The New York Times on the WebTherapists Hear Survivors' Refrain: 'If Only'
September 25, 2001
By ERICA GOODE
They are an uneasy current running beneath the stories of close calls, courageous acts and sudden losses: regrets shaped by hindsight, what-ifs and if- only's, wishes to undo what cannot be undone.
A woman replays over and over in her mind the argument she had with her husband on the morning of Sept. 11. It was a silly spat, about where the two would meet that evening, says a therapist the woman confided in. Her husband left in a huff, without kissing her or saying goodbye. Within hours, he was missing in the rubble.
A group of firefighters in Brooklyn retrace an endless circle of lost possibilities. "If only we had left a moment later," they tell a counselor. "If only the traffic pattern had been different."
An investment banker, late to work that Tuesday, cannot stop imagining the last moments of each of his colleagues in the World Trade Center, how this one would have been frightened, how that one would have been a fighter.
"The sense is, he should have been killed with everyone else," said Dr. Yael Danieli, the clinical psychologist that the man consulted.
In the wake of devastation, especially that wrought by humans, often come feelings of guilt and regret, said Dr. Danieli, a founder of the International Society for Traumatic Stress Studies, who has worked with survivors in Rwanda and Argentina, and other experts on the psychological impact of trauma.
The joy of being alive is tinged with shame at having survived when others did not. Or as one firefighter put it, "I feel guilty that I'm glad I wasn't there."
Dr. Edna Foa, a psychologist at the University of Pennsylvania, said she had not seen a trauma victim that did not feel guilty about something.
And faced with events that evoked, at least momentarily, images of nuclear war - a resonance given eerie echo in the designation of the World Trade Center site as "ground zero" - even people spared immediate losses may feel they must somehow make up for being alive when so many died.
"There are concentric circles of survivor experience," said Dr. Robert Jay Lifton, a psychiatrist at Harvard, who has studied the survivors of Hiroshima, the Holocaust and other human-inflicted terrors.
"At the center are those people who are directly affected by the planes attacking," Dr. Lifton said. "But in New York, the survivor experience is more broad. There is a feeling of self-condemnation unless one can offer one's energies to those who have suffered."
This collective sense of a debt incurred by survival, Dr. Lifton and other experts said, may well have contributed to the almost desperate need to feel useful expressed by many people in the days after the attacks.
Blood donors lined up for hours and many were distraught at being turned away. Volunteers flooded crisis lines and other services. Firehouses and police stations overflowed with gifts and tributes.
Guilt may seem an irrational response to events that were impossible to predict and even more impossible to control. But, at least in the immediate aftermath of disaster, Dr. Danieli said, the idea that one could somehow have prevented what happened may help ward off the even more frightening notion that the events were completely random and senseless. This attempt to hold on to some vestige of control, she said, can be discerned in many survivors' distress.
"You can't sleep, you can't let go," she said. "There is a fear of dreaming and particularly of nightmares. It sounds terrible, but one would rather suffer the torment instead of letting oneself truly experience total helplessness, and to take that helplessness into the image of the world around us."
Dr. Danieli added that regrets also could be a way for relatives and friends to maintain continuity by holding on to those who have died and to begin the process of mourning.
Some, she said, may be afraid to go to sleep "because in their sleep they may forget the person and that feels disloyal."
Researchers have found that some aspects of the way people cope with sudden losses appear to be an integral part of the mind's basic equipment for interpreting the outside world.
For example, in studies beginning in the 1970's, Dr. Baruch Fischhoff, a professor of social and decision science at Carnegie Mellon University, and other psychologists have demonstrated that once people know the outcome of an event, they routinely overestimate how much predictive information they had beforehand.
"If I ask you to remember how you saw things in the past, before you knew how they were going to turn out, you can't reconstruct your own previous perspective," Dr. Fischhoff said.
This "hindsight bias," he believes, may be an adaptive mechanism, crafted by evolution as a way to integrate new information with old.
But for survivors, it can translate into a conviction that they should have known what was about to happen - and done something about it. A husband who urged his wife not to continue working at the World Trade Center after the 1993 bombing there, for example, might in hindsight feel responsible, though the impossibility of foreseeing hijacked planes hitting the towers may be obvious to everyone around him.
"You can't be obligated to prevent unforeseeable events," said Dr. Edward Kubany, a psychologist affiliated with the University of Hawaii at Manoa, who studies survival guilt.
"There is only one satisfactory action to a why question," Dr. Kubany said, "and that is bad luck, wrong place, wrong time."
The urge to mentally "undo" horrible events by going over in one's mind all the things that could have kept them from happening is also a basic psychological response, according to work by Dr. Daniel Kahneman, a professor of psychology at Princeton, and his colleagues.
"It's very easy to imagine an alternative to what actually happened and for some reason, people are really driven to do this," Dr. Kahneman said in an interview.
He began studying the mental need to run through alternative outcomes after his nephew died in a 1975 plane crash while in the Israeli military. "We just kept thinking, `If only,'" Dr. Kahneman said.
The obsession with what could have been can be especially intense, he added, when the victim was present at the scene only by chance, rather than as part of a normal routine.
For the survivors of the terrorist attacks, for example, the sense of regret is probably most palpable for the relatives of those who, in the ordinary course of events, should not have been there: emergency workers who switched shifts that morning, people attending a one-day event at the World Trade Center or those who were there to deliver a package or visit a friend.
Dr. Kahneman noted that when he was in the Israeli army, the officers did not permit troops to exchange assignments or shifts because if a soldier was killed after such a trade, "the survivor was in deep trouble" emotionally.
For most people, the guilt, regret and other emotions traumatic losses inspire will dissipate in time, healed in the company of family members and friends, by the rituals and traditions of bereavement and by the outpouring of support that Americans have offered the victims.
But survival guilt that persists for months or even years is also a feature of post-traumatic stress disorder, a severe reaction to trauma, both in its acute and chronic form.
Many experts believe that how well people recover depends in part on the meaning that is eventually derived from those losses.
Dr. Viktor Frankl, a psychoanalyst, found that Holocaust survivors who were able to place their experiences into some larger context of meaning fared better psychologically.
Dr. Frankl, himself a concentration camp survivor, wrote that on forced labor marches, he kept himself alive by summoning the image of his wife.
"I heard her answering me, saw her smile, her frank and encouraging look," he wrote. "Real or not, her look then was more luminous than the sun which was beginning to rise."
Dr. Lifton, in interviewing survivors of Hiroshima, said that "what many came to as a kind of meaning was their having been the first to experience these dreadful weapons."
"They could therefore know something about what the weapons do to people," he said, "and could warn the world about their dangers."
Dr. Lifton added, "We, as human beings and as survivors, have to create that meaning in relation to the event. The meaning can be enormously varied and the experience itself doesn't give you meaning automatically."
Dr. Michael Garrett, the deputy director of psychiatry at Bellevue Hospital, tried to convey a similar message when he counseled firefighters in Brooklyn.
"These firemen are tough guys, and getting them to talk about this is difficult," Dr. Garrett said.
While the Red Cross fliers the firefighters receive tell them to eat regularly and get enough rest, he noted, "the response of most of these guys is, `When I'm off duty, I go to a funeral.' "
Dr. Garrett said he encouraged them to focus on what they accomplished at the scene, on how much they helped other people.
"Retrospective thinking torments people," he said. "Real life moves forwardly."http://www.nytimes.com/2001/09/25/he...4d89d1710e2487
Copyright 2001 The New York Times Company