The terrorist attacks of September 11, 2001 left almost 3,000 fatalities and more than 6,000 people injured. They also occurred at a time when there was a surge of interest in emotional and psychological trauma.
It is hardly surprising, therefore, that many researchers actively sought to uncover PTSD associated with the aftermath of 9/11. But in a study published in The Lancet Psychiatry, my colleague, David Wainwright, from University of Bath, and I propose that there has been an overemphasis on uncovering psychological trauma. This is potentially harmful to the minority of victims who are in real need. It also elides significant evidence that, when confronted by terrorism, people often show resilience and defiance.
Our purpose was to review the history of academic inquiry into the association between terrorism and mental health, and to explore its consequences. To do so we first compiled a list from psychological and medical databases of all the research literature we could find that linked these concepts together in their titles or abstracts. After removing less relevant papers we were left with some 330, all of which were read and analysed.
The tendency to look for any such connection actually only emerged quite recently. Research on terrorism, historically, focused more on politics or physical damage. That changed shortly before the 2001 terrorist attacks on the World Trade Centre in New York. The growing recognition of PTSD encouraged a social and cultural climate more attuned to the possibility and consequences of psychological damage.
Most of the pieces we reviewed appeared after 9/11 but, notably, there had been an emerging interest in the field driven by earlier incidents in Omagh (1998), Oklahoma and Tokyo (1995), as well as in Israel both during and after the first Gulf War (1991).
The most striking lesson we drew was that overall, right across the board, terrorism is not terrorising – at least not in the sense understood by much of the research conducted after 9/11 that actively sought evidence of PTSD. The actual rate of PTSD was on a par with that after any other potentially traumatic event – typically less than 5% for civilian populations. That ought to be a cause for celebration.
But that’s not how the evidence was reported. Instead, across a range of high profile, peer reviewed journals, we found studies that, while referring to PTSD, were actually drawn to measuring a subset of its criteria, in effect expanding the bounds of what they reported.
For instance, the first criterion to assess PTSD from the then Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is the need to have experienced an event “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others”. This has been described by some as the “gatekeeper” to the diagnosis and was absent from most of the surveys. These were often conducted over the phone by volunteers with limited training. And, as they could check just a few items from the then standard 17-point checklist for PTSD, the researchers would report finding what they then variously described as “pre-PTSD” or “PTSD symptoms” instead.
As different research teams applied distinct symptom checklists in their surveys – rarely using diagnostic interviews – the results and conclusions from these were “virtually impossible to compare”.
To then describe what was found as being “partial PTSD” or “spectrum PTSD” could only serve to confuse matters. It is akin to labelling nausea and vomitting – which are both possible symptoms of bubonic plague – as bubonic plague symptoms.
Responding to a cultural mood?
Why did this happen and what are the consequences? Well we certainly do not propose that anybody misrepresented their data. Rather, we suggest that the cultural mood or script today increasingly predisposes people to looking for mental health impacts. They then fail to notice when their own evidence points the other way.
For instance, examples of people relying on their own social and community networks to recover were read as reflecting a lack of awareness about psychological services rather than signs of resilience. But it does not help the minority who truly need such support when many more are referred for counselling. The vast majority of people affected by terrorism continued about their everyday lives relatively unimpaired and, in many instances, defiant.
Overall, we concluded, the evidence pointed to a considerable degree of coping with extreme adversity. And this was despite a dominant social narrative often promoted by politicians and officials, as well as media commentators and academics, to the effect that terrorism is somehow bound to impact our mental well-being adversely.
If anything, this shows some limits to those who presume that language or discourse can significantly shape or determine our existence. Researchers, particularly in Israel, noted the possibility for resilience and even healing at such times, as well as the problematic deployment of the PTSD label as a call for resources and recognition, or alternatively to demand professional intervention.
Europe and America, they averred, within which such individualised mental health categories arose, are particularly obsessed with the self and identity. In fact, we are all relational constructs of families and communities. So a proper understanding of mental health requires a greater appreciation of culture and its transformation over recent times that a narrow empiricism is unable to provide.
It may be more useful for government, academics and commentators to focus on what really happens at such times than to emphasise a narrative of vulnerability which, while of little direct effect, reflects rather more their insecurities than those affected by adversity.