This week, partly due to the anniversary of the destruction of the World Trade Center, with awareness of the life changing flooding and fires and earthquakes that wreaked havoc around the world in the past week, and also in response to some shocking and tragic events that occurred to clients on my caseload – I decided to write about the experience of psychological shock: of the fateful moments when we find ourselves suddenly living in a totally new story than the one we were living in second before.

We walk around, generally, living in a story that we expect will continue, that we believe is secure enough, and that can be transformed in a flash, into an entirely new narrative, one we would never have chosen or expected. Our household has survived several of these kinds of thunderbolts, these fateful shocks – and my son describes the sensation as being “picked up and flung from one multi-verse into another.”

Crises are thunderbolts which shake our very foundations. Cancer and other life-changing diagnoses, unexpected violence, sudden death or disabling injury, accidents, stillbirth, the exposure/discovery of long held secrets, natural disasters, terrorist attacks, political coups (and even surprising political events such as Trump’s election and Brexit) , the out break of war. The world around us shifts completely and violently. The life we thought we were living seems to have been reduced to rubble. We are plunged in a new land almost instantaneously and are lost, disoriented, grieving our old life and fearful of the challenges that face us in the new one.

We are always seduced by the story we are living in, we like to believe they are substantial and secure. Massive anxiety is activated when the rug of expectable reality is pulled out from under us, when the pattern has been disrupted, and we have not yet acclimated to the new patterns of life that await us.

All psychotherapists, even those with “boutique practices” who prefer to see only the “stable worried well” need to be skilled in the processes of crisis intervention that are required after a transformative or destructive shock has occurred, as fateful and tragic shocks can strike any (or many) of our clients at anytime.

Because this is part of our training and professional purview, we are often summoned, explicitly and implicitly by our communities during times of tragedy and disaster – and for some of us, depending on where we live – terrorism. As mental health practitioners we have obligations to our communities, and not only our clients, in times of communal dysregulation

I wrote about my own instinctive, perhaps over-activated “social worker’s” response when New York City was flooded by hurricane Sandy, and noticed that the disaster felt similar to the aftermath of 9/11, even though this time we were warned and prepared by the National Weather Service.

On the morning of 9/11 we obviously had no such warning. I saw the first plane hit on television, in my apartment near Bellevue Hospital, and, not wanting to admit our narrative was being disrupted, I headed out on foot to go across and downtown to see a new office to rent with a colleague of mine. Along the way I heard the sirens, and hoped that they would get everyone out of the building after the fluke terrible accident. I had been downtown working in a restaurant the first time the WTC was bombed, and had I passed out cups of water to smoke covered people coming out of the stairways. Everyone was safe if shaken. A few had smoke inhalation but no one died. I was sure the scene downtown was similar this time.

I passed St. Vincent’s hospital – and a man came running out of their psychiatric ER screaming: “We are at war and none of you even know it!” Poor man, I thought, he must be decompensating and fearful of being admitted. When I reached 6th. Avenue, I saw that a second plane had struck the second tower. I have no recollection of hearing it. From a mile or so away I saw what I assumed were waiting area “couches” flying out of the upper floors of the burning building. It was only when I reached the office, and others in the building had their radio on, that I realized that the man in front of St. Vincent’s was right.

It was several years later before I realized that there was something strange in my memory- that it was unlikely that I had seen “couches” being thrown from the towers, and that they were human beings leaping from the flames.

Cell phones were out, so, as quickly as possible, I headed back to Bellevue Hospital where my husband worked as a psychologist (I stopped only to withdraw as much cash as I was permitted out of an ATM along the way since we had no idea what would happen next). When I found him he told me that the ER’s and morgues city wide were essentially overstaffed, with emergency personnel, but empty: “There aren’t even bodies.” They were asking for mental health volunteers to help manage the enormous crowds and endless stream of people who were amassing at the hospital gates in search of missing loved ones.

My husband and I spent eight hours cross checking names against a list of no more than twenty admissions. Some people chose to continue their search, and wandered off, stunned, to inquire at the next nearest hospital. Some were at the point of breaking, and collapse, and pulled into to sit with a crisis worker. As the sun began to set, we were told to redirect people to the Armory, where crisis workers would interview anyone with still missing family members. We were told to tell searchers to go home, to get hairbrushes and toothbrushes, to search their waste baskets for fingernail clippings or used bandaids – anything that they could use for DNA matching, that DNA was the most viable method of identification. Providing defacto “clients” with this information, noticing who could take in its horrifying implications, who merely nodded with a dissociated stare, and who couldn’t hear me at all. None of us could grasp that nearly 3,000 human beings had been vaporized before our eyes.

The day after 9/11, when our cellphones worked again, I called every one of my clients to understand how they had, or had not been impacted. Many of my clients worked and lived downtown. My office at the time was across the street from the Empire State Building – and was twice evacuated due to bomb scares- once by a terrified screaming young National Guardsman – while I was in session, further traumatizing clients who had been downtown. Twice I guided traumatized clients – both of whom had been covered in ash the day before, one who had raced downtown to rescue their medically disabled father, down 30 flights of stairs in the night. I decided it wasn’t safe or healthy for me or my clients to practice there and I transferred my practice to phone session, and met a few clients in coffee shops, and on park benches, for a week. I secured a temporary base in a friend’s home office until the new office, that I had visited on the 11th was ready for us to take residence.

On the second day after the events, I signed up through our the New York State Society of Clinical Social Workers to provide crisis intervention and bereavement support to companies in crisis who had been impacted by 9/11. I had a supervisee who was assigned to a company who had lost 90 percent of its employees to support the survivors. I was sent to work with a news agency who had lost 11 reporters in the building that day.

When I arrived, I was escorted by the stunned and clearly overwhelmed human resources representative to a conference room with six or seven other “crisis intervention specialists” Several wore expensive suits and watches, carried clip boards and brief cases, and offered themselves up as “Critical Incident Debriefing” experts, corporate consultants. We waited to be assigned to smaller meeting rooms to provided stunned and bereaved co-workers, several of whom had experienced the acute stress of fleeing the buildings just before they had collapsed, and who had fled the cloud of dust, having lost track of their presumed dead colleagues in the chaos. And the “Debriefers” used this moment to try to assert their modality: “I think we need to make sure that we all have the same plan, and are using the same methods before we go in there.” the head suit asserted. “What exactly is your plan?” he asked me directly. I looked to either side of me hoping he wasn’t really engaging me in this conversation. When it was clear that I was the one being confronted I responded:

“You should do whatever you do. As for me, I plan on actively listening to people talk about whatever it is they want and need to talk about, and that is it.”

“Well, that isn’t best practice, these need to be structured interviews!” he asserted as I was signaled toward my temporary office by the woman from HR.

“Well, the last thing that I would want to be subjected to in the middle of all this is a ‘structured interview’ so I guess I’m just sticking with my listening and acting like a human being thing. But, I promise if anyone tells me that they want a structured interview I’ll be sure to direct them to the sign up sheet on your clipboard!”

For the next two weeks, people came in and out of my “room” and grieved their lost friends, struggled with survivor’s guilt, expressed their fears about how the world would change, that terrorism and war would escalate. Muslim workers and those who were of middle eastern descent spoke about how their children were being terrorized at school, how their wives were hiding in their homes, how shop clerks were refusing them service. The world was topsy turvy. No one knew what would remain the same, and what would change forever. No one knew what the new norms would be.

I pressured no one to tell me any details that they did not want to. I let them tell me whatever they needed, in whatever order it came to mind. I did not ask them to tell me their story of the events, or ask what floor they were on. Sometimes they seemed to start the conversation mid-thought, still trying to wrap their heads around what had happened. I normalized and universalized their responses – we were all lost, and we had all lost a way of living. Yes we were traumatized, yes we were bereaved, but also: our story had been ripped out from under us, and we were all finding our way in a new world. We talked about what we wanted to remember, and we talked about the difference between repression, dissociation, and the healthy processes of benign forgetting. I allowed people to practice self-regulation. If they became too upset, flooded or disorganized, I asked if they would like to slow down or change the subject or if they needed space to fall apart. If they wanted to sit silently and weep, and say nothing else – I let them. If they needed to complain about their anger at politicians or neighbors or supervisors – I listened. I taught people about internalizing and externalizing responses to extreme stress. I taught people what to watch for in themselves and in those around them – as signs that an acute stress response or healthy grief was becoming entangled in more severe post-traumatic disorder. I told them what their options were for additional help if they continued to struggle with intrusive thoughts or flashbacks in a few more months, if they experienced protracted sleeplessness, or repetitive nightmares, or if they noticed their tempers were short or their irritability became excessive. I told them that if they felt too numb for too long that was a sign to seek help too. But for now, I told them, it was normal. It was expectable. That feeling “crazy” was expectable for in a world turned upside down. It was too soon for any of us to feel normal.

I talked about how we might with each new day, or several times through out each day, seem to suddenly “remember” or “rediscover” what happened after a period of dissociated numbness or forgetting, and we might feel strange for momentarily forgetting something so massive. I explained that grief moves in waves, sometimes tidal waves, that build to an excruciating crescendo, and then recede. I told them that generally we can trust that our psyche would time us out, switch us off intermittently when the fear or grief or pain or disorientation became too severe. I told clients with previous trauma histories to monitor themselves more closely, and made sure they had access to services.

I explained that we may understand, and accept cognitively what has happened, that an act of mass murder had occurred in our community, or that someone we cared for has died, but that our emotional lives don’t take in information directly, they learn only experientially. That the emotional centers of our brains would be reaching backward, trying to re-establish the comforts of our old patterns, our old attachments, our old expectations.

No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality.~ The Body Keeps the Score, B. van DerKolk

Our emotional processing cannot understand what has been lost until we have lived with the loss long enough to become familiar with it, to recognize it as a pattern. We can only emotionally accept a loss that we have repeatedly encountered to be true, over and over and over, until the new reality has become familiar to us.

Since that time, critical incident debriefing and associated models (originally developed as a method for offering support to first responders while documenting their official account and not created to treat trauma victims) has become a highly controversial methodology, with many studies suggesting that it is destructive to trauma victims. It is no longer considered “best practice” to require survivors of extreme or violent events to describe their experience in detail, and that doing so may actually encode trauma more deeply, undermine healthy defenses, and compound PTSD, rather than improve outcomes.

In my experience of that day, and of listening to those who were more directly impacted than I was, I noticed that people remembered certain aspects of their experience in vivid detail: I know exactly what I wore that day, shoes, pants, belt, shirt, necklace, earrings down to my undergarments. But that other aspects of our experiences were cloudy, or confused, or out of sequence or impressionistic. Like my seeing slow motion sectional furniture being tossed out of the towers. In my mind’s eye, that is still the image I remember. And I am grateful for that. Had I been pressured to recount the details of that moment in the hours that followed, it is likely, that while I was still emotionally vulnerable and shaken, I would have recognized cognitively that my narrative did not make sense, and my distorted perceptions may have “corrected” themselves, which would have intensified a traumatic experience, and may have constellated into intrusive flashbacks.

Our coping mechanisms, our unconscious defenses, and our security operations can certainly fail and be overwhelmed, but when they are working, even when they strain our perceptions or recollections of reality, they should be left in place and allowed to do their job. Benign forgetting is an important part of recovering from traumatic exposure.

Among the difficulties that some survivors of famous large, community disasters, including 9/11 may experience –  is that they are never permitted to forget even if it were neurocognitively possible. 9/11 is patriotically remembered,  by tourists, by television, the tower of lights is set up each year, and venturing out of the house on that anniversary day, and every exposure to the media, becomes a re-traumatizing flashback inducing trigger.

That being said, anything that a client themselves feels driven to talk about, that they need to process in the presence of another person should be accepted. It is important to keep client’s grounded in the present as they recount the experience, client and therapist should pause regularly through traumatic recounting, to monitor breathing, heart rate, and how “present” the client is in the room. It isn’t corrective for a client to become trapped in a flashback that seals them alone and powerless in a memory from the past. The purpose of retelling in the days immediately following a traumatic shock, is (as we discussed a bit in Seminar #2 on trauma narratives) to support the client in taking control over the story itself, of re-experiencing it in active relationship to the therapist as an active audience, to support the client in processing the events in the present as about the past – an event they have already survived – not as an event that is continuously able to be reactivated in the present.

But part of what we find difficult to tolerate is that old or new – our “norms” are far more fragile than we would wish, and events such as this force us to contend with existential realities. Life is not “fixed” and neither are human beings. The universe is in constant flux, and we perch precariously upon small periods of stasis, clutching tightly with our toes.

But this demand for eternity is too clearly a consequence of our wishes to be able to lay claim to reality. That which is distressing may none the less be true. Transience -Freud 

Earlier this week a client of mine and their child were struck by a metaphorical thunderbolt which left my client’s life in jeopardy and took the life of the baby. I decided to visit the client in hospital, knowing that the odds of the client receiving sufficient early crisis intervention was unlikely. After we both wept together, the  “session” that followed reminded me of the shock and grief responses of people who had absorbed a terrorist attack. There is trauma, and there is bereavement, but there is also, another experience, a glimpse of an incomprehensible and terrifying reality: that we do not live in a safe universe. That nature is beautiful, is sometimes peaceful, and can be suddenly, shockingly cruel.

That which is distressing may none the less be true. We are fragile. Our happiness is fragile. Our expectations are illusions which sometimes manifest, and sometimes do not.

One of the ways we attempt to make sense of such events is to look for some locus of control – an external one – blaming others or an internal one – self-blame. Self-blame in traumatic scenarios is an attempt to content with the distressing but true existential reality that we live in a universe that offers us only limited control of our fates. Object relations theorist Ronald Fairbairn calls this the Moral Defense, where we “take on the burden of the badness” in order to preserve our illusion that we live in a moral, instead of a natural or random universe.

In Fairbairn’s words:

it is better to be a sinner in a world ruled by God than to live in a world ruled by the Devil(Fairbairn, 1952, p.p. 66-67).

Fear of our real existential fragility, awareness of temporality, has its own costs: Our attempts to protect ourselves from distressing truths can result in more distressing self-injury, self-recrimination, or damage our relationships to others.

One of Freud’s loveliest pieces of writing is found in Murder, Mourning and Melancholia – it is a brief mediation on the fragility of our realities called “Transience” – and it reminds us that the story can change, utterly, and in an instant, and that there is exquisite beauty and value even in that fragility.

He tells the story of a walk in the park, with a young poet, who bemoans the fact that the beautiful blossoms before them will eventually wither. This knowledge, for the poet, disrupts his ability to enjoy them.

The limitation of the possibility of enjoyment makes it even more precious. It was incomprehensible, I declared, that the thought of the transience of loveliness should cloud our delight in it…

….It must have been the psychical revolt against grief that devalued the pleasure of beautiful things for them. The idea that all this beauty was transient gave the sensitive characters a foretaste of grief over its destruction, and as the psyche shrinks instinctively from everything painful, they felt their enjoyment of beauty to be spoiled by the idea of its transience.

 

But next, the entire course of history changes, and not only are the blossoms gone, but the entire scene is wiped away:

…My conversation with the poet took place in the summer before the war. A year later war broke out and robbed the world of its beauties. It destroyed not only the beauty of the landscapes through which it passed, and the artworks that it encountered on its way, it also shattered our pride at the accomplishments of our civilization, our respect for so many thinkers and artists, our hopes of finally overcoming the differences among peoples and races. It sullied the sublime impartiality of our science, brought our instincts to the surface, unleashed within us the evil spirits that we thought had been tamed by centuries of education on the part of our most noble men. It made our fatherland small again, and made the rest of the world remote once more. In this way it robbed us of so much that we had loved, and showed us the fragility of much that we had considered stable.

But have those other qualities, now lost, really been devalued to us because they have proved to be so frail and unresisting? To many of us it appears that way, but again, I think, wrongly. I believe that those who think this way, and who seem prepared for lasting renunciation because that which is precious has not been proved to be enduring, are only in a state of mourning over their loss. We know that mourning, however painful it may be, comes to an end of its own accord. Once it has renounced everything that is lost, it has also consumed itself, and then our libido becomes free once again, so that, as long as we are still young and active, it is able to replace the lost objects with objects that are, where possible, equally precious, or with still more precious new ones. ~ Transience, Freud

 

The Tower of Babel is an apt metaphor for the function and aftermath of traumatic shock: We collectively construct what we believe, are secure, permanent, well built realities, made of impenetrable stone.

…The law of the tower of Babel is universal, i.e. that it works both in individual biography and in humanity. ~ Meditations on the Tarot: A Journey into Christian Hermeticism

We imagine our narratives are sturdy. We build them high into the air so that we can survey the landscape and we imagine it offers us the ability to anticipate and circumvent any disaster.

The building of the tower of Babel had as its effect the “thunderbolt” of the “descent of the Lord,” who “confused their language” – that of the builders – and “scattered them abroad over the face of all the earth” (Genisis xi, 7-9) so they would no longer understand one another’s language. ~ Meditations on the Tarot: A Journey into Christian Hermeticism

The feeling of being unable to communicate our experience to others, the inability to be understood, and understand each other the sense of feeling confused, scattered, fragmented and diffused are common experience both communally and personally.

Questions are crises and the “answers” that it seeks are states of consciousness resulting from these crises. ~ Meditations on the Tarot: A Journey into Christian Hermeticism

But shocks are also illuminations that allow us to see the world as it truly is, in all its wilderness, even if we can only tolerate that reality for a flash. For some, in the throes of the aftermath of existential shock – it is healthier and preferable to allow them to use any defense, including the moral defense of self-blame or externalization, as the reality that we live in a world that is both beautiful and cruel and fragile is truly intolerable. For others, the costs of self-blame may be self-annihilation, and those clients will need to be supported by those of us who have negotiated the thunderbolt of existential realities and become adept enough in withstanding them, to help them at least find some solace in the ground of Truth.

Once mourning is overcome it will be apparent that the high esteem in which we hold our cultural goods has not suffered from our experience of their fragility. We will once again build up everything that war has destroyed, perhaps on firmer foundations and more lastingly than before. ~ Transience, Freud.