Date Published: September 1, 2021
On the eve of the 20th anniversary of 9/11, psychiatrist Sandra Lowe, MD, talks about what we’ve learned about trauma and resilience from treating responders. Her answers have implications for COVID-19 and beyond. Dr. Lowe is Medical Director at the World Trade Center Mental Health Program Clinical Center of Excellence at Mount Sinai.
From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about coping with adversity, I'm Jon Earle. My guest today is Dr. Sandra Lowe. She is a Psychiatrist and Medical Director of the World Trade Center Mental Health Program here at Mount Sinai. The program cares for 9/11 responders and volunteers. We spoke on the eve of the 20th anniversary of the 9/11 attacks. Dr. Lowe explained what we can learn from the most resilient 9/11 responders, and she talked about some of the factors that contribute to posttraumatic growth. So without further ado here is Dr. Sandra Lowe.
A couple of weeks after this is released will be the 20th anniversary of 9/11. I'm wondering what you're thinking about as that day approaches?
Dr. Sandra Lowe 00:51
I'm thinking about a lot of things. I think about some of the responders we have lost, who have died to numerous conditions. I think of those who have really worked so hard in their treatment and are doing well. I'm thinking about how, 10 years ago, I really would not have imagined that the program would be as relevant as it currently is. We continue to see patients coming in every week, patients who may have had some psychiatric symptoms early on and are now relapsing, or some who are just coming in for the first time. In anticipation of the 20th anniversary, we as clinicians know that patients have what we call “anniversary reactions,” that is a worsening and exacerbation of some of their symptoms, depression or PTSD symptoms as the date approaches because they have more memories or associations to the date. The media is focused on 9/11. So people start having these anniversary reactions, usually in August. This year, we started to see them in April and May. I have to add that this being a unique year in that we are coming through a pandemic that has been an additional stressor on our population and that has had an effect very likely in the exacerbations that we're seeing over the past several months.
It sounds like there's still a huge need for mental health services for this population.
Dr. Sandra Lowe 02:57
There certainly is.
One of the things I'm interested in is—when we talked, you sketched out these two populations; you talked about this population of traditional responders, this is firefighters and police, and a population of non-traditional responders, those are ironworkers, cleanup workers, volunteers, etc. And we talked a little bit about how those two populations have different resilience trajectories. And so I wanted to go into that a little bit, because that strikes me as one of the resilience lessons of this work. So tell me a bit about that. Tell me who has found it easier to cope in the aftermath of 9/11 and why?
Dr. Sandra Lowe 03:36
Yeah, that's a really important question and it has been one of the lessons that we have learned from our experience in caring for the responders. In some studies that have been done taking a look at who fares better with respect to psychiatric symptoms, it was striking that the traditional first responders actually had lower levels of PTSD symptoms, lower than the non-traditional responders. What accounts for that? Well, one of the reasons seems to be that the traditional first responders had a greater sense of community and support within the firehouses. There's a strong community feeling there within these stations. They had more support. In addition to that social support, which we know is going to be conducive to resilience, these individuals also had more resources. They had a better socioeconomic status very often than individuals who went into construction or cleanup work, so they had more access to healthcare services. They didn't have to worry as much about making sure that they were working, that their work was there because they knew their work was going to be there. They had sick days available where some workers didn't. So there was a certain safety conferred by both the connection within their work communities and the resources that they had.
That sort of makes sense intuitively, right? I’m imagining firefighters and police officers being able to meet up at the station house afterwards and swap experiences and maybe some morbid humor and sort of get by that way. Was that camaraderie—it sounds like it was a big part of it?
Dr. Sandra Lowe 05:53
Definitely. It certainly is something that the traditional responders with whom we work express, that they have buddies that they've really relied on. And you mentioned being able to just sit and talk. There's a very healing element in being able to share your own experience of a trauma, of a shared trauma, which is what 9/11 was. It was a trauma that a large group of people were going through at the same time. So being able to have that as some common ground and being able to share your experiences about the trauma is very helpful in protecting against severity of symptoms going forward.
And professional training, too, I read was important. Traditional first responders, police and fire were, are trained and have experience going through potentially traumatic experiences, whereas an ironworker who was called in to work in the cleanup site maybe had never seen anything like they saw and had no training as to how to cope with that.
Dr. Sandra Lowe 07:14
Yeah. One of the findings in some of the studies is that a sense of perceived preparedness and actual preparedness was also protective against development of PTSD symptoms. So EMS workers, FDNY, NYPD, they actually have preparation education instruction on what they might see in a scene of trauma. They also have education about how to manage it. Well, you know, what do you do so that when exposed to something that to them is also traumatic, they have something to fall back on. They are able to say, "Okay, my chief, my mentor, my boss told me this is what I need to do." And that clicks on and they're able to take some action. Whereas the construction workers, for example, who went in and encountered body parts, something that they weren't at all prepared for, they had no frame of reference for that. They had no idea what that would be like or what to do in that situation, and that resulted in more alarm, more panic, and just not knowing what to do in a sense of being more lost in the situation, which is frightening.
You know, 20 years ago it wasn't the Stone Age, but it still kind of blows my mind how unprepared we—I don't know who the "we" is even, society, the government—were for this event. Like how could we not know that going to Ground Zero as a cleanup worker and experiencing those conditions and seeing body parts would be potentially traumatizing?
Dr. Sandra Lowe 09:15
Well, it wasn't the Stone Age, you're right, but there was a lot that we didn't know. We certainly didn't know a lot about resilience. We at that point were doing debriefings, which has been later identified as something that doesn't help and may actually hurt individuals who have seen trauma.
What is debriefing?
Dr. Sandra Lowe 09:44
Debriefing is taking a group of individuals who have been exposed to some traumatic event and having them talk about it, talk about what they saw or what they did. On the one hand you could say that sounds like a really good idea, but in fact, what people need after a trauma can be very individualized. Some people need to communicate with their loved ones, and that's what you need to be able to provide to them. "How can I help you connect to your loved ones?" "Oh, you don't have your insulin on you, let me get you to someone who can help you with that." Being able to support their basic needs first. So processing trauma is not necessarily what everyone needs right away. They may need that later or not. So it's really attending to the individual's needs. That's one of the things that we have learned. And actually for some people who attended these group debriefings, the repetition of this trauma in the midst of a state where they were really distressed seemed to kind of sear that trauma in their minds. And they've found it more difficult to avoid the recurrent or intrusive memories that we often see in PTSD. So there were things that we didn't know, and there were things that we knew and as a community, a society, we did not implement. So I think another lesson from 9/11 is that we need to prepare. We need to prepare not just the supplies, although that was also an issue then as it has been through COVID pandemic here in New York, but prepare individuals. Having some element of mental health awareness, well-being resources available within the work. I'm talking about, yes, resilience—being able to incorporate that. Hopefully people will not be exposed to a trauma or some terrible event. But if they are, they will have something that will have already prepared them and strengthened some of their internal resources so that they can better cope with the trauma in front of them.
How would you rate our response to COVID-19? What's it been like for you to see another, even larger, mass event? It sounds like you do see the signs of progress from 20 years ago.
Dr. Sandra Lowe 12:45
Yes, at Mount Sinai very early on in the pandemic the trauma of the health workers, the essential workers, was identified as something that needed to be addressed. And there were mental health teams that were going out, checking in, making themselves available to the staff, having 24-hour hotlines that we manned. In case somebody needed us, they knew that we were going to be there. That support was put into place right away. And within a very few short months the [Center for Stress, Resilience, and Personal Growth] was established. Again, an acknowledgement that this is going to be needed, that there was trauma that needed to be addressed. So we did implement some of the lessons that were learned.
There's so much we can talk about in terms of the incredible resilience of this group of people, this population. One thing, or one piece of information that I came across, was a stat about the percentage of police, of traditional and non-traditional responders, respectively, who developed PTSD. I was surprised that those numbers are both under 10 percent, and I was wondering what you make of that and whether that was surprising to you.
Dr. Sandra Lowe 14:17
Well, some of it depends on when the assessments were made. So over the past 20 years, there were assessments that were made a year after 9/11, five years after. The most recent one is I believe the 2016 data that we have. And the presence of posttraumatic stress symptoms at that time within the responder population was about 14 percent, which is about three times what you would find in the general population. The percent of depressive symptoms was a bit lower, it was actually very close—it was about 12-13 percent—which again is higher than the general population. So we're talking about 15 years after. If you take a look at that data earlier on, you'll find PTSD symptoms of 30 percent in the responders. So the message there is that some people are getting better, and we do know that there are different trajectories. The majority of people who are exposed to psychological trauma do not develop PTSD, about 75-77 percent. Those who do may recover over a period of time. Some will actually have chronic symptoms, and those are a lot of the people that we see in the program. Some people will be coping well enough, and functioning for a significant period of time, and then something else happens. For some people it was Hurricane Katrina. For some it could be a personal tragedy. For some it was COVID. And at that point, the symptoms that were under the surface become manifest, and we see that coming out. So it goes back to knowing the individual, taking the time to get to know who they are and what their needs are, because it's going to vary over time. In addition, there was a very recent paper, I think it was in December of 2020, that took a look at posttraumatic growth in the 9/11 responder population, and that was very interesting because we do a lot of research and work on understanding the negative effects of trauma. And we need to do that because that's how we're going to learn what these individuals need and how to best help them—
Let's just take a moment to explain for people who aren't familiar with the term what we mean by posttraumatic growth.
Dr. Sandra Lowe 17:17
Posttraumatic growth is usually described as a positive psychological change that may occur after a traumatic event that results in a higher level of functioning, an improved sense of well-being compared to prior to the trauma. It differs from resilience in that resilience generally focuses on the ability to adapt to adversity and come back to your baseline functioning. Well, some people actually have an experience of growth, and in this paper that I was referring to they took a look at individuals with PTSD and they found that almost 30 percent of them reported, this was a self-report, significant areas of growth after their trauma. And surprisingly these individuals seem to be some of those who had the highest degree of PTSD symptoms.
What form did that take? The growth, I mean.
Dr. Sandra Lowe 18:42
The paper used a scale known as the posttraumatic growth index, and it asks individuals to answer questions from not likely at all, to most likely, a Likert scale, regarding certain domains that we identify as reflecting growth. So things like a sense of well-being, quality of relationships, and overall functioning. And in this study that was taking a look specifically at the 9/11 population, identified certain factors, actually two factors, that seem to be the most salient for our population. One of them was interconnectedness, a sense that individuals described a greater ability to rely on others, or a greater ability to connect with others and relate with them when it comes to a traumatic event, an enhanced trust of others. So interconnectedness seemed to really be an area of positive growth for a significant number of 9/11 individuals. The other was described as personal growth, and that described reflecting on priorities in life and finding that they had an opportunity to reflect on what was most important to them in life. They found that that was very helpful in that it was associated with their having gone through the trauma, feeling a sense of greater self-confidence or being more self-reliant. So those were the two areas that really seem to light up for our population. Now, when they took a look at, or theorized why the interconnectedness, they went back to what is it that some of the traditional responders in particular had in common, and that was that connection, that social integration, social support, but essentially they found that any individual who identified a social support and social integration later experienced greater posttraumatic growth.
Interesting. So it sounds like you're connecting what we were talking about at the beginning of this conversation, the community, the station house, the union, these places where people can get together and talk. That there's a direct connection between that and posttraumatic growth, like that is maybe the mechanism.
Dr. Sandra Lowe 21:37
Yes, and that is what's being looked at particularly when there is a shared traumatic experience like 9/11, like COVID. When there is a shared experience, being able to be connected and have a community, whether the community is a firehouse, or a faith community, or an extended family, it's having that support that seems to lend a protective mantle on individuals that helps them remain kind of whole in times of crisis. And apparently it also helps them with posttraumatic growth, with achieving a state as they reflect on it that says—it's not as if they didn't suffer through the trauma, they did, and it was not because of the trauma but because of the way in which they struggled and questioned the effect of the trauma and tried to realign their values with, okay, so what does it mean right now? My world has turned upside down, let me pause and reflect. It's in the process of working through that that people end up growing in certain ways.
I was wondering whether you could share a story of somebody that you've worked with who maybe demonstrates this posttraumatic growth that we're talking about?
Dr. Sandra Lowe 23:17
In broad strokes I can describe a patient who is a traditional first responder, who took on a lot of shifts of work, because his idea of taking care of his family involved working a lot of shifts in order to ensure that the kids went to college and he could pay for them. That they had a nice to live in. So that's what he focused on. It was after 9/11 when he developed some physical symptoms that limited his ability to work. He eventually had to retire due to these physical conditions, chronic pulmonary disease from 9/11. It was only after that that he realized that in speaking with his family, because he wasn't speaking much to his family before because he was working all the time, that what the family actually needed was for him to be around more. So he started coaching his kids' Little League teams. He started to become more connected to the community, because now he was going to these practices and talking to other parents or other families. He feels that despite the losses of 9/11, the losses in terms of his physical health and the suffering that he experienced with his psychological health, in the end, he feels closer to his family, closer to his community. And he feels that his set of personal values, his sense of self, and what's meaningful to him, to his life, has been brought into sharper focus, and that may not have happened, he feels, had he not had to struggle with 9/11 and the aftermath of it. That's one individual, but I've heard it in many different versions in a lot of our patients.
We've talked a lot about social support, and I suspect that family and loved ones are a big part of that. How do you think about the role of a loved one in that situation?
Dr. Sandra Lowe 25:47
First of all, I think that we need to be better prepared to educate family members about trauma, about the effects of trauma, and about what they can do to be helpful, because they don't know, they're afraid that if they say something it might be upsetting to their loved one who experienced some trauma. So helping them understand what they can do, but also helping them understand what some of the effects of trauma are and that their loved one may actually shut down, may actually not want to talk to them. Or for some of our responders, because of their PTSD symptoms, they become very hypervigilant of danger and they become very restrictive. They don't want their kids going away to college, because they're afraid. So they become very restrictive and it comes from a place of love and wanting to protect their family. But it's important for family members to understand that in order to help minimize family conflict. A lot of families dissolved post-9/11 because there wasn't enough of an understanding about what the individual was going through. The families themselves didn't get the help that they needed, and some responders became estranged from their children. So it's important for families to be educated and be aware. And I can tell you just from my experience of getting to know some of the responders, my patients' families over a period of time, when they feel that they understand what is happening with their loved one and what they can do to help, it brings them closer together. For me to hear family members speak sometimes just with tears, with happy tears in their eyes, about getting their loved one, their spouse, their brother, their parent back after they've gotten treatment, for them to know, okay, there was this something that was happening, but the person I love was there all along and now there he is, he's back. It's wonderful to hear that, and families are all very appreciative.
That's such a powerful image, it brings tears to my eyes. I'm noticing we have about 10 minutes left, so I want to make sure Nicci and Emma have a moment to ask any questions that have come up. So Nikki and Emma, if you're there, please feel free to join us.
Emma Stoneham 28:49
I feel like I had questions, but then you answered them as you were speaking. I feel like this also is just a topic that affects everyone in the country, even if you don't know someone going through trauma, it's like a third degree. You know a loved one's loved one, or a friend's loved one, so it's just a topic that even if it doesn't affect you directly, it affects everyone who was there and who experienced some part of it.
Dr. Sandra Lowe 29:19
And the reality is that we ourselves don't know when we will walk into a traumatic situation. So as you're saying, even if you're not directly connected to someone now, or you haven't experienced it yourself, learning about it and learning about what's protective, and learning about the importance of support, and talking to others, and getting mental health treatment when it's needed. Carrying that around in your back pocket is insurance in the event that something terrible happens, and terrible things sometimes happen.
Can you break that down? So in terms of not in a paranoid, defensive-crouch way, but what can a normal person do as kind of like the healthy protective measures, knowing that this is a part of life this will happen.
Dr. Sandra Lowe 30:19
Yeah, I mean there are kind of just the basic self-care wellness practices, which are going to be psychological and physical wellness practices. Very simple things, such as getting a decent sleep, making sure that you have some boundaries between your work and your recreation, social time, that you don't neglect that part, strengthening your relationships, tending to them like you would tend to a beautiful garden. You need to tend to relationships every day and invest in them. That's going to make a major difference in the event that you do need it in the future. We need it every day, but when we've gone through something terrible, it's a huge difference for us. Practices such as meditation, exercise, getting outdoors, finding a hobby, an activity that you take pleasure in, something that you can turn to in times of stress. If faith is a part of your life, strengthening your relationship with the faith community, meditation for some individuals, spirituality in that form. So these are things that we can do, and these are good things for us to do every day and they're going to protect us in the event that we need it.
Dr. Lowe, thank you so much first and foremost for your work and also for joining us on Road to Resilience.
Dr. Sandra Lowe 32:12
Thank you very much.
Dr. Sandra Lowe is a Psychiatrist and Medical Director of the World Trade Center Mental Health Program here at Mount Sinai. That's all for this episode of Road to Resilience. The podcast is a production of the Mount Sinai Health System in New York City, it's made by me, Jon Earle, Nicci Cheatham, Emma Stoneham, and our Executive Producer, Lucia Lee. From all of us, as always, thanks for listening and we'll see you next time.