Making Sense of Chaos: How USU Researchers Responded After 9/11 and Advanced Modern Military Mental Health Care

25 Years Later, Longtime Leaders at the Center for the Study of Traumatic Stress Reflect on Their 9/11 Experiences and Lessons Learned

September 11, 2026 by Melissa Reichley

On the morning of September 11, 2001, two military doctors who now lead the Center for the Study of Traumatic Stress (CSTS) at the Uniformed Services University of the Health Sciences (USU) were at Walter Reed Army Medical Center in Washington, D.C., when American Airlines Flight 77 struck the Pentagon.

CSTS Director Dr. Stephen Cozza, then chief of Walter Reed's Department of Psychiatry, walked from his office to the Behavioral Health clinic, concerned that sensitive patients were watching live coverage of the disasters unfold on TV. CSTS Associate Director Dr. David Benedek (USU class of '91), then Walter Reed's director of Forensic Psychiatry, confirmed they were all watching. Cozza told Benedek, '"We need to go to the Pentagon."

The team worked on site for several months and has partnered with USU researchers ever since to turn what they learned into practice standards.

The Evolution of Behavioral Health Response

Before 9/11, Walter Reed's psychiatry department largely focused on treating individual patients with standard disorders. After the Pentagon attack, Cozza, Benedek, and their colleagues were called up as a collaborative group and needed to pivot to an operational disaster response model. That shift began a new era in how military psychiatry supports those who experience trauma and grief.

"The Pentagon attack consolidated our group, our clarity, and our specialty in the area of trauma, trauma response, and disaster response," says Cozza, who began conducting research at USU in 2006 after retiring from the Army.

The events of 2001 also put CSTS on the map in terms of disaster and terrorism response, says CSTS founder and longtime Director Dr. Robert Ursano, who retired from USU and Federal service in May 2026. "It was our responses to those events throughout the center and the university that made us internationally known."

The Immediate Response: Creating Order from Chaos

When Cozza, Benedek, and their team of more than a dozen mental health colleagues arrived, the scene was more stark than anything they could have imagined. "It was mass chaos," says Cozza. The Pentagon was billowing black, acrid smoke. Most of the 24,000 people inside had been evacuated, but fires still burned as responders carried people out to triage areas.

Four missions were established, embedding the team of psychiatrists, psychologists, and social workers into the response. The "outside mission" supported rescue workers in search and recovery efforts at the crash site, watching for distress and enforcing rest breaks. The "inside mission" cared for Pentagon employees grieving colleagues and coping with disrupted operations. At the Pentagon Family Assistance Center, in a nearby hotel, mental health experts counseled families of the missing and deceased. The team also worked with hospitalized survivors to monitor those at risk for post-traumatic stress.

Much of the work was psycho-educational. The team explained to first responders, survivors, grieving families, and thousands of Pentagon employees that the way they were feeling was understandable based upon having experienced really horrible and unpredictable events. They clarified the difference between expected predictable responses to very stressful events and actual illness or psychiatric disorder.

Overcoming the Stigma of Mental Health

Mental health problems have been stigmatized for centuries, and that stigma was alive and well in 2001. Cozza says the importance of mental health outcomes tied to disasters and stress has long been minimized. Case in point: In the aftermath of the attack, Walter Reed rapidly established an emergency decontamination and inpatient unit with approximately 60 beds to care for those suffering physical injuries, Cozza recalls. Those beds weren't needed.

"The most immediate response that was required was related to behavioral health-but, not just in the context of disorders like PTSD," says Cozza. "History has repeatedly shown us that psychological responses to disaster, trauma, and war create the largest number of casualties. But they are also the casualties that, with proper support, can return to the fight."

Benedek bypassed some workers' initial reluctance to seek mental health care by putting fact sheets in a pocket on his door. "No one was coming saying, 'Hey, I need to see a psychiatrist. I work at the Pentagon.' But if I had a fact sheet on 'how to talk to your children' about what occurred or 'stress management tips in the aftermath of a traumatic event,' those sheets would disappear," he says.

Much of the consultation Cozza and Benedek did on site was checking in with people informally-not done in a medical record. This "therapy by walking around" intervention revealed most of those exposed didn't have disorders; they were simply trying to find ways of adapting to the experience and the stress they were under.

What matters in the wake of a disaster is the impact traumatic stress has on behavior-sleep, daily routines, substance use, patterns of risky behavior-all critical to readiness and military mission, says Cozza. "We should think less about mental illness, and more about how we promote individual and community responses that keep people healthy and functional after they've had these experiences."

There was no mental health clinic inside the Pentagon until 9/11, says Benedek. Today, psychiatric assessment is standard protocol for service members treated for serious injuries after terrorism or combat, and mental health consultation is recognized as a critical component of field training at USU's Operation Bushmaster.

The Importance of Support for Leaders

While field teams worked at the Pentagon, Ursano, a retired Air Force colonel and then-chair of the USU Psychiatry department, and Dr. Carol Fullerton, scientific director for the Center for the Study of Traumatic Stress and a professor of Psychiatry at USU, supported their colleague, Navy Capt. (Dr.) Thomas Grieger (USU class of '85) and others from USU who were deployed to the Pentagon. Tasked with evaluating Pentagon and Walter Reed casualties and medical staff, Ursano helped his colleagues process the experience.

"The people directing a response are often the ones who go unattended," says Ursano, considered the "father" of disaster psychiatry. "Leaders need support. They overlook themselves. They put themselves at risk and they deal with very complex problems."

Cozza says Ursano was a steady presence for those out in the field, helping them to contextualize what they were doing and plan forward. The USU colleagues on campus acted as a sounding board, helping to provide objectivity and clarity to Cozza and Benedek, who were within the chaos of the day-to-day activity. "Having those echelons of engagement is an important piece of disaster response - being able to reach back to people who are less personally present," says Cozza.

In addition to supporting field teams, Ursano provided expert guidance on traumatic stress to federal agencies, academic institutions, and national media outlets.

Lessons Learned: Building a More Resilient Force

CSTS researchers have developed sustained research programs on disaster mental health, terrorism preparedness, workplace resilience, community resilience, and military and civilian traumatic stress. They have also expanded national and international collaborations in disaster psychiatry and public health.

Cozza, Benedek, and Ursano have collectively produced dozens of publications on what they learned after 9/11. Key lessons include:

• Trauma responses such as depression and PTSD can be delayed and worsen years later, so screening beyond initial flags is critical. Research led by CSTS researcher Grieger, Cozza, and Ursano informed development of the Post-Deployment Health Assessment (PDHA) and Post-Deployment Health Reassessment (PDHRA), which screen patients at regular intervals.
  
  
• Bereavement after sudden, violent death is distinct from normal grieving. While most people recover over time, about 15% of family members experience significantly elevated grief and functional impairment years after losing a loved one. Findings from the National Military Family Bereavement Study, led by Cozza, contributed to the addition of diagnostic criteria for Prolonged Grief Disorder to the Diagnostic Statistical Manual of Mental Disorders (DSM-5-TR) in 2022.
  
  
• Combat injury and disaster affect the entire family. Cozza coined the term "injured family" and helped develop tools for parents and clinicians to talk with children about combat injuries. Research continues into family interventions that support rehabilitation, which is directly linked to retention and readiness.
  
  
• Large-scale data reveal subtle risk factors once invisible. Previously led by Ursano and now helmed by Benedek, the massive Army Study to Assess Risk and Resilience in Service Members (STARRS), with more than 4 million data records, has evolved into predictive models that test how to reach service members at elevated risk for suicide. Ongoing research is testing how AI can give commanders and providers real-time input on service member health and risk.

Future-Forward Readiness

Emergency mental health response has evolved in many ways since 9/11. The operational principles built on lessons from 9/11 have shifted military mental health from observation to proactive surveillance. By integrating big data and AI to understand risk at scale, researchers continue to refine predictive models to prepare for future large-scale combat operations.

The 9/11 response and subsequent wars also fueled broader collaborations between military and civilian academia, which will be even more important in mass casualty environments where military health systems might need the support of civilian trauma centers.

As the military prepares for future conflicts, it does so knowing force readiness is only as strong as the mental health of its service members.