July 1, 2002
Mary Ann Travis
A 4-year-old boy zooms a toy airplane into a cardboard building, crashing the plane and toppling the building. The boy plays out this Sept. 11-like scene in a therapy session with his mother. He's in foster care and wants to get reunited with her. He exhibits intense anxiety symptoms. He wonders, can she keep him safe?
Charley Zeanah (A&S '73, M '77)--a handsome, quiet man--is the boy's psychiatrist, leading the mental-health team treating the boy and observing the scaled-down re-enactment of the Sept. 11 World Trade Center calamity. It's not surprising that safety is an issue for this boy, says Zeanah. But, now, Zeanah adds, safety is an issue for everyone. Since Sept. 11, Americans have entered "a new era where we don't know what's going to happen at any point," says Zeanah.
It's a more frightening, dangerous world, a fundamentally different world. People in other parts of the world have experienced this uncertainty before, but Americans haven't, until now. And Zeanah says, "I think there's no going back. We're in it. And that's it." Zeanah is a professor of psychiatry at Tulane's School of Medicine and author and editor of Handbook of Infant Mental Health (Guilford Press, 2000).
Zeanah's colleague in the Department of Psychiatry and Neurology, professor of psychiatry Phil Griffin, agrees that Americans have been changed by Sept. 11. We've got a worried state of mind--for good reason. Griffin wears a jeweled American flag pin on his suit coat lapel. He says, "We are a big, easy target because of the way our country is. That this finally happened makes us aware that it could happen again. The fact that we are vulnerable to that kind of thing is an enormous wake-up call."
Griffin has been a faculty member at the School of Medicine since 1976. He earned a PhD in psychology from the University of South Carolina. He treats patients with illnesses ranging from schizophrenia to depression to substance abuse at Charity and De Paul hospitals in New Orleans. Often, his patients have muddled thinking, including one man, absorbed and upset by the Sept. 11 events, who commented, "I'm going to go to Vietnam and kill some Japs."
Few people are as confused as Griffin's delusional patient. Most Americans know the facts as reported by our free press: 19 hijackers, part of a radical Islamic network, completed suicide missions to cause extensive destruction in a jihad or "holy war" against the United States. Denial is often what people undergo in the face of trauma, says Griffin. But the vivid images--broadcast repeatedly--of the planes exploding into fireballs as they hit the Twin Towers can not be shut out.
"This was too big and too vivid, " Griffin says. "The images were there for us to see. So, denial--not a chance this time." The last time the World Trade Center was bombed was in 1993. And Griffin says that that time, somehow, we managed to deny that the terrorist attack happened. When terrorists bombed the Navy ship USS Cole docked in Yemen in October 2000, many Americans forgot about that, too, says Griffin.
But the massive--and complete--destruction of the New York twin-tower icons can not be blacked out, whited out or obliterated. The pictures are in our minds and memories. Cameras were everywhere, documenting the devastation and making imprints of the crashes and the buildings and bodies falling. Griffin cites a survey that found that the average American adult viewed eight hours of television on Sept. 11. And the average American child watched three hours. We all saw the planes hit the buildings many times.
"It's like a scar," says Griffin. "It's not going away. It's going to be with us." The Sept. 11 images recur as part of our collective post-traumatic-stress experience. Just as older Americans remember the Dec. 7, 1941, bombing by the Japanese at Pearl Harbor in Hawaii, which propelled the United States into World War II, we won't forget the World Trade Center attacks. Americans of another generation remember where they were when they learned that President John Kennedy was assassinated in 1963.
"You'll remember where you were and who you were with when you first heard about the planes hitting the skyscrapers," says Griffin. Sept. 11 is that kind of historic, societal event.
Griffin notes that The New England Journal of Medicine published results of a survey taken within a week of Sept. 11 in which 90 percent of those surveyed admitted to at least minor symptoms of anxiety or tension attributable to the disaster. And 40 percent said they had major symptoms, including difficulty sleeping, increased irritability, substance abuse, intrusive and upsetting recurring images of the destructive attacks and hyper-vigilance.
As would be expected, respondents closer to New York, Washington, D.C., and Pennsylvania, where the fourth hijacked plane went down, reported more stress symptoms. Shock usually accompanies denial in response to traumatic events, says Griffin.
With denial of the Sept. 11 event undercut by the widespread visible evidence that the plane crashes did indeed occur, Americans got a double dose of shock. And some people coped better than others. Griffin has worked with patients who have suffered traumatic stress from maritime accidents and robberies. These events change people because they didn't believe it could happen to them, he says. "Once it's hap-pened to you, you become more vigilant. You become a changed person. The world isn't nearly as safe a place as you thought it was. And that's what happened to us on Sept. 11."
People deal with stress in two basic ways, says Griffin. They try to escape it or they try to control it. As individuals, we're kind of helpless and dependent on others to control the events of Sept. 11. "The escaping and controlling defies the average person right now," says Griffin. "We're letting our government do it." People in the Middle East, Africa, South America and Europe have lived with terrorist threats for some time. And they go on about their business, perhaps anxiously, but doing what they've got to do. That's what Americans have to do now, too, says Griffin.
"We've got to answer the bell every day because it's what we do. The sun comes up and people expect us at work. People expect us to come home from work. Your kids still need you." For vulnerable people, though, Sept. 11 stacks another stress on them. "People who are vulnerable are simply vulnerable," says Griffin. The depression-prone will dwell on the events in a debilitating way. But resilient people will bounce back--and resiliency may be programmed in people during their childhood. "When you're brought up by parents who help you to become resourceful and let you make decisions--some good and some bad--you become resilient and able to cope better," says Griffin.
Resilience and reality checks are helping Americans deal with postSept. 11 anxiety. In reality, the number of people closely involved with the Sept. 11 event is miniscule. "It sounds cold to say that the chances are so small of that happening to you when thousands have been directly affected, but it remains the truth," says Griffin. The latest official death count from the Sept. 11 terrorist attacks in New York is 2,893.
And while we watched in horror as the World Trade Center crumbled, imagining thousands crushed or burned to death on each tower's 110 floors, the reality is, according to USA Today, 99 percent of the buildings' occupants below the impact of the crashes survived. So, in fact, rescue efforts worked well and evacuation plans saved lives. Still, schoolchildren on playgrounds and New Yorkers on the street scan the sky worriedly when they hear low-flying aircraft overhead. Airplanes trigger the memory of the disaster, and many people have avoided flying.
Griffin treated flying phobics before Sept. 11 and says many fears contribute to being afraid to fly. One is the fear of not being in control. Yet, he says, people should not focus on spectacular, but unlikely, outcomes such as planes crashing but instead realistically assess the low probability of your dying in such an accident.
The Sept. 11 catastrophe put people in touch with their own vulnerability, says Griffin. In many cases, we reached out to connect with family, friends and even strangers. For example, a local art director and man about town abruptly decided to get married, postSept. 11.
A Tulane student got a call from her dad, who is divorced from her mom and from whom she hadn't heard in years. He worked at the World Trade Center and wanted to let her know that he was all right. "The fact is, we're not going to live forever," says Griffin. "Nothing's guaranteed and nothing's certain. I think tragedy can make people adjust their lives accordingly and try to do things that they might otherwise have put off." Time will diminish the pain and sorrow of loss. "Anybody who has lost a loved one knows that time helps," says Griffin. And so does activity--and now there is a flurry of activity. We are at war in Afghanistan, and American soldiers are tracking down the al-Qaida network of terrorists behind the Sept. 11 attacks.
If average American citizens can't control or escape the amorphous possibility of a terrorist attack, we can fly the American flag--everywhere--on our cars and houses, schools and businesses, from plumbers' trucks to dry cleaners' vans, from mansions to tiny shotgun houses. Even corner bars have painted the Stars and Stripes in red, white and blue on windows and fences. We also can give--in astounding amounts--blood and money to the Sept. 11 victims and families.
The flag phenomenon is a way to show support for our country, says Griffin. "It's a symbol that unites us. It's all of us." In crisis, we consider ourselves one nation. "And we pull together enormously well," he says. "I've got to believe that our current enemies must not have known that about us. They must not have read their history books. Because if they thought that we would just fold over and say, well, you're right, we need to stop supporting Israel and we'll do this. ... How wrong could they possibly have been?"
Griffin likens the radical Islamic terrorists to the Barbary pirates from Morocco, Algiers, Tunis and Tripoli, who for centuries demanded ransom in the form of money, arms and boats from European countries in return for allowing European ships access to trade in African ports. In 1801, the United States as a young country stood up to the pirates, refusing to pay ransom.
By 1815, after some military action, Barbary piracy ended. "We're a free country," says Griffin, "and we're seeing the down side of that now." Anyone can come into our country with whatever beliefs he or she has. But we don't always have to have terrorism, Griffin adds. We can end terrorism the same way we ended piracy.
While Griffin is not a military historian, he understands that a dominant characteristic of the American psyche is power. "We are a big, powerful country," he says. "We started off being a country with a war against an established power--England. And we've found somebody to fight every few years since then." During the American Civil War, we even fought among ourselves. Griffin says the American identity is the superpower, the innovator, the developer, the technology leader, the educator, the optimist.
"That is part of who we are. Every country isn't a powerhouse. We are. We're able to defend ourselves, and we're able to defend others as well." Our power, might, riches and the hegemony of our culture cause resentment, Griffin acknowledges. But we have a history of doing the right thing, and we will do it again.
"We do the right thing every time," he says. Yes, there is the ugly American, says Griffin. "There's the obnoxious traveler and his conspicuous consumption, but most of us don't like that person either," he adds. Americans have enormous resolve when it comes to defending the country and all it offers and represents, Griffin says. "Someone miscalculated how determined we are to keep our way of life and do things the way we like to have them done."
The desperation of the terrorists is hard for most Americans to understand, says Griffin. The poverty in Middle Eastern countries, lack of hope for a better life on Earth, dearth of democratic institutions and political parties, fear of modernity, oppression by their own leaders, suppression of civil rights, scarcity of a free press, religious fanaticism--all these factors contribute to the terrorist mentality.
But, Griffin says, "Americans find it puzzling that people would hate us." A key reason we're hated, says Griffin, is because of our religious freedom. What we see as a strength and virtue is held against us. On the surface, Americans don't have religious issues with people. In actuality, Griffin says, many Americans have only vague ideas about religions other than Christianity.
Most Americans don't understand Islam, which is practiced in America by from 1.5 to 7 million people, according to the Washington Post. Janet Johnson (PHTM '00), assistant professor of psychiatry, says, "We fear what we don't know or don't understand." If something, such as another religion, is not familiar, it is frightening. "It takes time and effort to learn about another religion," she says. "A lot of people would rather just take what's handed to them and listen to the news as the truth. They don't sort through and figure out what's right, what's wrong, what do I believe?"
Johnson is concerned about belligerent responses to the terrorist attacks such as, "We're Americans, we're tough. We'll kick your ass." Johnson has a medical degree in psychiatry from the University of Missouri and did a postdoctoral fellowship in schizophrenia re-search and treatment at Columbia University. She's been a member of the Tulane medical school faculty since 1996, and in 2000 she earned a master's in international health from Tulane's School of Public Health and Tropical Medicine.
From her global viewpoint (Johnson traveled in Kosovo and Latin America as part of her coursework in public health), she laments the misunderstanding and miscommunication surrounding the Sept. 11 terrorist attacks and the resulting war in Afghanistan.
From her travels, the warm, friendly and open Johnson says she's discovered that people around the world are more alike than they are different. "And our differences are small. Even when you compare the major religions, they all have the Golden Rule. They all have variations on the same themes. And people have the same basic emotions and want the same basic things out of life. To continue to kill each other when we're in the 21st century seems like we're going backward instead of forward."
Johnson, like Griffin, acknowledges that the American psyche radiates power. "We're the cowboys," she says. "We're John Wayne. That's who we are. We came over and started this new country and beat the British. We conquered the West. I do think it is part of our psyche that we're No. 1, and, by god, we're going to stay No. 1. You don't mess with us. We mess with you. We tell you what to do. We're right. Our democracy's the way it should be."
Johnson finds it bothersome that our politicians have characterized the terrorists as purely evil--or worse, crazed--and America as only good and above reproach. The aggressive stance of American leaders who say, "We will hunt them down. We will get the evil-doers," vexes Johnson.
Of all countries, America is supposed to be inclusive and tolerant, says Johnson. By no stretch of the imagination does Johnson condone the terrorist attacks but she wishes we'd make more effort to look at things that led up or contributed to these violent acts and the perpetrators' frustration and hatred. There are two sides to every conflict, she says.
"I don't think they understand us any better than we understand them. But we are the greatest nation. It is our responsibility to take the lead and try and open the doors of communication. I don't see that that happened for many years. And I think that gets perceived as arrogance. I'm not a politician. I'm not a historian. But, psychologically, it makes sense." Johnson is a psychiatrist. "I think we have to stop having wars and start having talks." She stops herself and laughs. "That sounds very simplistic. If I knew how to do that, I could rule the world, right?"
Perhaps Johnson can't be sanguine about war because she's seen its effects up close in the Vietnam War veterans she treats at the Veterans Hospital in New Orleans. Thirty years after the war, these men still suffer from post-traumatic stress disorder resulting from the life-threatening, disturbing experiences they underwent in the jungles of Southeast Asia fighting a war that divided America rather than united it.
"The Vietnam veterans have definitely been stirred up since Sept. 11," says Johnson. Now that we are at war in Afghanistan, memories of Vietnam have been vividly re-stimulated, re-triggered and re-activated for these former soldiers, most of whom are now in their 50s. They are outpatients seeking treatment for depression, substance abuse problems and sleep disorders stemming from their war experiences in the 1960s and early '70s.
Lack of sleep is a common malady for her patients, says Johnson. "They are always keyed up, and they've got short fuses. It makes sense if you think about the lack of sleep for that long. Anyone would be irritable." The bodies of these war veterans are wearing out, she says. And they are angry--angry both at the terrorists and at our government. "They're angry at the government in a global, generic sense," says Johnson. They feel as if the government should not have permitted the security lapse that allowed the terrorists to strike in New York and Washington.
They are also angry at the show of patriotism because during the Vietnam War they didn't have that kind of support. "They got spit on and called baby killers," says Johnson. "They're worried about young boys--[their sons' (if they had them) generation]--going to desert or jungle warfare like they did because they know firsthand what that's like. They're angry about all the flag waving." Johnson says she tries to point out to her patients that Americans know a mistake was made in the shabby treatment of Vietnam vets.
She tells them, "The positive that you've done for fellow soldiers is that we don't make that mistake again. We don't treat our soldiers like that, regardless of whether we agree with the war or not." Of course, not all Vietnam War veterans came out of the conflict with psychological disturbances in the form of post-traumatic stress disorder.
The American Psychiatric Association says PTSD occurs in people who are "exposed to a traumatic event in which the person experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury or it threatened the physical integrity of the self or others." PTSD was not identified as a psychiatric illness until the early 1980s. Before that, war veterans who had symptoms such as night terrors or flashbacks, psychic numbing or general anxiety, depression, inability to sleep, poor memory, difficulty concentrating or completing tasks and survivor's guilt were said to be suffering from "shell shock."
Researchers have found PTSD in every culture in which they've looked for it and approximately 30 percent of people exposed to PTSD-classified traumatic events--whether combat, accidents, physical attacks or disasters such as the World Trade Center attacks--have lasting symptoms, says Michael Scheeringa, assistant professor of psychiatry.
The remarkable thing about PTSD statistics may be that 70 percent of people exposed to trauma have no lasting symptoms. "We're more resilient than we think," says Scheeringa. "You could say we're geared for trauma to be part of our lives. If you want to speculate about our evolutionary adaptive mechanisms, we're built for this."
Most of us aren't as fragile as we think. New York City is requiring all its police and firefighting personnel to get psychological assessments and then counseling, if needed, in the aftermath of Sept. 11. That's a good thing, says Scheeringa, fresh-faced even with his beard. Just as Johnson and any therapist would, Scheeringa believes in the healing power of talk.
The best way to get over a traumatic situation is to talk about it, he says. Scheeringa graduated from Indiana University's medical school and did an infant psychiatry research fellowship with Charley Zeanah at Louisiana State University Health Sciences Center before they both came to Tulane in 1998.
Scheeringa, Zeanah's protege, is in the middle of a longitudinal study of PTSD in children from ages 1 to 6. A major finding of Scheeringa and Zeanah is that to help young children overcome trauma "you have to help their parents deal with the trauma, too." Therapy for young children includes talking about the frightening event or acting it out--with the parent's participation. And many families don't want to talk about traumas such as domestic violence, sexual abuse, car accidents or vicious dog bites.
Now we can add to the list--terrorist attacks. Kids look to their parents for comfort, solace and protection. They want to know that their parents will keep them safe. "It's a kid's job to read their parents," says Scheeringa. Kids are always taking cues from their parents about how to handle things. If a child senses that a parent is upset and doesn't want to talk about scary things that happened, he adds, "The kid says, oh, I've got to back off because Mommy's upset." Griffin concurs.
"Talk to your kids," he says. "Regardless of what you might think of yourself, you're a superhero to your children. Make sure that they know that you're there to protect them and to be with them and not let harm happen to them."
Immediately after the Sept. 11 terrorist attacks, Zeanah says he felt a profound need to talk to his own three children and make sure they were okay. "I felt a need to connect with them," he says. Zeanah worries about the world today's children will live in. He suggests limiting children's exposure to media violence and says that adults should fulfill the role of protector for their children. He also says we shouldn't dwell too much on the dangers of terrorist attacks.
Zeanah reminds us: "Sept. 11 was a national cultural experience but many children suffer ordinary trauma every day, and we shouldn't underestimate it. It's painful for us to face. But let's not forget that there were lots of kids experiencing lots of real, problematic events before Sept. 11 and after Sept. 11. We tend to ignore or forget that."
Mary Ann Travis is managing editor of Tulanian and a senior editor in the Tulane publications office. Send her an e-mail to firstname.lastname@example.org.
Tulane University, New Orleans, LA 70118 504-865-5000 email@example.com