Anne Yarowsky is a candidate at the Institute for the Psychoanalytic Study of Subjectivity.

On a recent afternoon in the Mt. Sinai Hospital World Trade Center Worker and Volunteer Mental Health Intervention Program, a screening and treatment program for the rescue and recovery workers at Ground Zero, a 47-year-old Spanish-speaking electrician, describing his experiences through a translator, told me in a low, soft voice but in chilling, emphatic clarity, "9/11 has marked my mind." He was referring to his "tragic nightmares," the repeated images of the towers collapsing, his inability to sleep for more than two hours at a time without waking up, "afraid I'm dying, choking for air." He was referring to his grief and guilt for the many friends he lost in the towers, his increasing sense of isolation, his thrice-weekly headaches, his avoidance of Manhattan (which, as a contract worker, offered him less opportunities for work), and his disregard for his grooming ("I once cared to have nice clothes that matched," he remarked, pointing to his tattered jeans and sweater). As his head dropped lower he said he was feeling hopeless, and although he would like to be in a relationship (he is divorced), he was finding it hard to be with people. He cried when describing a previous trauma, the death of a newborn son shortly after birth, and he cried for his remaining son whom he missed and who still lived in his native land of Ecuador.

As screenings go, this one, like so many hundreds before it, was difficult in content and deeply disturbing in its details (the majority of the screenings include gruesome, unimaginable descriptions of carnage), but as screenings go, the emotional tone, though grim, was calm. Not at all like the session with the 45-year-old ironworker from New Jersey, who worked for seven days at Ground Zero cutting out bodies from the twisted steel, who, terrified of being back in Manhattan for the first time since 9/11, insisted, pleaded, that I open all the windows and door of the room during our talk (this was a cold March day), so that if he needed to flee there would be nothing in his way to stop him. I pushed up the windows looking out on New York's Central Park, opened the door to my office, put on my coat, and for the rest of the session tried to contain a tall, once-strapping male who had lost 50 pounds since 9/11 and who, after going hunting a few months back had begun the traditional rite of deer carving when the image of the deer's open, bloodied carcass sent him into a state of unmitigated panic and intensely activated post-traumatic suffering. Since his "reliving" with the sight of the carcass, right up until the time of our screening, the once-daredevil ironworker had not been able to leave his house and had completely stopped working. For the rescue and recovery workers at Ground Zero, this scenario is not unusual.

More than two years out from 9/11, the intense suffering of the rescue and recovery workers witnessed by the 3 psychiatrists, 9 clinical social workers, and dedicated supporting administrative staff of the screening and treatment program is widespread, and in many if not most of the new cases that come in our doors, it is worsening. It is the human face of post-disaster psychic trauma in men and women ranging in ages from 18 to 65, who come from places such as Brooklyn, Staten Island, the Bronx, New Jersey, Indian reservations near the Canadian border, El Savador, Kenya, Russia, Poland, and Cambodia to tell us their story of 9/11, their ongoing story. The NYPD come to us, active and retired firefighters, technicians and engineers from the MTA, Port Authority police, morgue workers and workers from the medical examiners' office, ironworkers, Con Ed workers, telephone technicians, operating engineers, and Spanish- and Polish-speaking asbestos workers, as well as one of the clergymen who blessed the body parts at the temporary morgue. They come and tell us of their panic, their difficulty leaving the house, or they tell us about the opposite, their compulsive activity to dull their emotional and, in some cases, physical pain. They tell us about constant hypervigilance ("I feel that while we're sitting here someone is going to throw a bomb through the window and kill us," said one female worker I interviewed); they tell us about their impaired concentration, nightmares that cause one individual to jump out of bed and then literally put on his suit and tie as if he is going to a funeral. They describe their depression and in some cases their increased alcohol usage to manage the pain and make unendurable, intrusive images go away. There is pervasive suicidal ideation among this population. But below their current highly activated symptoms is the presence of an equally persistent, one could say, existential, phenomenological crisis in each of these workers that drives their symptoms' activation. "Disaster has special meaning for each of its victims worthy of clinical attention," writes Katz and Nathaniel (2002, p. 521). "Indeed, that very attention may help to reduce symptoms. . .."

Divining this personalized meaning behind their work at Ground Zero is one of the organic goals of treatment, and it haunts and weaves its way through the workers' stories. For many, it is the meaning of their bald, unblinking confrontation with death, a death that ultimately gets taken in and through identification becomes their own, like the rescue and recovery workers who were already working in the area on the morning of 9/11 and who, in the course of what was starting out to be just a normal day's work, ended up witnessing not only the unreal sight of the planes crashing into the towers but of people jumping or diving from the windows. They could see the crazed, desperate jumpers going down with hands held in prayer or with hands holding onto the hands of a partner who jumped with them, or they saw them jump alone, arms and hands held spread-eagled, and then unbelievably splatting onto the pavement in five-foot-high liquid fountains. For the individuals who saw these sights and then went on to provide rescue and recovery services, their position in the world is tenuous, and their identification with death now causes them to feel as if at any moment they are about to die too. (Many of the workers say they still hear the sound of thumps, of bodies dropping.)

Identification with death also pervades the consciousness of the rescue and recovery workers who arrived at Ground Zero in the days and weeks after 9/11 and who, like the workers already at the scene, witnessed mass death in the horrific visualization of the body parts that covered the area (from our interviews it would seem that there were no bodies discovered intact) - a lone hand clutching a still-ringing cell phone or the pair of hands tied up in wire, presumably the hands of one of the airline stewardesses - or the equally horrific absence of body parts, which created what one construction worker referred to as the "death dust," the dust the workers stepped in and worked in and got over their clothes and into their nostrils every day and night they were there. One ironworker told me he can no longer take showers because they trigger his post-traumatic symptoms as they remind him of the showers he took while working at Ground Zero trying to cleanse his body of the dust. Death as overwhelming loss is experienced representationally in these workers' lives and is concretized in their loss of concentration, sleep, loss of appetite, loss of pleasure in family members, friends, and sex.

Trauma, it has been said, is the shattering of an experiential world. And the world of the men and women we are seeing has been transformed from a world of safe, predictable assumptions about humankind to a world of random and vengeful, colossally meaningless horror - a story of death, where a father goes to work in the morning and three weeks later the family buries the only remaining part of his once vital self, a tooth. These men and women no longer feel safe in the world, as if the stimulus barrier, a defense erected to keep us from terrible realities, has been permanently ripped away. Loss, therefore, is one of the existential meanings driving these workers' symptoms, as is the profound grief of these individuals and the intractable survivor's guilt and powerlessness that racks almost all the workers we speak with. "If I had just taken one more tool with me, I could have saved someone," said one ironworker in tears. "If I had known what was really happening down there, I would never have sent my men down there, the ones who never came back," said another. Many of these sad, guilty men and women make Sisyphean efforts to rid themselves of their guilt by daily penitenciary acts and thoughts, each trying to make up for what they consider to be their fatal "mistakes" at Ground Zero.

But finally, and in some cases perhaps more powerfully, it is the underlying meaning of each individual's past traumatic experiences and how the themes of those past experiences - unexpected personal horror or death, powerlessness in the face of overwhelming danger - now resonate within their own experience of 9/11 and accelerate and intensify their current symptoms and reactions, provoking as it were an almost double-loaded PTSD (this is almost certainly the case with rescue workers who are also Vietnam vets). By way of example, for many female rescue and recovery workers, repressed or unfinished memories of childhood sexual abuse have emerged since their work at Ground Zero; for two middle-aged male workers I interviewed - both adopted at childbirth - the loss borne of 9/11 has led them for the first time to search for losses from their past, their lost biological mothers. One medical worker I interviewed worked at the city morgue during Ground Zero and two months later was called to the Flight 587 plane crash in Far Rockaway in which he described the hundreds of intact bodies he sifted through. "I just remember loading all those bodies on top of each other in the truck," he said, still obviously reeling in shock. From his tone and his description I suddenly visualized old movie footage of the Holocaust, of dead, lifeless, gray bodies being loaded into the back of German trucks, one on top of the other. I was taken aback by my reaction, I didn't know where it had come from, but five minutes later, and out of nowhere, the medical worker told me that both of his parents were concentration camp survivors. When I asked him if he had ever talked to anyone about his experience as a child of Holocaust survivors, he said no, but it was clear that this experience had everything to do with the complicated and debilitating reactions he was having now at this present time to his experiences both at Ground Zero and the crash site.

As of this writing, almost 4,000 rescue and recovery workers have been screened by our mental health program and approximately 750 workers have continued for treatment. There are thousands more we need to get to, talk with, listen to, and treat. It is a daunting, sometimes devastating task, but it is daily infused with incredible hope as we begin to witness the ice melt and the terror subside in these living victims. With help from our program and perhaps from others that hopefully spring up like it, the rescue and recovery workers will get better, but they will never be the same.

Copyright ©2003 by Anne Yarowsky.

References

Katz, C.L., and Nathaniel, R. (2002). Disasters, psychiatry, and psychodynamics. Journal of The American Academy of Psychoanalysis, 30(4), 519-529.