Trauma and PTSD: Aftermaths of the WTC Disaster - An Interview With Yael Danieli, PhD

Martin L. Korn, MD

Disclosures

Medscape General Medicine. 2001;3(4) 

Introduction

Dr. Martin Korn talks with Yael Danieli, PhD, clinician and trauma specialist in private practice, about the World Trade Center disaster and issues of trauma for the victim and for the clinician.

How do you see the recent terrorist attacks in the United States?

This is a massive, cataclysmic event. In about 45 minutes, more than 5000 people at the World Trade Center, lost their lives. Many other lives have been shattered. I am speaking only about the direct victims, as we would call them, and those who attempted to help the situation, such as police and firefighters. I mean, the real heroes in our midst who really went beyond and made everybody feel more human, and with the leadership of the Mayor Giuliani and Governor Pataki. Particularly the mayor -- he's really an inspiring, embracing, and encompassing and containing figure who somehow figured out how to do what I call "compassionate articulation" for the experience of people in New York City. Of course everyone else, to some degree or another, has been impacted as well. Certainly, New Yorkers and the whole country and certainly the world. I have received hundreds of E-mails from around the world and everybody seems to be involved. The vulnerability of the powerful, that is, every trauma has in its essence vulnerability, helplessness, and fear, but this happened to "the most powerful." What's unique about this trauma is that it happened in America. Otherwise, the massiveness and the systematic planning for this, the Machiavellian systematic planning, are quite similar to other such events in the past.

Can you compare this to some of the other traumatic events you have studied and worked with?

I don't like to compare events. There are elements of events that share some similarities. However, I think it would be very wrong to say this is like another because each one is totally unique and must be seen within the sociocultural, economic, and political contexts in which it happens. We are learning more and more about the systematic planning of this event. There was systematic planning, although totally unique, in the Nazi holocaust. There was systematic planning in Rwanda. There were years and years of clear, systematic planning in Bosnia. There are many differences as well. For example, this happened in, the most prepared city in the world in terms of medical services. In Rwanda, our medical interventions were limited; while here, tragically, with all the preparation and the extremely technologically advanced hospitals here, the doctors were sitting and waiting. The tragedy was that nobody came after the first wave of the fortunate few who survived. So here we are totally prepared, unlike many other countries, totally equipped, but we must sit and wait, and all the doctors who are used to taking care of and rescuing people have the same sense of helplessness we all do. The television coverage, while extremely important in terms of providing information and orienting people to what's going on, giving a running commentary on what's going on, showed the images in homes where children were watching over and over again. This was an immense trauma to them. Again, there is no way to judge anybody in this business except the terrorists and those who fail to really take seriously the threat. I think part of why I said it's unique in America is that everyone including Americans thought of America as the most powerful and as such denied the credibility of many of the threats.

Do you agree that there is a widespread perception that this is a defining moment, that the world will not be the same?

Absolutely. The world will never be the same. Some people call it a loss of innocence. I think it's also a loss of naiveté. There's a difference. The sense of the powerful that somehow became vulnerable, that is more the naiveté part. The innocence is a different level. That describes the failure of humans to act humanely and the intrusion of evil in such a planned way into people's lives who would like to think that the world is good. I think there isn't enough of that distinction. Some people see it as a sociopolitical event, as an act of war, but I see it as an absolutely evil thing.

War is evil. Let's be very clear. Whenever people are out to kill people, that is evil, especially innocent people. Of course it's evil. Of course it could be politically motivated. It could be socially motivated, economically motivated. It could be ethnically motivated, it could be religiously motivated. We could go on and on through all the layers of identity in this world. But just the same, the intent is evil and the effect is evil. Evil is introduced into the goodness of people's lives. That's what we mean by loss of innocence. Innocence is really about believing that the world is a good place, a safe place where people's lives are respected and where life is cherished. All of that innocence just blew up in our faces, and the effects will be felt for years and years. The United States has been protected, perhaps by our very beloved oceans and perhaps by our own sense of power, which always scared me a little, and now you know why. Because when you believe it, you forget sometimes that you, too, are vulnerable, and then you're not as cautious and as protective of yourself. This is true of individuals as well as countries.

Now, you asked about the effects on the immediate victims. Of course, it's crushing and there's no way to generalize about that. They lost loved ones. They lost the fabric of their lives. Again, it's multidimensional. I have written about the multidimensional nature of trauma and it should be analyzed that way. What is important about this trauma is that it has all the elements that all researchers have shown necessary for posttraumatic stress disorder to develop. The fear, the helplessness, the overwhelmingness, the intensity, everything that predicts the disorder is right here. Again, why shouldn't I generalize? The loss of a mother, the loss of a father, the loss of a son, the direct loss of a breadwinner or the protective person who suddenly now couldn't protect? People find it difficult to sleep. They're either afraid to dream, they can't let go, they can't relax to sleep. They're in extreme grief. They're stricken right now. Many people are still in shock and in disbelief that this has happened. Many people are frightened. Last Friday, I was walking in the street and the fighter jets came over? Everybody in the street cringed. We all looked up and cringed. Some people literally fell to the floor. That's to be expected. My advice would be "don't pathologize, don't medicalize, and don't trivialize." And I think looking only for symptoms...is doing all three.

You have written about the role of transference in the treatment of the traumatized individual. What should the clinician be aware of in this regard?

I have written about this on several occasions, for example in my recent book Sharing the Front Lines and the Back Hills. Originally, the book aimed at international protectors and providers -- those who go out to intervene in those horrible situations. The horrible irony is that I prepared it presuming that we apply this to other parts of the world, now, it's hit us and we are here. The phrase counter-transference is very loosely used in the sense of all feelings that all therapists experience -- in all phenomena they experience -- thinking, feeling, acting, that are really generated by the trauma. This may lead the therapist to not listen and not feel, misdiagnose, and therefore not be able to help. Much of it is unconscious. I had noticed that originally when Nazi holocaust survivors and their children, who in my study of hope, uniformly said not only that most people didn't listen to them or believe them when they tried to share their experiences, but that therapists, too, wouldn't listen.

I became extremely alarmed, and most eager to understand why the people who were supposed to help through listening, through understanding, also shared in the conspiracy of silence. I saw it because all survivors, those who went to health professionals, say that the professionals didn't listen. They behaved like the rest of the population. I figured that if I studied people who are well-trained and open and used to introspecting and understanding what's going on with themselves, it may shed light on the general conspiracy of silence between survivors and society. It has been most harmful to survivors for very many years. So I studied and found many ways in which therapists don't listen.

Can you elaborate?

I can give you general categories. The main classes of what I call counter-transference themes were a defense, in which they were numbing, denying, avoiding, distancing, clinging to professional roles and reduction to method and theory, like listening only to the past or listening only to the present. That was the most prevalent and all of them were defense maneuvers. Then you have a major class of guilt. What I call bystander's guilt. By the way, this is what The New York Times will report on, the survivor guilt, and you see that all over the place. You don't just see it in the immediate survivors who would think about, "the last conversation I had with him or her," or "what I could have done more," or "I should have, I could have." You find it in everybody. Just writing a check feels very useless. All of us try to do something. There are major existential functions to survivor guilt.

How would guilt in the clinician play a part?

The clinician will say, "I am available 24 hours. Call any time." The clinician would play the victim who could inflict that sense of guilt. The clinician would mix up survivor guilt, which is passive guilt (simply that I was there but for the grace of God) with active guilt, which is the kind of guilt that you do have to feel or you are psychopathic; for example, when you did something wrong. So the result is to not be able to set reasonable limits, or not be able to listen. It causes too much pain to listen to the loss and to the horribleness. Also, the therapists themselves may feel totally enraged. Who are they going to share it with? Sometimes it flips on the survivors or they start feeling very guilty. I really elaborate on this in great length in my book.

One of the issues about the holocaust is that there was a concern that some people survived and that talking about it would open up old wounds.

Most of that is a projection of the therapist. It's the same as blaming the rape victim and asking her whether she was wearing something seductive. Blaming the victim is one result of rationalizing your own sense of guilt. If you blame the victim, then you don't have to feel guilty. Then you don't have to feel the pain and the rage and all those feelings that are extremely hard to contain. The third class is rage. They're all interactive, but I'm giving you the major classes. The rage in the clinician sometimes shifts toward the survivor.

You don't have room to be enraged immediately. Just like people attacked Muslims all over the country because there was no visible, immediate, or clear target for their rage. You sort of go with it everywhere. That's displacement, of course, but in the absence of target. Rage is the most difficult emotion to experience in a therapeutic setting for the clinician. It's extremely hard to contain. Most therapists went back to a sort of refresher therapy or for special training. Because of their inability to control rage or cope with it effectively. There also might be a sense of shame. Some of them started talking about patient resistance, which was another issue.

Did you see rage as a particular issue here in that the clinician would also be involved simultaneously with the event in some way?

Yes. At one level or another, everybody was victimized, including all the therapists. Maybe not directly, but yes. In some ways directly and certainly indirectly.

What about shame that you mentioned before?

Shame and disgust are very profoundly important reactions and very difficult to deal with. Then you have dread and horror. All of that cluster that is very difficult to contain. Then you have your own grief and mourning. Sometimes people feel engulfed by it and sinking into it. With all these feelings, to contain them is a real challenge. And yet, if clinicians cannot, they can't really provide a holding environment in the clinical sense to the people they're trying to help. All this gets reflected even in the language. Some people call it murder, some people call it death, as if it's a normal thing. Then you have the more cognitive part where the therapist sees the patient or the victim as a victim or as a hero and that generates a whole lot of different reactions, doesn't it? If you see the patient as victim, you know it's pathetic. You have to rescue, and then you're in the position of liberator. If the patient is a hero, then sometimes you just listen with adoration and don't ever attend to the pain and the suffering. Then you have the whole other class that is in contrast to all of this, which is what I call privileged voyeurism. Some therapists just like to listen to the details of it over and over again. They would ask questions to know more of the details for themselves rather than to respond to where the person is at. And you have competitive feelings. What I call the "me too" reaction. We are all survivors. I know exactly what you mean. There's nothing that shuts people off more readily than, "I know exactly what you mean." It's another way to shut the person off and to not listen. Then you have others who have actually shared the experience with someone who has previously been traumatized in other ways. That can create a sense of bond. That again, may or may not be helpful because it can lead to "I know exactly what you mean." At the same time, it can lead to a more ready ability to listen, to empathize, to let the person mourn. Then comes the whole challenge, especially in these kinds of traumatic situations, of religious, ethnic, political, identities. How much do you allow the person to talk about that? What do you need the person to be? Proud of their heritage, for example? What if the victim is Muslim? Can you tolerate that versus you're feeling? Once they really articulate their victimization, say, only in a political way. Can you tolerate that? Or do you need to take them down to just psychological terms? This is really not all of them. I am sort of running you through the map. You have the whole slew of whether the victim was a child or an adult or an older person in the family setting -- when you think of family and the function in this family -- and what was ruptured? There is so much.

Can you talk about the effect on children?

One of the things I find amazing is that people most readily talked about children from the first day onward, which is absolutely justified of course, but on the other hand, I thought that it was somewhat of a defense to not talk about the adults. That it's okay to talk about children as vulnerable because they are the symbol of vulnerability, aren't they. It's far more acceptable somehow to speak about all those vulnerable children, so I would like that to be mentioned, because while I totally participated in the talk about children, I had to talk to children and listen to them and maintain the protective shield for them. I think it was in some way an escape. It still is. Children, especially those who have seen it over and over again, were traumatized. They didn't have to look at it over and over again to experience the trauma. Everybody talked about it anyhow.

We have lots and lots of children in the city and around the country watching. We have a lot of adults being very anxious and feeling vulnerable. And they're the parents and the teachers and they are those whose function is to protect and be the all-powerful, containing, protective membrane against the evil of the world. That has been shaken. Until now, this kind of phenomenon was specific to video games and TV shows, if they were allowed to watch them. Now, my God, it's the news. It's about real stuff. A lot of children are terrified. In a funny way, some of them are much more openly articulate about their feelings than are the adults. It is very interesting.

How might families help the children cope?

By reasserting the protective and containing function of the family. To eat well. To not resort to self-medication, to drugs, to alcohol. To try to maintain some semblance of normal life. You can't say go back to normal, because there is no going back to normal from this, but the challenge is to establish a new normality after this. I would take the children in. I would listen very carefully about their ideas of the new normality. It is a collaboration. I would find ways for them to do things so that they don't remain in helplessness. To participate in the helping...to talk more about the rescuers and the good people, not only the evil people, so there is a balanced view on this. Absolutely, to listen to them. Listen to every fantasy. Do not stop them from articulating, even if it makes you anxious. That's a real problem, because in many families when there is a loss, let's say the husband dies, the wife is the center of a loss and all the attention, and somehow the children are supposed to be OK. Of course, we know that has been a mistake even with normal bereavement.

Then you have the other phenomenon in which everyone responds with all the good will and everything, however, the attention span tends to be very short. I am afraid of what will be after this fantastic generosity of spirit and bonding start to fade. Everybody is into this. It's a high. That is where I am afraid. When the first time you hear "Let bygones be bygones." That is a very scary phrase. I was terrified in the first 2 days when in all news shows they asked "What about closure?" My God! You didn't even know who was dead and who was alive, and people are supposed to close already? You remember, we talked before -- you asked me about comparisons to other traumas, to other massive events like these? And I said, this is American and part of the trap, part of the danger here is the quick fix. Let's quickly diagnose, let's quickly decide who's responsible, who's not. Everybody else is helping. Get over with it. We'll rebuild it. We'll get back at the evil and we're the great. I'm very afraid of that, and that is uniquely American.

That is part of the traumatizing. That is the traumatizing culture. It doesn't allow people to grieve. We have all this literature about complicated bereavement, about incomplete bereavement, etc. I don't want that to happen. So that is a great concern of mine, and it's a concern of mine with therapists as well, those who may not have really learned much about bereavement and mourning in general. Maybe they learned a little, but may have not learned about the relationship between trauma and mourning and loss, and how that really complicates matters tremendously. For example, again to show how this is not unique to this experience. In common with Japan, with Armenia, with the holocaust, with Bosnia, with Rwanda, there are very few bodies to mourn. How do you mourn when there is nothing concrete in your hands? In effect, I suggested to the city today, through The New York Times, that every family without a body or without concrete evidence of the deaths (I'm not talking about DNA confirmation) will receive a beautiful jar of some of the ashes after it no longer compromises the investigation or the DNA identification -- because they need some. We call it transitional objects. They need something in their hands. Unlike the families of the holocaust, most of these families have pictures of their loved ones. The holocaust was without anything for many, for most. Some were fortunate enough to have something. I think this gift will be very important. I think it will be creatively healing, for example, to ask the artists around the city to design these kind of jars or something so it will be communal.

One of the things you've talked about is the role of leadership. I'm very interested in that aspect as well. Can you talk more about that?

Absolutely. We have a model. Giuliani absolutely arose to the challenge. God, we are blessed with him. It's hard to imagine anybody doing any better. One key of it -- this emerged for me in a discussion with Bruce Shapiro who is a reporter for The Nation -- he asked me how do I see the role of leadership and the media? We both sort of struggled for the words. A new concept jumped at me "compassionate articulation" -- like being a good therapist for the city. I articulate compassionately, what people are going through. I mean "compassionately," because "empathetically" simply means that I can try to figure how you're feeling, but compassionately adds the layer of "and I reach out to you." I think compassionate articulation. I think that is what Bush did yesterday in his speech. He compassionately articulated the concerns of this nation. He really managed to do it in such a way that people felt unified. Not only unified by being there, by being victimized, but unified by his sense of containment -- of articulation of what people felt.

Any other thoughts...

The counter-transference reactions I've found are not to the patients. In that sense, it's the wrong word as well, but rather, it is to the event. It's bad news and good news. The bad news is that you neglect the individuality of the patient and you neglect the person who is sitting with you in need of help. The good news is that you therefore can be trained to negotiate these reactions prior to seeing any patient. I've done many training sessions around the world. We've had a seminar called Counter-transference and Trauma for years and years and years and we basically work with the therapists' reactions, as much as, or sometimes more so, than the patient to really keep the therapist totally present in the situation, rather than resorting to counter-transference or defensive maneuvers. Again, therapists need healing, too. That's where the principle of self-healing comes in.

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