"No one has escaped the impact of the attack," said Neal L. Cohen, M.D., commissioner of the New York City Department of Health and Mental Health. He was speaking about the eight million New Yorkers who are in various stages of mourning about the loss of life at the World Trade Center, but his words are equally applicable to horrified onlookers throughout the world.
On October 2 Darrel A. Regier, M.D., executive director of the American Psychiatric Institute for Research and Education and head of APA’s Division of Research, and Juan J. Lopez-Ibor, M.D., president of the World Psychiatric Association (WPA), cochaired a video conference that linked sites in Madrid (where the WPA was holding its International Congress), New York City, and Washington, D.C. Its purposes were to share with their colleagues the response from mental health professionals to the attacks, to consider the most efficient interventions in the months and years to come, and to show the solidarity of the community of psychiatrists for those who are working with survivors.
The participants, who included representatives of the U.S. government, the Uniformed Services University of the Health Sciences, the World Health Organization (WHO), and the Pan American Health Organization (PAHO), agreed that the tragedy was both "very global and very personal," as described by Thomas A. Bornemann, M.D., WHO’s senior advisor for mental health.
José Miguel Caldas de Almeida, M.D., the Washington-based coordinator of PAHO’s mental health program, told of the hundreds of phone calls, letters, and e-mail messages he had received from around the world.
"Most people feel like they’re living in Manhattan," he said. "It almost seemed more catastrophic for them than for me."
Participants described the immediate responses of mental health professionals in New York and Washington, D.C., to the attacks (see stories on page 7, 8, and 15). Woven through their accounts and in later comments were observations about what worked in the first stage of response, the challenges ahead, and even about the unexpected and unsought opportunity the disaster offers to demonstrate the importance of mental health services.
Many speakers seemed to search for words to capture the immense scope and impact of the tragedy and its aftermath. Bornemann said, "The magnitude of this disaster is overwhelming. My years of experience have not prepared me adequately for what we have gone through."
John Oldham, M.D., medical director of the New York State Department of Mental Health, echoed the sentiment that the dimensions of the tragedy force everyone into uncharted territory. The CEO of a major international company that lost 200 employees in the attack asked for advice about the timing of a memorial service. "I didn’t know what to say," remembered Oldham. "There’s no blueprint for this situation."
He also was called by a woman whose company was housed in a building adjacent to the World Trade Center about how to prepare her traumatized employees for a return to their workplace. They had run into the street after the attack, certain that they were about to face death.
Although the attack was unprecedented, meeting participants were able to identify factors that helped them respond effectively to the crisis. James L. Stone, M.D., commissioner of the New York State Office of Mental Health, noted that his office had already done substantial disaster preparation in anticipation that the Y2K problem might disrupt delivery of mental health services.
Ann Norwood, M.D., associate chair of the department of psychiatry at the Uniformed Services University of the Health Sciences, said, "It helped a great deal that we in the military had established procedures for dealing with such matters as notifying a family member about a death and about dealing with the aftermath of a disaster. We quickly prioritized members of our population at the Pentagon in terms of their need for mental health services. Family members, search and rescue workers, and coworkers of those who died were at high risk. As the days went on, we learned to add other employees, such as the jogging partners and members of car pools of people who had died in the attack."
"Collaboration is essential," said Stone. "A crisis is not a good time to develop relationships." He had already established trust in his colleagues at the federal Center for Mental Health Services (CMHS), New York City’s department of mental health, and the city’s hospitals through years of working together.
Bernard Arons, M.D., director of CMHS, agreed, saying, "Relationships deepen and strengthen as a result of dealing with a tragedy like this."
Bornemann said, "The crisis may be global, but the response is local. The real action is in the field."
Steven Mirin, M.D., APA’s medical director, spoke of APA’s work in providing logistical support for its district branch offices when its members responded to the crisis. CMHS immediately sent a team to help New York state and city officials with grant applications for financial assistance to provide mental health and related services. The American Psychiatric Foundation, APA’s charitable arm, established the Disaster Services Fund to help community and local organizations that are providing psychological support and counseling (see story on page 16). APA also approved grants of $10,000 each for the New York County, Washington, D.C., and Pennsylvania district branches as part of its Erich Lindemann Disaster Grant Program.
Expertise about the complicated issues concerning disaster and trauma proved invaluable in the days immediately after the attacks. Mirin said, "In the first two days alone, we responded to 200 calls from the media. We were able quickly to post material on APA’s Web site that had been developed by APA’s Committee on Psychiatric Dimensions of Disaster and to develop guidelines for parents to use in talking to their children. We held briefings for individual members of Congress [see story on page 4] and a symposium for Capitol Hill staff" (see next issue of Psychiatric News).
Norwood said, "We provided consultation to military command on how to deal with grief."
Cohen said that New York City Mayor Rudy Giuliani, who has been widely praised for his leadership following the attack, turned to mental health experts for guidance on how to help New Yorkers cope with the psychological fallout.
Robert Ursano, M.D., chair of the department of psychiatry at the Uniformed Services University of the Health Sciences and chair of APA’s Committee on Disaster Psychiatry, noted that professionals in the field of psychiatric aspects of disaster have already developed a body of knowledge.
"It’s important to restore a sense of safety," he said. Even something as simple as developing a list of the known dead helps alleviate anxiety and creates a sense of order.
Arons said, "I’ve been gratified by the stories of heroism and resilience. We need to say more about the accounts of people supporting each other. They create a supportive environment for those who are continuing to respond to the crisis."
Ursano said that the attack must be viewed like a wave that continues to reverberate throughout the ocean.
"Remember that overdedication is a risk factor. Our heroes [during this first phase] could become our patients, if we don’t help them protect themselves." He noted that how people are able to deal with secondary sources of stress, such as loss of a job, transportation, or even a babysitter, will become important to the ability to recover.
As time passes, there can be a separation between those who are able to restore their sense of normality and others who remain distressed. This divide creates a new class of victim. Leaders must effectively allocate the resources that are coming into the system and find ways to convey to the public a sense of appropriate feelings and behavior. They must address the growing fears about bio-terrorism.
Several participants noted the importance of nontraditional approaches to the provision of mental health services. Cohen, for example, said, "We will need to think outside of the box to reach insular groups like firefighters who traditionally do not use mental health services. We need to go beyond clinic walls and to reach people at work and in faith-based organizations."
Bornemann said, "We must make our voices heard. People must understand that mental health services are an integral part of any public health response."
The Web address for the WPA is www.wpanet.org/home.html. ▪