What 9/11 Recovery Workers Teach Us About COVID-19 Coping

By guest authors Joshua Stieber, Ph.D., Karen Estefane, Ph.D., Aleksandra Rayska, Ph.D., Jaleh Hamadani, Ph.D., and Jonathan DePierro, Ph.D.

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Wisdom from 75,000 WTC responders informs how we adapt and make meaning now.

With barren city streets, cheers for frontline workers, wailing sirens, protective gear, and makeshift morgues, the images of the COVID-19 pandemic conjure up those of another New York catastrophe: September 11th. As psychologists who work in a clinic dedicated to the first responders of 9/11, we have developed an intimate view of how a disaster can reverberate through the lives of individuals from different walks of life. Some of what we have learned through our work has become increasingly relevant to our current times as society is coping with an ongoing pandemic.

To provide background on the WTC Health Program: It began in 2002 and is administered by the National Institute for Occupational Safety and Health (NIOSH) under The James Zadroga 9/11 Health and Compensation Act of 2010. There are 75,000 WTC responders who are registered with the Program—including law enforcement, paramedics and EMTs, journalists, fire personnel, construction workers and carpenters, and other workers and volunteers. Over 34,000 responders have WTC-associated aerodigestive disorders (such as chronic sinus inflammation), mental health conditions, and cancers associated with WTC exposure. Over 15% have been “certified” for at least one 9/11-related mental health condition (CDC, 2020), most commonly Posttraumatic Stress Disorder (PTSD). Our Mount Sinai mental health clinic, the first WTC monitoring and treatment program, and now the largest hospital-based WTCHP Clinical Center of Excellence, annually monitors over 20,000 responders and provides treatment services for certified conditions.

In continuing our work through the pandemic with our 9/11 responder population, now via telehealth sessions, which nevertheless preserve the core practices of psychotherapy, four key lessons about times of crisis have emerged. These lessons from those, who endured the aftermath of 9/11, have much to teach us as a society.

Lesson 1: Know your sensitivities and vulnerabilities

Childhood adversity is common. The process of healing emotional wounds from 9/11, often involves reckoning with resonant earlier life difficulties. As patients react to COVID-19, the past comes forward, often unpredictably. The death of a loved one, the stress of a frontline worker, or the fatigue of carrying out safety measures—these pandemic realities evoke painful memories. When such memories are directly reawakened, the intensity of accompanying emotions—fear, grief, anger, helplessness-is powerful.

Our understanding of trauma has diverse roots. From a biological perspective, early life stress is thought to prime physiologically sensitive individuals, making it more likely that they develop PTSD following traumas in adulthood (e.g. Raabe & Spenger, 2013). From a psychodynamic perspective, symptoms such as panic, anxiety, or depression as an adult are often related to the limitations a person faced in responding to a difficult environment earlier in their development. Many decades of clinical and research work highlight the multi-layered way that present stress evokes pain from the past. Readers are encouraged to reflect on ways that this pattern might be at work as they cope with the pandemic.

Lesson 2: When we struggle, we rely on old coping mechanisms

One of the most common defenses against emotional pain and distressing memories is denial. The path of denial is understandable under such strain, taking various forms in 9/11 responders and others who have survived trauma: drinking, distraction, minimizing the experience, or trying to convince ourselves repeatedly that we are unscathed (Horowitz, 1997). Some of these strategies are helpful while in the “thick of it” but become increasingly problematic over time. Our attempts in avoiding the pain inevitably intensify the pain in the long run.

We now know that the rigid use of a defense, such as denial, can make an individual more vulnerable to developing PTSD. Thus, one of our goals in therapy is to help our patients develop greater awareness of their ways of dealing with difficult situations and emotions, to prevent problems from worsening. Throughout the process of our work, we see individuals gradually let go of the long-held and strongly fortified defenses, approaching life with more flexibility and choice. The work allows the individual to foster the capacity to reflect on decisions, rather than act impulsively out of strong emotion.

Outside of psychotherapy sessions, readers can also tap into these benefits. What emotions do you feel when you watch news related to COVID-19? What past experiences influence these feelings? What are your typical ways of responding to difficult situations? What are alternative ways of responding?

Lesson 3: Growth begins with acknowledgment

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The current trauma of the pandemic for many of our patients has reactivated earlier traumas. We now witness many of our patients remembering memories of 9/11 that they had not discussed or becoming increasingly aware of the emotional weight that their experiences hold. As clinicians, the reactivation of trauma grants us a unique opportunity to work through unresolved past traumas as they come to the foreground. Approaching these memories and emotions with curiosity, we help patients to see the potential for growth amid all the inner struggle. The working through allows our patients to free up the psychological resources that were previously used to keep these memories and accompanying emotions at bay. Furthermore, the confronting and processing of traumatic memories allow the individual to learn and to grow while becoming more integrated and whole.

If we can find ways to turn inward and reflect, there are major opportunities for posttraumatic growth. Acknowledging the toll of traumatic experiences can be excruciatingly difficult and is an important and necessary step. It moves one from trying to organize life around avoiding trauma to beginning to accept disowned parts of the self, have self-compassion, manage difficult emotions better, see the trauma(s) as only one part of one’s broader life story, and live more fully.

Lesson 4: Connect to meaning in suffering

Therapy entails coming to terms with the impact of the past, experiencing emotions that we have avoided. Grief is a common reaction: grieving the fantasy that childhood was not the vision we held it to be, grieving the atrocities committed by a parent, grieving time lost by staying trapped in the past.

The pandemic complicates grief reactions, unfortunately, due to preventable loss and isolation. Given the risk of viral transmission, people die apart from their loved ones; many mourn in solitude. These difficult experiences can also undermine one’s sense of stability and safety. Accompanying some of our patients through the grieving process in these current times has been a powerful experience.

Viktor Frankl (1963) argued that opportunities for meaning can be found in the way individuals respond to and navigate unavoidable suffering. Some patients find comfort in the perspective and wisdom imparted to them by their response efforts to 9/11 and navigation afterward of distress. They survived 9/11 and feel they can survive this. They may themselves be surprised by the presence of altruism, spirituality, humor, and social support. Gratitude, particularly giving thanks for one’s life and one’s contributions, can mitigate the negative effects of trauma and help people connect more with others. Think about one or two things that you are grateful for or that give you a sense of meaning and purpose even now, in uncertain times.

In our work, we have borne witness to a range of responses, from the extremes of being completely overwhelmed to denial in response to the pandemic. Our task remains to help patients to flexibly cope, maintain the connection with reality, be able to remain functional, and find a way to achieve some sense of satisfaction and meaning during this difficult situation.

Conclusion

Our patients have wrestled with many of the questions that have arisen in this pandemic and will continue to reverberate in whatever comes next. These are questions of survival, meaning, safety, closeness, independence, and growth. We assuredly do not have all the answers as therapists. But we have seen in our patients that these are questions that demand to be faced. Yes, they can also be avoided, but this often just means they are alive but buried. To return to our original question: what have we learned from patients defined by a disaster? Among many other lessons, at the forefront for us is that a pandemic is both a shock and an opportunity to confront some of the most essential aspects of what it means to be a human in an uncertain world.

Acknowledgments

The authors would like to thank all the rescue, recovery, and cleanup workers and survivors who participate in the World Trade Center Health Program as well as our colleagues and support staff.