Terror trauma: Is America stressed out?

One of Israel’s leading experts on Acute Stress Disorder suggests that the traumatic experience of the terror attacks on the United States may scar not only the individuals directly affected, but may also produce lasting changes in the identity of …

One of Israel’s leading experts on Acute Stress Disorder suggests that the traumatic experience of the terror attacks on the United States may scar not only the individuals directly affected, but may also produce lasting changes in the identity of American society as a whole. Israel’s long experience with terrorism may provide some valuable lessons for a nation that until now has been relatively insulated from attacks on its own soil.

Dr. Ilan Kutz, director of Psychiatric Services at Meir General Hospital in Kfar Saba, Israel, indicated that the full impact of the trauma may only be felt in months or even years. “At least as far as terrorism goes, America has been insulated from the kind of terrorism that Israel has experienced,” he says. “Until now, many Americans enjoyed the luxury of believing that there was a kind of unwritten contract between their deeds and consequences. There was a kind of moral naiveté that human rights and human life can be assured by “doing right and being right.” The unimaginable shock of the attacks in the heart of America might have ruptured that illusionary envelope of safety for good.”

The scale of the Sept. 11 attacks, too, was also beyond belief, even for Israelis accustomed to and hardened by suicide bombings. “When it comes to horrific events,” Kutz said, “size and intensity do matter. There is a world of difference between a traumatic event and a catastrophe. An explosion of a terrorist bomb on a street is a traumatic event. It will injure some 20 to 120 victims, many of them mildly. Having airliners come out of the sky, smashing and imploding the largest and mightiest structures in the world, and burying thousands of people under the rubble, cannot be defined as a traumatic event. This is a calamity, a disaster of the largest scale.”

“Our sense of reality … cracked”
The distribution of those affected, Kutz said, was atypical in the extreme, inverted relative to the usual ratios. “Usually in a terror attack, for each person killed you have about 10 injured and some 20 people acutely affected emotionally by the trauma. Here you had only a very few injured, thousands killed – actually vaporized – and an unknown number of spectators whose degree of involvement has yet to be determined.

Some, he said, may develop a Post Traumatic Stress Disorder (PTSD), a chronic debilitating mental state. Even for the hundreds of millions who watched on TV, the impact on our entire set of assumptions about the world, about basic safety and trust, is substantial. Our sense of reality and world order may have been shattered or at least cracked.”

Kutz said that typically 5 to 10 percent of people exposed directly to a severe trauma will show lasting effects. Typically those that were physically present at the disaster – seeing, hearing, and smelling it – are at the highest risk, along with anyone who lost someone close to them. But he noted that individuals who are prone to traumatic stress, especially if they or a close family member have experienced traumas themselves, could have the disorder triggered just by watching it repeated on television.

To some extent, the media’s continuous repetition of the cataclysmic events and the endless interpretation of its implications had a positive psychological effect, serving as a sort of desensitization process and as a kind of group facilitator for viewers trying to work through and make sense of the experience. Kutz noted that even in Israel, for days after the event, people were trying to come to grips with their feelings of shock and depression.

“People here [in Israel] and elsewhere,” he said, “have a need to make contact with each other, go over the story again and again, and just like the repeating and expanding TV loops, create a narrative that will make some sense and provide coherence. People all over are trying to restore the sense of safety and continuity as if we had physically been there, as if we personally had suffered from Acute Stress Disorder.”

ASD: symptoms and coping mechanisms
Acute Stress Disorder is the name for a relatively new psychiatric category, created to distinguish it from PTSD, the name usually applied to describe the more entrenched chronic disorder, which is typically not diagnosed until after six months have passed.

People suffering from ASD often have nightmares or flashbacks immediately following the trauma. They may feel numb and have difficulty responding normally to everyday events. They may be on edge, have difficulty sleeping or have outbursts of anger or tearfulness. Some abuse alcohol or drugs to blunt overwhelming feelings or to help them sleep.

Responding to trauma by reasserting control
Kutz’s experience in Israeli terror events has led him to codify intervention techniques for assisting victims in coping with the effects of trauma. He suggests talking about the trauma – the more the better. Expressing the experience and hearing the accounts of others are essential for integrating that abnormal event with other aspects of one’s life into a new narrative, a new reality-organizing principle to replace the one that was shattered.

Kutz recommends that summoning the forces of reason can also help. Rational thinking about fears can be helpful in reminding oneself of the low statistical risk of terror attacks.

Healthy attachments to supportive figures and familiar objects offer protection and reassurance against feelings of vulnerability. Religious beliefs can serve the same reassuring, reality organizing purpose. Charismatic leaders who convey a sense of confidence can boost moral and restore the sense of safety.

Kutz noted that trauma from terror can cause adults to regress into a child-like state. Those who become most valuable to the public are leaders who can play a fatherly role in a crisis, like New York mayor Rudolf Giuliani. “He was able to step out and say, I’m here; I’m with you. This is tough but we”ll get through it together.”

“Revenge”, Kutz observes, “enters as a reality-organizing principle” that offers to divert attention “to action and heroics as an attempt to ignore the feelings of pain and helplessness.” While this approach might work for some people, he notes, for others such attempts to “play the hero” are likely to ring hollow.

As for the Anthrax scare, the impact of uncertainty far outweighs the actual threat itself. Laboratory animals, Kutz noted, are eventually more panicked by the anticipation of an electric shock than by the shock itself. As U.S. President Franklin Roosevelt said: “What we have to fear most is fear itself.” He compared the situation to 1991, when Israel was under missile attacks. He said that while the Kfar Saba area where his hospital is located was not hit, the sirens produced a much higher than normal incidence of heart attacks.

And what if it happens again?
Kutz said he did not expect that there would be another terrorist disaster on the same scale. If it were to happen, however, he said that the result would likely be profound confusion and despair in America. Repetition would create a sense of helplessness and of being trapped, with no way out. Among the likely popular reactions to such an event, he believed, would be extreme rage, including the expressed desire to exterminate enemies.

As for the long term prognosis for the United States in dealing with its terror trauma, Kutz predicted that, barring more catastrophic terror attacks, some sense of normality would return: “Human beings are flexible and accommodating creatures. We can ‘get used to’ just about anything.” But even if most people not directly affected will get over the shock and suffer no lasting damage, he concluded, no one who witnessed the event will ever be exactly the same: “Our sense of safety will remain scarred and sensitized.”

Kutz suggests that some Americans would become ‘more Israeli’ if terror attacks became more frequent events. “Terror becomes part of the everyday cost of living,” like road accidents. He said that in their relation to terrorism, Israeli were akin to those who become accustomed to living in the shadow of a volcano, knowing there was a price eventually to be paid: “You know that once in a while the mountain is going to blow, but in the meantime you get on with your life.”