in a group setting. Some employers—with the best of intentions—made such groups mandatory or at least highly recommended that employees participate in them. The goal of CISD was to prevent PTSD. The idea behind the treatment was that if people shared their experience with others, this would accelerate the processing of the experience and avoid long term negative psychological consequences.
We learned from data collected after 9/11 that not only did CISD not prevent PTSD, in some cases it caused PTSD in survivors of the attacks and that the standard of care at that time was at best ineffective and at worst inadvertently damaging. These findings really shook up the field of trauma and disaster response, and motivated research into understanding people’s natural process of recovery from trauma, which most people will do, and to identify interventions that would actually help facilitate recovery. The standard of care now is Psychological First Aid, which was largely developed after 9/11.
photo: Charlie Samuels
For more information: