Marianna Spicer-Brooks

Can repeated viewing of horrific images such as those of Sept. 11 and its aftermath result in clinical depression? Can it generate post-traumatic stress in a fashion similar to that documented in people on the front lines of carnage?

One Maryland psychiatrist thinks it can, and his thesis is supported by a cadre of mental health experts with years of experience studying the effects on viewers of seeing violence on television.

As a television journalist with nearly 22 years of experience, I am, like many of you, well versed in the arguments we make when deciding to air violent or graphic images. As the Director of News Standards and Practices at the CNN News Group, I engage (with my boss) in discussions with the journalists here about the ethics of airing violent or graphic images on a regular basis. Many decisions fall into a gray area. The intent of this article is not to take a position, but to present the position of some of the scientific community, as fodder for discussions in your newsrooms.

I've been forewarned that these views may stiffen journalistic necks by the thousands. I hope it will tweak journalistic minds as well.

The Aftermath of 9/11: How Stressed Out Are We?

Let me set some parameters. First, the level of potential illness these clinicians are talking about is not just mild or moderate levels of "gee, that's really awful" anxiety. What prompted my interest in the issue was a not-yet-published paper by Dr. James Hutchinson. Based on his clinical experience, he theorized that repeated bombardment of viewers by the news media with the images of Sept. 11 could be causing the kind of stress associated with clinical depression.

Now, let it be said that, of course, we all know the immediate cure for such a problem--change the channel, turn off the TV, stop watching. The clinicians I spoke to acknowledge that people have that option. However, the Sept. 11 attacks were so unique, and the impact on those living in the U.S. so direct, people felt particularly vulnerable. They felt compelled to watch.

How can one separate the stress people felt from the events versus watching the coverage of the events? So far, there's only anecdotal evidence that significant stress has been caused by coverage as well as the events. People have reported they stopped watching because it upset them too much to be constantly reminded.

That large numbers of people were suffering from extraordinary stress symptoms after the attacks has been scientifically documented. A Rand survey by 10 psychiatric professionals on how the nation was feeling following the 9/11 attacks and the subsequent anthrax mailings was published in the Nov. 15 edition of The New England Journal of Medicine. The survey concluded that the Sept. 11 attacks resulted in "substantial" symptoms of stress for many Americans, and recommended that clinicians be prepared to help people with "trauma-related symptoms of stress."

The Pew Charitable Trust did two online surveys, finding that after the first anthrax infection was reported, while the anthrax scare didn't seem to be increasing stress levels more, almost 70 percent of Americans were concerned about new attacks, and more than half were worried those attacks would affect them or their families.

Multiple articles have appeared in the popular press, reporting on people who first watched attack coverage obsessively, then began regulating their intake.

Cause and Effect: What's the Scientific Evidence?

So how much is media coverage contributing to these documented stress symptoms? Obviously, television brought to people who were not in New York and Washington the sight of the attacks themselves, and their aftermath. What role has the coverage played, lengthy and detailed as it has been -- from the penetration of the first plane into the first tower through the rarely aired images of people leaping from the buildings, the center's collapse, and the days of desperate stories from the friends and families of victims -- in the development and exacerbation of the documented national malaise?

Dr. James Hutchinson is a Bethesda, Md.-based psychiatrist, internist, child psychoanalyst, and past president of the Washington Psychiatric Society. He says he thinks television news is designed to tweak the most basic human response to a threat.

Not much has changed in the way human beings react biologically to stress, Dr. Hutchinson says. "Nature usually does not abandon successful solutions," he says, "it elaborates them." People initially react to big crises such as Sept. 11 in much the same way they would have as cave men. Here comes a lion. There are three choices: freeze, fight, or flee. Many people are familiar with the term "fight or flight."

So how do average Americans, sitting in their living rooms, react to watching planes hit the World Trade Center?

Dr. Mark Schuster, who headed the Rand Corporation study published in the New England Journal of Medicine, told Reuters, "People reacted as if they were personally attacked."

Dr. Hutchinson's concern is that people were unable to react in a way that allowed them to dissipate their stress. The ancient, "emergency attention system" kicks in. Adrenaline and other stress hormones flow, to prepare us for flight or to fight.

But people can't really "freeze," so they "freeze" in other ways. They stop flying. They stop going to the mall. They are afraid to go anywhere, or do much of anything.

There's little they can do to fight, unless they're in the military or working for a government agency that plans a response. And there's really nowhere to run and hide.

So they worry instead. And the more they worry, Dr. Hutchinson says, the more stress hormones they produce, the greater their potential becomes for real illness. Repetition of traumatic images makes it worse, and children handle it the most poorly.

Modern man has refined his emergency response. Where the more ancient reaction gives us "fast answers," Dr. Hutchinson says, and generates "fear or rage," the newer system generates "interest and calm reflection." The new system "allows us to consider problems in depth and bring our massive intellectual capacities to bear. But given enough stress, the ability to make that differentiation can break down."

As Dr. Hutchinson puts it, "excess arousal of the emergency attention system" carries with it the possibility of "inducing psychic trauma in the audience, which occurs at times of extreme emotional overload.

"It causes an oscillation between a numbing of feeling and recurrent bouts of intense feeling that can include fear, rage, or depression. Memories of traumatic events can either be burned into the brain like a flash photo, in which case they usually bring the intense distressing feelings back with them, or blotted from memory, in which case they generate a confusing hazy state where it is difficult to think."

That hazy state can interfere with memory, even basic facts, Dr. Hutchinson says. "They may become emotionally paralyzed or give way to impulsive behavior driven by fear or rage. In psychic trauma, the sense of danger has been so overwhelming that there is a semi-permanent change in a person such that the emergency system can be turned on full blast by almost nothing. These changes can last from weeks to the rest of a person's lifetime."

Dr. John Murray, a professor of developmental psychology at Kansas State University, has studied the effects of television violence, particularly on children, for many years. Among his studies are those that monitor the areas of the brain activated when people watch violent images.

One study concluded that the same areas of the brain are activated by watching violent images as are activated in patients who suffer from Post-Traumatic Stress Disorder or PTSD. While he has not been able to do a study that compares the impact of viewing real versus fictional violence, he believes the areas activated will be the same. In PTSD, recalling traumatic images or events can debilitate the sufferer.

Continuing to talk about the threats, or repeated viewing of them, can make it worse, he says. "The same issues keep being refreshed in new and more traumatic ways."

"Cues keep you aroused," Dr. Murray says, "the constant talk about threats, increased threats. Arousal doesn't go down if you have constant re-generating cues." Of course there are cues besides watching television coverage, he points out, such as a plane flying overhead, but people spend more time watching TV.

Dr. Joanne Cantor is the author of Mommy, I'm Scared and an expert on the impact of televised violence on children. Studies she has done show that children are especially frightened by what they see on news shows. They worry that what they are seeing will happen to them or their families next. "Many kids don't want their parents to go to work, or work in high buildings. They don't want their parents to fly anywhere."

Teachers Dr. Cantor talks to are saying their students are reporting they're not sleeping, and are talking about the attacks a lot. She recommends that teachers not show breaking news coverage of such events as 9/11 in the schools. The instinct to allow your students to experience history, she says, may not necessarily be the right one.

"Exposure to TV news on 9/11 is a good predictor of poor coping among kids," she says.
But she believes even adults will react more intensely to real rather than fictional images. "The stress involved in that is very strong," Dr. Cantor says, "and it's not as easy to put away." The stress reactions "don't go away in a few minutes," she says. "The effects on your body stay with you, in not sleeping. Memories of things that happened under really intense fear are really almost indelible, as we've seen in vivid memories of movies."

The effects of this stress can range from stomach problems, high levels of anxiety, problems sleeping, increased consumption of alcohol, or smoking. "Many people who gave up smoking went back after 9/11 as their security blanket," Dr. Cantor says. "However people handle stress, that is what they're likely to do."

This attack was different for Americans, says Dr. Teri Elliott, who specializes in disaster psychology. "Americans have had a sense of security, and this really violated that. That's going to be the longest term impact-- it violated our sense of safety. America's looking at the world differently, not feeling as safe, as confident in their government to keep them safe."

And, the more graphic the image, the more permanent its effect, she says. She was appalled that any media outlet used pictures of the people jumping from the World Trade Center. "It is absolutely true that graphic pictures get forcibly embedded in memory and can have a negative effect on well-being. There were thousands of people who didn't know if their family, or their neighbor was alive. What was the benefit [of showing those pictures]?"

Give Me an Example…

Dr. Hutchinson believes that the media, for competitive reasons, directs its coverage toward eliciting the "emergency attention response," or the ancient system. This, he says, "amplifies the emotional impact of the terrorist act. It lessens the capacity of the public to think and respond rationally to the new circumstances."

• Here are some examples Dr. Hutchinson lists in his paper that he believes the media does which elicits this response:
  
• Visuals of dangerous or catastrophic events, particularly if they involve human aggression (a bomb is more frightening than a volcano or flood).
  
• Showing individuals who have been injured, killed, or are displaying extreme emotional responses.
  
• Suddenly showing a catastrophe without preparing the audience ahead of time. "It is unexpected events that most fully engage the emergency response."
  
• Repetition of graphic visuals (the bullet actually striking President Kennedy's head or the explosion of the Challenger).
  
• Emergency sounds - explosions, gunfire, sounds of people in panic.
  
• Evidence that "authorities" are out of control and unable to respond.
  
• Idealizations of the enemy's cunning or capacity.
  
• Use of "hot" words such as "catastrophe" or "panic."
  
• Speculation about "what might come nex.t"
  
• Anything that conveys that the viewer is also in danger. The more immediate the threat, the more it addresses the emergency response.
  
• Anything that conveys the viewer is helpless-- especially the idea that the situation is unique or presents unsolvable problems
  
• Presenting extremists on the sides of a conflict. They are more likely to suggest dangerous conflict is near and to thus engage the emergency response.
  
• Presentation of any behavior that is bizarre or unusual.
  
• Holding the audience in attendance while waiting for "breaking news."

Dr. Cantor adds that she hates the "scary music" which often accompanies "breaking news." "There's no reason to do that," she says. "We know that it's scary. Scary music just sort of revs up your emotional reaction to a higher level, and we don't need it."

Dr. Elliott objects to the repetitive nature of the coverage. "[What matters is] how you show it, how often, and zoomed in. Showing what happened was OK, but, in the first hour, you didn't need to see it 5,000 other times." In the best of all worlds, Dr. Elliott said, she wishes the news networks hadn't gone to 24-hour coverage, but done evening summaries, breaking in if something "momentous" happened.

And, Dr. Elliott objects strenuously to what she believes was an inappropriate invasion of the privacy of victims. An interview she saw with an executive of Cantor Fitzgerald bothered her the most.

"The man wasn't emotionally prepared to do that interview, or to know what he was saying yes to. He has to watch that interview, his family has to watch that interview, not once, but a thousand times. It's like Columbine," she says. "That kid [falling out the window] had to see that all the time."

The Contrarian View

My original intent in this article was to present the view of the clinicians you've already heard from, by itself, as fodder for debate. I did, however, try to find clinicians who disagreed with them.

I don't claim to have done an exhaustive search, but most journalists know, expertise lives in a small community, and everyone knows everyone else, especially those who disagree with them. I spoke to a couple of these "contrarians," and found the following:

1) They say there hasn't been much, if any, research done on the relationship between viewing graphic, real images on TV and the development of clinical depression. There has been a lot of research done on the relationship between violent entertainment programming and aggressive behavior. The contrarians I spoke to are in disagreement with the American Medical Association, the American Academy of Pediatrics, and the American Psychiatric and Psychological associations on that subject.

2) The generally agreed-upon view of the three contrarians I interviewed was that vulnerable people are more susceptible to developing depressive symptoms, but that people have the option to turn off the TV.

One of the contrarians, Dr. Marty Cohen, is a psychologist who does crisis intervention with first responders. He says caution is called for, because images can be potentially traumatic, but he also feels that seeing the images of Sept. 11 can be cathartic. Seeing the attacks and the aftermath can force people to get past a denial stage similar to that in grieving. He points to the rituals of viewing bodies at wakes and throwing dirt on the coffin at burials. "It helps [reality] sink in," he says.

There are biochemical reactions to what we feel are threats, he says, but there are things we can do. Just because we can't fight a sabre-toothed tiger, doesn't mean we can't get physical exercise -- walk around the block, run. He acknowledges that news coverage suggesting such ways to relieve stress might be useful.

Dr. Stuart Fischoff, who specializes in media psychology at Cal State and consults with the television and film industries, believes that "exposure to upsetting TV stimuli has more powerful effects on people predisposed to certain reactions, or to people who already have weakened defense systems." However, he says, the traumatizing effects of monitoring real-life continuous coverage of crises is "real." He commented on that subject following Oklahoma City, and advised one call-in viewer who was "beside herself with anxiety over non-stop watching of the coverage of the bombing, to turn off the TV and go outside and decompress." He says that was not well-received by the network he was appearing on, and he wasn't invited back for a number of years.

Tell Viewers To Turn Off the TV?

So, barring the unattractive option of telling our viewers to turn off their TV's, are there other choices those of us who decide what to put on the air should do? Does any of this lead you, as a journalist, to believe you should change your thinking on the showing of violent or graphic images?

Tempering the "emergency" response to crisis presents a real dilemma for journalists. Our training teaches us to respond quickly, almost by instinct, to cover the event, and to get our coverage of that event out to our audiences--viewers, listeners, or readers. We do some filtering--the debate over showing the people leaping or falling from windows in the twin towers, for example. But we also face the question of whether we should withhold from our audiences things we know or have seen.

In other words, even if we accept part or all of Dr. Hutchinson's thesis, and the advice of Drs. Murray, Cantor, and Elliott, can we change the way we present news? By being responsible in one way, are we being irresponsible in another?

Dr. Hutchinson says the following can minimize the likelihood of emotional trauma, and are more likely to evoke a more useful, functional response:

• "Verbal description is preferable to visual.
  
• If a frightening visual IS used, it is described first in words that give the audience a chance to prepare psychologically for what is coming.
  
• Visuals of people responding bravely, competently, sympathetically and effectively to the emergency.
  
• A calm demeanor in the anchor (anchors appear to have control over what appears on the screen, and thus are seen as dominant figures in the situation).
  
• Placing danger in statistical and historical contexts. ("While the danger of these events is not negligible," Dr. Hutchinson says, it probably does not compare to the danger of the Cuban Missile Crisis or even the danger of Pearl Harbor. After Pearl Harbor, it was almost a full year before the Allies had even won a battle against an enemy that was utterly ruthless and had won unprecedented victories up until that time. The higher attentional systems are adapted to placing dangers in a context and making cost/ benefit assessments with regard to threats.
  
• Presentation of interpersonal connections and response. The outpouring of volunteers, money, blood donation, ecumenical religious services, etc., offered a potent form of soothing.
  
• Critical assessments of the enemy's difficulties, flaws in thinking, etc.
  
• Concrete recommendations for lessening the danger.
  
• All clear signals. Return to regular programming. Using humor or displaying the humor of others at appropriate times.
  

The debate over government response, the exploitation of the crisis by special interests, and threats to civil liberties as part of the "war effort" is critical at this stage, Dr. Hutchinson says. The debates should not happen in the middle of reporting on the crisis, he says. He also recommends that both sides be represented at the same time, and that they be civilized, as opposed to fighting, which only increases the confusion and anxiety of the viewer.

Dr. Hutchinson says he believes, for the most part, network anchors have done an excellent job of keeping their cool and, as a result, the public's.

Dr. Elliott suggests some real "how-to" advice mixed in with the reporting, something that teaches people something rather than continuous "rehashing." How can people protect themselves? How do we stay calm? She suggests having experts present techniques such as breathing exercises and relaxation techniques commonly used to treat anxiety disorders andthat have been shown to reduce the physical symptoms of stress that can lead to more serious illnesses.

She also suggests providing experts who can talk about how to help children who lost parents, or just children who are scared and not coping. How people can help the community is important to share as well, she says, and not just at the beginning of the crisis, but three months down the road. Dr. Elliott points out that the rush to donate blood resulted in a lot of wasted donations.

"We've learned there are stages, emotional stages, that people go through in the recovery process from a crisis," Dr. Elliott says. "This is true for communities as a whole, as well. The media is there in the immediate stage-- the heroic stage-- people coming together and helping each other."

Then, Dr. Elliott says, the media goes away, and doesn't report on the next stage, the "disillusionment stage." "The reality of what has happened sinks in. The media is not there to help people know what they have to do to get their lives back together."

It's important to let people know they are "going to backslide," Dr. Elliott says. "They're going to feel worse, or depressed. They think it's [just] them, and don't see it as a natural part of the healing process."

"If we want to get our communities together," she says, "showing the process can help."

When You Cannot Turn Away

One final note directed specifically at journalists. Members of the media generally don't have the option to turn off their television sets or stop reading the newspaper. Dr. Hutchinson believes, for this reason, journalists are at additional risk. What can the media do to prevent making itself sick in covering these events?

Dr. Cohen notes that on the front lines of a crisis, "the cops and the firefighters have actions they can take." The media, he says, are doing their jobs, but not directly helping in the crisis, and in some cases might be seeing the specific results of an attack even more closely than the first responders, through telephoto lenses, for example.

And those back in the newsrooms that view the video coming in, all of it, make decisions on what pictures to use and what information to report, can be secondarily traumatized. Dr. Cohen has seen this effect in the case of the professional crisis interveners who debrief police, EMS, and firefighters after especially traumatic events, and are traumatized themselves.

"Don't keep it bottled up inside," Dr. Elliott says. "Take breaks, get away from it, play with your kids, read a book that doesn't have anything to do with war and terror and violence."

The Journalists Weigh In

Before publishing this article, I shared it with the Poynter Ethics Fellows, and some time in our final session this month was dedicated to discussing its merits. The vast majority believed the news coverage has been appropriate, and before our formal discussion, expressed to me their vigorous disagreement with the psychiatric experts in the article. I didn't talk to one Fellow who thought the pictures of people falling from the World Trade Center should not have been published. For those I spoke with, seeing those stark, desperate photos brought home the utter tragedy and horror of what happened more than any other single picture.

Others felt that we needed to make sure we provided a psychological balance to our coverage, that there were things we could do to mitigate the harm we might cause by showing such images.

One of the Fellows felt that, rather than limiting the airing of video of the crashes and the collapsing towers, the television news media should still be showing those images. "Lest we forget," was his justification. It is human nature, he said, to get past tragedy and move on. This event is one we need not to forget, and he said that holding back those images could be doing a disservice.

A commonly held belief among the Fellows was that we as journalists can't control how our viewers and readers consume our products.

Even those who felt the coverage had been appropriate expressed to me privately that they were concerned about the impact of the coverage on their children. Some had allowed no viewing, others complete access. Some related stories about their children expressing deep anxiety about their parents traveling. Others said they'd seen no evidence of heightened anxiety.

One Fellow suggested that it was important for theses like these to be considered by journalists, to extend the discussion beyond what is newsworthy. She said, "We need more ideas like this to make our decisions more difficult."

One of the Fellows noted that I had not expressed my own feeling about the thesis in the article. That was my purpose, not to express a point of view, only to present the point of view of a group of experts whose job it is to monitor and treat mental health, just as it is our job to decide what is newsworthy and responsible.

However, there is one opinion I will express. I believe these decisions should be difficult. Those of us who make them know they are, and I don't think we can go wrong making them as difficult as possible.