RAFAEL PI ROMAN: I'm speaking with Dr. Jack Saul, psychologist and director of the International Trauma Studies Program at NYU. Doctor, we've heard a lot about post-traumatic stress disorder. How serious is the problem of post-traumatic stress disorder in New York City now more than six months after the event?

DR. JACK SAUL: It's very serious. There are many people calling in for help through LIFENET, the hotline that the Department of Health has set up. And we're expecting to see probably thousands of people who will have traumatic stress symptoms, and will need some kind of professional help over the next months, and maybe even into the next couple of years.

RAFAEL PI ROMAN: What are the symptoms?

DR. JACK SAUL: Well, post-traumatic stress disorder really is a collection of different symptoms. You have... symptoms of re-experiencing the trauma in some form, like nightmares, or flashbacks, avoidance of cues that remind one of the events that one's experienced. Sometimes social isolation. And also people can be kind of hyper-aroused, and their arousal system is influenced in a way that can prevent them from being able to concentrate, attend to their normal daily activities, and also they can have sleep difficulties, and these problems can be quite debilitating for people.

RAFAEL PI ROMAN: Now are there phases of symptoms? I mean, six months later should we expect a certain series of symptoms to occur to people who may be facing trauma?

DR. JACK SAUL: People experience these symptoms in different phases. It really depends on the person.

RAFAEL PI ROMAN: But you can't predict what symptom will happen in six months and one year later?

DR. JACK SAUL: No, it's different for different people.

RAFAEL PI ROMAN: Now, is this trauma, or is this general set of symptoms, something that can affect anyone, from a victim of the attacks who survived, to a family member of somebody who was lost, to somebody who experienced it just on television?

DR. JACK SAUL: Yeah, even watching TV people can have these kinds of reactions.

RAFAEL PI ROMAN: And how are different people dealing with this kind of trauma?

DR. JACK SAUL: Well, first of all I want to clarify that not everyone gets post-traumatic stress disorder who goes through something like this. In fact, a small minority of the people who have experienced events like this will have these kinds of reactions. Most people spontaneously recover after events like this, especially if they have the support from family, and... support in their community. The most important factor that promotes recovery after a major psych-social trauma like the events of 9/11 is family support and community support.

RAFAEL PI ROMAN: From reading things that you have written, I see that you do emphasize the community aspect of dealing with trauma. Can an individual, by him or herself, cope with this trauma and get out of it?

DR. JACK SAUL: I think individuals do cope, but I really see recovery from trauma as a social process. It happens when people come together with other people, and they can talk about what they've been through, feel supported by others, solve some of the problems that they are faced with because of the disruptions in their lives... I think that there's been a tendency to overemphasize the stress symptoms, and people really experience a variety of different reactions after these kinds of events. And in fact, most people, I think, identify other kinds of problems that are more serious.

In the downtown community where I live and my children go to school, there have been tremendous concerns about environmental safety, and what kind of systems we put in place to insure that the adults and children in the community are safe. And there's been a concern about economic issues facing these families, and people have had to move out of their houses and had their lives really disrupted for weeks and months. And it's this accumulation of stress on people's lives that have been very problematic, and they've needed to really come together with other people to figure out how they are going to solve some of these problems which they and others are faced with. This is not just an individual trauma; it's a collective trauma. And a collective trauma really needs a collective response and a collective voice, too. So the experience -- how people come to terms with these events and integrate an understanding of these events in their lives -- is a collective endeavor. It's not something that's usually achieved individually.

RAFAEL PI ROMAN: And that's because trauma comes from real problems, real concrete problems and those problems usually can be solved only communally or collectively. Is that what you are saying?

DR. JACK SAUL: Yes... We were trying to shift the paradigm... from the focus on individual's psychological stress to the impact that this major event had on the community. And I think that you've seen that, in the days after September 11, people came together, there was a sense of United We Stand, people were very open, altruistic, I mean, it was an amazing thing to see New Yorkers really reaching out and helping each other. And that's a kind of -- we see that as a kind of biological response, what we call survival mode. And people are also kind of hyper-alert to cues of danger in the environment. And after a while, after a few weeks, that survival mode kind of subsides and people go back into their usual protective mode in which they are very tired after having been dealing with all the stresses in their lives, and [have a] thin skin. There's a bit more aggressiveness and irritability going on, and the danger at that stage is that people fragment in the communities... They kind of retreat into groups that they feel safe in and see other groups in the community as enemies and struggle over resources, over ways of dealing with the problems, and also some people are ready to deal with certain things more than others... People are in different places, and this can create tension. So we wanted to alert the community to the fact that this is a normal aspect of response... after a disaster, and that people should be looking out for this, and making sure that they can be careful about the reactions that they have, and be careful not to attack other people.

RAFAEL PI ROMAN: So we go from United We Stand to, Don't Stand too Close to Me, even more than before the attack, you are saying. And you want people to know that?

DR. JACK SAUL: Yeah, and that people should be alerted to that. And that there are things that people can do to minimize some of these fragmenting processes in the community, that we need to continue to come together for a common purpose. And then the next stage, which I think we're moving into now, is that the community itself, the communities around New York, really need to develop their kind of positive visions of recovery. And this is kind of up to each community to decide. What are we going to be like after these events? We're not going to be the same. We're not going to return to how things were before.

RAFAEL PI ROMAN: You're talking about moving from coping with the current situation to envisioning a future that you want to have?

DR. JACK SAUL: Yes. How are we going to rebuild our community? How can we be closer as a community? How can we deal with future crisis that may happen? How can we continue to support each other? And also there's the process of responding to a disaster [that] takes from three to five years. People are going to have ongoing emotional reactions to these events, and they are going to need the support of the community to help them process what's happened. The community needs to tell its story of how it experienced the events of 9/11, and how it recovered from these events. That process of collective storytelling in the community is a very important part of the recovery process itself.

RAFAEL PI ROMAN: Now, where do you see this happening in a positive way? Where do you see these stories being created?

DR. JACK SAUL: Well, the trend is already starting toward a way of looking at community recovery now. The Department of Health in New York City is looking to promote community programs, which are run by members of different neighborhoods, and communities all across New York. And there's going to be a conference next month to help generate ideas about what communities can do. There's also a number of programs around New York, like New York City Recovers, which is linking different groups that are engaged in recovery activities together to know what people are doing and to share ideas. And there was a very interesting program called "Imagine New York," which is bringing together people for workshops to think about what should be done to the site downtown, how to envision New York in the future. And it's involving artists and people from many different professions. The thing about community recovery is that it puts the emphasis not just on mental health professionals that promote recovery -- we don't have a monopoly on the recovery process. People with many diverse skills can bring those skills together to promote recovery. I think that artists play a very important role in promoting recovery after such events. Media professionals, community activists, Internet specialists, disseminate information that's helpful to people. And gardeners, as we've seen.

RAFAEL PI ROMAN: We just saw the story of Marianna Koval and the memorial garden. That's one of the examples that you are talking about?

DR. JACK SAUL: Yes, I think that there is probably going to be a movement to build gardens and to plant, as part of a recovery process, because this really is a wonderful symbol of rebirth, of...

RAFAEL PI ROMAN: Is that why gardening is so therapeutic?

DR. JACK SAUL: Yes, it's being involved with life and the permanence of life in the face of destruction. And these kinds of activities are very important in promoting a process of recovery. Reaffirming the beauty in life, the positive things in life, and reconnecting with those things which give life meaning and joy to people is part of the recovery process.

RAFAEL PI ROMAN: Now, you have been working in Kosovo dealing with trauma. Is that through the International Training Studies program?


RAFAEL PI ROMAN: So part of your work as a director of the International Trauma Studies Program at NYU has taken you to Kosovo quite a few times to deal with the trauma there. What lessons did you learn there that you have brought to post 9/11 New York City?

DR. JACK SAUL: Well, one of the things that we saw there [was] that we needed to partner with our colleagues there in order to help them develop a public mental health system that could address the many needs in their country... They have very strong families, very large extended families, and very tight-knit communities. And that in order to really capitalize on the resources that can promote recovery [they] needed to develop approaches that really help these families recognize the resources that they have and to facilitate those resources.

Many of the families in Kosovo experienced massacres where numbers of people, 5 or 6 men in the family, were murdered, and these families really needed to pick themselves up and rebuild, and rebuild, literally -- rebuild their houses, rebuild their communities. And rather than just having them go to a mental hospital or a mental health clinic for help, we have seen that our colleagues there have gone to the communities, and have helped facilitate the strength in those communities to support these families... These are strong families, and by working with these families and recognizing the many things that they could to do to rebuild, and [by] supporting them in that process and supporting them being able to tell their story with each other rather than be silent about it, that this has been tremendously healing. And it's very efficient and economical to have a family heal itself with a little bit of support [rather] than have numerous little health professionals coming in which they don't have there.

So when I had this event happen in my own neighborhood, one of the first things I thought was what I can do to apply some of what we've learned in the international context to helping our neighborhood and helping our community. And we know that what is most helpful is bringing people together to engage in practical projects in which people can be active. And in the context of rebuilding -- or in our case it was moving the whole school from one school to the next three times -- the community came together. They painted the school. They moved all the furniture from one school to the next. And it was that active process of helping out which brought people together, and brought people together for support as well, and it gave them a context to talk about how they were impacted by these events, and what has been helpful, and to share solutions. And that's what helps in the international context. And in fact, the most important intervention internationally after a war is to create a soccer league. Where you bring the youth together with a structure, with some -- an activity that's fun where they can have a competition against other youth rather than kill other youth... They come together and they can really feel connected. Promoting these positive connections in families and communities is probably the most important intervention that you can promote after such a massive trauma.

RAFAEL PI ROMAN: Now you have two young children, right?

DR. JACK SAUL: I have a boy, 8, and a boy, 5.

RAFAEL PI ROMAN: And they both go to PS...


RAFAEL PI ROMAN: The closest elementary school to the Twin Towers. And you've been working with that school. What kind of activities have you been?

DR. JACK SAUL: Well the first thing we did, the mental health professionals who were parents in the schools set up a family support network where people could come for some -- to have someone to talk to about some of the problems they were facing. But then we found that what we needed to do was to bring people together for community forums where they could talk about some of the ongoing issues facing the school community. We also brought together the teachers at one point to talk about what they could do to support each other, because what tended to happen was that the focus was being directed primarily toward helping the kids, but the kids are actually quite resilient and it was the parents, I think, who were feeling a tremendous amount of distress, and kids look at their parents and they say, well I see my parents don't need any other burdens, I'm not going to go talk to them about some of my own feelings and issues. And by helping parents to address and support each other around some of the distress that they are feeling, that's actually the best way that they can help their children, because then they can be more available to their children if they are also taking care of themselves. It's a little bit like on an airline they tell you to put your own mask on first before you help the child. It's the same, I think in a situation like this as well.

RAFAEL PI ROMAN: Let's talk about the role of the media. What role has the media played in relieving trauma and stress or exacerbating it?

DR. JACK SAUL: Well there's a lot of controversy about the role of the media. First of all there was, I think there was, concern among many people that the trauma was actually -- the events of 9/11 were actually -- exacerbated by the repetitive imagery on TV. And we know that this can cause traumatic reactions in people, to watch the towers falling over and over again. It becomes ingrained as a memory, as a disturbing memory in people's psyche. And we saw after the airing of the program on CBS on that six-month anniversary, many people were calling into the hotline distressed after having seen that.

I think that the problem... was in the way that it was presented as something that you can't miss. And there weren't enough safeguards presented beforehand, warnings that people who might feel that this is disturbing should probably not watch it. Or if they are going to watch it, watch it with friends, and be able to talk about it afterwards. In fact looking at a program like this can be positive... It can help people process some of these events and understand these events, but not just by watching the TV. People need to do it with other people; the program itself can be the catalyst for talking about people's reactions, and feeling some support within a family or a group. So it's a double-edge sword. But the media itself plays an extremely important role in promoting recovery. The media is the storyteller in our society. And the way the story is told, the way it's put together by many different people telling their story, it becomes part of the collective story, which is really a part of the recovery process. And the media needs to be careful that the story it's telling is broad enough to include many different people's participation. Like for instance, I think some of the communities in New York that have been very affected by the events of 9/11 are the refugee communities and the Arab-speaking communities. And it's extremely important that they be able to have a voice in the collective voice here, because they experience something quite different, and they need to have that space to be able to talk about.

RAFAEL PI ROMAN: Are you optimistic that the collective story will be told correctly, [that it] will be told in a way that everybody will feel part of it?

DR. JACK SAUL: I'm mixed about that, because I think in what we've seen in the past around how traumatic events are told by the media, often the simple story is told. And sometimes it's told in ways which are sensationalistic and really don't allow for people to talk about kind of the ongoing effects that these kind of events have on their lives, not just the events of that day. But these events really affect people for years afterwards and that story doesn't get told very often. And I'm hoping -- I think that there's an awareness in the media now. There are journalism schools that teach trauma in their curriculum. We have a program at NYU with The Center for War Peace and News Media, a trauma and media program for journalists that teaches about how to deal with one's own reaction. The journalists own reactions in response to traumatic events, how in effect to sensitively interview trauma survivors, and also how to... at least to talk about what role the media can play in promoting recovery. I know that that's not very popular among some journalists and media professionals because of the illusion of neutrality. But what the media does can have a tremendously negative effect, or it can have a tremendously positive effect, and I think it's very important for media professionals to know the difference.

RAFAEL PI ROMAN: From your vast experience with the issue of trauma, and how to deal with it, is there anything else that you can tell us? Something that either the media or the community or the government or individuals are missing that we could begin to act on now that will ameliorate and relieve trauma for people in New York City?

DR. JACK SAUL: I think the main thing is that we need to basically come together to think about what's important for recovery. And one of the future challenges that we're going to have, as a community, is to develop our mission for recovery. Many communities that have been impacted by terrorism or political violence, or war, develop a mission... Maybe we need to not just have a memorial, but maybe we need to have a center in New York that works... against terrorism or against the killing of civilians. Something that creates a lasting good for the world at large and that we, as New Yorkers, can build and contribute to the world... To turn this traumatic event into an opportunity for something very positive.

RAFAEL PI ROMAN: Doctor, thank you very much.

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