After the attacks, many HIVers felt guilty, ashamed and alienated. Dr. Arthur Fox reports on what they can offer a wounded nation.

In the aftermath of the murderous destruction of the World Trade Center here in New York City, many of the HIVers I treat in therapy worried that they were not having the "appropriate" feelings about the tragedy. Some felt angry at themselves because they couldn't assist in the immediate rescue effort: They were, of course, forbidden to give blood; many felt too frail to volunteer for the Red Cross. Others felt inexplicably irritated at, or resentful of, those around them. All of these HIVers felt alienated because they became preoccupied with their own personal failings -- such as health concerns or relationship problems -- at a moment when they were supposed to be unified in national grief and anger.

My patients' sense that they were "inappropriate" is due mostly to the fact that the feeling aroused by the terrorist attacks -- aggression -- is one that many of them have trouble recognizing and dealing with in a healthy way. When humans are threatened, a "fight or flight" response is universal. But directing aggression at the appropriate target -- the cause of the threat -- is not. For many people living through the social and psychological hazards of HIV, shame or guilt -- anger directed against oneself -- was a quicker reflex than rage.

Shame can make people feel abnormal and excluded from the common experience. But interestingly, some of my patients also felt an uncanny sense of coherence -- that the outside world was finally making sense. For Wally, a New Yorker I have worked with for four years, the main effect of the disaster was a weird sense of harmony. "I feel calm," Wally told me. "Everyone else is suddenly panicked and anxious, angry and sad, and I'm like 'This is how I feel every day.'" It's not that Wally doesn't feel grief for the victims and the bereft. He does. But he also feels contempt -- especially for the official sentiment that "life will never be the same again."

"These self-entitled people never imagined anything like this could happen to them!" he says. "This sense of precariousness that everyone is talking about -- it's like bread and butter to me. I've experienced no 'loss of innocence.'" As friends and colleagues express, say, their outrage, Wally tries to join them. But this only reinforces his sense of alienation. "I feel like I'm acting in a movie," he says. " It's so unreal."

Wally's response is not unusual among HIVers, particularly those who have survived childhood abuse or neglect, discrimination, illness and multiple losses. Early-life trauma can interrupt psychological development, especially the integration of destructive impulses; when this happens, the management of aggression can become a lifelong struggle. Many can, like Wally, repress their early aggression enough to build a strong network of friends and a successful career. But violence on the scale of the terrorist attacks can temporarily break down these old defenses. Then thoughts and feelings emerge that seem inappropriate -- ranging from anger at the victims to a vague affinity for the hatred embodied in the footage of the airliners slicing into the buildings' steel ribbing.

Therapy has helped Wally accept that such a response is a relic of his early life and, however morbid, doesn't invalidate his behavior in the outside world. In fact, the public actions of many HIVers in this time of tragedy bears testimony to how remarkably altruistic and "appropriate" abuse survivors can be.

Wally's sense that he is "in a movie" isn't abnormal, either. Many New Yorkers in the weeks after the terrorist attacks reported feeling a sense of shock and disbelief. This is a psychic strategy for suspending emotion in times of grave danger, maximizing the ability to respond rationally and quickly. Some people can let the shock recede fairly quickly. But for others, symptoms of post-traumatic stress such as nightmares, irritability, hopelessness, anxiety and numbness can linger. (There is evidence that people who have experienced previous trauma -- from abuse to an HIV diagnosis -- may be more vulnerable to these symptoms after a new trauma.)

The first step in the work of healing is to establish a feeling of safety. But how do you recover from trauma in a world where "safety" may be unrecoverable? This paradox is something many HIVers already know about: Those with the virus have learned how to live day to day with danger and instability; people who have lost many friends and lovers have had to face prolonged shock and protracted mourning. As the thousands of people whose worlds were shattered on September 11 struggle to work through their grief and fear, HIVers are in a position to share wisdom about how to do this and show compassion for how hard it is. This may be the greatest contribution HIVers can make to the national healing process.