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The correct reference for this paper is: Anne Speckhard, “Acute Stress Disorder in Diplomats,
Military and Civilian Americans Living Abroad Following the September 11th Terrorist Attacks
on America”, Professional Psychology: Research & Practice Vol 34(2), Apr 2003, 151-158. (The
published version may differ slightly from this copy).
Running Head: Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
Acute Stress Disorder in Diplomats, Military and Civilian Americans
Living Abroad Following the September 11th Terrorist Attacks on America
Anne Speckhard, Ph.D.1
1 Anne Speckhard, Ph.D. is Adjunct Associate Professor of Psychiatry, Georgetown University Medical
Center, Professor of Research, Vesalius College, Free University of Brussels and psychological consultant
of Advances in Health. She currently resides at 3 Avenue des Fleurs, 1150 Brusssels, Belgium. Military
Address from the U.S. is PSC 81, Box 135, APO AE 09724
E-mail: Aspeckhard@brutele.be or Speckhard1@aol.com Telephone: 322-772-1237; Fax: 322-772-1237.
The author would like to acknowledge the assistance of Dr. Sergei Sivuha of European Humanities
University, Belarus, for his assistance on the statistical analysis of the data.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
2
Running Head: Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
Acute Stress Disorder in Diplomats, Military and Expatriate Americans
Living Abroad Following the September 11th Terrorist Attacks on America
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
3
Abstract
Can an expatriate witnessing attack of his country from afar develop acute and
posttraumatic stress reactions? In Brussels fifty expatriate Americans were surveyed in
the ten weeks following September 11th . Ten percent (n=5) of the sample showed acute
stress disorder in the first week and four percent (n=2) persisted with traumatic stress
indications in weeks following. All participants showed symptoms of distress:
derealization, reexperience, avoidance, heightened arousal, trouble working and assault
on world assumptions. For most, symptoms diminished over time. Increased
psychological readiness in terms of assessment, prevention and treatment methods is
called for in response to mass terrorism.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
4
Acute Stress Disorder in Diplomats, Military and Expatriate Americans Living Abroad
Following the September 11th Terrorist Attacks on America
The events of September 11th, 2001 struck terror into the hearts of all Americans,
even those living far from home. Expatriate Americans witnessed the horrific attacks by
television, either in nearly live time or in the repeated television coverage. Of those
working for the military, State Department or for New York City based businesses the
attacks were taken quite personally, especially among those familiar with the offices in
the Pentagon or New York city, who had colleagues there, or who likely would have been
victims had they been posted stateside at that time. Even those participants with no work
or personal ties to either site took the attacks quite personally due to the extensive
human-interest coverage in the media and the symbolic nature of the attacks on their
nation.
In addition to the attacks themselves, their aftermath created new fears for
Americans living abroad with heightened awareness of the possibility of being included
as future terrorist targets. Suddenly personnel found their sense of security and
worldviews assaulted. Security was abruptly heightened around the world, particularly at
U.S. embassies, military and other installations. Overnight, many Americans found that
they were suddenly confronted with armed guards, barbwire and truck-bomb barriers
surrounding their work places. For months after the attacks they received security
circulars on how to increase their own personal and familial security and how to detect
and deal with mail bombs and anthrax filled letters and other forms of bio-terrorism. 2
2 The author held stress debriefings for 250 military, civilian and foreign service workers and their spouses at their work and
gathering places in the two months following September 11th and thus was well aware of the heightened fears and changed work
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
5
The bombing and collapse of the Twin Trade towers, and partial collapse of the
Pentagon with the resulting three thousand plus deaths, could easily be expected to cause
acute and posttraumatic stress disorder in those close to ground zero. Indeed, traditional
theories of posttraumatic stress disorder view proximity to disaster as a risk factor for
development of either disorder, a finding that has also been born out in numerous studies
(Hanson, et al, 1995; Pynoos et al, 1995; Hodgins et al, 2001; Schwarzwald, 1993;
Fehon, Grilo & Lipschitz, 2001; Shalev, 2001). But what about those who witnessed the
events from afar as did American personnel living abroad? What level of exposure,
through television, media and personal contact, would be expected and how should
psychologists expect this population to fare? According to the Diagnostic and Statistical
Manual of Mental Disorders, 4th ed (DSM-IV-R) (APA, 1994), an event capable of
engendering acute or posttraumatic stress disorder is one in which the person
experiences, witnesses, or is confronted with an event or events that involves actual or
threatened death or serious injury, or a threat to the physical integrity of self or others and
that the person’s response involves intense fear, helplessness, or horror. Certainly, the
events of September 11th fit the criteria for those proximate to the disaster. It was of
interest to the author to learn if an attack perceived at a distance by Americans abroad
could also cause symptoms of either disorder.
This paper reports on how a voluntary sample of American expatriates posted in
Brussels, Belgium (or its nearby vicinity) responded within the two months following the
terrorist attack of their country: inquiring if they would have heightened anxieties,
environments that many expatriates experienced following the terrorist attacks. She also had access to all of the security notices
circulated both within the embassy tri-mission community and within NATO headquarters.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
6
increased concerns and even posttraumatic symptoms along the lines of acute and
posttraumatic stress disorder (PTSD).
Disaster Stress Self Assessment Survey
In Brussels, Belgium approximately one thousand six hundred American
diplomatic, civilian and military personnel are posted within the tri-mission community
(i.e. to the U.S. Embassy to Belgium, to the U.S. mission to the European Union, and to
the U.S. Mission at NATO). Hundreds more American military staff are posted by the
Department of Defense to Supreme Headquarters Allied Powers Europe (SHAPE; which
is within forty minutes of Brussels) and to NATO (within Brussels) and there are also
hundreds of Americans working as civilians for NATO and as expatriates posted to
various international and American businesses. In Belgium, NATO headquarters was
named, immediately after the September 11th attacks, as an imminent target for additional
terrorist attacks. The U.S. embassy in Paris was also discovered to be the target of a
foiled bombing, with the conspirators found to be living in Brussels. Americans posted
in Brussels were suddenly confronted with the fact of the multi-cultural nature of their
city: that twenty percent of the population is of Arabic descent and Muslim and that
terrorist cells had been discovered living there. Likewise, anxieties over threats that
might materialize were heightened when “anthrax” letters were received at NATO
headquarters – reaching well beyond the mail- room security into the Secretary General’s
private office – and at Embassy Brussels. These powder-filled letters were later
discovered to be only hoaxes, but they still had the intended effect of creating feelings of
terror and vulnerability, especially since at the same time the U.S. media was reporting
anthrax deaths in the United States. Thus, even though the actual attacks occurred at
great distance, Americans living in Belgium suddenly found their workplace and home
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
7
security threatened, and many were thrust into a state of heightened arousal. Hence, it
was decided that this group would make a good sample to test the question of how
American personnel overseas fare while witnessing the large-scale terrorist attack of their
own country and its aftermath.
The sample for this research was nonrandom3 consisting of fifty Americans living
abroad during the September 11th terrorist attacks on the U.S. who were recruited to
anonymously take a two- page survey entitled “Disaster Stress Self Assessment”. The
participants were recruited at their work places in U.S. facilities in and near Brussels
including: the U.S. Embassy to Belgium, the U.S. Mission to the European Union, the
U.S. Mission to NATO, Supreme Headquarters for Allied Partners Europe, and NATO
Support Activity and hence represented diplomats serving in the foreign and commercial
services, armed forces, and civilian government workers and their spouses.
To diagnose for acute stress disorder the DSM- IV-R (APA, 1994) requires the
presence of symptoms of dissociation, re-experience, avoidance, and arousal causing
clinically significant distress, all of which occur for a minimum of two days and a
maximum of four weeks, within a four week time period of the traumatic event. It was
decided that the terrorist attacks did not have a clear end point since additional threats
were anticipated as well as retaliatory actions. Thus the time beginning immediately after
the attacks ensuing through a ten-week period of heightened threat (i.e. beginning with
the terrorist bombings and including the anthrax scares) was considered a suitable time
3 The researcher requested permission to officially contact employees for participation in the survey in order to be able to draw a
random sample. However, given the unexpected nature and suddenness of the attacks, each of the bureaucracies was
overwhelmed with increased demands for security and could not possibly respond quickly to such a request. It was thus
impossible to get past bureaucratic procedures to draw a random sample within the time frame of the questionnaire. Hence the
value of collecting the information in a timely manner and within the frame when acute stress responses could still be measured
dictated the decision to use a nonrandom sample.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
8
frame for sampling for this disorder. The research began on September 20th and surveys
were collected in weeks two to ten following the attacks up to November 19, 2001.
All participants who wished to discuss their reactions with the researcher were
invited to do so, and many did so at some length (nearly all doing so after they filled out
the survey). This anecdotal information was anonymously recorded as well. In addition
to the surveys, the author ran six stress debriefings4 during this time frame for the above
named organizations and for the American Women’s Club of Brussels. In these
debriefings a short presentation regarding typical responses to disasters, acute stress
disorder and normalizing of responses was given followed by an opportunity for the
participants to discuss feelings and concerns. In this manner additional impressions were
also collected that add perspective and validity to the paper and pencil measures. One
third of the subjects were recruited at these stress debriefings organized at the work place
(nearly all filled the survey out before the debriefing), the remainder were recruited in
public areas at the workplace such as the community liaison office, the cafeteria, through
other subjects, etc. Many filled it out in the presence of the researcher who was nearby
but not interacting with the participant, others took the survey at work or at home and
returned it by inter-office mail or over the Internet, some including letters with additional
comments about their symptoms of stress.
The research instrument entitled “Disaster Stress Self Assessment” included thirty
closed-ended items designed to reflect the diagnostic criteria for Acute Stress Disorder
(APA, 1994). These items covered the following five fields:
1. Dissociative symptoms
4 These debriefings were basically discussion groups involving psycho-education, discussion of common responses to traumatic
events, and involved only spontaneous and completely voluntary processing of emotional responses to the terrorist attacks.
They were one hundred percent voluntary and had no relationship to the structure or methods of critical incident stress
debriefings, which have in recent years been the subject of controversy.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
9
2. Reexperience,
3. Avoidance
4. Increased arousal,
5. Symptoms impairing psychological, social and occupational functioning,
including questions regarding coping or failure to cope, issues of conflict with
significant others, and desire for professional help.
6. In addition, a sixth field was added concerning assault on world assumptions.
Questions concerning depersonalization were not included due to concerns raised by
participants who pre-tested the instrument. They stated that such questions seemed to
apply to “crazy” people and answering them made them feel so uneasy that they would
decline participation in the survey. Hence it was decided that derealization was likely an
extreme response and alienating the subjects was not worth the benefit of including such
items.
Answers of never, rarely, sometimes, and often were possible choices for the thirty
items, and participants differentiated between their initial responses for the first week
after the attacks and the time period at which they filled out the survey. These were
followed by open-ended queries about their chief worries, stress responses, coping
mechanisms, family concerns and what support they felt was missing. Likewise, they
were asked to give non-revealing demographic information: age, sex, marital status, type
of government or civilian service, and rank.
The survey was designed to give a score on each of the five individual factors
making up acute stress disorder as well as a total stress score to be compared with a cut-
off for acute stress disorder when the criteria were met in each category.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
10
The results of the survey were tabulated using two time frames: subjects recall of
their responses the first week after the attacks and the time of the survey, which was
during weeks two to ten after the attacks. This second time period represented a period
of decreasing alert as compared to the actual attacks, although even during it there were
still many scares. For instance October first was rumored as the date of an attack on
NATO, and the month of October included the time period of heightened anthrax scares
and deaths in the states, receipt of anthrax letters at the embassy and NATO and the
beginning of the war in Afganistan which caused perceived threat levels following Sept
11th to fluctuate from week to week. Because it was not a smooth decrease in threat
level, but instead an inconsistent lowering and then re-heightening of threat (although
never re-heightening to Sept 11th levels) it was concluded that given the small sample
size the most logical thing was to collapse this time period as one group in comparison to
reactions in the first week.
While all of the participants completed the disaster stress portion of the survey
fully, some failed to give complete demographic information. This was likely due to
concerns about anonymity. In particular in regard to age only sixty percent of the sample
gave information: with the ages ranging from nineteen to sixty-one, with the average of
forty-two. The sample was fifty-two percent female and forty-two percent male, with
six percent undisclosed. Sixty-two percent of the participants were government or
military employees, two percent civilian non-government, twenty-eight percent were
spouses and eight percent failed to identify themselves. Of the government employees:
sixty-one percent were diplomats or civilian government workers, thirty-nine percent
were military. Military ranks ranged from sergeant to major, Foreign Service from FS-1
to FS-MC, and GS ranks were from GS-12 to the Senior Executive Service.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
11
Means for the acute stress disorder variables are reported in Table One for the two
time periods – recall to the time of the disaster and time at which the survey was taken.
The general and most important findings are that ten percent (n=5) of the sample showed
acute stress disorder in the first week and four percent (n=2) persisted with indications of
traumatic stress in the weeks following. All participants showed symptoms of distress
ranging from derealization, reexperience, avoidance, heightened arousal, trouble working
and assault on world assumptions at the time of the disaster, but for nearly all categories,
symptoms diminished over time. The only symptom that did not decrease over time was
avoiding talking about the event, which increased at the time of the survey.
Linear regression was applied to the total intensity scores for each category of
responses (dissociative, re-experience, avoidance, arousal, assault on world assumptions
and dysfunction) with military status (military/civilian); gender (male/female); marital
status (married/unmarried); age, and time since the attacks as independent variables.
Only gender and military status were significant with women and civilians having higher
stress responses to the September 11th attacks as shown on Table Two. T-tests of these
variables showed the following:
1) Females showed higher levels of dissociative effects (t (48) =2.793, p=0.007); re-
experiencing effects (t (48) = 2.853, p = 0.006); avoidance effects (t (48) = 2.013,
p = .050); arousal effects (t (48) = 4.137, p = 0.000); assault on world assumptions
(t (48) = 2.356, p = 0 .023); dysfunction (t (47) = 2.423, p=0.019) and total scores
(t (48) = 3.702, p = .001).
2) Military personnel showed lower levels than civilians for dissociative effects (t
(46) = - 3.289, p=0.002); re-experiencing effects (t (46) = -2.411, p = 0.020);
avoidance effects (t (46) = -2.187, p = .034); arousal effects (t (46) = -5.089, p =
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
12
0.000); assault on world assumptions (t (46) = -2.441, p = 0 .019); dysfunction (t
(45) = -2.535, p=0.015) and total scores (t (46) = -4.733, p = .000). This effect
appears to demonstrate that military are more tolerant to exposure to this type of
event as they showed less symptoms than their civilian counterparts.
3) Marital status and time since the event had no significant effect.
4) Age as converted to a dummy variable (dividing the group into age forty or less
and forty-one and above) was significant as follows (with younger age being
better - older age being more affected) by dissociative effects (t (48) = - 2.961,
p=0.005); arousal effects (t (48) = - 2.202, p = 0.032) and total scores (t (48) = -
2.337, p = .024).
Acute Stress Responses in the Wake of Terrorist Attacks
Assessment Issues for Acute Stress Responses following Disaster and Terrorist Acts
The relatively recent introduction of acute stress disorder (ASD) as a diagnostic
category occurred as a means of facilitating identification of those individuals most at
risk for developing longer-term PTSD following exposure to a traumatic stressor
(Koopman, Classen & Spiegel, 1994). ASD describes posttraumatic stress reactions that
occur between two days and four weeks following exposure to a traumatic event and thus
differs from PTSD in terms of timing and in its heavier emphasis on the development of
dissociative symptoms. The predictive power of this diagnosis is impressive.
Researchers report for example that seventy-eight percent of trauma survivors who meet
criteria for ASD suffer PTSD six months following the trauma, and sixty percent of those
who display acute posttraumatic stress symptoms (subclinical ASD) but no dissociation
develop PTSD (Bryant & Harvey, 1998; Harvey & Bryant, 1998) and these rates persist
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
13
even two years after the trauma (Harvey & Bryant, 1999). Hence the importance of
importance of assessing for ASD following a mass disaster or terrorist act cannot be
overlooked especially when one considers how far reaching some terrorist event can be.
As in this case, the effects of terrorist attacks in New York City and Washington, D.C.
reached across the Atlantic Ocean affecting Americans living abroad.
At the time of the September 11th terrorist attacks there were few scales available
to measure ASD and each had their drawbacks. For example many researchers use
measures developed for PTSD to measure aspects of ASD such as the Impact of Event
scale (IES; Horowitz, Wilner, &Alvarez, 1979) to index acute intrusions and avoidance
or the PTSD Symptom Scale (Foa, Riggs, Cancu, & Rothman, 1993) to assess the range
of intrusive, avoidance and arousal symptoms in the acute phase. These however do not
encompass dissociative symptoms and additional measures such as the Dissociative
Experiences Scale (DES; Bernstein & Putnam, 1986) or the Peritraumatic Dissociation
Experiences Questionnaire (Marmar et al., 1994) must also be used to assess dissociative
responses. Two measures that have been proposed to measure acute stress responses are
the Stanford Acute Stress Reaction Questionnaire (SASRQ; Cardena, Classen, & Speigel,
1991) which has been modified from a seventy-three item questionnaire to a thirty-item
inventory that indexes ASD symptoms (see Stam, 1996). But neither has been validated
to date. The Acute Stress Disorder Interview (ASDI; Bryant, et al, 1998) is a validated
19-item, dichotomously scored interview schedule that is based on criteria from the
Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric
Association, 1994). However it is an interview that requires professional administration
versus a paper and pencil test.
Readiness in the Psychological Profession for Large Scale Response to Trauma
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
14
The terror attacks of September 11th caught the whole world off guard. The
psychological profession was not immune. This researcher for example found that there
is currently a lack of standardized measures that can be “taken off the shelf” to quickly
and accurately assess for ASD and that quick research and treatment responses for
terrorized populations are hardly “at the ready”. In this study the availability of psych
info and other data bases made it possible to quickly construct a paper and pencil
measure that was based both upon the DSM –IV criteria and the work of others, but it
could not be validated or standardized prior to its application. A recent gathering of the
world’s top experts on psychological responses to terrorism at a NATO sponsored
Advanced Research Workshop underlined this concern. Psychologists, clinicians and
researchers, are unprepared to professionally respond to massive terror attacks of a
biological, chemical or nuclear nature and even to simple terrorist attacks involving huge
numbers of citizens (NATO Advanced Research Workshop, 2002). Given the current
concerns voiced by officials in the United States and abroad regarding the likelihood of
increased terrorist threats it would be very useful to clinicians to be able to turn to
established data banks of measures to help assess large groups of individuals not only for
purposes of research but also for triage and prevention. The availability of such paper
and pencil measures might make a huge difference if large groups of individuals were
exposed to an act of terrorism enabling clinicians and researchers to learn who is having
adverse reactions and who is most at risk for developing long term PTSD. The
implications for prevention and treatment are very important given the current world
atmosphere of increased tension and expectation of increased terrorism.
There are of course some significant measurement issues that researchers must
keep in mind when developing such measures. For example ASD as a diagnostic
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
15
category is often not a stable diagnosis but rather fluctuating in its course. Hence the
diagnostic rate can be variable depending upon when one is assessed. According to the
DSM-IV the dissociative symptoms may occur either during the trauma or at any time
during the month after the trauma. In this study symptoms of ASD decreased over time
in general but not in every case. Likewise in this study as in every case when a terrorist
act is the traumatic stressor there are problems in defining when the event is over if there
exists after the attack an increased perception of threat following the initial attack. This
was seen in this study where the onslaught of anthrax letters and rumored “next” attack
sites created increased arousal states for weeks following the initial stressor event.
Psychological Readiness for Treatment Responses to a Mass Terrorist Event
It is important to note that this study revealed significant acute stress reactions to
terrorism even in those far removed from the actual site of the attacks which raises the
issue of the potentially huge numbers of individuals who might be adversely affected by
mass terrorist attacks and increased threat levels the world over. For psychologists this
introduces the need to think creatively about what can be done to ameliorate stress
responses and about how to prevent the development of PTSD in large populations
following acts of mass terrorism. Certainly when huge groups have been exposed to
trauma individual assessment and treatment might not be feasible and group approaches
may be useful.
Group approaches are likewise not straightforward nor agreed upon. Over fifty
years ago stress debriefing was introduced as a means of caring for traumatized WWII
soldiers (Shalev & Ursano, 1990) and since then many brief psychological crisis
intervention services have been developed for use in the immediate wake of trauma and
disasters. Some of these are models developed primarily for emergency service
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
16
personnel and are described by Mitchell, 1983 and Dyregov, 1989. Some have since
been expanded for wider use. Psychological debriefing – the current trend – has been
described by Bisson, McFarlane and Rose (2000) as "a single-session semistructured
crisis intervention designed to reduce and prevent unwanted psychological sequelae
following traumatic events by promoting emotional processing through the ventilation
and normalization of reactions and preparation for future experiences" (p. 555).
Likewise Foy, (2001) writes: “Debriefing is usually an early (e.g. 1-3 days posttrauma)
group intervention, facilitated by mental health professionals or trained peers. Usually,
PD includes some or all of the following: (a) an introduction to the rationale and methods
of PD to group members; (b) explanation of confidentiality; (c) time to describe traumatic
events and discuss initial reactions; (d) time for describing emotional responses to the
experience; (e) discussion of the recognition, normalization, and management of
symptoms; (f) discussion of implementing knowledge and coping strategies; and (g)
identification of internal and external sources of support. The aforementioned draws
attention to a critical issue in evaluating the effectiveness of PD–that is, the lack of clarity
regarding what actually constitutes PD.”
While psychological debriefing remains imprecisely defined its proponents argue
for its efficacy in reducing acute traumatic reactions while opponents argue that it is
useless and can even cause harm. The reality is that in review of practice there is a lack
of standardization across interventions, differences in timing, duration, trauma type,
recipients and facilitators. Likewise the studies of psychological debriefing generally
lack baseline data, usually have self -selected participants and lack appropriate and
randomized control groups so it is difficult to know whether they help or harm. (Foy,
2001; Neria & Solomon, 2000; Bisson, McFarland, and Rose, 2000).
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
17
Hence it is clear that if mass terrorist attacks were to occur on a more devastating
and widespread scale, psychologists might be terribly unprepared in terms of mass
assessment, prevention and treatment plans. There is therefore a need for each
government and their nongovernmental units, including the profession of psychology, to
develop appropriate psychological service responses (in terms of assessment, treatment
and prevention) to massive terrorist attacks. Clearly more research, treatment approaches
and models must be developed to create a state of readiness for such events.
Implications and Discussion
The research question of this study, examining if there would be evidence of acute
and posttraumatic stress disorder symptoms in a sample of Americans posted abroad as a
result of witnessing the September 11th attacks on America is answered affirmatively.
Witnessing one’s country being attacked, even from afar can be cause for posttraumatic
responses – especially in this day of live television coverage and endless replay.
However it is also clear from the statements made by respondents that it was not only the
September 11th attacks that contributed to their acute stress disorder symptoms but also
the possibility of further attacks and the heightened sense of arousal caused by this
increased threat status.
It is a significant finding of this research that ten percent (n=5) of the sample
showed immediate signs of acute stress disorder in the first week after the September 11th
attacks and four percent of the sample (n=2) persisted in such a state. Likewise, the
average respondent felt a sense of derealization over the trauma, reexperienced it in
intrusive thoughts and flashbacks and felt increased arousal particularly in terms of
increased threat.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
18
Peritraumatic dissociation has been linked in some studies to the possibility of
later developing posttraumatic stress disorder (Birmes, et al, 2001a; Birmes, et al, 2001b;
Fullerton, et al, 2001). It is significant to note in this sample that twenty percent of the
respondents experienced all four areas of dissociative symptoms (derealization, numbing,
dazed and partial amnesia) (on the sometimes to always level) and ten percent persisted
with these symptoms beyond the first week. While it seems unlikely that anyone in this
sample would develop long-term PTSD, five of the respondents did briefly suffer acute
stress disorder and two of these persisted in their symptoms. Acute stress disorder has
also been implicated as a potential pathway for later development of PTSD (Harvey, et al,
1999; Hodgins, Creamer & Bell, 2001; Bryant, et al, 2000).
Traumatization, the use of dissociation as a defense and the long-term
development of PTSD all revolve around the inability of the traumatized individual to
incorporate an emotionally overwhelming, terrifying and inescapable experience into
existing schemas. Instead of finding a way to process the trauma, the victim’s mind
sequesters the terrible reality as an unprocessed experience, reminders of which are to be
avoided. Unfortunately until it is resolved, the traumatic memory keeps intruding into
consciousness causing havoc with healthy functioning. In this sample dissociative
defenses were used to keep the traumatic reality at bay, with derealization (i.e. not
accepting the reality of the attacks) being the most prevalent symptom at the time of the
disaster, while emotional numbing, reduction in awareness and traumatic amnesia were
also utilized at the time of the disaster. Reexperience and avoidance were also indicated,
(with intrusive thoughts and nightmares being common) and but over time it appeared
that most of the sample participants were working through, versus avoiding their
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
19
traumatic responses to the attacks and the general trend was toward a decrease in
posttraumatic symptoms. Hyperarousal was also present but also diminished over time.
The majority of the sample stated that they had experienced an assault on
previously held world assumptions: that they had a new recognition for how fragile life
is, and that they felt a new sense of uncertainty about the future. They were struggling
for ways to incorporate their new post September 11th reality of increased workplace
threat and heightened security measures – meant to protect - but often in reality
increasing their sense of threat. Workers struggled with newly organized procedures
such as bomb drills and new mail handling procedures. Circulars warning of how to
respond in a biological or chemical threat situation created a feeling that the world had
changed overnight. Were they to now order gas masks and keep them nearby? Was it
better to forgo receiving mail at all for a time? One woman told of her husband calling
frantically from work to tell her to remove the “Economist” magazine from their home
due to an embassy e-mail (later discovered to be a hoax) warning that some copies had
been laced with anthrax. “You should have seen me with my plastic gloves and tweezers
trying to take it out of our home.” She recounts. “He was so afraid. He didn’t want the
kids to be infected.”
Having a work force experiencing difficulty concentrating, increased arousal
states, flashbacks and even resorting to substances to cope is troublesome. Certainly in
this sample, anxieties were increased by the September 11th attacks and their aftermath,
and help for dealing with the increased sense of threat would have been welcomed by
respondents. Fifty-five percent of the sample stated the desire for group discussions and
twenty percent would have accepted confidential individual counseling in the first week.
Given the receptivity to help it is important to consider how to best offer assistance.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
20
It remains an essential research question to understand how persons under threat
develop new schemas and if preventive measures can be developed to inoculate those
facing increased threat against psychological disorder. Given that news pundits have
labeled “the world as forever altered following September 11th”, for personnel serving
abroad it raises the question of how to best help them deal with the increased threat levels
and perhaps even how to raise resilience to this type of occurrence. It is significant to
note that military men in the sample had the lowest stress scores in general indicating
perhaps that military training and combat readiness skills may be a factor in creating
increased resilience to this type of stress. This is not to say that the military respondents
did not also show symptoms of distress, but that their responses were on the whole lower
than the mean scores.
Groups in which respondents can discuss and work through some of their
responses to the disaster, educational groups, easy access to confidential counseling,
sensitively written materials all appear as common-sense responses to situations of this
type. Indeed in response to the attacks, and expressions of need, the author volunteered
to hold simple stress debriefings in which common psychological responses to disasters
were discussed, risks of threat were put into perspective (death by anthrax compared to
current TB rates for instance, death by terrorist attack compared to the risks of driving,
etc.) and participants were given a chance to discuss their emotional responses. Unlike
some psychological debriefing approaches these sessions were entirely voluntary and did
not require anyone in the group to do any “emotional processing”. Instead helpful
information was given, including common responses to disaster, which generally sparked
quite animated discussions among the participants where they expressed emotions to the
levels they chose. Feedback to the author regarding the six stress debriefings that were
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
21
held was overwhelmingly positive (Speckhard, 2002). Participants especially
appreciated discussion of potential self-care and anxiety reduction methods that they
might use to stabilize their emotional and familial distress in response to the attacks.
However, objectively judging the sessions, the researcher observed that there
were both positives and negatives to such groups. For instance when gathered together
individuals had the opportunity to discuss fears and found relief in doing so, however
they also exchanged fears and potentially called attention for other group members to
threats that they hadn’t considered. Thus the groups gave the opportunity for both relief
and emotional contagion. The same was true for security debriefings and security flyers
circulated at the workplace. Intended to reassure, they often heightened fears. One
worker stated, “After I read what to do in a biological attack, I felt sickened. I don’t read
those papers anymore.” Another worker stated, “After the bomb drill at NATO I became
more convinced that our security system is not adequate to protect us.”
Clinicians who work with expatriates or those preparing to serve the country or
their corporations abroad can equip them to deal with the new stresses of terrorism threats
in a number of ways in groups or in individual formats. First it is helpful to discuss the
fears engendered by heightened security measures and to discuss the new threats and
what they mean for the person. A common problem with those facing new threats can be
the tendency to over focus on it, especially if the media supports an obsessive new
interest. In this case it is helpful to point out and contrast the new threat to other threats
that the person takes for granted – such as getting in a car and driving in dangerous traffic
each day, despite the odds of dying. In this way the new threats can be put into
perspective and lose some of their ability to intrude on conscious attention. At the same
time it can be useful to teach or review strategies of self-awareness, vigilance, and safety
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
22
measures against terrorism for those who may be in fact be facing increased danger (e.g.
such as monitoring ones surrounds while driving, locking cars, examining and taking
precautions before opening mail, etc.) and in doing so help the client by monitoring and
addressing any anxieties raised by the need for increased self protective measures. When
the awareness of new threats brings up fears of mortality these fears can also be used as
therapeutic catalysts to discuss life choices in light of the potential fragility of life. Often
spouses and family members have different tolerances for threat and it is also useful in
therapeutic contacts to help family members to discuss their fears and desires regarding
prevention. Teenagers for instance may chafe under restrictions to avoid roaming in
ethnic areas that seem safe to them but potentially dangerous to parents. Spouses may
differ on how much precaution the other needs to take, and issues of potential loss and
abandonment can come up when they each contemplates that the other could be the
object of terrorist attack. These fears can be used as opportunities to enhance family
communication and to address existential issues as well as those unresolved from
childhood. Likewise, the employee may have issues he needs help addressing in the
work place, such as the need to address new security measures that seem harassing or
lapses in security that create potential for danger. Again clarifying the issues, putting
them in perspective, and support for communicating one’s needs and objectives within
the organization in an effective manner is useful.
This research found significant distress, posttraumatic and acute stress disorder
responses in expatriate Americans to the September 11th attacks on America. It
highlights the need for research and educational programs looking into how not only
expatriates, but all persons living under increased terrorist threats can make adjustments
to reduce anxiety, aid in creating new schemas and even inoculate resilience into the
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
23
workforce for the “new world” we live in post September 11th. Likewise there is a need
for psychologists to work towards readiness in assessment, prevention and treatment of
acute and posttraumatic responses both in response to the threat of continued terrorism
and the possibility of a mass terrorist attack. We will continue sending our foreign,
commercial, civilian, and military services to work overseas while the threat of
worldwide terrorism seems unlikely to decrease anytime soon. In response we must
equip our people at home and abroad and our profession, psychologically as best we can.
Acute Stress Disorder in Diplomats Living Abroad Following Sept. 11th
24
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