On Sept. 11, 2001, with the attack on and collapse of the World Trade towers, the world, as many of us knew it, changed forever. Although most of us have continued living our lives as we always have going to work, going to school, aspiring to success some essential assumptions, about ourselves and about the world, have been shattered.
Many Americans, and New Yorkers, especially, report negative changes in their sense of safety, trust of the "other" and of authority, a sense of uncertainty about what the future will look like, and, above all, an uneasiness about whether they will ever again feel secure in a country considered to be the strongest, richest, and most stable in the world. An attack like the one on Sept. 11 was simply not supposed to happen here. That it did was, literally, earth shattering.
Shortly after the Sept. 11 attacks I was invited to join the Trauma Studies and Services program at the Anxiety Disorders Clinic at the New York State Psychiatric Institute. At that time, I was planning to return to my patients and my research at Tel Aviv University, after completing a sabbatical and an additional year of leave in New York. September 11 changed my plans completely. The malevolent nature of suicide terrorism to which Americans were exposed for the first time, its ongoing nature, and the severe anticipated psychological aftermath created a unique opportunity for Columbia University clinicians and researchers. With colleagues, I found myself immersed in developing a comprehensive program that included treatment for victims and bereaved individuals, training clinicians in the treatment of trauma-related conditions and various research projects aimed at learning about post traumatic stress disorder (PTSD) and traumatic grief in affected populations, both in Manhattan and elsewhere.
Building on the Israeli experience of war and terrorism, as well as on findings from previous post-disaster mental health research, our "trauma team" has assumed that, although the majority of the exposed population will likely show a consistent resilience, a significant minority is likely to suffer from PTSD and traumatic grief, and that some of these individuals will develop enduring and disabling mental health problems. We assumed an elevated risk for psychopathology in the more highly exposed and vulnerable populations, such as evacuees from the towers, bereaved persons, rescue workers, the elderly, immigrants, and those with pre-existing mental illness.
As expected, all Sept. 11 studies to date some of which have been conducted by Columbia University researchers showed elevated prevalence of 9/11 related stress symptoms in Manhattan and nationally, although the use of different methodologies led to different estimates of the numbers of people affected. For example, the studies conducted in New York the first weeks after the attacks found prevalence of 7.5 percent (Galea et al., 2002) and 11.2 percent (Schlenger et al., 2002) of PTSD, respectively. Understanding the nature of suicide terrorism is crucial to drawing accurate conclusions from these findings. The relevant question is: What made many of us so vigilant and on alert after the attacks, including those without full blown syndromes, and why are significant numbers of people still reporting elevated levels of stress?
The answer lies in an interplay between individual and contextual factors. The outcome of exposure to suicide terrorism is not only a consequence of an expected, human response to extreme trauma known to be associated with or predicted by a number of physiological, psychological and social factors but also, strikingly, has to do with the unique nature of suicide terrorism. It is now known that the main aim of suicide terrorism which deliberately causes massive destruction and gruesome death is to induce fear and helplessness, to diminish safety and stability, to weaken crucial social bonds, and, also, to hurt the economic, political, and social order of the society in which the attack takes place.
Therefore, terrorism-related post-trauma should be viewed not only as an outcome of the exposure itself, but also in the context of the act as a political and social event (or events) linked to the dreadful agenda of the organization backing the terrorist team. Indeed, the Al Qaeda operation was very effective on all fronts, accomplishing its devastating aims by knocking individuals, the nation and the world community out of balance. However, since the clash between the fundamentalist, religious societies and pluralistic, secular western societies is not over, it is plausible that more suicide attacks will take place in the future. And that means that further challenges to an individual's mental health as well as the community's public health will also occur.
Responding quickly and accurately to vulnerable communities and individuals by continuing methods of detection and outreach to vulnerable populations is an immediate, vital mission. However, focusing only on affected individuals is not sufficient. One of the most consistent research findings that has been overlooked is that the majority of those who were exposed to trauma were found to be less affected and/or were quicker to recover than expected. This understudied phenomenon is extremely critical from a scientific point of view, and its study can teach us if, and how, we can enhance resiliency and recovery in individuals and communities. By studying resilient victims, survivors and the bereaved, we will be able to better understand the full spectrum of the human trauma response, to reach out to groups at risk, to develop specific programs, and to disseminate knowledge regarding how to shield individuals and communities who are facing possible traumatization.