Understanding Terror-induced Trauma

by Yael Fischman, Ph.D.

(Acknowledgement: I thank Jaime Ross, Ed.D, for his critical review of this article.)

Introduction
The terrorist events of September 11 have generated increased awareness on the subject of human- induced trauma. Inasmuch as natural disasters can be extremely distressing and anxiety provoking, the intentionality involved in human-induced disasters tends to cause deeper psychological injury.

These recent terrorist episodes have evoked reactions such as shock, disbelief, disorientation, fear, concerns about safety, anger and grief. After the initial shock reaction, we are hearing of symptoms such as mood swings, irritability, hypervigilance, fatigue, trouble concentrating, and difficulty sleeping.

In addition to providing emotional support, mental health providers need to let people know that these are normal reactions in these circumstances. Also, some practitioners may want to the address somatic symptoms, which have included increased heart rate, fast respiration, tensing of the stomach muscles, or feeling cold. The activation of these symptoms and eventual return to homeostasis result from the action of the hypothalamus-pituitary-peripheral-gland links. Situations perceived as emergencies drive the sympathetic nervous system to release its chemical messengers.

Somatic symptoms thus develop when the limbic system ëreactsí to the perception of threat. The hypothalamus signals the sympathetic nervous system, which in turn stimulates the adrenal glands to release epinephrine and norepinephrine to mobilize the body for ëfight or flightí. The parasympathetic nervous system works in opposition to the sympathetic nervous system. When the traumatic incident is over, the parasympathetic nervous system stops the alarm reaction by turning off the production of epinephrine and norepinephrine and allowing the body to return to its pre -trauma state.

Retraumatization
People who have experienced a traumatic event related to war, torture, or other situations in which their safety has been compromised, are vulnerable to re-experiencing such traumatic events when they witness (directly or through the media) a situation such as the recent tragedy in New York.

Exposure to an unsafe environment, an experience of intense helplessness, or the inability to control profoundly painful situations, may lead traumatized persons to re-experience prior traumatic events. The activation of earlier traumatic memories may generate heightened emotional reactions to stimuli reminiscent of their previous trauma.

Old memories related to war, torture, rape or other painful events might reappear, usually in the form of flashbacks. Posttraumatic flashbacks are a perceptual re-experience of a specific traumatic event. For example, the sight of an airplane crashing into a building in New York City may elicit in war refugees a vivid flashback of a similar event at their country of origin. Sights, sounds, or smells associated with previous traumatic experiences may all trigger traumatic flashbacks.

Traumas may also be re-experienced in situations that are different from the initial trauma. They may reappear in the form of nightmares or flashbacks. According to Briere (in press) these intrusive experiences include both the memory of the traumatic event and the negative affective responses which have been classically conditioned to such memory.

The activation of traumatic memories may cause diverse symptoms such as feeling paralyzed, cold, hypervigilant or with irregular or fast heart beating; also anger, shock, frustration, fear or sadness. Special attention might be directed at certain sounds, movements, smells, or words that bring memories of past unsafe or menacing events. Some people will experience numbness, emotional constriction, or a need for distancing or social isolation.

In addition to clear symptoms of retraumatization, refugees recently arrived from countries torn by war are expressing serious concern about their safety. We are hearing questions such as ìif this is not a safe place, then what is?î Besides providing emotional support, it is necessary to gradually tap into their inner resources. This process will assist them in the development of new paradigms of safety in an apparently menacing world.

The recent acts of terrorism have not only affected those who waited for years to come to a country that they saw as their only safe haven from war and terror. Some health centers have also seen an increase in request for services by survivors of state terror in their own countries decades ago. For example in a recent article published in the Los Angeles Times , Ariel Dorfman speaks on behalf of his compatriots:

"I have been through this before. During the past 28 years, September 11 has been a date of mourning, for me and millions of others, since that day in 1973 when Chile lost its democracy in a military coup, that day when death irrevocably entered our lives and changed us forever."

Hence, Chilean immigrants requesting services at this time are possibly dealing with the impact of retraumatization. Many are flooded by recollections of another Tuesday September 11, when the day started with "terror descending from the sky" to destroy the official presidential residence. In a similar vein, many Asian survivors of war trauma who found refuge in this country decades ago, are now displaying trauma symptoms and expressing severe concerns about their safety and their ability to protect their families. In this regard it might be helpful to keep in mind that for most refugees, traumatization is a cumulative ongoing process. It includes the initial trauma of arrest, torture or war, and continues with a dangerous journey to a place of exile. It also requires dealing with losses of loved ones, home, community and legal status, as well as adaptation to life in exile.

Hate Crimes and Retraumatization
As a result of the recent events, there have been acts of physical brutality, and displays of racial hate against people of Arabic descent in several places across the country. These attacks have deeply affected individuals of Arabic origin who were born and raised as American citizens, and have contributed to retraumatize a large number of Muslim refugees who are new to this country. As days have gone by, Muslim clerics are reporting that for every act of hatred, they are now seeing ten acts of good will. This sentiment was echoed in a recent meeting of diverse religious leaders hosted by the Simon Wiesenthal Center in Los Angeles. Inasmuch as members of traumatized ethnic minorities must hear, unequivocally, that we strongly oppose all hate crimes, it may be helpful for them to understand that such aggressive reaction has stemmed from fear-induced rage. Terrorism elicits very strong emotions, leads many to feel that the world has become an unsafe and unpredictable place, and irrationally believe that attacking the dangerous "others" will increase their security.

The Healing Process
The complex reality of people traumatized by the intentionality of human-induced disasters presents a special challenge to caregivers. The processing and resolution of trauma symptoms in a context of safety and support requires an understanding of the impact of trauma as a psycho-physical and a psycho-spiritual experience. (For references related to the healing process, please refer to Rotschild, 2000; Ross & Gonsalvez, 1993; Herman, 1992; van der Kolk, 1987; Bettelheim, 1980; Krystal, 1968) It is important to be mindful of the meaning that each individual ascribes to the trauma, and of the social, political and ethical implications that arise as aftereffects of human-induced trauma. Adequate treatment should address all these elements as different, albeit interactive domains of the patient's experience. (References for this subject include work by Fischman, 1998; Brom and Witzum, 1995, Kinzie and Boehnlein, 1993; Eth, 1992; Pope and Garcia-Peltoniemi, 1991.)

The planned nature of disasters such as those of September 11, 2001 tend to shatter people's belief in personal invulnerability and in the world as predictable. To reestablish a belief in a predictable and meaningful world and a reconnection with purpose, it may be necessary to explore different existential concerns. Since there are no universal answers to such issues, each clinician will access the spiritual, ethical and moral resources that are congruent with his or her belief system, and translate those into therapeutic interventions responsive to patients' needs.

In the aftermath of this tragedy, we hear about people seeking revenge at any cost. However, others are trying to reestablish a sense of meaning by channeling their emotions into positive action. Some are trying to develop new paradigms for life and safety, which tend to be more spiritually oriented than their previous ones. Others are gravitating towards religion. We are hearing more about prevalence of spirit over matter, of good over evil.

The Jewish Day of Atonement, Yom Kippur, happened to fall very shortly after the events in New York. As has been the case with other religious leaders, rabbis focused on the need to unite in prayer. The following excerpt of a sermon by Rabbi Simon Jacobson of Meaningful Life Center www.meaningfullife.com seems to summarize much of the current sentiment:

"Yom Kippur is the holiest day of the year because it is the birthday of the single most important ingredient in life: HOPE . . . that there is healing after loss, that there is hope after destruction. That even after great loss we can rebuild in ways that are greater and stronger than ever before . . . We must channel our potent reactions into a force for good. Especially after we have witnessed the vehement passion of madmen, our commitment to goodness and love has to be with at least as much passion as the horror waged against us. For every force of evil there is an equal and even greater force of good. When we fear evil conspiracies - awful people gathering to perpetrate terrible acts - we must congregate together with even more passion to recommit to our battle for justice and virtue . . . Let us resolve now to join together to create an unprecedented amount of light, more powerful than any opposing force, a unity that manifests the greatest blessing of all: Shalom, peace and wholesomeness for all people. We are on the verge of a spiritual revolution - a transformation from within."

The Wounded Healers: Vicarious Traumatization
The search for meaning is also relevant for caregivers. Many are feeling overburdened by the amount of pain that patients are bringing into treatment. Figley (1995) writes about compassion fatigue. Other terms used to describe the impact of the trauma on caregivers include "secondary wounding," "contact victimization," "secondary traumatic stress," and "traumatic countertransference."

McCann and Pearlman, who in 1990 introduced the concept of vicarious traumatization, state that persons who work with victims may experience disruptive and painful psychological effects and go through a transformation that parallels the experience of the victim. This entails changes in their identities, worldview, self-capacities, ego resources, cognitive schemata and psychological needs. Herman (1992) affirms that trauma is contagious and that the clinician may experience, to a lesser extent, the same terror, rage and despair as the patient.

The study of human-induced disasters corroborates that those in secondary contact with the victimís suffering are themselves vulnerable to develop traumatic countertransference. Therapists working with individuals traumatized by violent political repression may undergo intense emotional responses, ranging from denial to overidentification. (Fischman, 1991).

Clinicians have an ethical responsibility to deal with their own secondary traumatic stress, otherwise they either minimize their ability to heal, or may even harm the therapeutic process care. McCann and Pearlman (1990) focus their attention on therapistís self care and emphasize subjects such as balance, self acceptance, and connection.

The terror is impacting caregivers. We know by now that crisis workers are at risk of developing both primary traumatic stress due to their direct exposure to traumatizing events, and secondary traumatic stress, from aiding traumatized persons. Consequences may include ill health, substance abuse, and relationship difficulties. According to T. Torres (personal communication, October 9, 2001) a number of rescue workers at the site of the Oklahoma City bombing showed significant psychological aftereffects such as disruptions in interpersonal relationships, episodes of substance abuse and other serious psychiatric symptoms. It will be useful to obtain information on the impact of that event on clinicians, and assess their level of vicarious traumatization.

Clinicians are being exposed to the same traumatogenic environment as their patients. Some are experiencing the aftershock of the September events with the same intensity as their patients. Others are themselves refugees and are experiencing symptoms of retraumatization. There might be those who have suffered a more direct impact if people close to them died in the New York attacks.

Up to date the subject of therapy in a traumatizing environment has been more pertinent in countries where therapists themselves have been exposed to direct or indirect repression. For example, Elizabeth Lira (1995) discusses her experience treating victims of political repression in Chile. Therapists there felt compelled to become deeply involved. The graveness of the situation and their level of commitment led them to work long hours. They did not take care of their health or of their own personal problems.

These clinicians were affected by the patients' sufferings and by political threats, but were not aware of their own individual reactions. The impact of this threat was not sufficiently registered to elicit adequate psychological support for them. The demand for assistance was too immediate to allow a proper consideration of the impact on therapists. Lira states that traditional distancing resources are hindered when therapist and patient share the same historical period and the existing threats make them equally vulnerable.

Other clinicians working under conditions of war or state terrorism have made reference to feelings of loneliness, abandonment, isolation and marginality. Interestingly, therapists treating exiled survivors of torture in countries of refuge have echoed similar feelings. These feelings may well be inherent to this type of work. They lend themselves to diverse interpretations and should be explored further in a separate study.

This may be a time for clinicians to increase opportunities for self care and peer support. Some may also wish to stay connected to a source of meaning or to explore new paradigms to understand and deal with human pain.

Editor's Note: Bibliography listing upon request.

Yael Fischman, Ph.D is the cofounder and Clinical Director of the Institute for the Study of Psychosocial Trauma, and is also in private practice of psychotherapy in Santa Monica, California. Her latest book , Mujer, Sexualidad y Trauma addresses women's sexuality and the prevention and treatment of incest and rape. It focuses on domestic violence, and on the treatment of trauma resulting from sexual torture during war, political repression, and the sexual exploitation of refugees. She can be reached at: yael@trauma-institute.org .

Republished with permission of the author. Article originally published in Dialogus "A Free E-mail Newsletter­­Furthering the Dialogue to Better Serve Survivors of Torture" Volume 6, Number 1, November 2001. Dialogus provides a forum for members of the torture treatment centers in the U.S. who serve survivors of torture to participate in a dialogue about innovative approaches in their work with survivors as well as share resource information, news, and solutions to challenges we face.

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