September 11th survivors and the refugee model. (Professional Exchange).

This article compares the experience of people working in the area of the World Trade Centers (WTC) on September 11th to the experience of refugees. The refugee model provides a better description of survivors' experience than a diagnostic model. The author's service provision for an organization adjacent to the WTC after September 11th serves as a basis for suggesting this' alternative perspective. Positive and negative aspects of diagnosing victims of disasters are discussed both in general and specifically related to post-traumatic stress disorder. Information regarding the refugee experience is presented and related to the experience of WTC survivors. Implications for framing the treatment process in similar disasters are suggested.

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Following the September 11th terrorist attacks, the diagnosis of Post Traumatic Stress Disorder (PTSD) from the Diagnostic and Statistical Manual of Mental Disorders (4th ed. text rev.; American Psychiatric Association, 2000) was used to describe the reactions of people working and living in the vicinity of the World Trade Centers (WTC). Mental health professionals, the media (Fackelmann, 2002; Vedantam, 2002), government officials, and politicians used the label of PTSD as these groups discussed the effects of the terrorist attacks. Professional organizations such as the American Mental Health Counselors Association (AMHCA), the American Counseling Association (ACA), and the American Psychological Association (APA) posted information about PTSD on web sites. These professional organizations provided links to websites containing basic information as well as such specific topics as how to talk to children about the disaster.

As part of a group of professionals providing services in New York City in the weeks and months following September 11th, the first author provided crisis intervention services to the employees of an organization located across the street from the WTC. Initially, the services that were provided involved direct intervention with employees. After a few weeks, the first author extended his services to include consultation with management in order to assist managers in responding to employees' ongoing needs. In total, the first author provided services for approximately 18 months, until shortly after the organization returned to lower Manhattan.

In the first month, everyone, in the author's experience, met the criteria for Adjustment Disorder with Anxiety or Acute Stress Disorder, the precursor for PTSD (DSM-IV-TR, 2000). After that month, almost everyone the first author worked with was still experiencing symptoms consistent with PTSD. In addition, the first author observed many of the employees' family members meeting diagnostic criteria for PTSD and other anxiety disorders. Gorner and Swanson (2002) supported these observations in an article discussing PTSD in New York City after the terrorist attacks.

However diagnosis, specifically PTSD, was only one way to depict responses and help people cope with reactions to this particular event. Based on the first author's experience, diagnostic labels did not appear to provide a holistic understanding of survivors' reactions. Van der Kolk (1996) validated this concept by stating that a diagnosis of PTSD does not begin to describe the complexity of people's reactions in overwhelming experiences. Because of observations of stress reactions to this unique historical event, the first author began thinking about alternative views to describe the experience of the survivors. The resulting comparison with refugees reported here is an alternative explanation that better describes the lived experience of the survivors from the immediate area of the WTC.

DIAGNOSTIC LABELS

In order to examine an alternative to using diagnosis for understanding survivors' reactions, it is necessary to describe the advantages and disadvantages of the standard diagnostic nomenclature. First, these advantages and disadvantages are discussed generally, then specifically applied to the diagnosis of PTSD, as this was the most frequently used label for survivors. Finally, the use of diagnosis to understand problems being experienced as a result of exposure to traumatic events is examined.

Advantages

Yassen and Harvey (1998) state that a natural tendency for most clinicians is to utilize diagnosis to classify survivors' reactions. These authors contend that most likely diagnostic labels are used not so much to describe the reactions after a trauma, but rather to help clinicians feel comfortable. The comfort afforded by the use of this classification system may be due to the advantages of the system. General advantages of using the DSM-IV-TR (2000) include definition of homogeneous groups of clients (Hinkle, 1999), facilitation of communication between professionals about these clients, and guidance toward appropriate interventions (Mezey & Robbins, 2001; Welfel, 2002). Diagnosis can also inform professionals about prognosis, implications, treatments, and potential outcomes (Mezey & Robbins, Hinkle, Ivey, & Ivey 1998).

In relation to the diagnosis of PTSD, two notable advantages are client education and disability claims. Clinicians may provide information about PTSD to educate clients about the disorder, comfort clients, afford them a sense of relief, and legitimize their experience (deVries, 1996). Being educated allows clients to regain a sense of control by helping them better understand what to expect, which in turn may relieve stress. Clients no longer have to worry about going "crazy" or that they are just feeble minded or cowardly. Society also gains from understanding the course of, in this case, PTSD. The blame that accompanies decreased levels of functioning attributed to PTSD and the myth that clients can "just get over it" is overcome through educating the public. As we stated previously, the media and professional organizations were able to help educate the public with respect to PTSD after September 11th. We speculate this process helped to reduce overall stress levels within society as whole and individuals as well.

Second, a diagnosis of PTSD may also be useful should the illness interfere with a person's ability to function, specifically on the job. PTSD, more than other mental illnesses, is recognized by the legal system as a cause for tort litigation and consideration for workers' compensation (Pitman, Sparr, Saunders, & McFarlane, 1996). Unlike other diagnoses such as major depression, which may be considered an ordinary disease of life, a person diagnosed with PTSD can point to a specific time when the symptoms began. The courts look upon the time factor related to PTSD favorably during hearings for workman's compensation and in assigning responsibility to organizations for not providing a safe work environment (Pitman et al.).

Disadvantages

Despite general diagnostic system advantages, disadvantages do exist. Ivey and Ivey (1999) criticized diagnostic systems for their failure to account for client developmental and systemic issues. Hinkle (1999) concedes that some professionals view diagnosis as making all human life a form of mental illness. Hinkle further acknowledges that diagnosis can promote a mechanistic approach and be used inconsistently and unreliably. Welfel (2002) adds to this argument by acknowledging that present diagnostic categories are often overlapping and inconsistent. Further disadvantages include labeling, stigmatization, and bias (Hinkle).

One advantage of using diagnosis in general, informing prognosis, is more of a disadvantage in the case of PTSD. Prognosis is the idea that diagnosis suggests the typical course or evolution over time of psychological problems (Dilling, 2000). For clinicians who are knowledgeable, diagnosis describes the normal duration of a disorder or illness and suggests whether symptoms associated with the illness will be stable, worsen, or improve. Prognosis also indicates mode of onset and characterizes if symptoms will be episodic or continuous (DSM-IV-TR, 2000). The value of this information is without question; yet the prognosis for PTSD is somewhat unclear (Staab, Fullerton, & Ursano, 1999; Wilson, 1994). According to the DSM-IV-TR, symptoms may fade away in as soon as 2 months or persist for years. Some individuals meeting the criteria for diagnosis with PTSD have symptoms that are short term (Brewin, 2001) and acute (Wilson) whereas others experience a delayed onset (Somansundaram, 1996) and have less severe but more chronic symptoms (Carlson, 1997). In addition, questions have been raised about the relationship of the presence of pre-existing psychological problems and the development of PTSD (James & Gilliland, 2001). The result is that although general patterns in the course of the PTSD have been identified, no clear definitive statement can be made as to who will develop what problems and who will not (Shalev, 2000).

Given the debate on the course of PTSD, advantages of the diagnosis must be considered with caution because of the diversity of the experience. This situation is especially true in the wake of a disaster such as September 11th. Simply counting symptoms is not adequate and will identify too many false positives. Questions arise with respect to spontaneous remission of symptoms, chronic versus acute symptoms, and predisposing conditions making it difficult to determine a clear diagnosis for some people. Furthermore, the idea of typical or expected reactions to trauma is a cause for concern among experts regarding the wholesale labeling of victims after a trauma (Salzer & Bickman, 1999; van der Kolk & McFarlane, 1996). The unclear picture of the prognosis for PTSD provokes concerns about the applicability of the diagnosis in the aftermath of a crisis or disaster.

Diagnosis and Crisis Intervention

Callahan (1998) outlines the contradiction between the use of diagnostic labels and crisis concepts. He states that, although the traditional medical model has not been emphasized, some diagnostic concepts are applicable to crisis intervention. A significant advantage of using diagnosis with trauma clients is that it allows research across different types of trauma (Mollica & Caspi-Yavin, 1992). This benefit cannot be minimized; yet in most crisis situations the focus is on helping victims; whereas research is secondary or an outgrowth of the intervention process (McFarlane, 2000; Raphael, Wilson, Meldrum, & McFarlane, 1996).

Recently, clinicians (Silove, 2000; Stuhlmiller & Dunning, 2000b) knowledgeable in crisis intervention and trauma have begun questioning the use of diagnostic labels to describe and explain the reactions of people who have experienced a trauma or crisis. Although this practice clearly has advantages, the continued medicalization concerns experts in the field of crisis intervention because of the reductionist framework (Silove). At the heart of the debate is the concern about categorizing normal or typical reactions to a crisis as pathological (Tucker, Pfefferbaum, Nixon, & Dickson, 2000). Recent authors have put forth the belief that imposing any type of classification system that is based on pathology is unfortunate (e.g., Ursano, Fullerton, Vance, & Wang, 2000; Stuhlmiller & Dunning, 2000a). In fact, Stuhlmiller and Dunning (2000a) express concerns about how psychological growth resulting from exposure to crises has been overlooked. Moreover, they recognize the importance of issues such as strengths, hardiness, and resiliency when considering crisis intervention responses. Knezevic and Jovancevic (2001) also believe that the "psychiatricisation" for people who are victimized by wars should be done with caution.

Although diagnostic labels offer a quick method to communicate symptoms, this method of understanding did not appear to address the context for the reactions of the people in lower Manhattan on September 11th. The experience of WTC survivors was very different than people, for example, who are diagnosed with PTSD as a result of child abuse. The label does not identify the uniqueness of the experience and, therefore, does not communicate accurately. Preliminary research on people's reactions to September 11th has simply counted symptoms to determine a diagnosis (Gorner & Swanson, 2002). Whereas this process may allow research and comparisons across traumas, it is misleading with respect to understanding the meaning of the event for these people.

REFUGEE MODEL

A more novel method to understand the people the first author worked with after September 11th was to see them as refugees. Refugees are people, many of whom experienced a trauma, who have been forced from a location, usually their homes, but in this case their place of work, to another location not of their choosing (van der Veer, 1998). This description corresponded well with the experience of the people who worked in lower Manhattan. Van der Veer describes eight experiences commonly shared by refugees. The first three experiences of political repression, detention, and torture were not applicable in the WTC disaster. However, the remaining five experiences of violence, disappearance of relatives, separation and loss, hardships, and exile were applicable to the experience of the organization's employees and are discussed below. In addition, consequences of the refugee experience, according to van der Veer, also include traumatization, uprooting, and hierarchy of suffering. Each is applicable to the people the first author worked with.

Experience

Survivors of September 11th from lower Manhattan experienced the violence of the attack. A few of the people saw the first plane crash into the north tower of the WTC; whereas many saw the second plane hit the south tower. During the escape, many employees watched people jump from the windows of the WTC. The first author talked with employees who described in detail the sound of the people who jumped landing on the street and the remains left on the sidewalk. Many of the people the first author talked with were caught in the dust cloud as the towers collapsed. Each stated they thought they were going to die as the cloud enveloped them. Vacating the area proved a challenge as public transportation was stopped. All of the employees were missing for periods of time, some as much as 36 hours as they struggled to find a way home. The inability to contact family and friends also caused significant distress for everyone. Employees expressed that they felt significant responsibility for co-workers and made attempts to make certain they had escaped lower Manhattan. They also wondered if co-workers who happened to be in a meeting that morning in the WTC and friends who worked in the WTC were safe. Several days passed before they learned that their co-workers had died in the attack.

Separation and loss issues were not limited to the loss of life but also included the loss of possessions. The hasty evacuation resulted in leaving behind almost everything: personal effects such as purses, coats, and so on and professional items such as files and information required for business. Returning to retrieve these items was an ordeal. The process in itself was stressful for most people. Damage to the building resulted in having to be escorted into the building to retrieve items. The establishment of martial law also meant being cleared through at least four checkpoints. At each checkpoint, identification was requested and verified. While moving from two of the checkpoints, everyone was escorted by police or the National Guard who was armed with what appeared to be assault rifles.

The attack also resulted in the organization's relocation to four sites in Manhattan, Long Island, and New Jersey causing a feeling of being "exiled." Surroundings were no longer familiar, and daily routines had to be adjusted to the new environment. For example, all employees incurred hardships about having to change family schedules in order to adjust to a new commute. Many had longer days due to transportation difficulties. Employees also expressed anxiety because of the lack of amenities in the area in which they were relocated. Another issue related to both loss and exile involved the separation of friends with whom individuals worked. Since the organization was forced to relocate in four different places, friends were separated, resulting in diminished support networks.

The employees remained in this exile for almost 18 months, initially not certain if they would return to their office space in lower Manhattan. During that time, they adjusted to their new surroundings; and when returning became a possibility, some became distressed (van der Veer, 1998). Surprisingly, not all the distress was in anticipation of returning to lower Manhattan. Many of the employees had adjusted to the temporary space and did not want to leave. When the employees of the organization began returning to the lower Manhattan work site, as expected, many experienced memories of the traumatic event. The feelings of fear, sadness, and anger reappeared. Research on the experience of refugees concurs with the emotionality observed by the first author. Refugees do not want to return because they may have accommodated to the new surroundings by starting new lives or may be vulnerable to encountering the same situation (Jaranson, Martin, & Ekblad, 2000; van der Veer).

Consequences

The consequences of being refugees can be discussed in terms of traumatization, uprooting, and hierarchy of suffering (Jaranson et al., 2000; van der Veer, 1998). Each concept is applicable to employees of this organization. Van der Veer defines traumatization as "extreme, painful experiences, that are so difficult to cope with they are likely to result in psychological dysfunction both in the short and in the long run" (p. 4). However, van der Veer expresses caution about identifying the consequences of the experience of being a refugee to PTSD, stating that a psychiatric approach does not offer a satisfactory description of the experience of the traumatization of being forced from familiar surroundings. Jaranson et al. also express concern stating that the medicalization of what may be expected reactions to a sociopolitical problem is to be done with care. Van der Veer and Jaranson et al. acknowledge that there is a risk of refugees developing a diagnosable mental illness, but the occurrence of mental illness is sporadic and infrequent. These views are consistent with recent publications in the area of crisis intervention that question regularly assigning diagnostic labels to people who have been traumatized (e.g., Ursano et al., 2000; Stuhlmiller & Dunning, 2000a).

Traumatization for the individuals the first author provided services for came in several forms including watching people jump from the windows of the WTC, knowing people who died in the attacks, being caught in the streets as the WTC collapsed, being afraid more attacks would come, and so on. Each of these events alone is enough to result in trauma, and combined, the trauma was overwhelming. Many of the people expressed a sense of shock during the experience saying they were unable to process their perceptions. For example, many people reported being mesmerized and found it difficult to look away as they watched the fires burn and people jump. Others reported a sense of calm as they fled from lower Manhattan. The majority of people in this group stated they believed death was close and focused on preparing for that inevitability. A few people in this group stated they dissociated or depersonalized during the events of that day. The process of dissociation and depersonalization is not uncommon for people experiencing extreme trauma (van der Kolk, 1996).

Uprooting is another concept put forward by van der Veer (1998) that was found applicable to the organization's employees. Uprooting is the "experience of being forced to leave one's familiar surroundings and to settle in new and unfamiliar environment for an indefinite period, which brings stress and can cause various long-lasting adjustment problems" (van der Veer, p. 4). The employees of this organization were forced from a well-known location and had to relocate in other parts of the city. Because several locations were needed to provide office space, friends were separated, working relationships altered, and familiar patterns changed. This situation resulted in problems similar to that of refugees who, because of being uprooted, lack known support systems (Gorman, 2001; van der Veer). In addition, difficulties related to uprooting also can be considered a sort of culture shock (van der Veer). The new locations were to unfamiliar surroundings and resulted in the need to learn new routines. The environment of the relocation sites was also different, from being in the one building in the financial district of lower Manhattan to being scattered throughout the area in four locations, none of which bore resemblance to their former building. Adaptation took time. Some adapted well; whereas others did not. Again, this experience is consistent with that of refugees (Jaranson et al., 2000).

An additional related idea identified by van der Veer (1998) is that of a hierarchy of suffering. This concept refers to the belief that some of the individuals have more of a right to be traumatized than others. Consequently, some individuals have more of a right to receive intervention services than others do. The resulting dynamics of this concept rippled through the organization. The people who were at the location across the street from the WTC became "heroes" to those who were away for business or not present that day. These "heroes" were held in awe and reverence as they shared their experience during the group intervention process. A negative outcome was that those who were not present felt guilty about the need for services. They did not believe their trauma was as legitimate as those who watched the events from their office windows. As time has passed, the hierarchy has decreased, but remains evident and has been used as part of the intervention process to help explain reactions of individuals. During the return to the office space after 18 months away from lower Manhattan, the organization acquired new staff that was not employed during the September 11th disaster. These people experienced a similar guilt about receiving services even though the threat of a new attack was as real for them as for those returning.

Treatment

Approaching the situation using a refugee model resulted in a de-emphasis on symptom reduction and instead emphasized empowering individuals. This process involved helping the employees of the organization reclaim autonomy and self-efficacy (Gist, Lubin, & Redburn, 1999). Gorman (2001) outlines three steps for this process: (a) the establishment of safety; (b) the process of reconstruction; and (c) reconnection. Although Gorman discusses these steps as linear, the experience of the first author was that the empowerment process was more fluid with individuals progressing at different rates and, at times, regressing.

Establishment of safety addresses the development of rapport and the gaining of confidence in self and support systems (Gorman, 2001). Rapport with the employees of the organization was established quickly. The quick development of rapport is typical for situations of high intensity (Kleespies, Deleppo, Mori, & Niles, 1998). Initially, sessions focused on employees telling the story of leaving the area and the relief as they realized that they were not going to die. Interestingly, employees wanted to tell their stories repeatedly over several weeks to the first author, each time adding additional information. They seemed to need to tell the same person the story as they remembered new details. As self-confidence and support systems developed, the focus of sessions shifted. The employees began exploring the meaning of the experience. Examples of exploration included feelings about the experience of watching the people jump from windows, the impact on themselves and their families, and so on. This process is consistent with that of refugees who need to feel safe by having a sense of control over themselves and their support systems (van der Veer, 1998). Also applicable is the idea that trauma victims need to establish safety and build trust before exploratory work into the meaning of a traumatic experience (Herman, 1992).

The process of reconstruction involves creating a narrative that gives meaning to the multiple traumas (Gorman, 2001) such as violence, separation and loss, hardships, and exile (van der Veer, 1998). As the employees' feelings of being in control increased, they were able to restructure their belief schemas and attitudes (Gorman) and to begin finding that meaning. Treatment during this phase highlighted the employees' engaging in activities that were empowering and emphasized control over their lives. For example, some employees increased the time spent with their family; whereas others became more religious and thoughtful about life. At times, this process involved the first author supporting and validating ideas the employees had such as visiting family members that lived out of state. At other times, when employees feared that they were "crazy" because they had nightmares periodically, the first author "normalized" the experience to help them gain a sense of control and relief. This normalization came by the first author assuring them that occasional nightmares could be expected. Although some employees continue to struggle with attaining full control over their lives and experience symptoms related to PTSD, all have regained the ability function on a day-today basis albeit at varying levels.

The final phase of reconnecting and creating a new future continues with the employees. However, the constant reminders of possible terrorist attacks have complicated this process. Treatment in this phase has concentrated on helping the employees draw upon the aspects of themselves they most value (Gorman, 2001). Part of the process also involves maintaining a focus on empowering them to build on the positive facets of the experience such as spending more time with family, being more prepared should another disaster occur, and so on. Another focus of treatment in this phase has been to establish a natural debriefing process (Ursano et al., 2000), encourage employees to talk about the experience with one another, and use existing social support systems. This process appears to have helped build and sustain their self-confidence and social support systems.

RECOMMENDATIONS FOR MENTAL HEALTH COUNSELORS

In light of the distinctive nature of the trauma at the WTC in New York City as a result of September 11th, we recognized a need to define the experience of the survivors in a more comprehensive manner than diagnosis alone. An alternative concept, appearing to have merit in understanding experiences and reactions, is that of the refugee experience. Although this model does not fully explain the experience, the resemblance is remarkably close to the reactions that were encountered.

Based on the observations made during the work in New York City, several practical and research recommendations can be made. The practical recommendations provide a starting point for mental health counselors' offering crisis intervention for major disasters in the future. These recommendations are made with the awareness that all intervention in the wake of disasters must adapt to the context (Wilson & Sigman, 2000; Gist & Woodall, 2000). The call for research in this area is rooted in the need for a more systematic procedure to collect and analyze information about understanding reactions to disaster situations.

First, use of a diagnostic or medical model can be helpful in some ways, but must be balanced with other more novel ways to fully portray reactions after a disaster. Identifying and counting symptoms is only a start. Richness and depth to our awareness and understanding of reactions to trauma are needed. Closer examination of normative or adaptive reactions to trauma is one strategy that might lead to legitimizing alternatives to the medical model (Silove, 2000). Mental health counselors' use of a better differential assessment process may also be a means to developing new ways to understand reactions to trauma. Differential assessment is particularly important since many times a person with PTSD is also diagnosed with other mental illness such as other anxiety or mood disorders (James & Gilliland, 2001). It is possible the differential assessment process could take a focus that identifies neurological or physiological changes.

A second recommendation is to adjust mental health counselors' understanding of PTSD. At least two methods to restructure PTSD into categories have been published. Niles (1994) proposed four levels of PTSD: (a) traumatic reaction; (b) traumatic stress reaction; (c) post-traumatic stress reaction; and (d) post-traumatic stress disorder. According to Niles, symptoms at each level, moving from "a" to "d" intensify. Kira (2001) suggested a taxonomy that differentiates individual functioning levels and experiential objective criteria as a better method to understand PTSD. He breaks this taxonomy further by classifying the impact of a trauma on individual functioning into five types (i.e., attachment trauma, autonomy or identify trauma, interdependence trauma, achievement or self-actualization trauma, and survival trauma) and by having two categories for understanding the experiential component of his model (i.e., factitious or trauma-like events and real traumatic events). Further research is needed to establish the validity of these or others attempts to organize PTSD into sub-categories.

A third recommendation is the development of a theory that considers the concept of "crisis in context." Exploring approaches that are not reliant on the DSM-IV-TR (2000) as the model for understanding are needed. Literature in crisis intervention (e.g., James & Gilliland, 2001; Stuhlmiller & Dunning, 2000b) has previously called for the need for research in this area. The concepts presented here provide a starting point for this work. Mental health counseling research published in the area of trauma and crisis intervention provides invaluable information in the development of such a theory. In addition, research and theory (e.g., Brofenbrenner, 1986) in related fields may be a resource as this theory is developed.

The fourth recommendation concerns the development of additional research methods to study disasters. As stated previously, an advantage of the use of diagnostic labels allows for research across crises. Because not everyone in crisis experiences symptoms at a level meriting a diagnosis and given the limitations of diagnosis for crisis situations, other methods are needed. Specifically, mental health counselors' research could focus on ways to identify health-oriented ways to approach disaster research to account for the psychological benefits that may result from exposure to traumatic events. Research in this area may hinge on salutogenic vs. pathogenic models and static vs. organic models. It is recognized that this is a difficult task given the nature of crisis where the initial goal is to help and research goals are typically secondary.

As stated previously, the first concern in any disaster is providing assistance; whereas research is generally an after thought, at least for mental health practitioners. Yet, the events of September 11th changed the way people in the United Sates think about their vulnerability (Riethmayer, 2002). The field of crisis intervention will never be the same, but some lessons have been learned. These lessons include practical and useful paradigms for analyzing the aftermath of the next major disaster. Questions have also been raised that need more systematic research to help either refine or refute observations made during the attempts to provide service during this crisis.

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Rick A. Myer, Ph.D., is an associate professor and director of the Center for Crisis Intervention and Prevention, E-mail: [e-mail]. Holly Moore is a doctoral candidate in the EXCES doctoral program. Tammy L. Hughes, Ph.D., is an assistant professor. All are with the Department of Counseling, Psychology, and Special Education. Duquesne University, Pittsburgh, PA