9-11 Anniversary Reactions

Because many Americans will be profoundly affected by reminders of the September 11 attacks, Joyce Boaz, Executive Director of Gift From Within asked Frank Ochberg to reflect on anniversary reactions. Coincidentally, Dr. Ochberg was interviewed on that topic by Richard Kaplan, PhD, senior staff editor with Coffey Communications.

Here is an edited transcript of their interview:

Kaplan: Starting with the upcoming anniversary of the September 11 attacks, what kind of emotions would you expect people to be feeling?

Ochberg: Diverse. We have to be careful about generalizing too much. There are going to be people who lost a loved one on 9/11 or people for whom events were so personal and intense that the anniversary and public expression is bound to return them to the scene. They may have symptoms of PTSD. And they will recover some or perhaps all of the feelings that they had at the time. Even if those feelings have been resolved, they will feel fresh. This can be very frustrating: "Here it is, all over again." People who have made a good recovery are thrown back in time. It is the nature of the trauma response to feel as if you are returned to where you were in the first place — but it doesn't mean you are actually back there. Everything you've learned still applies. You've moved forward. It does not mean you're going to have to recover from the start all over again. Unfortunately, PTSD is not simply an episodic memory, but an intense and urgent re-experiencing that is beyond ordinary anxiety.

There's another group of people, comprised of those caring for the living rather than for loved ones who died. They will think about their friends or loved ones and ask themselves, "What can I do? How can I help?" They may feel protective, and resent the media for saturating the airwaves with images of terrorism. Some people do overdose on re-exposure to trauma images. Good advice to give those survivors is, "limit your dose if you know that too much trauma imagery is going to affect you negatively." Think of it being like a restaurant: there are restaurants all over town serving all kinds of food, but you don't have to eat it all. Avoid the news for a couple of days. Go on a diet.

There are other people, survivors, who really have a need to talk, a desire to talk. The need to talk differs by gender, age and ethnicity. Some of us aren't so good at expressing feelings, or we express them in a torrent. At anniversary time, there are going to be opportunities for survivors to talk and for others to listen. But some resent the talkers and some resent those who avoid expressing themselves. Be aware of your own way of coping, what works best. Survivors and people who care for survivors need to be aware of the differences in expressing emotion and be respectful of the fact that there is no one right way of grieving or coping.

Q: Can you suffer this kind of anniversary emotion even if, for example, you only witnessed the attacks on television from the safety of your living room?

You can certainly have profound feelings when reminded of last September. The Al Qaida attack was more than a traumatic event; it was a defining historic moment. Since then the nations of the world have experienced very significant shifts in alignment of power. The feelings evoked by the anniversary of 9/11 will not just be traumatic stress. This will be a time that forces us to think through how democracies should ally with one another. Democracies have to defend democracies, and we have to recognize that there are people who hate America. It doesn't hurt to experience frustration as we try to remain open and tolerant while being threatened with the real possibility of mass destruction.

But the question of whether one can suffer a trauma reaction when merely seeing a TV image is a valid concern. The answer is, "Yes." However, I want to define and describe two very different populations. First are the invisible survivors, victims of other traumatic events. For them, publicity about last September evokes painful personal memory - not of 9/11 but of their own trauma and tragedy. Understandably, they may feel neglected when there is so much national and international attention to one category of victim (WTC families who are celebrated and compensated), while these victims go unrecognized, unacknowledged. In some large American cities there is a murder a day. The surviving family members get no attention because their tragedies are less "mediagenic." We ignore the commonplace trauma that affects us all, but every so often we have a "chosen trauma" (a term coined by Doctor Vamik Volkin). These become almost mythic, historic events, enshrined in collective memory: The Alamo, The Titanic, perhaps the Challenger, possibly Oklahoma City. The "Chosen Trauma" can bring people together and define a culture. In that respect, all the people with private tragedies who are still hurting can watch 9/11 anniversary coverage and say, "I'm part of America. I'm in pain, too. I'm part of all of us, suffering with the direct victims of 9/11." There is a universal brotherhood and sisterhood of all people who have suffered, who have experienced human cruelty. Memorial planners need to find a way to bring every victim back to the embrace of the human group.

Then there are people who look at something on TV and are affected more than others, simply because they are sensitive, anxious or emotional. They have no history of unresolved tragedy. Their array of responses may resemble post-traumatic stress, but, technically, they do not have PTSD. However, they would be at risk for an anniverary reaction, because of their extreme emotional responsiveness.

Q: With September 11, is the recognition that no one has been caught or punished likely to trigger anniversary anger?

Let me contrast the aftermath of Columbine with the aftermath of Oklahoma City. The Critical Incident Analysis Group (CIAG) brought together community leaders from both locations to analyze those events in April, 2000 (See: http://faculty.virginia.edu/ciag/threats.html). After Oklahoma City there was a capture, a conviction and a sentence. That seemed to correlate with a better healing process than Columbine where the perpetrators killed themselves. The path to resolution in Littleton, Colorado included highly charged lawsuits that accused public officials of negligence. A September 11th anniversary reaction might resemble Columbine more than Oklahoma City and heighten our search for targets of outrage and blame, but I frankly don't believe so. I think we're going to find a way to celebrate our heroes and memorialize our victims.

Q: Are their ways of turning the anniversary into a positive experience? How?

In any anniversary of a tragedy, there are universal symbols of respect. For example, many religious traditions employ the lighting of candles as a memorial act that represents remembrance and hope. The literal joining of hands can create human bonds of understanding and rededication to things we value. But the anniversary of 9/11 requires painful introspection as well as traditional displays of optimism and solidarity. Americans could ponder how arrogant and insular we are capable of being, how disrespectful we can seem to members of other cultures. Why can't we rekindle our cherished values without using the occasion to separate ourselves from the rest of the world.

Q: Turning now to other kinds of losses, are there differences in anniversary response based on the type of loss or who was lost? For example, if it was a violent death?

Absolutely. We have an instinct to play detective or counter-terrorist after we lose a loved one to a criminal act. My colleague, Dr. Ted Rynearson, explains that if you lose a loved one to murder, there is often an obsession with the murderer, the moment of murder, and the crime itself (See GiftFromWithin.org). This delays the normal grieving process. Let's say you get past that, and you resolve your need to visualize someone captured and punished. The next emotional task is contending with an unnatural death. PTSD occurs because we experience horror and terror from violent loss — the images are stored in a particular way, disrupting normal memory, and emerging uncontrollably. This is quite different from enduring a loved one's anticipated, natural death. With natural death, a survivor is seldom troubled by flashbacks, although their grief may be severe, very similar to depression, with loss of energy, and inconsolable sadness. It is not unusual to take three years to recover from the natural death of a spouse. Violent death of a spouse is worse.

Q: Can a person be affected by the trauma of an anniversary even if they're not consciously aware of the date, especially a couple of years out from the event?

Yes, and that is what is meant by the term, "anniversary reaction." Maybe it's the season, the fullness of the leaves, the first heat of summer: it's in your bones. An anniversary reaction is having feelings that are stimulated by the anniversary of the trauma, even though you may be unaware that the calendar has come back to that date.

Q: There is more than one anniversary, isn't there? There's the anniversary of the loss, but also of the dead person's birthday, first holiday season without them, first Thanksgiving, first New Year's, wedding anniversary, Valentine's day, birthday...

Exactly. Those who have lost a loved one are moved to remember on birthdays, Father's Days, Mother's Days, on any day that once was a family celebration and now is a painful reminder of the absence. But 9/11 is one of these days that is going to live in infamy, a day of collective remembrance. It is very different to have a day of national consequence that is etched in everybody's consciousness. This causes a "flashbulb effect." It means you not only recall the tragedy, but you remember trivial events of that day as well. Why should you remember what you ate for dinner on September 11th? But you do. And because we can share recollections and talk about the trivial as well as the profound, we are brought together in personal as well as public ways.

Q: Are there ways of psychologically mediating against anticipated pain of an anniversary trauma that are not healthy? What are good vs. bad coping strategies?

How to minimize the unnecessary anguish or maximize the positive effects? I don't know of any kind of study or scientific evidence. Studies of effective coping in general, yes, but not of anniversary reaction studies. The outcome of good coping, studied extensively in the 1950's, was keeping anxiety within tolerable limits, preserving self esteem, maintaining social ties, tackling the task ahead whatever it was. For those who anticipate becoming confused, isolated, or overexposed to trauma images, there are some commonsense coping devices. You can adjust your environment to help. Say to yourself, "This is going to be 9/11. Where do I want to be? Whom do I want to be with?" You can choose who you'll be with, rather than having someone else's company imposed on you. If you prefer, construct your own rituals with your own friends. Maybe there's an ideal pen pal. We do this at Gift From Within. Unfortunately, for some of us, the family is the worst place for handling personal stress. Home might not be the best environment on 9/11.

Q: Is there anything wrong with you if you don't feel intensified grief or emotion on the anniversary of a trauma?

No. I don't think so at all. You don't want to make invidious comparisons on a day like this. Some of us never forget and keep trauma alive; some of us can detach trauma from our personal lives.

Q: On the anniversary of death by suicide, is there a danger that someone will commit suicide themselves? What should be the response to those suicidal feelings? In less extreme situations, do survivors sometimes fear repeating the pattern of the deceased person that ended in tragedy?

Let's start with survivor guilt, or guilt that is based on the feeling of failure to protect. Suicide is so damaging to parents and close friends because of the irrational responsibility that we place upon ourselves. Suicide of a loved one elicits self-blame. Where you have the contagion of suicide, it is rarely the parent following the child, but rather a chain reaction in the adolescent group. As in Romeo and Juliet there is often a romantic element, or desparate feelings of being cut off from others. Adolescent depression is dangerous because of impulsivity added to hopelessness. If all the ingredients are present, there could be a serious suicidal risk during an anniversary of suicidal death of a loved one: a heightened sense of loneliness and loss; a confusing return to the scene and the time; intensification of PTSD symptoms of being detached, estranged, from others.

If this set of behaviors becomes apparent, loved ones could help by saying, "Those are symptoms that you're going to get over." Or, "You may have PTSD, like the Vietnam veterans. There is good help for that." You refer someone to professional help on an emergency basis at the same threshold as for any other 9-1-1 call. Use it when there's clear and real physical danger, on the verge of feeling that someone will commit suicide or cause serious harm.

Q: With risk of suicide, what kind of responses would be cause for serious concern-evidence, perhaps, of dangerous levels of denial, anger, avoidance, even depression or psychosis? Alcohol or substance abuse? What about feelings of guilt, rage, fear, etc. that re-emerge? PTSD?

A marked change in personality, giving away things of value, withdrawing, saying, "I'm thinking of suicide." Additional signs are the absence of clear plans or commitments for the near future. Or a sudden, irrational cheerfulness after gloom (meaning that death has been chosen as an alternative to emotional pain). Suicide is often abetted by drinking, so hoarding liquor, moving from depression to alcoholic depression to alcoholic depression with access to weapons are danger signs.

Q: If you feel you need help, is there a right way to ask for it so that you get the attention you need?

There are people you can trust to take you seriously, and people you can't. People you can't trust may just happen to be those closest to you — a spouse, an employer, a parent. If so, it might be time to call a hotline with professionals who are trained to listen. How do you get a friend or a family member to listen to you? It is different for every person, but it couldn't hurt to say, in your own words, "Do you have time to listen to me now, because I need to talk about something serious?" Once you know someone is willing to hear what you have to say, although it may be hard to get it out, tell them that you're hurting, you're scared, and you're not sure how to get yourself to a safe place.

Q: Is there such a thing as closure? Does grieving ever end?

Closure is a bad word, overused five or 10 years ago, and people in my world are not using it anymore, because it falsely implies an end to something that doesn't end. You don't get closure on trauma, tragedy, the impact of human cruelty, but you do grow, you do get sadder and wiser and you do, more often than not, get the opportunity to help fellow travelers. Closure is a myth, but progress is not.