My Memories of “9/11” on the 15th Anniversary of September 11, 2001

... und explodiert nach dem Einschlag in das Gebäude. Beide Türme stürzten darauf zusammen. Kurze Zeit später prallte ein Flugzeug auf das US-Verteidigungsministerium in Washington. Die Flugzeuge waren zuvor gekapert worden. Vermutlich hat es hunderte Tote und Verletzte gegeben. (Foto: CNN)

My Memories of “9/11” on the 15th Anniversary of September 11, 2001

Introduction

If you have any memories of 15 years ago you certainly remember where you were, what you did and how you felt when terrorists took over two large airline planes filled with passengers and  crashed them into the World Trade Center in New York leading to the collapse one of towers and the death of thousands of people.

I would like to use this blog to recall my memories and thoughts about where I was, what I did and how I felt. As is often the case in recollecting traumatic events, I may not have every detail correct but this is how I recall things. I should state that I while I was in New York I was not near ground zero at the time and no one close to me was killed or injured.

As a psychiatrist, I previously had some experience in working with people who were traumatized. I was a consultant to a burn and trauma unit of a hospital and had written a book about this subject. A few years previously I was part of a team that studied the psychological effects of a major plane crash in Dallas and I had studied the psychological impact on emergency workers of doing their work, as well as the impact on members of the media who cover such events. I have had occasion to write and speak on related subjects before and after 9/11.

The Event

I was in my office at New York Medical College/Westchester Medical Center, which is a suburb of New York City. My secretary told me that she had heard that a plane had crashed into the World Trade Center. This immediately brought to my mind a childhood memory of when a small plane had crashed into the Empire State Building in New York City. My father was a New York City policeman at the time and called in the event to emergency services. He subsequently brought home, a small piece of twisted metal and wires that I was told were part of the plane. I was soon to learn that 9/11 was a much greater catastrophe than that event.

The nearest television to my office was on a closed psychiatric unit in the hospital not too far from where I was located. I made my way there and in the large day room all the patients and staff were watching a medium sized television. I quickly appreciated the magnitude of this event when shortly after I entered the room and focused on the TV, I saw pictures ofone of the tallest buildings in the world collapse on live TV. As I recall the experience, there was only a quiet murmuring or perhaps some groans coming from myself and the people viewing this together. I should point out that this was a closed psychiatric unit with acute severely mentally ill patients some of who would usually be in an agitated psychotic state, perhaps with hallucinations. I don’t remember any such manifestations being shown. It was almost as if many of the patients were jolted back to reality by this event. I didn’t study this phenomena but it reminds me of an experience that I had in my first year of psychiatric training. I was assigned to an inpatient unit at another psychiatric hospital in New York City when there occurred a highly unusual city wide black out of all power. As I recall, it was in the evening and the hospital basically went dark with no or very little emergency power for lights for several hours . I subsequently wrote one of my first papers examining the reactions of the various patients to this unusual circumstance.

While initially we had no idea of what was the cause of this plane crashing into the World Trade Center Building or that there were other planes involved. It was apparent that many people were killed although there was no indication initially that it would be in the thousands and that people were actually jumping out of windows to their death rather than being burned to death. As the magnitude became apparent, my natural instinct as was that of others, was to be concerned about my loved ones who worked in Manhattan. While I didn’t think that they would be at that location I made phone calls to assure that they all were safe. Many people did not receive good news as they checked with their family and friends. One man who I knew quite well, was director of clergy services at the hospital, lost his son at the World Trade Center. At that time I lived in one of many suburban communities outside of New York City where many people commuted to work by train. That evening there were many cars in the train station parking lot that were not picked up by people who had perished that day. Photographs of those cars that were not claimed by their owners that evening stands out in my memory.

The Aftermath

My wife who worked at a major hospital in Manhattan related how her hospital immediately had gone to it’s emergency plan waiting to receive large numbers of victims with injuries that were expected. Even the suburban hospitals such as mine went on to that mode where surgeons were called in and all personal were on standby expecting to deal with the overflow of casualties from this tragedy. But despite the approximately 3000 fatalities, I understand that there were very few injuries. The ash floating down on the city may have caused some minor medical problems.

Screen Shot 2016-09-05 at 11.01.40 PMIn the days and weeks following screen-shot-2016-09-10-at-12-08-59-amthis horrific event there was this very unusual phenomena of there being many posters on walls, trees, light poles etc not only downtown but in other parts of the city. The theme of these posters was looking for a lost relative. There would be a photograph and a brief description usually stating that the person worked in the World Trade Center and was missing. There would be a phone number to call if anyone knew about this missing person. The reality was that there were no missing people. The very few people who may have visited a medical facility were identified and all of these “ lost “ people had obviously died. However, understandably their loved ones in many cases could not initially accept what had happened and were trying to maintain hope . Over the ensuing days and weeks many of the posters remained in place but their makers had crossed out the word “ Missing” and there were words about how the poster was a memorial to them. Often there were flowers left next to them. I also recall passing a fire station from where many firemen had perished after they had entered the tower to save victims and had been inside when it collapsed. It was shrouded with black draping and an appropriate sign paying tribute to the lost heroes of that fire station.

I believe it was on Pier 92 in downtown that a massive social service outreach program was set up to assist the family and friends of people believed to be killed in the tragic event. There were places for people to register that they had lost a loved one. In many cases the remains of victims would not be found . There were psychological services offered to the distraught people many of whom were grieving lost loved ones.

I recall it was at this location that on the third or fourth day after 9/11 I was asked because of my previous experience in working with the media around traumatic events, to run a “debriefing group “ for members of the media who had been working day and night on this tragic news story. Many of them had spent hours interviewing grieving friends, relatives and the colleagues of the firemen who had died. They had seen and photographed the gruesome scenes of dead bodies and the partial remains. Some had photographed the falling bodies of the jumpers who chose to die this way rather than by fire. They spent hours talking on and off the air about all the details of news story, edited their material and in many cases went without or with very little sleep since the story broke. In the earlier days of “debriefing” victims of trauma the psychological approach had been to allow each person in the group to recount their experience. We had subsequently learned that such an approach often re-traumatized individuals who heard other people’s stories in the group. The approach now was more geared to explain to people about the symptoms which they might be having or might have in the near future and suggestions about how to deal with them as well as allowing them to ask any questions. We would also try to identify people having significant difficulties and offer them more individual help. In the course of running this group I mentioned how comforting members of the media particularly TV commentators might be to the public as they explain what is happening and try to keep the audience calm. Illustrating this point, I told them about a phone call I had just had with a family member who told me of a dream she had that Peter Jennings ( the ABC anchor) was talking and comforting her about the event. In the group I was speaking with was Peter Jenning’s TV producer who worked very closely with him and said she was sure that he would appreciate that story and she would tell it to him that evening. You can imagine how surprised my relative was when I called her and told her that Peter Jennings would soon know about her dream.

By coincidence I had been scheduled to do a Grand Rounds Presentation at a hospital in Manhattan not too far from ground zero 10 days after 9/11. It was pointed out to me that you could previously see the fallen tower from the room in which I was speaking. I don’t recall what the original topic was but we altered it to focus on that unforgettable event that had occurred in their backyard.

For many years   I have been a very small part of the large number of mental health professionals writing and teaching about how our profession can be helpful in dealing with mass traumatic events. As a therapist I realize that many people have their own individual traumatic experiences that impact them and often alter their lives. These personal traumatic events can be just as meaningful and life changing as a big event that affects large numbers of people .

While I was very fortunate not to have been  seriously traumatized by 9/11, but still the fear and worry that I had living through it along with millions of Americans  is obviously imprinted in my mind. Recounting it now in this blog relieves some of the pain  that is still associated with that memory.

 

Michael Blumenfield, M.D.

Mblumenfieldmd.com

 

My Experience During 9/11

At the time of the commemoration of the 10th anniversary of 9/11 I reflected on my experiences at that time. The phenomena of “missing persons” posters which appeared throughout Manhattan shortly after the tragic events is discussed as well as some other observations about this fateful event.

Several weeks ago we commemorated the 10th anniversary of 911 and like many of you. I reflected back on what I was doing and how that event impacted on our lives. The latter question will require much more continued contemplation. However, the memories of that day and subsequent weeks were quite meaningful.

I lived in the northern suburbs of New York City at the time and the local newspapers had photographs of cars in train station parking lots that were not picked up by commuters who had perished in the World Center attack. I did not think that I knew anyone personally who died or had a close family who was killed  in the tragedy. Several months later I found out that  a chaplain with whom I worked with from time to time at the medical center had lost his son who worked at the World Trade Center. Over the ensuing years I saw many patients whose lives were impacted significantly by this event and worked in intensive therapy with several of them.

On the morning of 9/11/01 I was at Westchester Medical Center when I heard of the unfolding events. The nearest television set was on a psychiatric inpatient service near my office. I sat with staff and patients and watched the second plane hit the tower. Although many of the patients had severe acute mental illness-schizophrenia, other psychosis, suicidal behavior etc., we all responded in the same manner. There were groans and tears and statements of  “those poor people.” There was no panic and no apparent incorporation of this reality into the patient’s delusions. It has been shown that people with decompensated mental illness often show improvement at least in their short term symptoms when they are faced with emergency or tragic events.

I was reminded of an experience I had while I was in training in New York City many years previously when there was a sudden unexpected blackout with loss of power citywide for at least several hours. I also was visiting on a psychiatric inpatient service when it occurred and most people handled it quite well. I eventually published a paper how this event did interact with the psychopathology of a two patients.

By coincidence I was scheduled to give a Grand Rounds presentation on September 21 , 10 days after 9/11 at a hospital in downtown Manhattan from which you would have been able to see the World Trade Center. Ironically the topic of my talk had been about disaster psychiatry but I changed it to specifically allow a discussion on how my colleagues had responded and what they had done to address the mental health issues related to this tragedy in their backyard. A center had been set up on Pier 92 for the survivors, families and friends  of the victims. Mental health professionals from all over the Metropolitan area donated their services to work with the Red Cross in helping these people with their physical and emotional needs.

At the time of this presentation, I walked around downtown Manhattan and the area surrounding ground zero. I noted the presence of something very interesting there and also scattered throughout Manhattan.. There were posters with pictures made by family and friends of people who had been in the World Trade Center at the time of the tragic events and did not come home. The posters, as you can see, were made from the point of view that these people were “missing.” They provided a description of the person with the request that if anybody were to see them they should call a specific telephone number. There were numerous such posters. The fact is that people were not found wondering throughout the city. The relatively few injured people who were brought to the hospital were identified and families were notified. Of course, the New York City morgue had a very sophisticated system of trying to contact any family members if they had made identification of the remains of victims. So what were these posters about?

They obviously were part of the denial phase of  the acute complicated grief that the survivors were beginning to feel as on some level they realized their  loved ones were killed. Within the next two weeks people began to make alterations in these posters which showed that they recognized that these people had died.  They crossed out the words “lost” or  “missing” and would write things like “in memory of”. The posters now would be adorned with flowers. I don’t recall this phenomena ever being reported in the psychiatric literature.

While I did not participate in the work on Pier 92, I was asked to do some “debriefing” activities for some organizations. One such group was the personnel of a major TV network. (I had done some previous work identifying the psychological trauma that members of the working press often experience in the course of their work). I was the co-leader of this group with a Professor from the Columbia School of Journalism.  Prior to this time debriefing activities would have meant trying to get the participants to express their emotional reactions to their recent experience in the disaster. More recent research had suggested that this wasn’t the best approach. In fact,  it might even make things worst. So our approach was a much more general approach in which we acknowledged the type of emotional symptoms that they might experience and made suggestions how to minimize them.

The evening before I worked with this group I had spoken with a family member of mine who told me that she had a dream that the well known television anchor from this network was having a personal conversation with her about the disaster. This dream appeared to reflect the importance that such TV personalities have in reassuring people at the time of frightening events. I was able to tell my relative that I spoke with the TV producer who worked with this anchor and she was going to tell him about her dream .

There has been a great deal written about this disaster in professional journals as well as in other media.We also will dearly hold on to our personal memories of that fateful day. Feel free to relate any of your experiences or thoughts about this day in the comment section below.

Psychological Problems Expected After Japanese Disaster

Psychological problems are expected after the recent earthquake and tsunami in Japan. In the past American psychiatrists with experience in disaster psychiatry have offered assistance to colleagues in other countries who are dealing with a catastrophic event and it is expected that this will occur with the current incident. In the initial phase psychological first aid will be given to the survivors and then symptoms of acute stress will be addressed. Between 10-50% of those impacted can be expected to develop symptoms of post traumatic stress disorder. Expertise in risk communication will also be helpful in dealing with the task of informing the public. This becomes especially relevant with the threat of radiation contamination from damaged nuclear reactors.

As the earthquake and tsunami disaster in Japan unfolds, we cannot help but feeling helpless and overwhelmed as we learn of the increasing death and injury toll and see the tremendous destruction. Even though some of us as psychiatrists and other mental health professionals have worked in disaster situations, very few of us have witnessed the magnitude of the events taking place in Japan.

Mental Health Experts will Offer Help

Edited by M. Blumenfield & R. Ursano

I am sure that there will be mental health specialists from the United States and elsewhere offering their assistance to our colleagues in Japan as has been the case with other major catastrophes. During the Kobe earthquake in Japan in 1995, I was a member of the Committee on Disasters of the American Psychiatric Association and we arranged to translate a good part of our mental health written materials for disaster into Japanese so I am sure they will be made available again  at this time. In that event and during subsequent events, American psychiatrists held conference calls with mental health professionals in impacted areas to offer the benefit of experience which we had from working in various events including plane crashes, The World Trade Center bombing, Oklahoma City, Katrina, 9/11 and other events. An organization called Disaster Psychiatry Outreach was formed by a group of young psychiatrists from New York who trained many psychiatrists who then participated in the mental health efforts in various locations throughout the world. For several years I participated with my colleagues in  teaching courses at the annual meeting of the American Psychiatric Association about disaster psychiatry. I am sure there will be many mental health professionals joining other volunteers  to assist the Japanese in dealing with this traumatic event.

I would like to briefly review some of the anticipated mental health issues in a disaster such as this one.

Psychological First Aid

Needless to say – the first effort is always rescue and attempt to save as many as lives as possible. All resources will be directed  towards  searching and finding the victims of this tragedy. First Aid to the victims should always have priority over mental health support but it should be given with Psychological First Aid.   this means that  food, water and shelter should be provided in a compassionate manner. An essential part of this effort is to communicate in efficiently and humanely  with families and loved ones who have survived.   Another part of this psychological first aid is going to be some kind of continued support to those who have suffered so many losses personal and material loses. The role of insurance, government support and foreign aid along with that of friends and family will be very meaningful and psychologically supportive.

Actual treatment might be better than a support group for some patients who have undergone severe trauma.

Not Just Grieving But Complicated Grieving

Edited by Fred Stoddard, Jr., Craig Katz, and Joseph Merlino

Whenever there is loss of life there is grieving by family, friends and I am sure by the entire country. Grieving is a universal process and while it is influenced by culture and religion, there are certain physical and emotional components of it that are well know by physicians, ministers, mental health professionals and anyone who has been around long enough to see such responses in themselves and others. There will be waves of emotions whenever anything reminds them of the loss, tears and depressive symptoms. While the lost person may never be forgotten, the severity of the symptoms and inability to function as before will usually improve over time with normal grieving. However a situation like this is one which falls into a different category usually named complicated grieving. Such a designation  is made when there is the death of large numbers of people especially when children are killed or large numbers of children are grieving, unexpected death often of horrible and bizarre circumstances. ( This designation also applies when there is murder or suicide which doesn’t apply here ).It is more likely to occur when the body has not been located and given a ceremonial funeral.  Complicated grieving usually is prolonged for at least a few years, sometimes longer. It is complicated by symptoms of severe depression and may lead to substance abuse and suicidal behavior. There is often a need of the  bereaved to to find an explanation for the event or seek some type of restitution. This may lead to tremendous anger directed towards the government and public officials even in a situation where there was a natural disaster. These feelings can  also get directed towards God and towards one’s religion. It becomes very meaningful for the government, and society to recognize the loss of lives. Memorial and commemorative services at anniversaries of the event as well as monuments and dedicated rebuilding becomes part of the healing process.

Acute Psychological Stress

By Robert Ursano, Carol S. Fullerton, Lars Weisaeth and Beverly Raphael

There are acute psychological stress symptoms which will occur in huge numbers of people in the days and weeks after the event.These will consist of extreme anxiety, depression, insomnia, bad dreams, flashbacks of the horrible events which they experienced, helplessness, numbing, detachment, feelings of unreality, depersonalization dissociative amnesia where a person can’t recall important aspects of the trauma, tendency to avoid anything or any thoughts to do with the trauma and a tendency to have an increased startle reaction or tendency to jump very easily. At this stage people are susceptible to abusing alcohol and drugs. It had been very common for peer groups and mental health professionals to organize debriefing group meetings where people who recently had been through a trauma would be encouraged to review  their experiences as well as their emotional responses including the personal meaning to them. It was thought that this approach could diminish the possibility of long term psychological symptoms. Subsequent research did not establish this as a valid approach and raised questions whether at times the group discussions created more anxiety in some individuals. While each situation is different and there are often limited psychological resources, the best psychological approach appears to be psychological first aid with warm supportive environment where the victims basic needs are met, valid information is supplied by caring people, efforts are made to connect with families, intermediate and long term planning is established and the victims are counseled about what type of psychological feelings they might be expected to have . People should be cautioned about tendency to abuse alcohol and drugs. During group meeting where information and other necessities are being provided, there should be screening for individuals who may need individual counseling, therapy with or without psychiatric medication.  People with pre-existing mental disorders may have an exacerbation of their condition although in some cases such people faced with an external catastrophic event may actually fare fairly well as they put aside their “personal demons” and actually cope better than usual. People with underlying mental conditions may need adjustment of their medication. In addition there can be an important role for the use of administering sleep medication , anti- anxiety medication of other psychotropic medication to some people during the acute phase of a trauma.

Post Traumatic Stress

By V. Alex Kehayan & Joseph C. Napoli

It is invariably that a certain number of people will go on to develop a post traumatic stress disorder where they can have persistent symptoms as described above. This can be quite distressing and incapacitating  for some people . There are several  psychological treatment techniques which may or may not include medication While the percentage is variable perhaps between 10-50% can have significant symptoms in months and years to come. We have learned that the majority of people in such situations have shown great resiliency and have a good psychological recovery over time . People closest to the areas of destruction are more likely to suffer although this is not invariably the case. Children are particularly vulnerable and should not be neglected in screening for emotional problems. Today with mass media, people watching the events can identify with their fellow countrymen and women and suffer symptoms. We now also know that there are psychological causalities among the police, fire, emergency personnel, hospital workers, morgue workers government officials and especially members of the working press who go out of their way to witness a great deal of the death and destruction.

Risk Communication

Mental health professionals can provide assistance and consultation in all phases of a disaster. There are also mental health experts who have studied the field of risk communication which is how public officials and the media provide information about potential danger. It has been shown that it is both essential for there to be a spokesperson who is trusted to deliver honest information to the public at the same time to do it in a manner to minimize fear and panic. This has been studied and there are techniques which this can be done in the most effective manner.

Psychologcial Impact of Radiation Threat

One additional thought related to the above issue of risk communication is the situation where there is the potential of radiation fallout to the communities surrounding nuclear plants which is the situation occurring as I am writing this. There was a similar situation in the United States with the Three Mile Island incident where there was a question of the accidental release of radioactive vapor into the air. Subsequent studies have shown that while there actually was no  physical danger many people suffered psychological symptoms especially women of child bearing age  and mother of small children who were highly anxious about the potential danger of radiation.

There are some excellent books on psychological issues in disasters which can be easily accessed. I have pictured  some of them in this blog. I welcome your thoughts on this very important current issue.