Alain Brunet, PhD, McGill University, Montreal / Adam Brown, PhD, New School for Social Research, New York / & Andrew Rasmussen, PhD, Fordham University, New York – Are three academics specializing in the study and treatment of PTSD.

With nearly 3 000 deaths and 6 000 injured, 9/11 is the deadliest act of terrorism in history, not counting those with ongoing health issues stemming from inhaling toxic dust. These attacks,  targeting the world Trade Center twin towers in New York city 19 years ago have cost hundreds of billions of dollars to the US economy and triggered an even more costly global military initiative to combat terrorism. But for most individuals who were attacked or personally witnessed the event, 9/11 meant enduring crippling and long-lasting adverse consequences. Thousands of first responders risked their lives to later on develop health and mental health problems. After 9/11, alcohol consumption in Manhattan increased by 25 per cent. Tobacco use rose by 10 per cent, marijuana by 3 per cent. Family members suffered as well: 3,051 children lost a parent on that day, and dozens of pregnant women lost their babies. According to a large representative survey, approximately 375,000 New Yorkers suffered from probable 9/11-related posttraumatic stress disorder (PTSD). This does not include other common 9/11-related diagnoses.

Crises are forced opportunities for societies to learn and to change. Important lessons in mental health were learned as a result of 9/11, and terms previously relegated to mental health professions such as trauma, PTSD, and resilience entered into common parlance. But adoption by lay people of the concepts and vocabulary of trauma was not the only change. Neuroscience, mental health science and epidemiology and psychiatric research were profoundly invigorated by 9/11. Novel treatments have emerged out of this research that gives us new hope. Here are eleven ‘learning experiences’ and a few thoughts about the changing science of PTSD:

9/11 – Lessons learned in mental health

1. Contrary to alarmist statements made by so-called experts in the aftermath of 9/11, not all New Yorkers, Washingtonians or Virginians were ‘traumatized,’ although very many were trauma exposed. Resilience, the capacity to bounce back, is the normative response to stress and upheaval among humans, even after the most horrific events. Prior to 9/11 there was little information about how people adapted emotionally following a major collective trauma.

2. 9/11 opened up conversations about the ubiquity of trauma. Until then, trauma was mostly linked with the military. The American Psychiatric Association referred to trauma as events “outside of the normal range of human experience.” Trauma is not only incredibly common but experiencing a variety of traumatic events in one’s lifetime is the norm.

3. Trauma, and by extension terrorism, can be a life-changing event. Whether we develop PTSD or not, most trauma-exposed individuals will experience the anguish of subsequent uncertainty, the disruption of our assumptive worlds, and the loss of trust in the foundations of our lives. As a brutal and unexpected confrontation with death, trauma is a ‘failed’ encounter with the grim reaper. It remains a permanent landmark in our lives, marking the frontier between the before and the after. Survival comes at a cost of long-term invisible psychological injury. But hopefully, for some, survival will foster posttraumatic growth.

4. In the immediate aftermath of a disaster, survivors’ needs revolve essentially around safety and practical, logistical help that help them meet their basic needs. This includes connecting with significant others to grieve and obtain emotional support, getting sufficient food, and accessing transportation and money. Less basic needs (e.g., psychological care and the need to find meaning) will emerge later.

5. Trauma survivors should not be pressed to talk about their trauma experiences, although we tend to think that talking is good. Talking with others can create a bond and knits meaning to something that does not make sense. But, thinking and talking about trauma should be done at their own pace with someone who understands and knows how to listen. There is such a thing as negative social support (e.g., ‘get over it’) and it can impair recovery.

6. However popular after 9/11, research shows that the use of structured debriefing groups had no effect—and for some people, it may have made things worse in the long run. Most trauma survivors do not automatically need to see a mental health professional. There is very little evidence for the efficacy of any kind of immediate therapeutic intervention and making normal reactions to abnormal circumstances seem like psychiatric problems may actually hurt people. However, a sizable minority of individuals will not recover spontaneously, and deserve help.

7. Many mental health professionals and people of good will are compelled to ‘do something’ in the aftermath of a traumatic event. However, one of the lessons learned after 9/11 is that therapists should not get in the way of public safety personnel and should be even more careful interfering in trauma survivors’ time-dependent, natural coping processes.

8. None of the above suggests that there is no place for psychotherapy following trauma. But instead of trying to provide psychotherapy to an entire population following trauma, a continuum of stepped care approach should unfold over time, whereby mental health advices are being distilled first to the masses via the media from very early on (fostering resilience), and increasingly sophisticated and specialized mental health help is offered with the passage of time to more vulnerable subgroups (e.g. firefighters, women, etc.)

9. Many scientists agree with certain advocacy groups who claim that PTSD is not a ‘disorder’ but rather an ‘injury’. Individuals with PTSD are not crazy or ill; they are injured badly. But contrary to a visible wound, the invisibility of the PTSD injury prevents trauma survivors from attracting sympathy… and appropriate compensation. This remains a problem to this day.

10. In the past PTSD was often considered a fabricated or exaggerated mental condition invoked by the coward or the laggard. 9/11 made us realize that personal weakness has little to do with whether one develops PTSD or not, and that survivors, many of them heroes, need to be cared for.

Some 88,000 individuals are currently members of the WTC Health Program (helped by the U.S. Congress’ Zadroga Act), and more are expected to join.

11. The ideas and concepts that 9/11 brought into the mainstream have been used to highlight the dire conditions of many other trauma survivors as well : child abuse and sexual abuse survivors, victims of racism and anti-LGBTQ discrimination, bullying targets and of course the veterans returning from conflict, to name a few.

9/11 – The day PTSD arrived to stay

American Vietnam veterans are credited for putting PTSD on the map; but as the most well-documented disaster in history, 9/11 put it in our face and forced us to stare at it. Before 9/11 only a handful of people knew what the ‘PTSD’ acronym stood for. Looking back, it is hard to believe that before 9/11, we, academics interested in PTSD, were considered to be working on a marginal, obscure disorder affecting mostly military personnel and victims of gender-based violence.

On 9/11 the image of trauma was completely shattered as the dystopic event intruded into the homes of millions of individuals via the TV set. 9/11 was an electroconvulsive shock, a schreck experience, a painful wake-up call that from then on traumatic stress was lurking behind the ordinary, at every street corner. It was not just for Viet vets anymore. In this day and age, trauma exposure has become the new normal, and PTSD a misfortune likely to strike anybody.

History books claim that recognition of the existence of traumatic stress has waxed and waned over time, at least since Herodotus described the deleterious effects of the battle of Marathon in antiquity on some of its warriors. This time, PTSD invaded our world as a concept and has been with us ever since. In fact, it would be easy to demonstrate that the mental health consequences of trauma exposure represent the most prevalent psychiatric entity across society; it is a global grand challenge waiting to be resolved by psychiatry and its allied sciences, but also by policy makers and diplomats. PTSD arrived on 9/11, but 20 years later the new question becomes when will it go? Can we eradicate it? Why not try?

9/11 – An explosion … of knowledge

In the early 80’s when PTSD in its modern form was introduced into psychiatric diagnoses, we still knew very little about it: how it developed, who was at risk, its scope in society, its course or its treatment. After 9/11, the annual number of scientific publications in the PubMed database on traumatic stress literally exploded, doubling every 7 year between the years 2000 (689), 2007 (1 491), and 2014 (2864).

This attention to the disorder has paid off. In just a few decades we have made so much progress in understanding how PTSD develops after trauma, what are the risk and resilience factors, the neurobiology PTSD, the genetic and epigenetic influences on PTSD, its prevalence and course. We have developed and refined animal models, questionnaires, structured interviews and inventories to accurately assess PTSD. We’ve found ways to use salivary, blood, urine, and sleep tests to augment these assessment measures. We have imaged the brains of thousands of PTSD patients, developed new drugs to treat PTSD, and even discovered several biomarkers—though none that do a very good job of predicting who will get PTSD following trauma, unfortunately. Even the basic science fields of learning and memory and the neurocircuitry of fear have progressed significantly because of the attention paid to PTSD. This makes sense considering that without reminiscing, it is virtually impossible to suffer from PTSD.

Advances in the treatment of PTSD

In 2020, no one should continue to live with PTSD, considering the existence of several evidence-based treatments. While no one would ever want to go back to times when we did not have medications, pharmacological treatment for PTSD remains only partially effective. The –very lucrative— treatment model in psychiatry has remained unchanged for the last 60 years, and applies to PTSD: one pill a day for an unknown period of time (typically years!) to mask your symptoms, at the cost of serious unwanted side effects (weight gain, inability to achieve orgasm, suicidal impulsivity, etc).

This medical model has been complemented (and challenged) however by the advances made in the field of psychotherapy. There are now several, evidence-based psychotherapies for PTSD that have held up well in clinical trials. Exposure therapies, inspired by the famous physiologist Ivan Pavlov, have been successfully adapted to the treatment of PTSD in the 1990s. Eye movement desensitization and reprocessing (‘EMDR’), a remarkable therapy involving eye movement was invented to treat PTSD has also shown promise. But even more stunning therapies are in the pipeline. We and others have shown that, not unlike what was depicted in the movie Eternal Sunshine of the Spotless mind, we can now selectively and durably decrease (though not erase) the strength of an emotional memory, a specific traumatic memory for instance, for the benefit of our patients, in just a few short visits.

Reconsolidation therapy, which relies on the evocation of a traumatic memory under the beta-blocker propranolol, is based on our most recent understanding of how memories are formed, stored, and retrieved. Because remembering is at the core of a condition like PTSD, blocking in part the re-saving of this memory has proven an astute and effective way of treating PTSD (see Brunet et al., 2018). This method, which may become the first curative treatment in psychiatry, has been used with success in the aftermath of other recent terrorist attacks in Paris in 2015 and in Nice in 2016. At that time, as was the case after 9/11, there was a lot of uncertainty with respect to the recurrence of other terrorist attacks. There was a pressing need to increase local treatment capacities. Reconsolidation therapy, which can be learned in just 3 days by experienced therapists, was taught to 200 French therapists, who in turn treated hundreds of patients in a matter of weeks, demonstrating the possibility for a community to recover from a massive outbreak of traumatic stress in a relatively short period.

Of course, let’s not forget that the best treatment for PTSD is eliminating the causes from which it comes. All of the resources, data collection, human and non-human research subjects, scientific papers and professional conferences on the study and treatment of PTSD have shown us since 9/11 is that traumatic stress can have long-lasting and profound impacts on our overall health and ripple through every aspect of our relationships and communities. On this anniversary of 9/11, let’s consider everything we know about PTSD – the way it can impact health, relationships, and society. We may not be able to prevent every tragedy, but we’ve come a long way. Today, let’s take those lessons learned and commit ourselves to reducing violence, poverty, population displacement, promoting diplomacy, and investing in sustainable environments.

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