Helping Each Other Cope

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Mark Schuster is codirector of the RAND Center for Research on Child and Adolescent Health, director of the UCLA/RAND Center for Adolescent Health Promotion, and an associate professor of pediatrics and health services at the University of California, Los Angeles. Bradley Stein is a medical researcher at RAND and an assistant professor of psychiatry at the University of Southern California.

People who are victims or witnesses of a traumatic event often experience symptoms of stress, sometimes for years after. Events in recent years have also taught us that people need not be present at the scene of a catastrophic event to experience stress symptoms.

The terrorist attacks of Sept. 11, 2001, were immediately broadcast on television screens across the nation. Remarkable video footage of the events and their aftermath was aired repeatedly. Many Americans may have identified with the victims or perceived the attacks as directed at themselves as well. Thus, even people who were nowhere near the attacks could have experienced substantial stress.

We at RAND conducted a survey of U.S. households three to five days after the attacks. Our primary goal was to learn how Americans reacted and how their reactions varied around the country. We also hoped to learn something about how people coped with their reactions.

AP/WIDE WORLD PHOTOS/WATERBURY REPUBLICAN-AMERICAN/BOB FALCETTI Waterbury, Conn., area residents gather in Library Park on Oct. 11, 2001, during the Unity In Our Community candlelight vigil in remembrance of victims of the Sept. 11 attacks.

We asked a nationally representative sample of 560 adults about their reactions to the attacks and their perceptions of their children's reactions. The sampling error on the survey varied with the particular questions, but it was no more than 4.3 percentage points for adults and no more than 7.7 percentage points for children (at a 95 percent confidence level).

People Were Stressed Far and Wide

Ninety percent of the adults surveyed reported experiencing one or more symptoms of stress, and 44 percent reported a substantial level of at least one symptom—such as difficulty concentrating, trouble sleeping, or repeated disturbing memories, thoughts, or dreams about what had happened.

These figures represent much higher rates of stress than those found in studies conducted prior to the attacks. Perhaps the best "baseline" for comparison is a 1987 St. Louis study, in which only 16 percent of respondents reported a lifetime history of at least 1 of 14 symptoms of stress related to a frightening event.

While those closest to the Sept. 11 attacks had the most substantial stress, respondents throughout the country reported stress symptoms. Sixty percent of respondents within 100 miles of the World Trade Center reported substantial stress reactions, compared with 36 percent of those over 1,000 miles away.

Children were also profoundly affected. Among the parents we interviewed, 35 percent reported that their children showed one or more signs of stress, and 47 percent reported that their children were worried about their own safety or the safety of a loved one.

Television may have played a role. Adults watched an average of eight hours of coverage of the attacks on the day of the attacks, with nearly a fifth of the respondents reporting that they watched 13 hours or more. Those who watched the most television reported the most stress. Among children whose parents did not try to limit their television viewing, watching more television was associated with having more stress symptoms.

We cannot say whether more television viewing precipitated higher stress levels. For some people, television may have been a source of information about the situation and what to do—and therefore may have provided a positive means of coping with stress. Others, especially children, may have reacted to the repeated viewing of terrifying images with heightened anxiety.

People Cope Best Together

People responded to the tragic events of Sept. 11 in a variety of ways (see figure). Almost everybody turned to others for social support. Ninety percent turned to their religion or another source of spiritual guidance. A majority reported participating in group activities like memorials or vigils, which can provide a sense of community.

About 40 percent reported avoiding activities (like watching television) that reminded them of the events. Health professionals have tended to regard avoidance as an impediment to emotional recovery. However, under these unusual circumstances and in the face of continuous television coverage, avoidance may not necessarily have been an unhealthy response.

The American Academy of Pediatrics recommends that parents consider limiting their children's television viewing of a crisis and speak with them about the crisis. Nearly all the parents we surveyed spoke with their children about the attacks. More than 80 percent of parents reported talking with their children for an hour or more, and 14 percent spoke with their children for more than nine hours. About a third of the parents tried to limit the amount of television news that their children watched. Parents of younger children and of those who had more stress symptoms were more likely to limit their children's television viewing.

Studies of prior disasters suggest that stress reactions diminish over time for the vast majority of people. But the Sept. 11 attacks, the shocking televised images, and the profound ramifications were unprecedented. We speculate that the psychological impact may not rapidly diminish for some people. We are conducting a follow-up survey to assess to what extent people have experienced persistent symptoms, such as accomplishing less at work, avoiding public gathering places, and using alcohol, medications, or other drugs to relax, sleep, or feel better because of worries about terrorism.

Indeed, many of our original respondents said they anticipated further attacks and thought that the attacks could occur in their own communities. Concerns about future attacks can heighten anxiety. Ongoing media coverage can also serve as a traumatic reminder, resulting in persistent symptoms. When people anticipate disaster, their fears can exacerbate existing symptoms and create new ones.

Our findings have important implications for health. If there are further attacks, clinicians should anticipate that even people far from the attacks will have trauma-related symptoms of stress. By intervening as soon as symptoms appear, physicians, psychologists, and other clinicians may be able to help people identify normal stress reactions and take steps to cope effectively. Clinicians can also tell parents what signs to look for in their children and how to respond to their needs.

Related Reading

"A National Survey of Stress Reactions After the September 11, 2001, Terrorist Attacks," New England Journal of Medicine, Vol. 345, No. 20, Nov. 15, 2001, pp. 1507-1512, Mark A. Schuster, Bradley D. Stein, Lisa H. Jaycox, Rebecca L. Collins, Grant N. Marshall, Marc N. Elliott, Annie J. Zhou, David E. Kanouse, Janina L. Morrison, Sandra H. Berry.