9/11:9/11: Mounting a Mental Health Mounting a Mental Health Response in the Wake of Response in the Wake of

Terrorist Attacks Terrorist Attacks

Presenter: Nancy E. Wallace, LMSWPresenter: Nancy E. Wallace, LMSW

International Conference on Social Work and Disaster RecoveryInternational Conference on Social Work and Disaster Recovery

Conference Theme: Conference Theme: Resilience and Strength in Disaster Recovery and ManagementResilience and Strength in Disaster Recovery and Management

National Taiwan UniversityNational Taiwan UniversityTaipei, TaiwanTaipei, Taiwan

13-14 June, 201113-14 June, 2011

9/11 Post Disaster Mental Health Impact9/11 Post Disaster Mental Health Impact

Expectations of consequencesProfound and far-reaching, affecting people

throughout NYC) area and the US who were the terrorists’ psychological target

Effective disaster mental health planning and response depend on accurate information about the numbers of people who will need various types of services

NationalNational survey conducted weeks after attacks found survey conducted weeks after attacks found 44%44% of adults and of adults and 35%35% children reported one or more children reported one or more substantial symptoms of traumatic stress (not PTSD)substantial symptoms of traumatic stress (not PTSD)

Risk factors for severity included being near or injured Risk factors for severity included being near or injured around the site of the attacks, losing a family member around the site of the attacks, losing a family member of someone close as a result of the attacks, being of someone close as a result of the attacks, being unmarried, having low social support, and reporting unmarried, having low social support, and reporting previous traumaprevious trauma

9/11 Post Disaster Mental Health Impact9/11 Post Disaster Mental Health Impact

Intentionally caused incidents of mass violence Intentionally caused incidents of mass violence characterized by large-scale loss of life, property characterized by large-scale loss of life, property loss and widespread unemploymentloss and widespread unemploymentAssociated with severe, lasting and pervasive Associated with severe, lasting and pervasive

psychological effectspsychological effects Mental health impact of terrorist attacks was Mental health impact of terrorist attacks was

initiallyinitially severe for many individuals within severe for many individuals within commuting distance of the World Trade Centercommuting distance of the World Trade CenterPrevalence of PTSD symptoms declined Prevalence of PTSD symptoms declined

dramatically dramatically 5 months5 months after the attacks, from after the attacks, from 7.5 to .6%7.5 to .6%

17.4 to 4.7%17.4 to 4.7% subsyndromal PTSD subsyndromal PTSD Minority of individuals continued to report relatively Minority of individuals continued to report relatively

severe chronic psychological distress severe chronic psychological distress

Preparing for Post Trauma InterventionsPreparing for Post Trauma Interventions

Major depressionMajor depression Substance abuse Substance abuse

disorderdisorder Generalized anxiety Generalized anxiety

disorder (GAD)disorder (GAD) Panic disorderPanic disorder Acute stress disorder Acute stress disorder

(ASD)(ASD) PTSDPTSD Brief psychotic Brief psychotic

disorderdisorder

PhysicalPhysical Muscle tremors, fatigue, chills, sweating, shock Muscle tremors, fatigue, chills, sweating, shock

symptoms, gastrointestinal distress, dizziness, symptoms, gastrointestinal distress, dizziness, difficulty breathing, chest pain, headaches, elevated difficulty breathing, chest pain, headaches, elevated blood pressure, feeling of hollowness, weakness, blood pressure, feeling of hollowness, weakness, sensitivity to noisesensitivity to noise

EmotionalEmotional Impatience, fear, anxiety, anger, irritability, Impatience, fear, anxiety, anger, irritability,

numbness, loneliness, guilt, shame, lack of numbness, loneliness, guilt, shame, lack of enjoyment in everyday activities, dissociation enjoyment in everyday activities, dissociation

CognitiveCognitive Difficulty concentrating or remembering things, Difficulty concentrating or remembering things,

confusion, limited attention span, decreased ability confusion, limited attention span, decreased ability to make decisions or solve problems, calculation to make decisions or solve problems, calculation difficulties, recurring dreams or nightmares, difficulties, recurring dreams or nightmares, reconstructing events in order to make it come out reconstructing events in order to make it come out differently, repeated thoughts or memories, intrusive differently, repeated thoughts or memories, intrusive thoughtsthoughts

BehavioralBehavioral Overprotecting self & family, isolating, startled Overprotecting self & family, isolating, startled

response, sleeping problems, avoiding activities that response, sleeping problems, avoiding activities that bring back memories, conflicts, keeping excessively bring back memories, conflicts, keeping excessively busy, tearfulness, crying for no reason, changes in busy, tearfulness, crying for no reason, changes in appetite, alcohol/ drug use, discarding treasured appetite, alcohol/ drug use, discarding treasured objectsobjects

SpiritualSpiritual Crisis of faith, questioning basic religious beliefs, Crisis of faith, questioning basic religious beliefs,

anger at God, displaced anger towards authority anger at God, displaced anger towards authority figures, increased faithfigures, increased faith

Normal Responses / Resilience and Strength Based Interventions – Short term

Psychological DisordersPsychological Disorders – – Long temLong tem

Initiating a Corporate EAP ResponseInitiating a Corporate EAP ResponseAssessment Directs the OutreachAssessment Directs the Outreach

Major Financial InstitutionMajor Financial Institution Ties to WTCTies to WTC 24 Hour Operation24 Hour Operation Potential Terrorist TargetPotential Terrorist Target Male Oriented EnvironmentMale Oriented Environment

Direct ViewsDirect Views Planes HittingPlanes Hitting Towers FallingTowers Falling Dust Clouds / People FleeingDust Clouds / People Fleeing

AftermathAftermath Respite CenterRespite Center Exposure to First RespondersExposure to First Responders Frozen ZoneFrozen Zone Trucks hauling debrisTrucks hauling debris

ImpactImpact Deaths of Workers, Family MembersDeaths of Workers, Family Members Direct Exposure / Indirect Exposure Direct Exposure / Indirect Exposure Past TraumasPast Traumas

Post Disaster InterventionPost Disaster Intervention Employee Assistance Program (EAP)Employee Assistance Program (EAP)

Initial Intervention modelsInitial Intervention models What went wrongWhat went wrong

Modified CISDModified CISD Crisis Incident Stress DebriefingCrisis Incident Stress Debriefing

Psycho-EducationPsycho-Education Resource DevelopmentResource Development TriageTriage

Support / Promotion for Strength, Resilience and Well-BeingSupport / Promotion for Strength, Resilience and Well-Being Acute Stress Symptoms, Acute Stress Symptoms, Grief, Depression, Sadness, Grief, Depression, Sadness,

LossLoss Normal symptomsNormal symptoms

Identification of mental disordersIdentification of mental disorders Depression, PTSD, Panic and AnxietyDepression, PTSD, Panic and Anxiety Substance AbuseSubstance Abuse Violence against WomenViolence against Women

Referrals for TreatmentReferrals for Treatment CommemorationsCommemorations Management Consultation and TrainingManagement Consultation and Training

Facing Challenges: Project LibertyFacing Challenges: Project Liberty Initiated by FEMA (Federal Emergency Management Initiated by FEMA (Federal Emergency Management

AgencyAgency Large scale public health interventionLarge scale public health intervention Coordinated outreach and crisis counseling program Coordinated outreach and crisis counseling program

for individuals, families and groups for individuals, families and groups Serviced more than 1 Million New YorkersServiced more than 1 Million New Yorkers Distributed funds to more than 100 mental health Distributed funds to more than 100 mental health

providers and community service organizationsproviders and community service organizations Service provision in multiple naturalistic community Service provision in multiple naturalistic community

settings, such as churches and social clubs, through settings, such as churches and social clubs, through a large network of trained mental health a large network of trained mental health professionals and paraprofessionalsprofessionals and paraprofessionals

Focus: Focus: Outreach, Crisis CounselingOutreach, Crisis Counseling Economic Hardship, Job or Housing LossEconomic Hardship, Job or Housing Loss Handouts and ResourcesHandouts and Resources Provider TrainingProvider Training

Facing Challenges: Project LibertyFacing Challenges: Project Liberty

NY state-initiated, federally funded service offering free counselingNY state-initiated, federally funded service offering free counseling Components:Components:

1-800-LifeNet / 1-800-LifeNet / Mental Health Association of New York CityMental Health Association of New York CityAssess and ReferralAssess and ReferralStaffed by CounselorsStaffed by Counselors

Outreach Outreach Direct Marketing Campaigns urging those struggling with the Direct Marketing Campaigns urging those struggling with the

effects of the terrorist attacks to call 1-800-LifeNeteffects of the terrorist attacks to call 1-800-LifeNetStrategic Timing – Critical Dates, HolidaysStrategic Timing – Critical Dates, HolidaysAimed at 6 audiences: general, parents, senior citizens, rescue Aimed at 6 audiences: general, parents, senior citizens, rescue

and recovery workers, teen-agers and Hispanics. and recovery workers, teen-agers and Hispanics. Theme "Feel Free to Feel Better“Theme "Feel Free to Feel Better“

Designed for TV, Newspapers and Radio featuring famous actorsDesigned for TV, Newspapers and Radio featuring famous actors Targets Groups / Culture / LanguageTargets Groups / Culture / Language

Internet TechnologyInternet Technology Geo-TargetGeo-Target Psycho-Education and Resource LinksPsycho-Education and Resource Links Web Chats with PsychologistWeb Chats with Psychologist

Project Liberty: Unmet NeedsProject Liberty: Unmet Needs Project Liberty's goals were not metProject Liberty's goals were not met

Agencies had difficulty navigating Project LibertyAgencies had difficulty navigating Project LibertyFunding problems and lack of flexibilityFunding problems and lack of flexibilityNo funds for psychiatric/psychological mental No funds for psychiatric/psychological mental

health care and high level professional staffhealth care and high level professional staffPL did not adequately address the psychological PL did not adequately address the psychological

and emotional needs of those affected by 9/11and emotional needs of those affected by 9/11Missed effective outreach to critical populationsMissed effective outreach to critical populations

Immigrants and other special populationsImmigrants and other special populationsMajor CriticismMajor Criticism

ENDED TOO SOON!ENDED TOO SOON!

Mass mobilization of all ARC resourcesMass mobilization of all ARC resources Titled September 11 Recovery ProgramTitled September 11 Recovery Program 60,000 families and individuals60,000 families and individuals

500 living outside US500 living outside US Cooperation of Red Cross in 62 Foreign CountriesCooperation of Red Cross in 62 Foreign Countries 100 NGO partners100 NGO partners Initial InterventionsInitial Interventions

Respite center for families and first respondersRespite center for families and first responders Case managementCase management

9/11 Mental Health and Substance Abuse Program9/11 Mental Health and Substance Abuse Program Ended January 2, 2007Ended January 2, 2007 Partnered with September 11Partnered with September 11thth Fund created by NY Fund created by NY

Community Trust, United Way of NY, MH Association of NYCCommunity Trust, United Way of NY, MH Association of NYC Long-term program for psychological distressLong-term program for psychological distress Primarily paid for services for all effectedPrimarily paid for services for all effected Started 8/02 – Almost a year after Terrorist AttacksStarted 8/02 – Almost a year after Terrorist Attacks Worked with 9/11 families, first responders, lower Manhattan Worked with 9/11 families, first responders, lower Manhattan

community based groupscommunity based groups

Red Cross ResponseRed Cross Response

Red Cross / September 11 FundRed Cross / September 11 Fund Flexible treatment options with licensed provider of choice Treatment options are: Counseling

Support, advice and education Medication Substance Abuse Programs

Rehabilitation and detox services for alcohol and drug abuse

In-Patient Care Hospitalization and/or substance abuse treatment

Auricular Acupuncture Acupuncture to the outer ear Used for alcohol or drug abuse, or for anxiety

Testing and Evaluation Assessment of child or adolescent social, emotional

and intellectual functioning

NYC 9/11 Benefit Program NYC 9/11 Benefit Program for Mental Healthfor Mental Health

Red Cross services endedRed Cross services ended NYC Department of Health and Mental NYC Department of Health and Mental

Hygiene, with benefit access coordinated by Hygiene, with benefit access coordinated by the Mental Health Association of New York the Mental Health Association of New York City City

Extended same services between January 2, Extended same services between January 2, 2007 and January 7, 20112007 and January 7, 2011

Now what? Now what? 1010thth Anniversary approaching Anniversary approaching Expectation of reoccurrence of symptomsExpectation of reoccurrence of symptoms

Post 9/11 ResearchPost 9/11 Research Unpublished Research: Unpublished Research: Study of Trauma Exposure and Study of Trauma Exposure and

Posttraumatic Stress Disorder in Survivors of the 9 Posttraumatic Stress Disorder in Survivors of the 9 September 11, 2001 Attacks on the World Trade Center: A September 11, 2001 Attacks on the World Trade Center: A 10-Year Perspective and Implications for Future Directions10-Year Perspective and Implications for Future Directions

Results: Direct exposure zone was concentrated within a radius of 0.1 mile and completely contained within .75 mile.

PTSD symptom criteria were met by 35% directly exposed to danger, 20% exposed only through witnessed experiences, 35% exposed only indirectly through a close associate

Outside of exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most had pre-existing psychiatric illness

Among those with exposures who developed PTSD, 40% had remitted by three years and 59% by six years

Conclusions: Exposures deserve careful consideration among populations affected by large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions

Anticipating the Anticipating the 1010th th Anniversary of Anniversary of

9/119/11 Dedication of the 9/11 Dedication of the 9/11

MemorialMemorial Death of Osama Bin LadenDeath of Osama Bin Laden Re-emergence of Trauma Re-emergence of Trauma

Symptoms and MemoriesSymptoms and Memories Grief and LossGrief and Loss Awareness of TriggersAwareness of Triggers MediaMedia Designing InterventionsDesigning Interventions Providing Resources and Providing Resources and

ServicesServices Importance of Rituals and Importance of Rituals and

CommemorationsCommemorations

Memorial Lights

Final ThoughtsFinal Thoughts

Reflecting on a decade of mental health research on the 9/11 attacks, the unprecedented scope, magnitude, and devastation created extensive complexities that still challenge both researchers and disaster response efforts

Requires coordination and collaboration of servicesRequires coordination and collaboration of services Assessment of needsAssessment of needs Development and funding for short term and long term Development and funding for short term and long term

mental health responses and interventionsmental health responses and interventions Interventions to support resilience and strengthInterventions to support resilience and strength

Individual, Family and CommunityIndividual, Family and Community Interventions for Psychological Trauma DisordersInterventions for Psychological Trauma Disorders

TrainingTraining ResearchResearch

Understanding criteria for PTSDUnderstanding criteria for PTSD EvaluationEvaluation

Contact InformationContact Information

Nancy E. Wallace, LMSWNancy E. Wallace, LMSW International Mental Health ConsultantInternational Mental Health Consultant Adjunct Professor, New York University Adjunct Professor, New York University

Silver School of Social WorkSilver School of Social Work United Nations Main Representative, United Nations Main Representative,

World Federation for Mental Health (WFMH)World Federation for Mental Health (WFMH) Past Chair and Founder, United Nations Past Chair and Founder, United Nations

NGO Committee on Mental HealthNGO Committee on Mental Health email: newallace@earthlink.netemail: newallace@earthlink.net tel: +1 917-842-4733tel: +1 917-842-4733