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

 

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.

Psychological Issues For Trapped Miners

33 miners became trapped underground in a mine collapse in Chile. A rescue tunnel will not be expected to be completed for at least 3 months. In order to anticipate the psychological issues which they may experience, similar situations of people being isolated for prolonged periods in the space program, submerged submarines and in Antarctica expeditions are reviewed. Various recommendations to maintain mental health during and after this ordeal are also discussed.

I recently had a phone call from a reporter from the LA Times asking me if I had opinions about the psychological issues that miners trapped in Chile might be having in view of the fact they might be there for another 3 months.

I hadn’t previously thought about this issue and was glad to offer certain possibilities. After the phone call I kept reflecting on this issue. 33 men cut off from their families and the world  in a relatively small space. Except for telephone communication and thin tube which could bring them food and water as well as  whatever small items could fit through the small opening, they were isolated captives. I don’t know what trauma they experienced at the time of mine collapse and whether they had some moments where they felt their life was in immediate damage. We also don’t know whether they still continually fearful for their lives and safety. After all, they are miners and they know the potential pitfalls of the rescue mission being undertaken.

An Event Outside The Usual Human Experience

When people experience a traumatic event that is out of the usual human experience, especially when it is life threatening to themselves or others, that is the major ingredient for developing a post traumatic stress disorder. If they are trained as to what to expect and how to protect themselves, that may help mitigate the trauma. However, as our soldiers have learned, there is no way to guarantee immunity from post traumatic stress. Sensory and sleep deprivation can intensify their response to trauma . The continued presence of the threat to themselves will also exacerbate the psychological symptoms as will the reintroduction of the trauma or something that reminds the person of the trauma.

While the isolation in a mine for this long  duration of time appears to be unprecedented, there are certain situations  where observations have been made on people isolated for long periods of time even with the ability to communicate to the outside world.

Space Travel Provides Model of Prolonged Isolation

The Space program comes immediately to mind where astronauts and cosmonauts were isolated on space stations for long periods of time. Several years ago after one such space trip a Russian cosmonaut wryly remarked, “All the conditions necessary for murder are met if you shut two men in a cabin measuring 5 meters by 6 and leave them together for two months.” With a larger group there is less likely to be intense reactions between two individuals but it certainly can happen.  One report divided the various  psychological responses during prolonged periods in space  into three phases. During the first, which usually lasted about two months, people were busy adapting, usually successfully, to their new environment. In the second phase, there were clear signs of fatigue and low motivation. In the final phase the people could become hypersensitive, nervous and irritable.  In discussing the anticipated expedition to Mars experts have been concerned the ever-present possibility of death by small breach of the space ship by a meteorite or sun flare and how that will effect them. As mentioned above, the trapped miners may very well be attuned to the possibility of some dangerous event where no help could be offered to them

Life on Submerged Submarine or in the Antarctica for Long Periods

Other examples of people being isolated for prolonged periods of time are life aboard a submarine which is on a mission requiring prolonged submersion or life in a remote scientific camp in the Antarctica. The psychological problems which have been noted in these environments include concerns about a limited amount of resources, the unchanging social group, social isolation, limited communication with the outside world, a self-contained ecosystem, the constant sense of danger, physical confinement, lack of privacy, lack of separation between work and non-work, limited opportunity for variety and change, limited sensory deprivation, and dependence on machine-dominated environment. This pretty well defines the anticipated psychological challenges facing the trapped minors. One big difference with those people isolated in the Antarctica  – if one member of an Antarctica team got annoyed with another, he or she would have the whole continent to walk away and be separate for a while. Astronauts and the trapped miners, however, would be very confined with no escape from each other, and they would be very worried about the supply of air and water.

Provide Basic Necessities Plus a Little Extra and More if Possible

The first rule for treating people who may be potentially traumatized is to give them the basic necessities of life plus a little extra when possible. This means food, water, warm dry clothes (or in this case since it is warm down there, dry comfortable cool clothes). The next things that they need are information and communication. They have to have confidence in the people talking to them and know they are receiving honest information. People in a crisis, whether it is on a airliner having difficulty, being in a flood, hurricane or the target of an ongoing  terrorist attack all  want to know what is going on and what is planned for the immediate and near  term future. While they will respond best to truthful information, sometimes it doesn’t help them to give bad news if there is nothing they can do about it.  So for example, sometimes the death of family members is withheld if practical, from a trapped or isolated person until they are rescued. It goes without saying that speaking to loved ones during separation or during an ordeal is usually quite supportive. If a telephone line or radio signal is available a video link usually  can be set up. Providing music, tv shows and broadcasts of sporting events or other entertainment can be psychologically healthy for them also . I understand that some computer games, which are very small and can fit in the small opening, are also being provided. A particular social environment naturally develops with certain people becoming leaders. A 63 year old miner among those down there  has become the spiritual leader according to reports that I read. Recommendations can be made to the miners, which may be helpful. For example it is very important that they maintain a regular sleep cycle, which will be based on the clock rather than on seeing daylight outside. Another recommendation that I heard was being given to them to help maintain their civility and sociability is that they wait before starting their meals until the food for all the miners has been lowered.

Psychological Help During and After Being Trapped in the Mine

It will be feasible for the miners to have individual or group counseling session with mental health experts even while they are in the mine through the communication set up. If needed, psychotropic medications can be prescribed for various individuals and lowered into the mine. Regular chats with mental health professional while they trapped underground even if informal and brief will allow assessment of potential problems, which might require more intensive discussions or medication. I have read about the development of technology to help determine when someone on a phone line is in psychological distress just by their voice characteristics For example, computers can now discern the emotional inflection in a person’s voice to look for signs of emotional trouble. If the computer does find that someone is in need of help, it is programmed to suggest ways to alleviate the problem, such as recommending extra rest, extra food, or possibly medications or the live counselor could do so at that point. Unexpected crisis situations may occur and will have to be dealt with as they occur. One situation, which occurred recently in the Chile mine incident, was similar to situations I have occasionally seen when someone was unexpectedly brought to the hospital. A worried spouse and a girl friend meet each other for the first time as they rushed to the bedside (or in this case to the site of the mine collapse).

It is difficult to anticipate which members of the trapped group of miners will have more psychological issues than the others, both while in the mine and in the aftermath. Perhaps the best indication is whether they have had previous traumas and how they have dealt with them. This is certainly no guaranteed predictor of the future. Even the presence of severe mental illness doesn’t predict problems in this situation. During World War II in Europe there was   a diminished amount of exacerbation of existing mental disease as compared to during peacetime. One of the almost universal responses to an overwhelming trauma is to try to block it out, either by isolating the emotional reactions and/or the memory of traumatic event. People in the midst of traumatic event will report that it seemed as if it were happening to someone else. The degree to which they keep these memories and feelings out of their consciousness can be related to subsequent symptoms, which they may have. Most prominent among post traumatic symptoms are flashback, nightmares, being easily reminded of the trauma with reoccurring feelings or going out of the way to avoid such reminders. Some people resort to alcohol or drugs to try to avoid such painful feelings. Suicidal behavior is sometimes seen in people who feel overwhelmed by their experience and see no way for improvement. These problems when they do occur can be very brief and transient. They may not occur until after a period of weeks or several month from the time of rescue. They can persist for several months or even a lifetime if not treated.

CBT ( Cognitive Behavior Therapy ) has been used successfully in treating PTSD. This is a therapy which consists of correcting negative misperceptions about the experience but also teaching the patient various relaxation techniques at the same time as they mentally re-experience some of their traumatic memories. Other patients will benefit from therapy, which helps them explore the psychological meaning of this experience as well as deal with relationship issues and any resultant drug or alcohol problems.

Resiliency and The Joy of Being Alive

A few years ago I put together a conference of leading experts in psychological trauma and then edited a book with chapters by them on various aspects of disaster. Independently, in each of their presentations and in their book chapter they all made a point of discussing  the resiliency that most people have in dealing with traumatic events. Although many victims of such events greatly benefit by treatment and may have lingering symptoms, the major of  of people in such a situation will have the resiliency, to put this event into some perspective and return to their previous functioning.

Jose Luis Inciarte

Despite clinical experience that mental health professionals might have with people who have been through other traumatic situations, it is still hard to really imagine or empathize how these people are feeling. When I worked as consultant to a burn unit we would sometimes arrange a visit to a patient with a severe burn by a someone who had survived the ordeal that they had been through.

Just this week a Uruguayan rugby player who survived more than two month of isolation in the Andes with 15 others after a 1971 plane crash brought a message of hope for the miners. This survivor, Jose Luis Inciarte said, “They are in the process of discovering the joy of being alive and the will to survive.”

Haiti Earthquake-Psychological Care Needed

More than 150,000 people have died in the recent devastating earthquake in Haiti. There is fear, anxiety, depression and tremendous psychological pain. The uncertainty about the future will intensify these emotional reactions. Most likely the initial help by mental health professionals will be to assist the stunned people in getting food, shelter and information about the whereabouts of their loved ones. Psychiatrists may write prescriptions for general medical conditions or even assist in emergency surgery. There also is a need for the authorities to provide “risk communication” of truthful information. Death notifications need to be done skillfully. Mental health professionals can be helpful in training for these tasks. In the immediate aftermath of a disaster, people may deny the reality of what has happened. There will be grieving by survivors for the many people who perished. Grief after unexpected violent death especially when it includes children can be prolonged and complicated with additional emotional problems including alcohol and drug problems. At least half of the survivors will have some symptoms of PTSD. There are various forms of mental health interventions which may be helpful. The psychological effect of such a disaster can also impact on the secondary victims which include all rescue and medical personnel as well as members of the media. Psychiatrists and other mental health professionals will play an important role in helping the people of Haiti to recover from this ordeal.

I am writing this blog 12 days after the devastating earthquake in Haiti. We are seeing and hearing about the tremendous need for food, water, medical personnel and supplies. HAITIThere are head injuries, broken bones with people  dying of infections and other complications of their injuries as well as facing the prospect of starvation. We know from experiences in other disasters that there has to be fear, anxiety, depression and tremendous psychological pain among the people of Haiti. Thousands of people have been killed with unimaginable numbers of people injured, displaced from homes, separated from families, without food, water or  shelter. There is great uncertainty about the future for these people and this alone will intensify their emotional reactions.

Is There A Role For Mental Health Professionals ?

Of course, at this time  there is a need for psychiatrists and other mental health professional in Haiti. However, everything is relative. After the terrorist attack in New York on 9/11 there was an abundance of mental health experts immediately available. They were put to work on the Pier 92, which was where the services for the victims were being organized. They were not assigned to do psychological therapy but rather assisted in helping the stunned people to get food, shelter and assist them in finding what happened to  their loved ones. Their psychological and interpersonal skills were no doubt helpful in carrying out these tasks even though most were not initially doing formal therapy.

Psychiatrists who have become involved in previous disasters often will write prescriptions for heart, thyroid, diabetic and mostly other non- psychiatric medications which people need and did not have .  (See my previous blog on this subject) Psychiatrists may also participate in the delivery of general medical care or even assist in surgery during the early stages of a disaster response.

We would hope that the people organizing and delivering the immediate care to the victims in Haiti are sensitive to the psychological vulnerabilities of the victims, especially the children involved. The leaders of emergency services also need to understand how important it is to provide truthful information to the people involved without inducing additional fears and anxiety. There are  special techniques to do these “risk communications

In addition, the people doing death notifications to family and friends of those who died need to be knowledgeable and skilled in this difficult task.  Psychiatrists and other mental health professionals can be very helpful in training emergency workers for these tasks but the best time to do it is during emergency planning and  disaster preparedness.

Emotional Reactions in the Aftermath of Disaster

We all can imagine the fear and anxiety that people will initially feel when an earthquake occurs with immediate devastation. We can see the stunned look on the faces of the people in images from Haiti . It may take a while for the emotions to catch up with reality. In such a situation the people may become disconnected from their feelings (called dissociation).

Denial

Sometimes the people involved are actually denying the reality that has clearly occurred. DenialIn New York City immediately after the destruction of the World Trade Center thousands of people “disappeared”.  So many people did not come home that night and were buried in the rubble. Once it was established missing people were not registered at local hospitals, it should have been obvious that these people had perished. However families began posting “missing persons posters” all around Manhattan with a picture and a  description of the lost person with a phone number to call if the person were found. It took a week or two before the originators of most of these posters came back and changed the posters to memorials with people often putting flowers next to them. While this specific phenomena may not be occurring in Haiti, we can only imagine the difficulty that people are having adjusting to the sudden disappearance of important people in their lives. This is made even more difficult since, for most a funeral was not possible and for many the bodies will never be found.

Grieving

It was estimated that 10,000 children were grieving after the loss of a parent or a close relative following the 3000 deaths in the New York tragedy in 9/11. In Haiti more than 150,000 people are estimated to have died in this disaster so you can do the math as to acute grief among adults and children.  When people die violently, unexpected or when children are killed, the grieving that follows by their loved ones takes on special characteristics. It tends to be complicated by other psychiatric conditions such as post traumatic stress, major depression or even suicidal thoughts. Grieving in such situations tends to bring on alcohol and drug use in some people. It is more difficult to resolve all the powerful emotions especially the anger and the grief which can linger on for many years.

It is probably fair to say that the entire country of Haiti will be going through a prolonged grieving period but most people will not require psychological counseling even if it were available. The social networks including the church will provide most of the support. In fact, it has been shown that  following most disasters the majority of people will have great resiliency and will bravely deal with the tragedy albeit with a heavy heart. Their lives will be changed forever and they will never forget what happened. There will be memorials and anniversary events, which will be helpful to the grieving process.

Post Traumatic Stress

Having acknowledged the resiliency that most people will show after such mass trauma, many people will have at least some symptoms of post traumatic stress disorder ( PTSD). They will have recurrent and intrusive distressing recollections of the events that they have seen and been through. This can include nightmares and daytime flashbacks. At times people will act or feel as if the traumatic event were recurring. There may even be hallucinations or misperceptions where real things are misperceived as something related to the recent traumatic events. For example, the noise or vibrations of a passing plane or truck might immediately bring back a flood of the feelings that occurred during the earthquake. This can include rapid heart beat, fast breathing and other physical symptoms. When there are even mild after-shocks following a major earthquake some people are overwhelmed with emotion.

In the aftermath of such an event,  people suffering post traumatic stress symptoms can make efforts to avoid conversations or thoughts associated with the trauma. They may avoid certain locations or even people who will remind them of the recent trauma. Some will feel detached and estranged from other people and may not be able to have any loving feelings for a long time. There can be difficulty in falling or staying asleep, increased outbursts of anger, difficulty concentrating and hypervigilence. Quite characteristically people who are having symptoms of post traumatic stress will have an exaggerated startle response in which they can typically  appear to “jump out of their skin” after a loud or unexpected noise.

While at least 50 % of people exposed to the horrendous experience of a major earthquake can have one or more of these symptoms, perhaps only 10-15% will have significant symptoms lasting for more than one month in a pattern, which mental health professionals will diagnose as PTSD. Depending on the criteria used, some research has suggested higher numbers than I have stated above..

Treatment For Psychological Problems after a Traumatic Event

We have learned a great deal from past experiences, how to offer psychological help in the aftermath of a disaster. As previously mentioned, it is most important to assist with food shelter and help people find out about what happened to loved ones. In the past survivors were commonly offered a group technique called “critical incident stress debriefing (CISD)” where people were encouraged to relive their emotional experience in a supportive group environment. This technique has come under scrutiny as to whether it is the best technique or not and when and if  it should be used. Experience has taught disaster experts that while some group meetings maybe helpful, it is usually best to use them to provide survivors with needed information about coping with real issues as well some general information about the emotional reactions which they may be having, perhaps cautioning about the tendency in such a situation for some people to turn to alcohol and drugs. At the same time such meetings will allow mental health professionals to observe and identify the participants who may be doing poorly and require more specific individual or group therap. This treatment may be a specialized cognitive behavior type of treatment or more traditional psychotherapy

There has been some interesting research, which suggests that certain medications given during the early stage of disaster may prevent or minimize the development of posttraumatic stress symptoms. However at the present time medications of choice that are given are usually mild tranquilizers or sleep medication. Obviously people with severe symptoms or preexisting major mental disorders may require specific medications.

The Secondary Victims of Disaster

The psychological effects of a disaster not only potentially impact the people who live in Haiti or were there when the earthquake struck, but can also effect the emergency personnel who flowed into Haiti to provide services and who can  become secondary victims. This includes all the fire, police, rescue teams and military personnel as well as the many doctors, nurses, including mental health professionals. Even though many of these workers are used to seeing people who are traumatized, injured and dying or dead, the magnitude of this tragedy may be beyond anything that they have seen or experienced.

ANDERSON COOPERThe Media Are Often Neglected as Potential Victims of PTSD

The other night I saw Anderson Cooper, CNN anchor, reporting from Haiti. He was telling about the dead bodies of children being pulled out of the rubble and other very difficult scenes. He was clearly emotionally affected. It is the job of the working press to view the worst of all the destruction, talk to victims, as well as the families of those who have perished. They often work around the clock without much rest. I have had experience working with media people who have been through disasters and I have seen the emotional toll that can be taken on them. (See Page 42-43 of this reference)

Conclusion

It will not be easy for the Haitian people to get through this tragedy without emotional scarring. I know that among the many volunteers assisting them and their helpers will be psychiatrists and other mental health professionals who will play an important role in the recovery from this ordeal.

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