26 Dec 2011


We thought our lives would never be the same and, for many, the losses and sorrow of that day endure. For many mental health professionals, our professional lives would never be the same either. Crisis response practice changed dramatically based on the enormity of the mental health emergency at the core of 9/11.

In the days and weeks following the tragedy of 11 September 2001, I was a Red Cross responder and Senior Administrator for the New York State Office of Mental Health, working with survivors and families. Coordinating with a multitude of government and international agencies at the Family Assistance Center in New York City, we shared a mission of creating a caring and compassionate environment. The Family Assistance Center was described by The New York Times as “a new vision of how social services should be delivered”. An entire agency and organisational structure was created overnight with overlapping roles of local, state, federal and international agencies, unclear and constantly changing requirements and expectations that shifted from day to day and sometimes from hour to hour. The scope of work, combined with the large number of providers and services under one roof, was unprecedented.

We thought our lives would never be the same and, for many, the losses and sorrow of that day endure. For many mental health professionals, our professional lives would never be the same either. Crisis response practice changed dramatically based on the enormity of the mental health emergency at the core of 9/11. In the wake of the attacks, many cities up and down the northeast of the United States prepared to deliver acute medical services with emergency rooms on alert. Sadly, on 12 September, those services were not needed anymore because there were so few physically injured survivors. Instead of physical injuries, there were the invisible injuries of psychic trauma: anxiety, fear, depression and numbness as families searched for their loved ones and began to absorb the devastating reality. Instead of surgeons and emergency room nurses, there were vast numbers of mental health professionals, social workers, psychologists, psychiatrists and psychiatric nurses who were mobilised or spontaneously converged to volunteer their services.

First, while emergency services at the American Red Cross had included courses on “Disaster Mental Health”, the specialisation was in its infancy. After 9/11, Disaster Mental Health became one of the fastestgrowing services of the American Red Cross. Across the country, mental health professionals were trained with newly refi ned skills and best practices emerging from 9/11. Collaborative networks and partnerships were developed or strengthened with local, state and national agencies and professional organisations. Response and mobilisation strategies and drills were scheduled regularly to ensure a consistent level of preparedness even when no large-scale disaster occurred. On the whole, during the past decade, professionals in the disaster response fi eld have sought to maintain a heightened sense of urgency and awareness that another natural disaster or disaster of human intent might be imminent. There is a natural pull by the general public and public offi cials to deny that potential future reality and lapse into complacency, with a resulting decrease in allocated resources.

The emerging practice of “Disaster Mental Health” utilises principles of “Psychological Image: slagheap @ fl ickr.com · Oct–Dec 2011 · 45 Focus First Aid”, and more fully developed as a practice model after 9/11. It is not psychotherapy. Instead, PFA provides comfort care, helping people to meet their basic needs immediately after a disaster, listening to survivors’ feelings and thoughts, connecting them with support networks, providing reliable and timely information and educating them about anticipated stress responses. Disaster Mental Health seeks to reinforce the strengths of individuals, families and communities and their positive coping strategies.

Skilled disaster mental health clinicians rely on a blend of clinical skills and training, intuition and experience as well as a keen responsiveness to non-verbal behaviour and cues. The work requires an ability to be with people experiencing unimaginable and intense loss and fluidly move with families within totally unstructured settings and connect readily hour after hour. Disaster mental health workers respond to the normal reactions families have to grossly abnormal events and circumstances and ensure that people are not alone during their worst nightmare.

Disaster Mental Health workers also recognise the very wide range of reactions frequently found within the same family in response to a tragedy. Their role is to be with each person as he or she uniquely expresses grief and loss, and to let them move at their own pace while accepting each other’s differences. Disaster Mental Health provides human connection and warmth, help with tangible needs like water, food and areas to rest and sleep. Acting as personal guides, responders help families through the complex maze of bureaucracy and tasks rendered overwhelming by stress, despair and confusion.

During the most painful ordeals of the families, Disaster Mental Health workers were indispensable escorts and supports. Family members of all ages were asked to provide DNA samples during the first weeks to assist in the identification of remains. Later, we were with family members as they received death notifications and accompanied them to the mortuary.

The families of victims made impassioned requests to visit Ground Zero. Two weeks after 9/11, around 50 family members with as many staff from the Red Cross Disaster Mental Health, the New York Police Department and a few clergy walked onto a Coast Guard ferry. Former New York City Mayor Rudolph Giuliani came on board and sat with each family. As we walked through the massive burial ground, now a shrine, each family member had their own way of mourning and expressing their pain. The taste and smell of acrid air, the painful sting in their eyes and sight of shredded clothing and paper hanging on the trees around Ground Zero, made their loss more palpable and final. Rescue workers took off their hard hats and held them over their hearts as families filed past and all work ceased.

One month after 9/11, we stood with families during memorial ceremonies at Ground Zero. Afterwards, individual services were held, families were presented with an American flag and a small rosewood urn with earth from Ground Zero in a brief respectful funeral with responders at their side. For many families, this was one of the few tangible ways to connect with their loved ones in the absence of recovered bodies.

After 9/11, in addition to training large numbers of mental health professionals in Psychological First Aid, mental health leaders across the United States recognised the need to have specialists trained in treating Post-Traumatic Stress Disorder for more long-term intensive interventions following disasters. PTSD, which is a diagnosis in the “Diagnostic and Statistical Manual” of the American Psychiatric Association, is an intense reaction of fear, helplessness or horror following the direct experience of a traumatic event. People suffering from PTSD may re-experience the traumatic event with intrusive thoughts, vivid and disturbing dreams and flashbacks, and attempt to avoid people, places and things that remind them of the traumatic event. They may be hyper-vigilant, trying to prevent another event and have difficulties with sleep, concentration and emotional control. First identified during times of war and called “Soldier’s Heart “(Civil War), “Battle Fatigue” and “Shell Shock” (World War I and II), the term and diagnosis of PTSD became a classification of military trauma following the Vietnam War.

Research done in the years following 9/11 indicates a positive treatment response from Cognitive Processing Therapy, a structured psychotherapy approach focusing on how individuals process information, interpret and cope with the traumatic event and try to regain a sense of mastery over his or her life. The goal is to enable the individual to return to their pre-disaster level of functioning by building on their resilience and supports.

Lastly, over the last 10 years, specialised training in Disaster Mental Health has been developed to highlight skills needed with special populations such as children and adolescents, older adults and people with disabilities in the aftermath of a disaster. Most recently, a new training curriculum on “Response to Radiation Disasters” was taught for the first time through the Institute for Disaster Mental Health at the State University of New York at New Paltz following the nuclear plant tragedy in Fukushima in March 2011. Throughout the decade, there has been a growing understanding of the need to continuously build community resilience using local resources, neighbourhood centres, places of worship and schools to restore them to their pre-disaster strength. The positive impact of the new expertise following 9/11 was seen in the response to subsequent disasters in the United States. After Hurricane Katrina in 2005, which devastated five states in the United States, skilled trained disaster mental health responders flew in to provide expertise and leadership to areas which had limited health and mental health networks.

Disaster Mental Health both during and after 9/11 is essentially about the power of human connection. For me, it is best encapsulated in an unforgettable moment from my first trip to Ground Zero by ferry with family members two weeks after 9/11. As the ferry approached lower Manhattan, the view of the devastation could be seen through the buildings that still stood. A large and quiet man stood apart from everyone at the railing, evidently alone on the journey. Though his body language indicated that he wished to be left alone, I was cognizant of the force of the images he would soon behold and put my hand over his on the railing. We said nothing. We pulled into the dock and left the ferry and walked into Ground Zero. Two hours later, on the way back to the Family Assistance Center, we found ourselves walking side by side into the building. He looked down at me and said, “Thanks for the hand.”

Jeannie Straussman () is a student support counsellor at the LKY School. She was previously Clinical Coordinator for Disaster Mental Health and Regional Director for the New York State Office of Mental Health. She is a consultant with the Institute for Disaster Mental Health, State University of New York at New Paltz.