Practical Psychotherapy: When It Really Hurts to Listen: Psychotherapy in the Aftermath of September 11

The work of psychotherapy demands that we listen to patients in a very special way. The process requires psychiatrists and other therapists, for a period of time, to step into their patients' emotional shoes. Then, stepping out of those shoes, informed by feeling the full force of the patient's emotional state, they are able to make empathic interventions that are responsive to their patient's internal needs. What happens when these shoes are also our own shoes, and the pain that patients are feeling mirrors our own pain?

In the months since September 11, many conferences and presentations have included discussions of the emotional aftereffects of the terrorist attacks. Posttraumatic stress disorder, grief, and loss have been the subjects of scientific panels, roundtable discussions, and Internet dialogues. Poignant presentations by individuals who were involved in immediate outreach have burned tragic images in the minds of those who were more physically distant from the events.

In efforts to understand how best to respond, experts have drawn on experiences and information gained during responses to other disasters. We have learned a great deal from the reports made by dedicated volunteers, many of whom have flown long distances to reach out to help survivors of earthquakes, floods, volcanic eruptions, and war. They have provided important insights into how to most effectively address the current crisis.

However, the September 11 attacks did not occur in some distant country. The fact that they occurred here in the United States shattered our sense of invulnerability and security. Our patients' natural reaction is to look to their therapists as experts in dealing with reactions to this kind of distress. They feel the need for a safe harbor and someone to help them contain their anxiety. At the same time, therapists themselves are experiencing many of these same feelings of grief, loss, and vulnerability.

A few days after the attacks, Schuster and colleagues (1) conducted a survey of a nationally representative sample of 560 adults in the United States. They found that Americans were experiencing substantial levels of stress: 44 percent reported one or more severe symptoms of stress, and 90 percent reported at least low-level symptoms. These findings show that catastrophes can have a strong effect even on people who are not physically present during a disaster.

What kinds of things have patients been talking about? It was not unusual after September 11 for clinicians to hear frightened reactions from psychotic patients who believed that they were responsible for the attacks. Some heard voices telling them that they personally had flown the planes and should be punished. As is often the case with hallucinations and delusions, it was relatively easy for clinicians to keep an appropriate psychological distance to best hear these patients.

However, it was quite different to listen to the stories of patients who were not psychotic: their grief and loss, precipitated by the death of loved ones who were killed in the World Trade Center, at the Pentagon, or as passengers on the hijacked planes, were very real. Many clinicians had themselves lost friends and family members as a result of the attacks.

One therapist described listening over and over again as a patient played her loved one's last good-bye, recorded on her cell phone. Another colleague described his conflicting feelings when dealing with a patient's heightened sense of vulnerability after losing her belongings in the World Trade Center fires. He was struggling privately to deal with his own feelings after losing valuable research data in the same fires. At one conference, a colleague spoke with a shaky voice and with tears in his eyes about a grief-stricken man whose wife was killed in the World Trade Center and who wept, "I can't stand the thought that I will never again lie in bed next to my wife, I'll never hold her again!" The psychiatrist reflected on how this had touched his own raw feelings about the loss of his wife two years earlier.

In addition to reactions of trauma, grief, and loss, people wonder how to interpret the events. They ask, "Will I ever feel safe again?" Many are reluctant to leave home or to be too far away from friends and family. "How do I reassure my children?" and "How do I reassure myself?" are common questions.

The literature contains some thoughtful commentaries about analysts' reactions to their own illness, aging, approaching retirement, loss of a loved one, and impending death. Dewald (2) questioned whether self-disclosure of the psychiatrist's own illness and reactions to that illness was helpful or harmful. He asked, "Is self disclosure helpful or harmful…does it facilitate patients' own dealing with their anxieties as a part of the human situation or is it a narcissistic gratification to talk about oneself?"

Coen (3) cautioned that we need to be sensitive to our own wishes for our patients. We need not fear that acknowledging to ourselves that we have desires and feelings toward patients will leave us scrambling to find our footing on some slippery slope. Rather, an expanded awareness will enable us to manage ourselves and to expand our work with patients. Clark (4), writing about illness in the analyst, reminds readers that the patient's needs must be given priority in our work. She cautions that the increased neediness of therapists in times of illness—or at any other time—may cause them to distort their perceptions of the patient and ultimately sabotage the work.

Both of these authors are describing events that nakedly reveal to patients the psychiatrist's vulnerability. Therapists' reactions to the terrorist attacks are not necessarily visible, sometimes even to the clinicians themselves.

Few can escape being marked by the events of September 11. Our own personal reactions may be rage, depression, and a sense of personal vulnerability. Therapists who experience these reactions must be aware that their own responses may make it more difficult to clearly hear their patients' concerns. We must take care that we continue to hear the patient's laments without the distortions produced by our own emotional reactions.

Clark wrote that in studies of motivation for becoming a physician, many physicians were found to have chosen the profession as a "kind of insurance policy against catastrophe…. This unconscious motivation does not allow the powerful healer to need healing." Inasmuch as this statement is true for an individual physician, he or she may have difficulty reaching out in an appropriate manner for personal sustenance, help, or consolation.

Because everyone defends against the reality of his or her own death, so too do we defend against vulnerability, and psychiatrists are not immune from such behavior. At the same time we must consider that denial can be one of the strongest healing mechanisms for persons who are ill. As emotional healing proceeds in the aftermath of that September morning, aided by the mechanism of denial, it becomes a sensitive balancing act to understand when to interpret and intrude on this mechanism and when to leave it alone. It is obviously part of the "learning to live with it" process of dealing with constant potential danger.

A move toward national denial was highly apparent on February 12, 2002, when the government issued a warning that the country needed to be "on alert" because there had been word that "something might happen." The public's reaction was quite different from the vigilant anxiety expressed a few months earlier. Wisecracks abounded, such as "Sure, just tell me where to look, George, and I'll get my machine gun ready!"

Clinicians must consider certain generalities in individualizing their reactions to patients:

• More regressed patients are likely to need more factual information. Addressing this need may involve acknowledging the reality of anxiety, including one's own. This acknowledgment must be balanced with an awareness that patients may be become increasingly anxious if they perceive their therapist as not only anxious but too frightened and vulnerable to contain both their own and their patients' emotions. Any expression of anxiety on the part of the therapist must be coupled with reassurance that that these fears are manageable and that the therapist will be a continued presence in the patient's treatment.

• With patients who are less regressed, the therapist must weigh carefully the temptation to share his or her own personal tragedies and worries or to join with the patient in inappropriate denial.

• Therapists should acknowledge their own feelings, share these feelings with colleagues and friends, and guard against their own potential for denial.

Throughout the literature that addresses clinicians' sense of their own vulnerability are references to the need for healers to monitor their reactions, process them with others, and feel free to seek out consultation or treatment. Wong (5), describing his countertransference during and after his illness, stressed the importance of self-monitoring, ideally in conjunction with a colleague. One reaction he recognized was greater identification with his patient's illness. The seeming universality of his response could interfere with recognition of what the individual in our office, clinic, or group is experiencing.

The day after the September 11 attacks, a reporter called to ask how the patients in our county psychiatric clinic had reacted to the tragedy. I passed the question along to our psychiatric residents, who described the intense reactions of several patients. Several of the residents and staff had their own concerns about relatives or friends who had been personally affected. When one wondered, "Did they ask how we were?" I had to reply, "No: We're the ones who are expected to be strong and give answers. We are looked to as the healers and helpers. That's why we must turn to each other for strength and support." This is especially true in the aftermath of September 11, when listening can be particularly painful.