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Helping to Heal 9/11 Families: An Interview with Dr. Marylene Cloitre

child's drawing of World Trade Center with word 'Love'

Above, 'The Power of Love,' artwork created after 9/11 by Soobin Lim, age 13, from the book 'The Day Our World Changed: Children's Art of 9/11.' 'When the World Trade Center was destroyed, many people started to cooperate more than ever before,' Lim wrote. 'I drew people's hands working and loving one another.'

Ten years have passed since the tragic events of September 11, 2001. Besides the attacks' large-scale impact on issues ranging from the infrastructure of downtown Manhattan to national security, perhaps their most heartrending effects were felt on a much more intimate, personal scale. As a leader in the care of children and families, the NYU Child Study Center was on the frontlines in the days, weeks, and years following the attacks, providing counseling, mental health programs, outreach, and education, and helping kids and parents with the delicate, difficult work of recovering from that day's deeply traumatic events.

Dr. Marylene Cloitre, former director of the CSC's Trauma Institute, was a leader in the CSC's response to 9/11. She now serves as the associate director of research at the National Center for PTSD at the Veterans Affairs Palo Alto Health Care Service in California and is an adjunct professor at NYU Langone Medical Center. She spoke with the staff of about the CSC's role in helping to heal the families affected by the events of September 11, 2001.

AOK: How did the Child Study Center initially become involved with the 9/11 recovery efforts?

Dr. Cloitre: Within the first few days after the attacks, a core group of Child Study Center educators and trauma specialists were able to assemble a 65-page document for parents, teachers, and mental health providers about what to expect in regard to psychological reactions that they or their children might experience in response to the tragedy and best how to deal with them.

What was remarkable was how quickly the document was put together, how accurate the information was, and also how well disseminated it was through both the Internet and hard copies. Most people were reeling from the shock and feeling very disorganized . The document was called "Caring for Kids After Trauma and Death." It became a template, even on a national level, for organizing education and outreach information around these kinds of tragedies. Over the years, we have revised and updated the information. It's an excellent guide for families, schools, mental health providers and others who work with children about managing trauma and loss.

AOK: How was the CSC able to disseminate the manual quickly during a time like this?

Dr. Cloitre: The Child Study Center already had relationships with most of the public schools and the school chancellor at that time, so the distribution of the guide came through the highest level. In addition, several psychologists at the CSC were already in place in the schools as mental health consultants before 9/11 happened. The Child Study Center also had a pre-existing organization that involved the leadership of the private schools in New York City, which met monthly, just to discuss adolescent and child development, including mental health issues. The CSC was guided at that time by the observation that schools are where children live. So if we wanted to engage in education, outreach and intervention as needed, schools were where we needed to be.

So, given this set of relationships, the CSC was in a good position to be able to respond quickly once the tragedy occurred, and it took three things. As in all disasters, the immediate response begins by relying on established relationships and pathways of communication, and it builds from there. The CSC was very fortunate to have that network of relationships with both the public and private school systems through which we could provide information and help.

The second resource was having a core group of trauma specialists and educators at the Child Study Center who could work well together. I was on the faculty at Weill-Cornell Medical School when 9/11 happened but was brought in by the CSC shortly after to organize and build various programs in response to the tragedy. We had a critical mass of clinicians and educators with expertise in trauma. You need to have experts in place who know what they're talking about and who know how to work with varying populations and systems, and people with different concerns.
The third resource was a lot of energy, focus, and commitment, and the CSC staff had that in abundance.
AOK: Responding to a tragedy of this magnitude seems overwhelming—after the manual, where did you begin?
Dr. Cloitre: It was a huge event, but there was a strong sense of urgency and need to respond. There was a rush of support, from the community, from the local and federal government, and from philanthropic organizations. Given the financial and other material resources available, we were able to focus on organizing outreach, education and intervention programs, developing them, and training other organizations to implement similar programs. That was a massive effort that went on for about five years. We organized the programs around specific communities as well as healthcare systems that would be supporting populations affected by 9/11. We worked directly with families affected by the attacks, along with schools, mental health agencies and primary care and hospital services.

AOK: As a clinician you were already very experienced in working with victims of traumatic stress. What are some of the most striking things you observed in working with 9/11 families?

Dr. Cloitre: In the CSC's School-Based Resiliency Program, for instance, we provided outreach and education to parents, teachers, and principals. Parents were very concerned about how to take care of their children. But teachers and principals—in fact, all the adults we were working with—had been exposed to this trauma. So we were working with traumatized adults who were worried about how to take care of their traumatized children. In effect, we had two jobs. The first was really soothing the adults, so that they were able to take care of the children. The second part was then teaching the adults how to care for children in the wake of a trauma. We had a mantra, which is actually an old mantra, from World War II: The children are only as good as the adults.

We understood that the point of intervention was not really the child. It was the adults, who were the children's source of safety.

The most profound observation I had when I worked with these families was that the source of resilience and capacity for going forward was often the children, not the adults—which is amazing. It was often the children who were more accepting of what had happened. Maybe part of the reason was that the children didn't know what was in front of them—they can't forecast the future in the way that adults can and do. But I saw a lot of parents who gained strength from the optimism, acceptance, and curiosity that their children had about what had happened, their desire to make sense of it, and their belief that they could go forward.

AOK: Were any of the programs developed by the CSC designed to address these differences in how adults and children responded?

Dr. Cloitre: We noticed that in the CSC's Child and Family Services program set up especially for 9/11 families, very few of the adults, especially the mothers who were bereaved, wanted to acknowledge that they had PTSD symptoms. It was partly the community we were working with, which was primarily firefighters and uniformed services people. As a help-giving community, they didn't think of themselves as needing help. But they would come in saying they were having difficulty parenting, partly because now they didn't have a partner to share the work with, and they had to take on both mother and father roles. They also didn't know how to respond to their children's grief and questions about death.

It was very clear to us that the parents were having difficulty parenting in part because they had PTSD symptoms. They were irritable. They were alternating between being hyper-vigilant and overly protective and being socially withdrawn, depressed and unengaged with their children. But we realized over time that providing programs focused on the parents' PTSD was not a strategy that effectively engaged 9/11 families. They really were focused on their children and being good parents.

So we began providing parenting programs and workshops. We did this in collaboration with Tuesday's Children, for about for 5 years, from 2004 to 2009. We integrated information about how parents could manage their own irritability and social withdrawal. We also tried to give parents permission, especially mothers, to think about themselves and their own health, as a means of being a better parent. We introduced them to the saying that the child is only as good as the adult.

AOK: What were some of the other programs developed by the CSC to help families cope and recover?

Dr. Cloitre: My favorite was the School-Based Resiliency Program, and my favorite part of that program was called Life Stories, a project we developed in collaboration with Columbia University's Oral History Program. We partnered with three different schools in Chinatown, and working with teachers in English and health classes, the children conducted interviews with people who'd experienced traumas and gotten past them. The participants were people who lived in the Chinatown community who volunteered to share their stories: a holocaust survivor, a firefighter, a gang leader who'd left gang life, who had seen a lot of death. The kids interviewed them and reported on what they had learned. Later, they created pictures and told stories, their own or others', about 9/11: what had happened to them, and how they were managing in their recovery.

It was a wonderful project, there were about 400 students involved. Their work went up in an exhibit at the Museum of Chinese in America (MOCA).

Another really important project was our Pediatric Outreach Campaign. We developed and sent written documentation, flyers for parents and children, flyers for pediatricians, as well as CDs that provided continuing education credits for physicians. The materials focused on how to recognize the physical as well as psychological symptoms of trauma in children at various ages or developmental periods. We provided example scripts and case scenarios for pediatricians about how to talk with patients and their parents about 9/11, which family doctors might not otherwise have been prepared to do. This program reached more than 3000 pediatricians in the local New York, New Jersey, and Connecticut area. While it was initiated because of 9/11, it provided a long term benefit in terms of educating pediatricians about how to see something right in front of them that they might not otherwise have paid attention to—what's this headache-stomachache-anxiety-nervousness about? It provided an opportunity for physicians to become better clinicians by talking to families and children about their reactions to trauma and stress.

AOK: Can you give some specific examples of success stories among individual families or children, or cases that stand out?

Dr. Cloitre: A good example of the general phenomenon of the resilience of children that I've mentioned, was a therapy case of a mother and an adolescent boy who had lost his father. Part of his therapy was writing a narrative about his dad, not only about his father's death and how he found out about it but what he loved about his dad and what he missed. The narrative is a memorial to his father. It keeps the memory of his father alive and keeps his relationship to his father alive as well, through his remembrances.

The second step in this part of the therapy was for the adolescent to share this story with his mother. She was prepared by the therapist in advance, and she had completed her own narrative about her relationship with her husband. But this particular step was an opportunity for the parent and child to share their feelings and observations about the loss, and ideally increase their sense of connection and bond.

The adolescent was willing to read his narrative to his mom on two conditions; first, that she not interrupt him, and second, that she not cry.

These conditions were so telling of his developmental stage. He was a teenager, and he wanted to tell his story his own way, independent of his mother. Secondly, the fact that he didn't want his mother to cry represents something I often saw, which was that children did not want to be a source of pain to their parents.

Bereaved children would say, I can manage my own pain, I can manage what's happened in our family. But they did not want to bring up things that would hurt or burden their parent. Children often felt a deep, deep responsibility not to create pain for their remaining parent, and probably underneath this was a wish and hope that their remaining parent was going to be strong and healthy. Again, part of our goal at the CSC was in fact to increase resilience and health in parents so that they could be a positive presence for their children. If the parents were okay, their kids were going to be okay, and again, the kids were usually more okay than their parents were, for sure.

AOK: What are some other things we can all learn from the families who experienced this firsthand?

Dr. Cloitre: A really important message that 9/11 helped us disseminate is that resilience is the natural human condition, and there are ways in which we can build it and grow it in our children and in ourselves.
The most important component of building or maintaining resilience is providing opportunities for people experiencing trauma to have a sense of empowerment or mastery. Sometimes that can be as simple as having them tell their story. Other times it becomes more involved and people build institutes or they write books, or they develop programs or they advocate for changes in laws, or they build better defense systems to keep events like 9/11 from happening again.

Another lesson of 9/11 is how important it is for people who have been traumatized to feel supported, either by those close to them or by their community. The concept of social bonds and social support really came to the fore in my mind watching people recover from 9/11. As a clinician I observed that the people who did best, who recovered most quickly, were those who had support, from their family or their community. This idea is backed up by quite a lot of research. Social support is the single most protective factor in keeping people from developing mental health problems in the wake of a trauma and in facilitating their recovery.

Particularly among the bereaved, those who did well were people who had help with simple but necessary tasks following the death or deaths of their loved ones—help making meals, filling out insurance forms, getting kids dressed and out the door in the morning. Many people came to us who were not directly affected but whose loved ones were, and they asked, what do I do? How do I show support? Often it's not doing any particular thing, but just telling their loved ones, "I'm here from you, tell me what you need." Different people need different things and it depends on their personality and their circumstance.

Sometimes, giving support can backfire. Some parents in our programs would say they were overwhelmed by all the support. They had too many lasagna plates and teddy bears at their door. It's always best to ask how to help rather than assuming to know what's best for the person. Practically speaking, if you don't know the person who has been affected that well, ask people who do know them: What can I do?

AOK: What advice do you have for families if they're still struggling with this, 10 years later?

Dr. Cloitre: I'm sure there are families still struggling. This was a huge event that changed many people's lives and the lives and the organization of many families. Some of the lucky ones just stumble into the realization that some good can come out of something terrible. That is a key element of trauma recovery in the long run.

For people who are still suffering I think the message is twofold. One is that over time it's necessary to accept that these events have happened in order for recovery to proceed. Secondly, it is necessary to make the effort to find something meaningful and positive about what has happened. Some people just happen upon this, they observe it, they feel it. For others it's much more of a struggle, task or challenge. But I think ultimately it's a requirement for recovery, that people create some positive meaning from the event.

In the research community, there has been an interesting debate about whether there is this thing called post traumatic growth. Some have framed the discussion in either/or terms: Are things worse or better after a trauma? The answer isn't one or the other. Both things happen. By definition, trauma results in changes that that are not good, and that are irrevocable. But alongside these changes are opportunities for growth. I think recovery from trauma means being able to purposefully engage in a search for growth, along with acknowledging the negative consequences.