September 11th: Trauma and Human Bonds (Book Review)

Author:  Coates, Susan W. , Jane L. Rosenthal and Daniel S. Schechter
Publisher: Hillsdale, NY: Analytic Press, 2003
Reviewed By: Nina K. Thomas, Spring 2005, pp. 52-54

"There is no such thing as an infant…
without maternal care one would find no infant."
D.W. Winnicott (1960, p. 39, n.1)

Winnicott’s assertion is, albeit in different form, one that many of the papers in this edited volume examine; whether it be in the neurobiological research of Myron Hofer, the attachment research of Peter Fonagy and Mary Target, as well as that of Daniel Schechter, or the clinical observations of Susan Coates, Daniel Schechter and Elsa First or those of Adrienne Harris. Pulling together the strands of neurobiology, attachment theory, clinical psychoanalysis, and epidemiological studies, September 11th: Trauma and Human Bonds is an almost uniformly valuable collection of contributions from prominent writers in their fields. Most complement one another, enabling the reader to integrate the neurobiological studies with those on trauma and attachment or the several epidemiological studies with those addressing public policy and treatment concerns.

The book takes as its premise that trauma and human connection are inversely related. “What changes a challenge into stress and stress into a genuine trauma may in part be derived from the fact that it is undergone alone” (Coates, 2003, p. 3). Even more, the authors contend, human connection provides protection against trauma, a point repeatedly returned to in several authors’ reference to the landmark Freud & Burlingham (1943) study of London children during the blitz. Freud and Burlingham found that children who remained with their families despite the continued wartime air attacks fared better than did those children who had been evacuated to the countryside. This, for its day, startling finding, is elaborated in the present work along a number of dimensions including what Fonagy and Target (2003, p. 101) conceptualize as “interpersonal interpretive function” (IIF). Although not a new concept for these authors (c.f. Fonagy, 2001), it is explicitly presented here in relation to trauma. They develop the argument for how each of the constituent elements of “IIF”—the capacity for stress-regulation, the ability to focus attention on the demands of the present rather than to be pulled by the past, and “reflective function,” or the capability of understanding “human behavior in terms of thoughts and feelings” (p. 103)—is shaped by the quality of the infant-caregiver attachment and in turn affects the child’s response to trauma. “Children with secure attachment relationships should be able to regulate their emotional arousal better in the face of stress or trauma (Kochanska, 2001)” (Fonagy and Target, 2003, p. 102).

The links among maternal distress, the stress of the child, and intergenerational perpetuation of trauma is detailed in the work of, among others, Daniel Schechter (2003). The child’s distress, he asserts, becomes “a posttraumatic reminder for caregivers who have memories of their helplessness, horror and outrage during a violent assault” (p. 126). In these instances, maternal deficits in the capacity to “mentalize” or reflect on the child’s mental and emotional states is significantly more highly correlated with behavioral problems (11.1 times more likely, Schechter, 2003, p. 126).

Coates, Schechter and First (2003, pp. 23-49) also examine the attachment-trauma connection in the clinical examples taken from their work at the Family Assistance Center at Pier 94 in Manhattan in the immediate aftermath of 9/11. These authors cite the same evidence as does Schechter (noted above) that “children whose parents did not know how their children were responding after September 11 were 11.1 times more likely to have behavior problems at ages six to 11 and 4.0 times more likely at ages 12 to 17” (2003, p. 32). Their clinical cases vividly portray the experiences for children and parents who faced the incalculable losses wrought by the terror attacks. The creation of a safe environment such as that of the Family Assistance Center, even in the context of the chaos that ensued from 9/11, serves as a model of the kind of intervention that can be effective in such acute circumstances.

Space limitations necessitate that each of the 13 chapters is a relatively brief contribution. Most of the authors have written on similar subjects in other forums. Even so, the powerful and important material they contain and the opportunity to read them together is rewarding. What is of particular value is that they are brought together under one roof, so that, for example, the significance of neurobiology to negotiating responses to traumatic events, or the reverberations across generations of attachment patterns between child and caregiver, or the implications for health policy of epidemiological studies and for designing interventions in the face of future disasters can be knit together from the offerings here.

Hofer’s rich summary of the developmental and neurobiological consequences of attachment and separation is one example of a study that has relevance across a number of the presentations in this volume. His work looks at mother-infant interaction as a regulator of normal infant development, specifically the relationship between neurophysiological and psychological development and their connection to mother-infant interaction patterns. The “hidden regulators” (p. 194) as Hofer calls them, in the infant-mother interaction system have profound impact on the child’s physiological and neurobiological development with important implications for the development of both brain and behavior of the child.

Hofer’s animal studies yield particularly interesting results for the long-term and transgenerational impact of interventions on the neurobiology that underpins behavior, particularly in terms of response to stress. He has found, for example, that “qualitative differences in the patterns of early mother-infant interaction could have long-term effects on HPA /hypothalamic-pituitary-adrenocortical axis/ responses to stress in adults…” (p. 201). He has found these effects to exist across generations in rat studies. Their implications for human behavior are unclear but, as he suggests, are likely to reward further study.

Only some of the chapters emerge expressly from the work the individual contributors did in the aftermath of 9/11 while others reflect the long involvement of their authors in different aspects of theorizing about, working clinically or researching aspects related to trauma and its effects. Beyond those already mentioned there are two additional chapters that I especially want to call attention to. These are the contributions of Herman, Aaron and Susser (2003) and that of Cournos (2003). Their work addresses mental health policy and provision in the face of disaster.

Herman, Aaron and Susser call attention to the need for a rational public mental health policy that works to inoculate the population against terrorism’s psychological imprint. Equally, they call for a long view in response to such events as the 9/11 attacks, to which delayed onset of traumatic responses continues to be likely. (It would not be unexpected, for example, that the devastation of the recent tsunami in Southeast Asia with its pervasive consequences for such a broad population could provoke a renewal of the traumatic losses and grief for many who survived September 11th.) The authors describe what is now a well-known course for disaster preparedness: shoring up communities, having a disaster plan in place, key community leaders identified and schooled in delivering clear messages to the public in order to decrease anxiety among the public.

In a particularly poignant chapter, Cournos directs her attention to the trauma of dislocation and loss that occur in the experience of foster care, a circumstance that makes foster children a population chronically at risk of traumatization. The psychological and emotional needs of these children are too easily and frequently forgotten. As with public health policy generally, provision currently focuses on addressing the physical rather than the psychic needs of this population, an issue Cournos’ writing movingly critiques.

Several of the authors included in this volume note that as a consequence of 9/11 the stigma previously attached to accessing psychological assistance in the face of difficult life events has diminished. I am less sanguine that there has been so robust an outcome of the terrorist attacks. Yes, there was significant provision in the aftermath of 9/11 for the psychological needs of survivors and funding continues to be available even more than three years later. Yet anecdotal reports from many involved in working with rescue and recovery workers indicate that seeking psychological help remains shrouded in concern that doing so reveals the person’s “weakness.” The issue is not addressed in September 11th. To what degree attitudes toward help-seeking have changed in the course of the post-9/11 recovery would be useful to examine. Such attitudes are powerful factors underlying the support or lack of support for a sufficient or even adequate public mental health policy and therefore even more are worthy of study.

I take issue with Coates’ proposition that that patient and therapist share the trauma of the 9/11 attacks facilitates “greater emotional clarity” (p. 13). That both parties experienced the event does not in itself enhance emotional clarity, nor is it either unique or facilitative. Although it being true leaves no doubt as to what occurred, it is equally possible that the presumptively “shared” experience can as much influence countertransferential deafness to the patient’s experience as it does clarity. Coates’ point is a minor one in the otherwise complex and rich presentations offered here. Nevertheless it bears remarking on lest the potential for muddiness in the work of digging out from traumatic events be overlooked.

In his contribution, Hofer offers the prospect that there is the potential for new knowledge to be culled from the ashes of the 9/11 attacks. For the most part, this volume does a great deal toward beginning that process. Reading September 11th: Trauma and Human Bonds vividly re-evokes the memory of the events for those of us who were part of that period in New York. September 11th is, finally, a good and worthwhile read.

Fonagy, P. (2001). Attachment theory and psychoanalysis. New York: Other Press.
Freud, A. & Burlingham, D. (1943). Children in war. New York: Medical War Books.
Winnicott, D.W. (1960). The theory of the parent-infant relationship. In The maturational processes and the facilitating environment. New York: International Universities Press, 1965, pp. 37-55.

Nina K. Thomas is a supervisor and co-chair of the relational orientation at the NYU Postdoctoral Program in Psychotherapy and Psychoanalysis and senior supervisor, faculty and training analyst at the Contemporary Center for Advanced Psychoanalytic Studies at Farleigh Dickinson University in Madison, New Jersey. She was one of the initial clinicians in the “Firehouse Clinician Project” inaugurated through the efforts of other NYU Postdoctoral members, providing psychological intervention in firehouses after September 11th and also Co-Chair of the American Group Psychotherapy Association’s Disaster Outreach Task Force, designing, implementing and evaluating group interventions of clinical services, support groups and training in the aftermath of September 11th under a grant from the New York Times Family Foundation 9/11 Neediest Cases Fund.

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