On Sept. 11, 2001, planes exploded in fiery clouds, buildings collapsed, and people ran for their lives. Immediately, frantic efforts began to gain control of the situation - to rescue survivors, protect the country from other attacks, and help the wounded.

Very soon, another aspect of this crisis came into focus. What about the emotional wounds? Of those who lost loved ones or who witnessed the attacks directly. And of a terrified nation, watching planes slam into buildings over and over on television.In the days after the attacks, and in the decade since, behavioral health researchers and practitioners have learned a great deal about how people cope with emotional trauma.

They've learned, often the hard way, about what steps help people deal with a wrenching event and which do not.

They've picked up practical lessons about how governments, organizations communities can respond effectively to traumatic events that hit on a grand scale.

Progress understanding Post-Traumatic Stress Disorder has helped veterans of the two wars that followed upon 9/11, in Iraq and Afghanistan. Manuals and protocols developed after the attacks have proved useful after tragedies such as the Virginia Tech shootings. And things learned about how to avoid chaotic response to large-scale trauma are being put to use today in places such as tornado-plagued Joplin, Mo.

Impact on children

On Sept. 11, Steven Berkowitz was working in Connecticut at the National Center for Children Exposed to Violence.

Berkowitz, now a psychiatrist at the University of Pennsylvania, recalls that, within minutes of the attacks, the U.S. Justice Department was on the phone. Department officials asked his center to develop guidelines ASAP on how parents and children could deal with the aftermath of the attacks..

Berkowitz gathered information on how to discuss the events with kids, and urged parents to protect their children from too much media coverage. He was concerned for children who were watching the TV news, and especially worried about children who had lost parents, or witnessed the attacks first hand.

Among those children were Bradley and Kirsten Cills of Bucks County. In 2001, they were living in New York City with their mother, Cherie Brummans. The first plane hit the World Trade Center as they were on their way to school. Kirsten Cills was 7 at the time, and remembers many small details of that chaotic and harrowing day.

"There were shoes everywhere," said Cills, "I guess people couldn't keep running with their shoes, their shoes kept falling off."

Her brother, Bradley, was 10 at the time, and remembers the buildings collapsing, and a wall of smoke coming at them.

Brummans says that Bradley witnessed people jumping from the building, and initially asked if the firemen were going to catch them with a big trampoline. Later that night, with the family finally gathered at the home of friends in Brooklyn, Bradley brought up the issue again.

"He said, 'Mom, I figured it out' " recalled Brummans. "'Those people today had to decide how to die, they had to burn or jump.'" Brummans said all day, she had simply tried to keep her children safe, but knew that the emotional toll would be enormous.

Berkowitz worked with many kids like Bradley and Kirsten Cills in the aftermath of 9-11. He said between 15-to-20 percent of them developed Post Traumatic Stress Disorder, or other mental health issues such as Obsessive Compulsive Disorder.

Both Bradley and Kirsten have been in treatment for different mental health issues since the attacks.

Well-meaning chaos and mistakes

Berkowitz says in addition to kids, mental health professionals were especially worried about first responders, survivors and direct witnesses.

A powerful urge to do something, to help was palpable, and makeshift counseling centers sprung up in churches and community centers. The mental health efforts were uncoordinated, recalls Berkowitz. Different organizations were trying different approaches, and mental health professionals - and other less-trained "counselors" -  were tripping all over each other.

One approach that was popular in the wake of 9-11 was "debriefing," where first responders were asked to talk about what they had seen in groups. That approach, says Berkowitz, has subsequently been shown to not be very effective.

"A lot of what we did back then was more experimental," said Berkowitz. "We had never dealt with a crisis of this magnitude before."

In the years since 9-11, several manuals and guidelines were published that help communities and individuals respond to the emotional aspects of crisis.

One is a document called "Mental Health Response to Mass Violence and Terrorism," published by the Substance Abuse and Mental Health Services Administration in 2004, which many have praised.

Several psychological first aid guides are also available now, and have been distributed widely.

Healing 'Hokie Nation'

These resources were a life line for Christopher Flynn, who heads the student counseling center at Virginia Tech University. He came to Virginia Tech in 2006 from a college in New Orleans, where he'd lived through Hurricane Katrina.

On April 16, 2007, Flynn received news that two students had been shot in a residential hall on campus. While he was working with students in the aftermath of that shooting, he got word of more shootings. He says his reeling mind could barely process the information he was getting.

Within minutes, though, colleagues started sending resources and manuals via e-mail, and this body of research helped him coordinate a solid mental-health response.

As classes resumed after a few days, Flynn made sure anybody who needed help or counseling had access to it.

"We put out call for licensed mental health professionals to come and volunteer," recalls Flynn. "Given what had happened, the resumption of classes went incredibly smoothly. I am not saying people didn't have a difficult time. They did, but the awareness that everyone had potential trauma paved the way."

Flynn said the close-knit nature of the Virginia Tech campus, and the strong ties alumni felt to the school, also helped the students cope.

A town leveled, but rising

Psychologist Vicky Mieseler is vice president for clinical services of the Ozark Center, near Joplin, Mo.

She notes that a disaster with the scope of the tornado that leveled much of Joplin last May destroys much of the infrastructure that a community relies on to cope. The twister took out eight counseling centers and 18,000 cars, including most of those used by her staff. She, too, noted the problem Berkowitz saw after 9/11 - too many well-meaning helpers wanting to do something, and not enough staff or time to get them registered and organized.

Eventually, another mental health organization set up a Web site where the volunteers could register, and their credentials could be vetted.

Mieseler that was a key to getting a grip on the catastrophe. She is now working on building a trauma center for children. Mieseler had submitted a proposal for this center two years ago, but didn't get funding. In the wake of the tornado, she has received state funding, and says chances for additional federal funding are good.

A veteran's struggle

University of Pennsylvania psychiatry professor Edna Foa is one of the world's leading researchers on post-traumatic stress disorder. She can tick off without hesitation the symptoms of PTSD: flashbacks, intrusive thoughts (that tape that keeps playing in your head), sleeplessness, anxious vigilance.

Tony Rakoczy, a Veteran Marine from Bucks County who did a tough tour in Fallujah, Iraq, during the height of the insurgency, lives those symptoms every day.

During a raid, he injured his right knee, and subsequently got an infection that severely damaged his heart. He underwent open heart surgery, and was honorably discharged. It turned out the heart problem was only one of his worries. The emotional wear and tear was worse:

"The day that I checked out from Camp Lejeune, N.C., when I came home, it started then," he said. "I didn't know what I was going to do with my life."

Rakoczy said he'd wanted to go into law enforcement, but that was no longer an option due to his health concerns. He felt at loose ends, and guilty because his old unit had deployed back to Iraq.

"My unit went to Ramadi and a couple of my close friends didn't make it," he said. "And to sit here and think that if I was there, maybe I could have changed something... These are the guys I was with, it's a brotherhood, it's a family."

Rakoczy was, he says, an "emotional wreck." His old buddies from Bucks County said they didn't recognize who he'd become.

"I found myself isolating," he said. "I didn't like to leave the house, loud noises bothered me. I couldn't sleep. It was terrible."

Stuck in his mind was the image of one 12-year-old Iraqi boy "with half his face missing."

Nights were the worst: panic attacks, night sweats, nightmares.

Taming PTSD

Foa, the Penn researcher, says these are all classic signs of PTSD.

She has developed an approach to treating the disorder called Prolonged Exposure Therapy.

Foa says those who develop PTSD tend to avoid thinking about the trauma, and recoil from places and activities that remind them of the trauma. So, this therapy has a two-pronged approach:

"The therapist will ask a patient to tell the story aloud, recount it, in lots of details, including emotional details, and it's very important to be in touch with their emotions. Repeatedly. We tape it, and that allows the patient to get new perspective about what the trauma was, and it allows them to change the perception about the world. This event is a story, a memory, it is not happening now."

In other words, they learn to distinguish between the memory of the trauma and their lives at this moment.

The other part of the therapy involves gradually returning to places and activities that the person has been avoiding; the movies, a crowded public place and so on. Reclaiming these activities, allows them to build confidence that the world is not an unsafe place.

Prolonged Exposure Therapy has been adopted by Veterans Administration hospitals, where it is one of several therapies offered.

A VA hospital proved to be a lifeline for Tony Rakoczy, who reached out to his congressman at the time, fellow veteran Patrick Murphy, who connected him to the VA hospital in Philadelphia. Receiving therapy and medications, he is doing better:

"I feel like there is hope now, and before I didn't have hope," he said. "I have a little girl now, and she is everything to me, she is my world, I tell my psychiatrist that's what makes me click."

Rakoczy says his physical woes from his Iraq service pale besides his emotional wounds: "Most people would tell you they'd would never want to have their chest ripped open and their heart pulled out, but I would do that six times over to get rid of the way I feel emotionally, I wish they could zap my head, zap my brain and erase everything."

A decade's hard lessons

Steven Berkowitz says trauma research has come a long way in the last decade.

Better treatments are available for people like Racoczy who live with PTSD.

Clinicians now have a much better sense of what prior factors put a traumatized person more at risk of developing PTSD or other problems such as Obsessive Compulsive Disorder.

Behavioral health organizations now have a much better sense of how to coordinate a quick, useful response to calamitous events that provoke widespread emotional trauma.

And there's also hopeful research on just how many people actually get past symptoms and work their way through to a healthy perspective on a life-changing event.

Drexel University's Sandra Bloom says that treating people for trauma can be a long journey with many steps, but when done right, treatment can be "fabulously successful", and can allow people to live meaningful lives.

"A trauma, by definition, is a life-changing event," said Bloom. "We as people or communities get to decide if it changes us for better or for worse."

Out of the Shadows airs on WHYY-FM, 90.9, at noon Monday, 10 a.m. Wednesday and 6 a.m. Sunday. Listen Live.

For more interviews and retrospectives on the Sept. 11 attacks, go to our special commemorative page, www.whyy.org/after911.