September will be a difficult month for a long time.
September will be a difficult month for a long time.
In the aftermath of buildings demolished by hijacked jets, innocents killed and injured, the president's declaration of war on terrorism, and the heartbreaking cleanup and reconstruction, there's plenty for Americans to commemorate on this first anniversary and those to come.
Mental health care professionals say that anniversary reactions are bound to occur broadly but especially in those people most directly affected by the Sept. 11, 2001, terrorist attacks on the World Trade Center (WTC) and the Pentagon. Survivors; relatives, friends and co-workers of victims; rescue teams and construction workers; and others who observed the devastating scenes are at risk for recurring posttraumatic stress symptoms. (Please see related article on the aftermath of Sept. 11 and mental health in September Mental Health Outcomes, in our print publication--Ed.)
The experts say there are any number of triggers that will re-evoke the horror experienced just a year ago. Among them, the prospect of prolonged and saturated media coverage is a major concern. During a session at the American Psychiatric Association's annual meeting in May, presenters warned that many people could suffer adverse reactions as they are inundated with media images and stories that recall the events of Sept. 11, and they urged broadcast and news outlets to think carefully about their coverage.
That concern is not misplaced, according to Sandro Galea, M.D., M.P.H., a medical epidemiologist at the New York Academy of Medicine who conducted research on media effects following the attacks. Preliminary data suggest that prolonged media viewing of images related to the events of Sept. 11 is associated with a greater likelihood of posttraumatic stress disorder (PTSD) in people who were directly affected, he told Psychiatric Times. The data are scheduled to be published within the next few months.
However, Galea commented that the area of media effects could benefit from more research because there is very little good data to measure whether they cause worse health outcomes. "The answer is we truly don't know," he said. "There is some circumstantial evidence that suggests that media viewing is associated with re-traumatization. There are specific groups and case studies, and there are some studies in children, but I think we don't have a definitive answer to that question."
Even though the verdict is not in, Galea said, "There is enough circumstantial evidence to suggest to me that the media should make an attempt to at least warn people of the possibility that viewing of certain images may be associated with greater likelihood of poor mental health outcomes."
Joann Difede, Ph.D., psychologist and assistant professor in the department of psychiatry at Weill Medical College of Cornell University in New York City, has also spent the last year researching and treating Sept. 11 victims suffering from PTSD. In one pilot project, Difede tested a method that relies on virtual reality technology in which patients are led through therapeutic re-enactments of the WTC attacks using computer-generated images viewed through a goggled helmet. While many people will suffer anniversary reactions to varying degrees, Difede told PT that excessive media coverage has the potential to add "just a little bit more pain."
It's that level of excess that's unnecessary, she added.
"The anniversary itself is going to be a trigger, but without the media there to kind of intrude itself into our lives, people can grieve and cope with the anniversary in their own way," Difede said. "But in our society, you open the morning paper and there's an image of the World Trade Center burning. You turn on the news, and there's a story about the terrorists and with it comes some horrible image of that day. In news shows that won't show the actual twin towers falling anymore, they often show other images of distress. Why do we need to see that again? We all have been distressed by that, particularly those who have lost loved ones and those who had to escape."
Ted Rynearson, M.D., is clinical professor of psychiatry at Seattle's University of Washington School of Medicine and medical director of the Homicide Support Project of the Virginia Mason Medical Center. His experience with the media attention given to traumatic events has left him skeptical that journalists, with few exceptions, will provide the type of coverage that is sensitive to viewers' psychological and emotional well-being.
"What I object to is the media capitalizing on the spectacle of the dying," Rynearson told PT. "The media is marketing the public's voyeuristic fascination with violent death."
What should be happening--although Rynearson is not sanguine that it will--is that the media should cover the memorials to victims of the tragedies. He said the New York Times' Portraits of Grief series, an ongoing effort to eulogize victims of the WTC collapse, is an example of a "terrific job."
"What they do is resuscitate the living memory of the person who's died, rather than getting obsessively focused on dying imagery," Rynearson said. "It's the spectacle of the dying itself that's the problem. What the media need to do is humanize this, because what the families are going through after a violent death of a loved one is trying to reconstruct that person's memory. Being re-exposed to the violent death imagery--which we all watched--there's nothing positive about that. What families need are restorative sorts of messages."
According to Rachel Yehuda, Ph.D., psychologist and professor of psychiatry at Mount Sinai School of Medicine and director of its division of traumatic stress, generalizations about the press and the impact its stories will have on the viewing public are often difficult to predict or control.
"Sensationalism is a loaded word," Yehuda told PT. "Will the media want to see the impact a year later of 9/11? Yes, I can't imagine it wouldn't, but that's not necessarily sensationalizing it. The issue becomes what are the stories and what is a responsible mental health professional to tell a journalist who is looking to understand what the stories are."
When it comes to stories about trauma, Yehuda commented that requiring journalists to anticipate the impact of their stories may be too much to hope for at this time. "I really believe [journalists] are trying to tell a story and that they believe it's their responsibility to tell their story accurately," she said. "They don't necessarily believe it's their responsibility to look after the mental health welfare of the [people] they're reporting about and they may not be wrong about that. And that's really what the question is: What is the media's responsibility? I'm not sure that a journalist has the same responsibility as a mental health worker."
Instead, Yehuda said that the intent of the coverage is key, and that even if images or stories depict troubling events, there may be an important educational purpose that should not be subverted. For instance, footage of concentration camps liberated at the end of World War II play an important societal role.
"If that kind of imagery is used for the right reason and with the right intention, it can have the right effect, even if it's disturbing and even if it depicts things that are traumatizing because sometimes you have to see how bad it is in order to effect social change," Yehuda said. "But that doesn't mean that every bad image has to be aired, and aired repeatedlyor to make it something to get ratings or to watch for entertainment, that's exploitative."
Frank Ochberg, M.D., clinical professor of psychiatry and adjunct professor of journalism at Michigan State University, and chair of the executive committee of the Dart Center for Journalism and Trauma, rejects the notion that there is a way to control the media's output in a free society, but he also believes there's room for more understanding and education.
"We're in an era where the media is a welcome partner. I don't give up on them at all," Ochberg told PT. "I do think they have a right to give the public what the public considers newsworthy and then individuals in the public have to discipline themselves to avoid overdosing. What a therapist does is enable a person to revisit these scenes in conditions of psychological security and dignity, and with a fair amount of education to explain why certain feelings are occurring."
Achieving a balance between the media's professional goal to deliver news and the public's responsibility to manage its viewing is an important objective, according to Roger Simpson, associate professor of communication at University of Washington and director of the Dart Center on Journalism and Trauma. He is also co-author of Covering Violence: A Guide to Ethical Reporting about Victims & Trauma (Columbia University Press: 2000). Until recently, neither the public nor the media had much information about trauma and any negative effects generated by images and stories, he told PT.
"Let's work on education on both sides," Simpson said. "So part of what the media present ought to be about trauma itself, and part of what goes into training and education of journalists ought to be about trauma. Then let's keep a free marketplace and let folks decide what to do about it once they have a little better knowledge to work with."
With the trail of disasters leading from Oklahoma City to Columbine to Sept. 11, attitudes among journalists have changed. According to Simpson, less than a decade ago, journalists were skeptical and said that understanding trauma did not have anything to do with the news business. Now, however, "they're willing to listen a bit." The Dart Center, as a result, has been active in providing training to journalism students and working professionals.
Esther L. Thorson, Ph.D., associate dean for graduate studies and research at University of Missouri School of Journalism in Columbia and senior consultant at its Center for Advanced Social Research, is an expert on the impact of media messages. She told PT that journalists have already responded in significant ways to mitigate the traumatic impact of stories and images.
"There's a lot of evidence that it's important to commemorate events like this," Thorson said. "And the media has an important role in helping us carry out that commemorative function."
The TV networks have promised to take a cautious approach, recognizing the dangers of viewer overload, according to a July 30 Wall Street Journal article. Part of the reason for that may relate to advertisers balking at sponsoring 9/11 coverage, fearful they will be viewed as exploiting the somber national mood. Nevertheless, "it is far better to err on the side of giving too much coverage than not paying enough respect to what happened," CBS president and chief executive Leslie Moonves stated in the article.
Cynthia R. Pfeffer, M.D., professor of psychiatry at Weill Medical College and director of the child bereavement program, is currently conducting federally funded research that will study the developmental outcomes for children who lost a relative on Sept. 11. She told PT that media coverage could be a positive force as well as a negative one and that turning this ordeal into a constructive message is an important goal.
"Perhaps what the media should be describing well ahead of the anniversary are the guidelines, so that people can take charge of their exposure so they won't become victims of being exposed again," Pfeffer said. "If people don't know when enough is enough, they won't know when to reduce their exposure. Media coverage might be a very important way of preventing potentially untoward effects."
The International Society for Traumatic Stress Studies issued its own recommendations to the public and the media following Sept. 11, urging the public to limit exposure to terrorism news, especially for survivors and all children. Meanwhile, it asked the media to issue warnings prior to exhibiting graphic depictions of violence.
"It's unrealistic to expect our free press to be controlled in how they report," said Michael Blumenfield, professor of psychiatry at New York Medical College and former chair of the APA's Joint Commission on Public Affairs. He told PT, "We can expect that the media will be attentive to the concerns that mental health professionals have and that we can work with them in minimizing any re-traumatization that may occur."
At press time, however, the APA had yet to issue recommendations for the media as the anniversary approached, according to a spokesperson, although several officials expressed an interest in developing them.