Mental Health: The Profession Tests Its Limits
By ERICA GOODE and EMILY EAKIN
New York Times September 11, 2002
New Yorkers were hardest hit by the terror of Sept. 11. But they also lived in a
city rich in the resources to deal with its psychological impact.
There were more psychotherapists and mental health agencies per square mile than
anywhere else in the country. Internationally known trauma experts taught at
local universities. City officials, schooled by the 1993 bombing of the World
Trade Center and the crash of Flight 800, were able to mobilize quickly and
think creatively in a time of enormous turmoil.
Even so, city and state officials found themselves operating in near chaos,
struggling to conjure, on the spot, a system mobile and flexible enough to reach
out to a traumatized community and adequate to the needs that were sure to
appear.
"The sheer scale of the event dwarfed most of our disaster mental health plans,"
said Chip Felton, an associate commissioner at the New York State Office of
Mental Health.
The emotional force of the attacks was so strong that many officials suspected
that even people used to coping on their own might seek professional help.
Trauma experts warned that people with severe post-traumatic stress disorder
might not come forward for months or years.
Ultimately, the officials found themselves orchestrating what was probably the
nation's largest — and least stigmatized — offering of free mental health
treatment ever.
But in the midst of the crisis, the city's abundance of mental health
professionals turned out to be a mixed blessing. There was no shortage of help,
but few practitioners were trained in disaster response. The trauma treatments
with the most evidence behind them were also the least available. City officials
and agencies like the Red Cross had little control over therapists who wandered
into firehouses, made their way to ground zero or stopped people on the street
to offer counseling.
The limits of experts' knowledge about trauma quickly became apparent. Much had
been learned from the study of natural disasters like floods and earthquakes and
individual acts of violence like rape or physical assault. But basic questions
remained, and it was unclear how much of what was known could be applied in this
case.
Many researchers say they are learning things from the terrorist attacks that
are forcing them to revise their understanding of trauma. Some argue that a
valuable research opportunity was squandered.
For all its horrors, Sept. 11 offered an unparalleled chance to learn why some
people are resilient while others are not, and which treatments are effective
for whom. But no mechanism was in place to allow researchers to collect the
relevant data in the first hours and days after a disaster.
"We didn't learn what we would have needed to learn so that we would be better
informed next time," said Dr. Rachel Yehuda, a professor of psychiatry at the
Mount Sinai School of Medicine and the director of the post-traumatic stress
disorders program at Bronx Veterans Affairs.
A year later, New York is more ready than it once was for a terrorist attack.
But disaster experts say the same cannot be said for the rest of the nation.
"We really were not prepared, our systems were not prepared, for something of
this magnitude," said Dr. Brian Flynn, who was the lead mental health adviser
for the federal Department of Health and Human Services during the crisis. "If
another attack happened tomorrow," he said, "we would probably not be much
better prepared."
First Response
Scattershot Approach to an Ill-Defined Need
In the 48 hours after the attacks on the World Trade Center, the phones at
Lifenet, the 24-hour referral hot line run by the Mental Health Association of
New York, were unusually quiet.
A delivery man called after escaping from the towers and driving his truck over
human body parts. Another man screamed over and over, "My sister is missing, my
sister is missing."
Dr. John Draper, the director of Lifenet, knew the deluge would come later,
perhaps much later.
"Just wait," he remembers saying.
The hot line would need more workers and more phone lines. Also, Lifenet, which
normally referred individual callers to mental health organizations, would need
to be transformed into a much more comprehensive resource.
Soon, companies, schools and senior centers were calling for help. Mental health
professionals were calling to volunteer their services.
"We wanted to be able to get practitioners out to family assistance centers, to
offices and schools, to stadiums where they were having memorial events," Dr.
Draper said. Dr. Draper got on the phone with city and state crisis intervention
experts, and with the representatives of major charities, planning how they
would coordinate services and what role the charities might play.
Over the next months, the hot line, its toll-free number advertised on subway
placards and in public service announcements, would become a barometer of a
city's distress, registering, call by call, the emotional impact of the
terrorist attacks.
At the Police Academy on East 20th Street, where Mayor Rudolph W. Giuliani and
his staff set up a makeshift command post on the night of Sept. 11, Dr. Neal
Cohen, the city's health commissioner, was also setting things in motion. "We
knew we had the potential for a public mental health crisis," Dr. Cohen said.
Very quickly, the city had established a support center at the Armory for the
relatives of those missing or killed. (It later moved to Pier 94.) Officials
consulted trauma experts from around the country and began planning to train an
army of volunteer therapists in disaster assistance.
Dr. Cohen directed his staff to mine research reports for everything they could
find on the psychological impact of the bombing in Oklahoma City "so that we had
some sense of what the range of post-traumatic stress disorder symptomatology
might be."
But in the weeks that followed, it was clear to experts that the treatments for
post-traumatic stress with the best track records were also the least available.
Researchers from four universities formed a consortium to train therapists in
one method, a form of cognitive behavioral therapy that challenges distorted
thinking and gradually desensitizes people to their memories and fears.
Meanwhile, mental health officials scrambled to document New York's mental
health needs with the figures they would need to obtain federal aid. Their
estimates won commitments for two grants from the Federal Emergency Management
Agency, totaling $154.7 million, which financed Project Liberty, the program
created to provide free crisis counseling. The program began operation in early
October, with Lifenet the number to call.
The state teams estimated that 3.1 million residents of New York City and the
surrounding counties would experience "substantial emotional distress" and that
520,000 would develop post-traumatic stress disorder, or P.T.S.D, a condition
diagnosed when symptoms like nightmares, flashbacks, startle responses and
avoidance of people or places persist for at least a month.
Those estimates were lower than estimates made in the weeks after the terrorist
attacks, but they turned out to be surprisingly accurate.
Yet as many trauma experts had also predicted, in the early days of the crisis,
psychiatric emergency rooms and clinics remained largely unused, and volunteers
found themselves with little to do.
"The first people to start showing up were those with prior psychiatric
conditions," said Dr. Elliot Jurist, a staff psychologist at New York
Presbyterian Hospital who volunteered on the evening of Sept. 11 at a crisis
service set up by the hospital. "People with serious psychiatric disorders who
had been doing O.K. started to experience symptoms."
Many volunteer therapists were already working through established agencies like
the Red Cross, and this assistance was invaluable, city officials and Red Cross
representatives said.
Other clinicians struck out on their own. They called companies, offering to
help employees talk about their feelings. In some cases, they made their way
past the barricades at ground zero and approached rescue workers.
Firehouses, their doors open to the public, were visited by a stream of
well-meaning counselors. But they were often unfamiliar with the Fire
Department's unique culture, staff members of the department's counseling
service unit said. In at least two cases, the staff members said, doctors
prescribed psychiatric medication on the spot to firefighters they had met only
minutes before. (The Fire Department itself recruited 45 clinicians from the
community, mostly psychologists and social workers, to work with the firehouses.
But these practitioners were briefed on fire service culture and introduced to
captains and lieutenants at the houses before beginning their work.)
Joan Westreich, a clinical social worker in private practice in Manhattan,
signed up with the Red Cross and worked the phone lines at a command center but
wanted to do more.
"I was doing counseling assistance in the elevator of my building, where there
were people afraid to go into the subway," Ms. Westreich said.
Experts said that such efforts undoubtedly helped comfort some distraught
people. But in some cases, counseling was pushed rather than offered. And there
was no good way for the public to tell what would be helpful and what would not.
In a paper presented at the American Psychological Association's annual meeting
in August, Dr. Lawrence Beutler of the Pacific Graduate School of Psychology in
Palo Alto, Calif., cited Sept. 11 as an example of why scientists needed to find
out much more about which therapies are effective and for whom.
"Everybody is convinced that their approach works," Dr. Beutler said.
Coping and Not
A Resilient Majority, but Some Still Suffer
Surveys over the last year suggest that in the aftermath of Sept. 11,
resilience was the rule, not the exception. Despite violence and uncertainty,
the vast majority of people found ways to cope and to go on with their lives.
Many Americans suffered distress, even extreme distress, but for most this was a
normal reaction to extremely traumatic events and subsided in a few weeks or
months.
"It is important to understand the distinction between emotional distress and
emotional disorder," said Dr. Thomas Frieden, New York City's new commissioner
of health. "Virtually everyone has varying degrees of emotional distress;
emotional disorder really implies an interference with functioning."
In a telephone survey conducted in January and February, Dr. Sandro Galea and
his colleagues at the New York Academy of Medicine found that 40 to 45 percent
of New Yorkers reported having at least one symptom of post-traumatic stress, a
significant drop from the 57.8 percent having at least one symptom in a survey
carried out five to eight weeks after the attack.
Dr. Roxane Cohen Silver, a psychologist at the University of California at
Irvine, found in a survey appearing today in The Journal of the American Medical
Association that 17 percent of Americans outside of New York City reported
experiencing some post-traumatic stress symptoms two months after the attacks.
Six months later, the figure had fallen to 5.8 percent.
"From a public health perspective, the major thing about 9/11 was not about
P.T.S.D. but about what are the normal reactions to a horrific mass casualty,"
said Dr. Matthew J. Friedman, director of the National Center for Post-Traumatic
Stress Disorder, part of the Department of Veterans Affairs.
But the same surveys that testified to Americans' recuperative powers also
showed that a substantial minority of people did not bounce back. For some, the
impact of the attacks has been disabling, often exacerbated by other stresses,
including the loss of jobs or displacement from homes.
New York registered higher rates of illness than the rest of the country: 11.2
percent suffered from "probable P.T.S.D." two months after the attacks,
according to a survey led by Dr. William E. Schlenger of the Research Triangle
Institute in North Carolina, compared with 4 percent of Americans outside of New
York.
But the highest rates of post-traumatic stress disorder — 20 percent in one
survey — were found among people most directly affected by the attacks: those
who lived near the trade center, who had friends or relatives killed or who had
lost jobs or possessions as a result of the attacks.
The calls Lifenet has received over the last year reflect both the wide public
distress of early months and the intense private suffering that for some people
continues.
The phones ring constantly now, each call bringing another plea for help.
A mother is worried about her 7-year-old son, who still dreams that planes are
hitting his house. A woman cannot stop picturing the debris that killed her
brother. A firefighter is ashamed to let his wife know that he is still so
distraught. He calls from a hideout in the basement, on his cellphone.
In the fall, Lifenet's phone logs — the hot line is anonymous — recorded frantic
searches for missing relatives, fears about anthrax, anxiety about future
terrorist attacks and a wide variety of stress symptoms. By winter, callers were
beginning to report more lingering problems: depression, phobias, an inability
to mourn normally or a loss of interest in daily events.
In recent months, the calls have increased in volume and intensity. Before Sept.
11, Lifenet received an average of 3,000 calls a month; in August, the hot line
received more than 9,000 calls, nearly two-thirds related to the terrorist
attacks. The approach of the anniversary and a new public service campaign have
drawn even more callers.
Many recent callers say they have never before sought counseling, never even
considered it. "I thought I'd be over this by now" is a frequent refrain.
Their stories are often so hair-raising that the phone workers — all mental
health professionals — sometimes have to put callers on hold while they regain
their own composure.
"I've never heard this kind of suffering in my life," said Adele Maddry, a
social worker who has worked at Lifenet since December.
Joey Truitt called Lifenet in early November.
On Sept. 11 he stood on his third-floor balcony in Union City, N.J., and watched
a ball of fire engulf the south tower of the World Trade Center. Through
binoculars, he saw people jumping from the towers and witnessed the buildings'
collapse.
The next day, his employer told Mr. Truitt he no longer had a job.
For the next six weeks, he did not leave his apartment.
He draped a black sheet over the picture window in his bedroom and did not
answer the phone. He went out only to buy cigarettes and cat food, wearing a
black sweatshirt, the hood pulled down over his eyes.
He had nightmares. In one, he was standing in the ruins near Deutsche Bank,
looking out across a landscape of paper and metal and twisted debris. In
another, he was calling out, "Does anyone need any help?"
He developed hives. He had vivid flashbacks of what he had seen. He started at
every noise. He talked to no one.
"I was so sure that nobody saw what I saw and nobody could feel what I felt,"
recalled Mr. Truitt, who had worked as a corporate travel agent in 1 Liberty
Plaza, across the street from the trade center, but was late to work the day of
the attacks. His withdrawal from life was so complete that some of his friends
thought he had died in the towers.
Lifenet referred Mr. Truitt to a mental health clinic on the Lower East Side.
But when he saw a counselor there, he said, she had no idea what to do for him.
Dr. Draper, Lifenet's director, said it took some agencies a month or so "to get
up to speed."
In the next months, Mr. Truitt went out only when he had to. Then, in March, he
watched a documentary about the terrorist attacks on CBS.
Somehow, he said, seeing the events unfold on television made him feel better,
not so alone. Last fall, experts warned that the constant rebroadcasting of the
planes' hitting the towers was in itself retraumatizing.
He joined a support group, got a job and signed up for a free treatment program
for post-traumatic stress disorder at Columbia University.
One year after the attacks, he still has nightmares and flashbacks. But he is
getting better. The events of that day, he said, "will be written on my soul
after I die."
The Front Lines
Treating Firefighters and Police Officers
Malachy Corrigan, the director of the Fire Department of New York's
counseling service unit, knew that when the funerals finally stopped and the
search for remains came to an end, firefighters would be in danger.
Exhausted and grieving, they would be at risk for post-traumatic stress
disorder, depression and other emotional ills.
In the last year, with the help of federal and private financing, the department
has quadrupled its counseling staff to 42 counselors and 13 support workers, Mr.
Corrigan said.
The unit also has 30 peer counselors, firefighters with special training, and
has provided firefighters and their families with a variety of ways to get help,
including paying for treatment by clinicians in private practice outside the
department.
Since Sept. 11, the counseling unit has seen 2,800 department employees or their
families, Mr. Corrigan said, while in a typical year, the unit sees 600. The
department has about 15,500 employees.
Sleep disturbances have been ubiquitous, Mr. Corrigan said. "Virtually everybody
in the Fire Department has had that symptom at some point this year."
Flashbacks — the uninvited return of thoughts, smells, sounds and images from
that day — have also been common.
The Fire Department is keeping track but will not yet say how many firefighters
are suffering post-traumatic stress disorder, depression and other illnesses.
But Mr. Corrigan said he was surprised that the number of firefighters suffering
from P.T.S.D. was "relatively small."
He estimates that 20 to 25 firefighters have been hospitalized for psychiatric
difficulties since Sept. 11, compared with an average of 12 hospitalizations a
year before the terrorist attacks.
Two firefighters have committed suicide in the last year, he said, and "in a
typical year, we don't even have one."
The New York Police Department, which, unlike the Fire Department, instituted
mandatory mental health education sessions last fall for employees who had been
at ground zero, sustained fewer casualties on Sept. 11.
The Police Department has had no increase in the number of officers recommended
for a change in duty status on the basis of psychological evaluation or in the
number of suicides or psychiatric hospitalizations, said Dr. Arthur Knour, the
director of the department's psychological evaluation unit.
"To the best of our knowledge, there have been no World Trade Center-related
suicides," Dr. Knour said.
But Dr. Frederic I. Kass, the medical director of psychiatry at New York
Presbyterian Hospital, who has been working with the police, said the number of
calls to an anonymous referral hot line set up last fall have increased over the
months, with more than 100 calls registered in August.
Still, he said, that number is tiny in a department of 40,000 uniformed officers
and 15,000 other employees.
"What has impressed me is their strength and resilience," Dr. Kass said.
Studies suggest that police officers, firefighters, morgue workers and others
trained to encounter death and violence may be less vulnerable than people
without such training.
Yet the "tough it out" ethos common in such lines of work can also encourage
denial.
A police officer who called Lifenet recently said that everyone around her was
acting as if nothing had happened.
"She said, `We're cops, we don't talk,' " said Ms. Maddry, who took the call.
The Delayed Response
Severest Cases are Slow to Show
After the Oklahoma City bombing, it took two to thee years for some survivors
with serious emotional difficulties to seek treatment, said Nancy B. Anthony,
the executive director of the Oklahoma City Community Foundation, which
underwrote the cost of psychiatric care for survivors and their families.
"I don't think people necessarily realized that they needed assistance until
they got to a nonfunctional point," Ms. Anthony said.
The tendency for people to wait until their marriages are falling apart, their
jobs are in peril or they simply cannot get dressed in the morning is one reason
the worst cases of post-traumatic stress from the Sept. 11 attacks are just
beginning to show up and will continue to show up over the next decade, experts
say.
"Everything we know about post-traumatic stress disorder suggests that it takes
a long time for the serious cases to make an appearance," said Dr. Yehuda of
Bronx Veterans Affairs.
Those cases, Dr. Yehuda and others said, will not be resolved with a few
sessions of crisis counseling.
Yet the federal government's disaster planning is focused almost entirely on
short-term relief. The emergency money that FEMA provides to states, for
example, normally cannot be used for anything except crisis counseling.
In an era of managed care, few health insurance policies cover long-term mental
health treatment. And few people can afford to pay for such care out of their
pockets.
Aware of these problems, two large charities, the September 11th Fund and the
Red Cross, announced last month that they would reimburse anyone directly
affected by Sept. 11 for the cost of longer-term therapy. Other, smaller
foundations have also given out grants for more extended treatment. In August,
FEMA gave New York state officials permission to use the relief money provided
by the agency to pay for more extended treatment.
Yet even with such resources available and widely publicized, it is still a
challenge for mental health officials to get the services to the people who most
need them.
Lifenet's calls have increased greatly, but they represent a fraction of those
people that surveys suggest are still having serious problems. Therapists in
private practice report little increase in their patient loads. The New York
Academy of Medicine researchers found only a very slight bump in the number of
New Yorkers who reported having seen a mental health professional — from 16.9
percent before the attacks to 19.4 percent five to eight weeks afterward. People
with post-traumatic stress disorder or depression were more likely to have
increased their use of mental health services, the survey found.
"But the increase was not clinically significant," said Dr. Joseph A. Boscarino,
a senior scientist at the academy. "We expected higher use rates."
Some family members of those who died say they have joined support groups or
found therapists on their own.
Jennifer Jacobs, whose husband, Jason, died in the World Trade Center, said she
was aware of the free counseling offered by Project Liberty and the Red Cross,
as well as by her husband's company. But she preferred, she said, to find "my
own person."
"You've really got to find someone who knows what they're dealing with," Ms.
Jacobs said.
For some people, the stigma attached to psychiatric treatment may still stand as
a barrier, despite the widespread acknowledgment that the events of Sept. 11
carried enormous emotional power. Others say they have received all the help
they need from family members and friends. Still others, said Dr. Draper, say
they are just not ready.
The Great Unknown
Looking for Answers, and Right Questions
Faced with a traumatic event of mammoth proportions, government officials and
the public at large turned to experts for guidance. Their knowledge, gained from
studies of natural disasters, acts of terrorism and other forms of violence,
proved enormously helpful.
But there were some questions researchers could not answer.
They could not say for certain how many people would suffer long-lasting
problems or what those problems would be.
They could not predict precisely who would fall ill, although they could name
some factors — proximity, a history of trauma, a feeling of unreality during the
event — that seemed to make people more vulnerable.
Nor could the experts agree on which treatments were effective, though they
could identify the techniques — cognitive behavioral therapies and
antidepressants — that had the most empirical backing. Many other treatments had
simply not been tested.
"There's zero data on what kind of treatments work specifically for victims of
terrorism, in the context of living with ongoing threat," said Dr. Randall
Marshall, a psychiatrist at Columbia and the director of trauma studies and
services at the New York State Psychiatric Institute.
In other areas, there was not only a lack of consensus but active debate, like
that over a popular type of debriefing. Some experts argued that the practice,
which involved a single session of group therapy, was ineffective and could even
slow recovery for some people. Others defended the debriefing method.
Last week, researchers in the Netherlands added to the debate, publishing an
analysis of existing studies. They found that while people who underwent the
debriefing session often said they found it helpful, there was no evidence that
it prevented the development of post-traumatic stress disorder.
The only way to resolve such disputes is to do more studies, experts say. Sept.
11, with all its horrors, offered an enormous research opportunity, and some
experts say the work now being done will advance knowledge substantially.
"Frankly, I think we will have more definitive data about the impact of this
disaster than has ever been the case," Mr. Felton of the state mental health
office said.
Studies conducted in the last year have already revised some assumptions,
challenging, for example, the way most investigators have defined exposure to a
traumatic event.
"Being directly affected is in some senses in the eye of the beholder," said Dr.
Schlenger of the Research Triangle Institute. "If you lived across from the
World Trade Center, you were obviously directly affected. What's less obvious is
that if you were sitting in Des Moines and your granddaughter just started
working in the World Trade Center, that's a pretty direct exposure."
A survey by Dr. Schlenger and his colleagues, published in August, also raised
questions about television's effects.
The researchers found that even for people with no direct connection to the
attacks, the symptoms of post-traumatic stress increased with the number of
television hours the participants reported watching each day.
But Dr. Schlenger said this relationship held regardless of how gruesome the
coverage was, suggesting that people who were already upset watched television
as a way to cope.
Dr. Schlenger's survey is only one of hundreds of research projects begun after
the terrorist attacks.
But some researchers contend that far more could have been learned if data had
been gathered immediately.
Neither Project Liberty nor the Red Cross systematically collects information
from clients about their prior histories of trauma, the extent of their support
systems, the nature and severity of what they experienced or what other stresses
— like financial problems or unemployment — they face. Project Liberty and the
Red Cross do not as a matter of course even record the names of people who
receive crisis counseling.
But Dr. Yehuda said being able to track people over time would help researchers
understand more about what makes some people resilient and others vulnerable to
severe emotional difficulties.
Other experts said it requires so much time and paperwork to obtain research
grants that moving quickly is nearly impossible.
Dr. Galea and his colleagues at the New York Academy of Medicine, for example,
plunged ahead with their survey purely on faith; the financing was not yet in
place.
But collecting data from the victims of disasters is also contentious.
After the Oklahoma City bombing, for example, all research was required to go
through the University of Oklahoma, to avoid duplication or the harassment of
survivors.
Mr. Felton said New York officials had considered a similar policy but decided
it would not be practical in such a large city, with so many research
institutions.
FEMA, for its part, has been adamant about not evaluating the effectiveness of
the crisis counseling it pays for, Dr. Flynn said.
He added: "There's always this tension between services and research. There's
always the fear that you're more interested in studying people than in helping
them."
Still, Dr. Flynn and others said, studying people is the only way to make sure
that the right people get the right treatments at the right time.
"People in society have to get very upset that we don't know," Dr. Yehuda said.
"And they have to understand that research is the vehicle that will allow us to
know."
Violence inflicted by human beings exacts a greater psychic toll than the
impersonal cruelty of nature, studies show.
Terrorists mine this power instinctively, their acts a means to the end of
spreading fear and panic, the first step toward a fragmenting of society.
Because of this, disaster experts argue, mental health — both in the broadest
sense of comforting anxious citizens and in its narrower definition of treating
psychiatric casualties — must play a central role in the government's planning.
In New York, the crisis ultimately produced an emergency mental health system
more prepared and flexible than before. The challenge, Mr. Felton said, is to
keep that system in place.
"What I would like to see in the future is that the structures and mechanisms we
had to put into place from scratch persist as part of a disaster model," he
said.
New York is ahead of the curve. Most other states have not even begun to catch
up.
Source: http://www.nytimes.com/2002/09/11/health/11PSYC.html?pagewanted=print&position=top
This "Mental Health E-News" posting is a service of the New York Ass'n of
Psychiatric Rehabilitation Services, a statewide coalition of people who use
and/or provide community mental health services dedicated to improving services
and social conditions for people with psychiatric disabilities by promoting
their recovery, rehabilitation and rights.
To join our list, e-mail us your request and, where appropriate, the name of
your organization to NYAPRS@aol.com.
