It sounds strange to say of anyone in New York on 9/11 that they were in exactly the right place at the right time, but in Paula Madrid’s case, that conclusion is hard to avoid. The trajectory that led her there had begun in Colombia, where, growing up, she had watched daily reports of South America’s violent drug wars. It was that environment that first sparked her interest in psychological trauma, leading to a degree and then a doctorate in clinical psychology. By early September 2001 she was 25 and living on Manhattan’s Upper West Side, where she’d completed her doctorate, but had yet to attend the graduation ceremony, and was just beginning to look for her first real job in trauma therapy. As it turned out, she wasn’t looking for long.
The population density of psychotherapists in Manhattan is, of course, a New York cliche — and in the hours immediately following the attacks, hundreds showed up at hospitals to volunteer their services. Madrid rushed to her nearest, St Luke’s. “But you can’t really do therapy in a situation like that,” she says. “It would be unethical. All you can do is what we now call psychological first aid, though at the time that phrase hadn’t been coined. We were inventing it as we went along. We just sat with people, let them talk, and maybe you can prepare them a little bit to recognise the symptoms of trauma when they come along later.”
Police officers and firefighters didn’t necessarily respond positively to offers of therapeutic assistance. One therapist told Columbia University researcher Karen Seeley of walking into her local fire station to find “a lot of guys in shock, a lot of post-traumatic stress disorder … they were in bad shape, they were crying, they were numb, they were flashing back.” But the firehouse lieutenant was understandably impatient at her suggestion that they take time off. “You don’t understand,” he said. “We can’t put them on leave. We don’t have anybody here. They have to go back.”
Psychological wounds
It was only over subsequent weeks that the scale of the psychological wounds wrought by that morning’s events would start to become evident. A few days after the attacks, Madrid got a call in response to a job application she’d sent out. “It was someone saying, ‘Well, you’re not licensed yet, but your background is trauma, and we’re trying to set up a unit for victims of 9/11, especially the children. Can you come in for an interview?” Twenty-four hours later was working at Ground Zero in a mobile unit operated by the Children’s Health Fund, a charity co-founded by Paul Simon. The first visitors to the unit were local parents who’d been forced to vacate their apartments, often accompanied by children who’d witnessed at close quarters the planes hitting the twin towers. Madrid and her colleagues offered talk therapy, medication and practical assistance for people trying temporarily to move house while in the throes of shock. “Some of those kids had seen the buildings fall, they’d witnessed bodies go down, hearing screams, and they were having nightmares — it was really, really awful, the things that people saw.”
“It was a difficult time, of course,” says Madrid, “but it was an exciting one too. Because this was my specialism and I knew I could do it. A huge part of being a therapist is ‘me, me, me’. Anyone who says it’s entirely selfless isn’t telling the truth. Trauma was what I knew. Bring me anything else, and I may not be able to do it. But trauma was my thing.”
As weeks turned into months, the complex psychological impact of involvement in such a high-profile collective trauma began to manifest itself. On the one hand, those who’d lost relatives and colleagues received an outpouring of support from friends and strangers, as well as benefitting from the vastly increased levels of funding that were secured for New York’s mental health agencies. There was no danger of their plight being forgotten. On the other hand, every news report replaying pictures from the attacks posed the hazard of “retraumatisation”. “In trauma therapy, you sit with a person and you say, this is a safe environment and here we’re going to explore your trauma for a half hour,” Madrid says. “For people who had to evacuate and thought they were going to die, watching it replay on CNN is exactly what they should not be looking at.”
‘They’d think it was all happening again’
Younger children, Madrid points out, would have been unable to grasp that what they were watching was recorded. “They’d think it was all happening again.” Life in the US, meanwhile, was far from an anxiety-free setting in which to focus on psychological recovery: as well as the constant fear of further al-Qaeda attacks, there was the anthrax scare, and the crash of American Airlines flight 587 over Queens on November 12, in which 265 people were killed. “We had several people who’d lost a relative in 9/11 and then lost more family members in the plane crash,” Madrid recalls. “That’s as severe and complex a trauma as you can imagine.”
Even in the wake of such a communal trauma, the stigma attached to seeking psychological help meant therapists sometimes had to be surreptitious. Counselling for cleanup workers was dispensed from a truck parked behind a mobile clinic offering treatment for respiratory problems, while police and firefighters were invited to “open house” events where therapy wasn’t mentioned, and the main thing advertised was free food.
By 2003, several 9/11 mental health initiatives had merged into the Resiliency Programme, which Madrid directed until 2007. Well into her time there, she was still encountering bereaved relatives who were convinced — or attempting to convince themselves — that their loved ones might still be alive, their memories erased by the shock of the attacks. “‘I believe he’s in a fugue state somewhere’ — I can’t tell you how many times I heard that.” Many others were able to begin their grieving only when scientific evidence of death had been identified. “I remember one woman, who’d lost her husband, where they found some DNA fragments two and half years later. She’d been hoping, hoping, hoping, and was immediately paralysed by depression. She needed to be hospitalised for several weeks.”
The attacks also posed a severe challenge to maintaining strict boundaries between therapist and client. “It’s one thing to hear a terrible story and have an emotional reaction,” says Madrid. “I do that all the time. But to sob with them, and say, ‘Hold on, let me tell you what happened to me’ — that’s not OK. Just because you’re a therapist, it doesn’t mean you understand trauma.”
By the fifth anniversary, many of those who lost friends and relatives “had reinvented themselves,” she says. “There were many who’d never quite regained their prior level of functioning — some alcoholics, and I was aware of a few cases of suicide — but also plenty of cases of what we call post-traumatic growth: people who’d somehow really learned the meaning of life. People who had no choice but to reflect on their lives and what it was they really wanted to be doing with them.” Madrid broadened her activities, working on the after-effects of Hurricane Katrina and the Asian tsunami, and later visiting Haiti after the earthquake. But 9/11, as a psychological phenomenon, still wasn’t ready to be consigned to history: the killing of Bin Laden in May unearthed unwanted memories — so that, as the 10-year anniversary arrives, a large proportion of Madrid’s caseload is once again 9/11-related. – guardian.co.uk