The impact of the terroristic violence on September 11, 2001 will affect people at all levels of involvement: victims, bereaved family members, friends, rescue workers, emergency medical and mental-health care providers, witnesses to the event, volunteers, members of the media, and citizens of the community, the country, and the world. Terroristic events can cause people to feel angry, frustrated, helpless, and afraid. Terrorism can also make people want to seek revenge. Studies have shown that acting on this anger and desire for revenge can increase feelings of anger, guilt, and distress rather than decreasing them.

However, there are strong mechanisms that contribute to natural recovery from traumatic events. Many trauma experts (Staab, Foa, Friedman) agree that the psychological outcome of our community as a whole will be resilience, not psychopathology. For most survivors, symptoms of fear, anxiety, re-experiencing, urges to avoid, and hyper-arousal, if present, will gradually decrease over time.

Coping Strategies

There are a number of common strategies that individuals utilize when coping with extraordinary stress in their lives. These strategies, while effective at manageable levels of stress, can become unproductive or detrimental when stress reaches overwhelming or traumatic levels. It is important to remember that individuals have their own way of and pace for processing traumatic events, and each individual must listen to and honor his or her own pace and way. It is suggested that survivors monitor their reactions and increase the coping strategies that have worked in other stressful situations.

Research on individuals with positive responses after a traumatic event indicates that their preferred coping mechanisms are to:

• When problem-solving, focus on brief time intervals (e.g., think only about what the next step is), or focus on a larger time interval to obtain a less devastating picture of the trauma (i.e., as one tragic event in a full and meaningful life)
• Maintain a view of oneself as competent and a view of others as willing and able to provide support
• Focus on the current implications of the trauma and avoid regretting past decisions and actions ¹

The process of converting traumas into growth experiences has the following characteristics:

• It is usually done by the individual alone, but confidants can also suggest new ways of viewing the situation.
• It usually occurs between 2 weeks and 4 months following the stressor.
• It can enhance one's ability to cope with subsequent stressors.
• It usually depends more on an individual's psychological resources than on the characteristics of the stressor event.
• It is intuitive, rapid, and sudden rather than being an extended logical thinking process (i.e., it is characterized by sudden insight and revelation). (Finkel and Jacobsen, 1977) ²

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Specific Coping Strategies for Traumatic Stress and PTSD Symptoms

Positive coping actions

Positive coping actions are those that help to reduce anxiety, lessen other distressing reactions, and improve the situation in a way that does not harm the survivor further. These types of coping actions improve things not only for today but for the future as well. Positive coping methods include:

• Using natural supports and talking with friends, family, and coworkers at your own pace. It is helpful to follow one's own natural inclination with regard to how much and to whom you talk.
• Learning about trauma and PTSD. It is useful for trauma survivors to learn more about trauma and PTSD and how it may affect them. Learning how common PTSD is and finding that these problems are shared by hundreds of thousands of survivors of trauma can help people with PTSD recognize that they're not alone, weak, or "crazy."
• Talking to other trauma survivors for support. When survivors are able to talk about their problems with others, something helpful often results. Through the process of seeking support from other trauma survivors, the survivor may come to feel less alone, feel supported or understood, or he or she may receive concrete help with a problem situation. One of the best places to find support is in a specially designed support group. Being in a group with others who have PTSD may help a trauma survivor reduce his or her sense of isolation, rebuild trust in others, and it may provide an important opportunity to contribute to the recovery of other survivors of trauma.
• Talking to a doctor about trauma and PTSD. Part of taking care of oneself means mobilizing the helping resources that are available. A doctor can take better care of a patient's physical health if he or she knows about the patient's PTSD symptoms, and doctors can often refer trauma survivors for more specialized and expert care.
• Practicing relaxation methods. These can include muscular relaxation exercises, breathing exercises, meditation, swimming, stretching, yoga, prayer, listening to quiet music, spending time in nature, and so on. While relaxation techniques can be helpful, they can sometimes increase distress by focusing attention on disturbing physical sensations or by reducing contact with the external environment. Be aware that while negative or painful physical sensations may become more apparent when a person is relaxed, continuing with relaxation in a way that is tolerable (i.e., interspersed with music, walking, or other activities) is, in the long run, helpful in reducing negative reactions to thoughts, feelings, or perceptions.
• Increasing positive distracting activities. Positive recreational or work activities help distract a person from his or her memories and reactions. Artistic endeavors have also been a way for many trauma survivors to express feelings in a positive, creative way. These endeavors can help improve a person's mood, limit the harm caused by PTSD, and can help a person rebuild his or her life. It is important to emphasize that distraction alone is unlikely to facilitate recovery; active, direct coping with traumatic events and their impact is also important.
• Calling a counselor for help. Sometimes PTSD symptoms worsen and ordinary efforts at coping don't seem to work very well. If the survivor of trauma feels fearful or depressed, it is important that he or she reach out and telephone a counselor, who can help the survivor turn things around.
• Taking prescribed medications to tackle PTSD. Many people with PTSD have found that by taking medications they are able to improve their sleep, anxiety, irritability and anger, or urges to drink or abuse drugs.
• Starting an exercise program. It's important to see a doctor before starting to exercise, but after getting the OK, exercise in moderation will potentially benefit those with PTSD in a number of ways. Walking, jogging, swimming, weight lifting, and other forms of exercise may reduce physical tension. These activities may also help distract the person from painful memories or worries and thus give them a break from difficult emotions. Perhaps most important, exercise can improve self-esteem and help people feel that they have some control in their lives.
• Volunteering in the community. It's important to feel like you have something to offer to others and that you are making a contribution. When you're not working, you may not feel that you are contributing anything worthwhile. One way that many survivors of trauma have reconnected with their communities and regained a feeling of connection and importance is to volunteer: to help with youth programs, medical services, literacy programs, community sporting activities, and so on.

Negative Coping Actions

Negative coping actions help perpetuate problems. They may reduce distress in the short term, but in the long-term, negative coping actions may short-circuit more permanent change. Actions that may feel immediately helpful but that can cause later problems include things like smoking or using drugs. These habits can become difficult to change. Negative coping methods can also include isolation, workaholism, violent behavior, angry intimidation of others, unhealthy eating, and self-destructive behavior (e.g., attempting suicide). Before people with PTSD learn effective and healthy coping methods, they may try to cope with their distress and other reactions in ways that lead to more problems.

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Practicing Lifestyle Balance

(Excerpted from: Saakvitne, K. W., & Pearlman, L. A. (Eds.). 1996. Transforming the pain: A workbook on vicarious traumatization. New York: Norton).

There are many ways to restore lifestyle balance, and keeping track of and making progress with as many of the following changes is a good way to regain balance after having been exposed to or witnessed cumulative traumatic experiences:

Physical Self-Care

• Eat regularly (e.g. breakfast, lunch, dinner)
• Eat healthily
• Exercise
• Get regular medical care for prevention
• Get regular medical care when needed
• Take time off when sick
• Get massages
• Dance, swim, walk, run, play sports, sing, or do some other physical activity that is fun
• Take time to be sexual--with yourself, with a partner
• Get enough sleep
• Wear clothes you like
• Take vacations
• Take day trips or mini-vacations
• Make time away from telephones

Psychological Self-Care

• Make time for self-reflection
• Have your own personal psychotherapy
• Write in a journal
• Read literature that is unrelated to work
• Do something at which you are not expert or in charge
• Decrease stress in your life
• Notice your inner experiences -- listen to your thoughts, judgments, beliefs, attitudes, and feelings
• Let others know different aspects of you
• Engage your intelligence in a new area, e.g., go to an art museum, history exhibit, sports event, auction, theater performance
• Practice receiving from others
• Be curious
• Say no to extra responsibilities sometimes

Emotional Self-Care

• Spend time with others whose company you enjoy
• Stay in contact with important people in your life
• Give yourself affirmations, praise yourself
• Find ways to increase your sense of self-esteem
• Reread favorite books, re-view favorite movies
• Identify comforting activities, objects, people, relationships, places, and seek them out
• Allow yourself to cry
• Find things to make you laugh
• Express your outrage in social action, letters, donations, marches, protests
• Play with children

Spiritual Self-Care

• Make time for reflection
• Spend time with nature
• Find a spiritual connection or community
• Be open to inspiration
• Cherish your optimism and hope
• Be aware of nonmaterial aspects of life
• Try at times not to be in charge or the expert
• Be open to not knowing
• Identify what is meaningful to you and notice its place in your life
• Meditate
• Pray
• Sing
• Spend time with children
• Have experiences of awe
• Contribute to causes in which you believe
• Read inspirational literature (talks, music, etc.)

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When to Seek Help

Several studies have pointed out that following a terroristic event such as the Oklahoma City bombing, many of those in closest proximity to the disaster do not believe that they need help and will not seek out services, despite reporting significant emotional distress ³ . Sprang lists several potential reasons for this:

• Some people may feel that they are better off than those more affected and that they, therefore, should not be so upset.
• Some may not seek help because of pride or because they think that distress indicates weakness of some sort.
• Some individuals may not define services they receive as mental-health intervention, especially if such intervention is unsolicited (e.g., lectures, sermons, discussions, community rituals). Indeed, because the goal of many disaster mental-health workers is to have interventions be a seamless, integrated part of an overall disaster effort, those who receive these services may not recognize them as mental-health interventions.
• Many individuals are more apt to seek informal support from family and friends, which may not be sufficient to prevent long-term distress for some.

It is critical to address this hesitance about seeking help given that a large portion of the individuals who were directly exposed to the Oklahoma City bomb blast continued to have active postdisaster psychiatric symptoms six months after the bombing. (PTSD was the most common disorder, and major depression was the second most common disorder ⁴ ).

There may be times when self-help strategies are not effective in reducing the effects of exposure to traumatic stress. Research has shown that exposure to trauma may result in a change in brain chemistry and function. Research has also shown that the use of antidepressant or other medication reduces both PTSD and depressive symptoms in individuals who are unable to use behavioral techniques to manage their symptoms. Individuals have also experienced partial or full relief from posttraumatic stress symptoms when using certain types of cognitive-behavioral treatment. As stated above, it is recommended that you seek assistance from your medical doctor or from a mental-health professional who is skilled in the treatment of trauma if:

• You are experiencing any symptoms that are causing distress, are causing significant changes in relationships, or are impairing functioning at work
• You are self-medicating with alcohol or drugs
• You are unable to find relief with the strategies listed above

Coping with PTSD symptoms and the problems they cause is usually a continuing challenge for survivors of trauma. As stated above, those who are able to convert traumas into growth experiences are often able to do so through sudden insight or revelation. For those who develop PTSD, however, recovery is an ongoing, daily, gradual process. It doesn't happen through sudden insight and there isn't a quick cure. Healing doesn't mean that a survivor will forget the trauma experiences or have no emotional pain when remembering them. Some level of continuing reaction to memories is natural and reflects a normal body and mind. Healing may mean that reactions will occur less often and be less intense. Healing also means having a greater ability to manage trauma-related emotions and having greater confidence in one's ability to cope.

When a trauma survivor takes direct action to cope with problems, he or she often gains a greater sense of personal power and control. Active coping means recognizing and accepting the impact of a traumatic experience and then taking concrete action to improve things.

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Seeking Help

Where to get help:

Listed below are some ways to find help. When you call, tell whomever you speak to that you are trying to find a mental-health provider who specializes in helping people who have been through traumatic events and/or who have lost loved ones. Check this website regularly for updated information on how to get help. We will be listing more ways to get help as they become available.

For Veterans

VA medical centers and Vet Centers provide Veterans with mental health services. These services are either covered by health insurance or they cost little or nothing, according to a Veteran's ability to pay.

To find a VA medical center or Vet Center near you, use the online VHA Facilities Locator. You can also go online to read more about services at Vet Centers.

VA medical centers and Vet Centers are listed in the phone book in the blue Government pages. Under "United States Government Offices," look in the section for "Veterans Affairs, Dept of." In that section look for VA Medical Centers and Clinics listed under "Medical Care" and for "Vet Centers - Counseling and Guidance." Then call the one nearest to where you live.

For non-Veterans

Some local mental health services are listed in the phone book in the blue Government pages. In the "County Government Offices" section for the county where you live, look for a "Health Services (Dept. of)" or "Department of Health Services" section. In that section, look for listings under "Mental Health." In the yellow pages, services and mental-health professionals are listed under "counseling," "psychologists," "social workers," "psychotherapists," "social and human services," or "mental health." Health insurance may pay for mental health services and some are available at low cost according to your ability to pay.

For anyone

Call your doctor's office or ask friends if they can recommend any mental-health providers.

If you work for a large company or organization, call the Human Resources or Personnel office to find out if they provide mental-health services or make referrals.

If you are a member of a Health Maintenance Organization (HMO), call to find out if mental-health services are available.

Call the National Center for Victims of Crime's toll-free information and referral service at 1-800-FYI-CALL. This is a comprehensive database of more than 6,700 community service agencies throughout the country that directly support victims of crime.

Contact your local mental-health agencies or family physician. The National Center for Posttraumatic Stress Disorder has a fact sheet with information on how to talk to your primary care physician about trauma and PTSD.

You may also wish to look in our Where to Get Help section for other suggestions.

References

1. Horowitz, M.J. (1986). Stress-response syndromes: A review of posttraumatic and adjustment disorders. Hospital and Community Psychiatry, 37(3), 241-249.

2. Finkel, N.J., & Jacobsen, C.A. (1977). Significant life experiences in an adult sample. American Journal of Community Psychology 5(2), 165-175.

3. Sprang, G. (2000). Coping strategies and traumatic stress symptomatology following the Oklahoma City bombing. Social Work and Social Sciences Review, 8(2), 207-218.

4. North, C.S., Nixon, S.J., Shariat, S., Mallonee, S., McMillen, J.C., Spitznagel, E.L., & Smith, E.M. (1999). Psychiatric disorders among survivors of the Oklahoma City bombing. Journal of the American Medical Association, 282(8), 755-762.

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