When Normal Isn't Normal Anymore

September 11, 2001, or 911, a date that evokes devastating images of horror and emotions that we are still struggling to understand and resolve. For many, there is a sense that the world has been permanently and irreversibly changed. As a nation, we are determined to go forward and resume our lives, yet the underlying tensions that exist are evident. These tensions are open and visible to any airport traveler asked to take off his shoes or to anyone observing armed national guard as they pass through security checkpoints. The air of anticipatory anxiety concerning when, where and to whom the next terroristic events will impact is palpable. All future events are now viewed with close scrutiny as we attempt to discern any possible links to the events of September 11.

Just like many of our patients, we, too, have been traumatized by these events. Understanding the strategies that we use to cope will be essential in helping our patients and ourselves to cope and begin the healing process. Trauma is often divided into four categories based on what causes the trauma: natural and technological disasters; accidents; interpersonal violence; and physical and/or mental abuse. The terroristic attack of September 11 was particularly devastating because it represented trauma from all four categories, or in other words, a quadruple traumatic experience. Furthermore, the September 11 attack has become a type II trauma (sustained and repetitive trauma) in that it has been reinforced by endless media coverage as well as federal government issued warnings of credible threats for ongoing attacks and biological terrorism.

In the aftermath, we remind ourselves and our patients that resiliency is the norm. Most will draw upon their inner strength and outside supports to find ways to cope adequately. We reassure others that symptoms do not necessarily equal psychopathology. Sleep disturbances, nightmares, inattentiveness, distractibility, and enhanced emotional lability may clearly be normal responses to abnormal events. We try to sift through our personal reactions and professional experiences to discriminate what is normal versus what may lead to persistent and more serious consequences such as acute stress disorder and post traumatic stress disorder. We are therefore called to screen these vulnerabilities in our patients, to educate the public and other professionals to identify who is at risk.

Risk factors that may contribute to ongoing difficulty in dealing with traumatic events may include prior traumatic experiences, preexisting mood and anxiety disorders and over involvement in the traumatic experience with an inability to separate oneself from the event. This may be particularly true for the rescue worker who is unable to leave the scene of the event, but may also be experienced vicariously by individuals "glued" to media coverage on the television.

As psychiatrists, we must be concerned about the potential clinical impact these world events may have on our patients. We must recognize that our patients may experience an entire continuum of responses from a very minimal response to one more dramatic that may include the individual reevaluating his life, experiencing blunted emotional response to those around him, experiencing emotional lability and exacerbation of any underlying psychopathology. We must also be aware that these events may rekindle past issues of grief and other traumas previously experienced.

Professionally, we are called upon to use our clinical skills to define what coping means in an ever-changing world. However, we must also now examine and redefine our own coping skills as we recognize that these world events have not only impacted our patients; but have, in fact, impacted our families, friends, coworkers and ourselves in a way we could never have imagined before September 11. Although the uncertainty of the future is a concern for all in our country, there has never been a more important time in our history for mental health professionals to educate the public while caring for those already in need.

-Mary Helen Davis, M.D. and Todd Cheever, M.D.

Back to Newsletter