1. 9/11: Mounting a Mental Health Response in the Wake of Terrorist Attacks Presenter: Nancy E. Wallace, LMSW International Conference on Social Work and Disaster Recovery Conference Theme: Resilience and Strength in Disaster Recovery and Management National Taiwan University Taipei, Taiwan 13-14 June, 2011

2. 9/11 Post Disaster Mental Health Impact   Expectations of consequences Profound 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  National survey conducted weeks after attacks found 44% of adults and 35% children reported one or more substantial symptoms of traumatic stress (not PTSD)  Risk factors for severity included being near or injured around the site of the attacks, losing a family member of someone close as a result of the attacks, being unmarried, having low social support, and reporting previous trauma

3. 9/11 Post Disaster Mental Health Impact  Intentionally caused incidents of mass violence characterized by large-scale loss of life, property loss and widespread unemployment Associated with severe, lasting and pervasive psychological effects Associated with severe, lasting and pervasive psychological effects  Mental health impact of terrorist attacks was initially severe for many individuals within commuting distance of the World Trade Center Prevalence of PTSD symptoms declined dramatically 5 months after the attacks, from 7.5 to.6% Prevalence of PTSD symptoms declined dramatically 5 months after the attacks, from 7.5 to.6% 17.4 to 4.7% subsyndromal PTSD 17.4 to 4.7% subsyndromal PTSD Minority of individuals continued to report relatively severe chronic psychological distress Minority of individuals continued to report relatively severe chronic psychological distress

4. Preparing for Post Trauma Interventions  Major depression  Substance abuse disorder  Generalized anxiety disorder (GAD)  Panic disorder  Acute stress disorder (ASD)  PTSD  Brief psychotic disorder  Physical Muscle tremors, fatigue, chills, sweating, shock symptoms, gastrointestinal distress, dizziness, difficulty breathing, chest pain, headaches, elevated blood pressure, feeling of hollowness, weakness, sensitivity to noise  Emotional Impatience, fear, anxiety, anger, irritability, numbness, loneliness, guilt, shame, lack of enjoyment in everyday activities, dissociation  Cognitive Difficulty concentrating or remembering things, confusion, limited attention span, decreased ability to make decisions or solve problems, calculation difficulties, recurring dreams or nightmares, reconstructing events in order to make it come out differently, repeated thoughts or memories, intrusive thoughts  Behavioral Overprotecting self & family, isolating, startled response, sleeping problems, avoiding activities that bring back memories, conflicts, keeping excessively busy, tearfulness, crying for no reason, changes in appetite, alcohol/ drug use, discarding treasured objects  Spiritual Crisis of faith, questioning basic religious beliefs, anger at God, displaced anger towards authority figures, increased faith Normal Responses / Resilience and Strength Based Interventions – Short term Psychological Disorders – Long tem – Long tem

5. Initiating a Corporate EAP Response Assessment Directs the Outreach  Major Financial Institution Ties to WTC Ties to WTC 24 Hour Operation 24 Hour Operation Potential Terrorist Target Potential Terrorist Target Male Oriented Environment Male Oriented Environment  Direct Views Planes Hitting Planes Hitting Towers Falling Towers Falling Dust Clouds / People Fleeing Dust Clouds / People Fleeing  Aftermath Respite Center Respite Center Exposure to First Responders Exposure to First Responders Frozen Zone Frozen Zone Trucks hauling debris Trucks hauling debris  Impact Deaths of Workers, Family Members Deaths of Workers, Family Members Direct Exposure / Indirect Exposure Direct Exposure / Indirect Exposure Past Traumas Past Traumas

6. Post Disaster Intervention  Employee Assistance Program (EAP) Initial Intervention models Initial Intervention models What went wrong What went wrong  Modified CISD Crisis Incident Stress Debriefing Crisis Incident Stress Debriefing  Psycho-Education  Resource Development  Triage Support / Promotion for Strength, Resilience and Well-Being Support / Promotion for Strength, Resilience and Well-Being  Acute Stress Symptoms, Grief, Depression, Sadness, Loss  Normal symptoms Identification of mental disorders Identification of mental disorders  Depression, PTSD, Panic and Anxiety  Substance Abuse  Violence against Women Referrals for Treatment Referrals for Treatment  Commemorations  Management Consultation and Training

7. Facing Challenges: Project Liberty  Initiated by FEMA (Federal Emergency Management Agency  Large scale public health intervention  Coordinated outreach and crisis counseling program for individuals, families and groups  Serviced more than 1 Million New Yorkers  Distributed funds to more than 100 mental health providers and community service organizations  Service provision in multiple naturalistic community settings, such as churches and social clubs, through a large network of trained mental health professionals and paraprofessionals  Focus: Outreach, Crisis Counseling Outreach, Crisis Counseling Economic Hardship, Job or Housing Loss Economic Hardship, Job or Housing Loss Handouts and Resources Handouts and Resources Provider Training Provider Training

8. Facing Challenges: Project Liberty  NY state-initiated, federally funded service offering free counseling  Components:  1-800-LifeNet / Mental Health Association of New York City Assess and Referral Assess and Referral Staffed by Counselors Staffed by Counselors  Outreach Direct Marketing Campaigns urging those struggling with the effects of the terrorist attacks to call 1-800-LifeNet Direct Marketing Campaigns urging those struggling with the effects of the terrorist attacks to call 1-800-LifeNet Strategic Timing – Critical Dates, Holidays Strategic Timing – Critical Dates, Holidays Aimed at 6 audiences: general, parents, senior citizens, rescue and recovery workers, teen-agers and Hispanics. Aimed at 6 audiences: general, parents, senior citizens, rescue 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 actors Designed for TV, Newspapers and Radio featuring famous actors Targets Groups / Culture / Language Targets Groups / Culture / Language Internet Technology Internet Technology  Geo-Target  Psycho-Education and Resource Links  Web Chats with Psychologist

9. Project Liberty: Unmet Needs  Project Liberty's goals were not met Agencies had difficulty navigating Project Liberty Agencies had difficulty navigating Project Liberty Funding problems and lack of flexibility Funding problems and lack of flexibility No funds for psychiatric/psychological mental health care and high level professional staff No funds for psychiatric/psychological mental health care and high level professional staff PL did not adequately address the psychological and emotional needs of those affected by 9/11 PL did not adequately address the psychological and emotional needs of those affected by 9/11 Missed effective outreach to critical populations Missed effective outreach to critical populations  Immigrants and other special populations Major Criticism Major Criticism  ENDED TOO SOON!

10.  Mass mobilization of all ARC resources  Titled September 11 Recovery Program  60,000 families and individuals 500 living outside US 500 living outside US Cooperation of Red Cross in 62 Foreign Countries Cooperation of Red Cross in 62 Foreign Countries 100 NGO partners 100 NGO partners Initial Interventions Initial Interventions  Respite center for families and first responders  Case management  9/11 Mental Health and Substance Abuse Program Ended January 2, 2007 Ended January 2, 2007 Partnered with September 11 th Fund created by NY Community Trust, United Way of NY, MH Association of NYC Partnered with September 11 th Fund created by NY Community Trust, United Way of NY, MH Association of NYC Long-term program for psychological distress Long-term program for psychological distress Primarily paid for services for all effected Primarily paid for services for all effected Started 8/02 – Almost a year after Terrorist Attacks Started 8/02 – Almost a year after Terrorist Attacks Worked with 9/11 families, first responders, lower Manhattan community based groups Worked with 9/11 families, first responders, lower Manhattan community based groups Red Cross Response

11. Red 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

12. NYC 9/11 Benefit Program for Mental Health  Red Cross services ended  NYC Department of Health and Mental Hygiene, with benefit access coordinated by the Mental Health Association of New York City  Extended same services between January 2, 2007 and January 7, 2011  Now what?  10 th Anniversary approaching  Expectation of reoccurrence of symptoms

13. Post 9/11 Research  Unpublished Research: Study of Trauma Exposure and Posttraumatic Stress Disorder in Survivors of the 9 September 11, 2001 Attacks on the World Trade Center: A 10-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

14. Anticipating the 10 th Anniversary of 9/11  Dedication of the 9/11 Memorial  Death of Osama Bin Laden  Re-emergence of Trauma Symptoms and Memories  Grief and Loss  Awareness of Triggers  Media  Designing Interventions  Providing Resources and Services  Importance of Rituals and Commemorations Memorial Lights

15. Final 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 services  Assessment of needs  Development and funding for short term and long term mental health responses and interventions Interventions to support resilience and strength Interventions to support resilience and strength  Individual, Family and Community Interventions for Psychological Trauma Disorders Interventions for Psychological Trauma Disorders  Training  Research Understanding criteria for PTSD Understanding criteria for PTSD  Evaluation

16. Contact Information  Nancy E. Wallace, LMSW  International Mental Health Consultant  Adjunct Professor, New York University Silver School of Social Work  United Nations Main Representative, World Federation for Mental Health (WFMH)  Past Chair and Founder, United Nations NGO Committee on Mental Health  email: newallace@earthlink.net  tel: +1 917-842-4733