Psychiatrists in the Midst of the Horror

"Nothing in my life so far has prepared me to face the sights, sounds, smells and emotions that accompanied the horror of Sept. 11," said Spencer Eth, M.D. For the last 20 years, Eth has spent his professional career treating and studying children, Vietnam veterans and others struggling with issues of trauma and grief.

Saint Vincent Catholic Medical Centers, where Eth is vice chair of the department of psychiatry, is an academic medical center of New York Medical College. Its Manhattan campus was the closest trauma hospital to "Ground Zero."

Eth's self-disclosure parallels the reactions of many psychiatrists and other mental health care professionals who remain on the frontlines providing help to anguished rescue workers, police, firefighters, families and co-workers of the missing or dead, teams in the medical examiner's office, workers aiding bereaved families, and countless others.

Eth recently testified before the U.S. Senate Committee on Health, Education, Labor and Pensions on "Psychological Trauma and Terrorism: Assuring That Americans Receive the Support They Need." In his testimony and in a subsequent interview with Psychiatric Times, he provided a glimpse of those first hours and days.

"Within minutes of the first plane crash at 8:45 a.m. in Building 1 of the World Trade Center, Saint Vincent's was ready to respond to the expected demand for emergency care. Over 600 patients were examined, of whom 162 were firefighters, police and rescue workers," Eth told the Senate committee. "Although these patients were treated for physical injuries, many also wanted to share with our mental health staff their terrifying experiences. One dehydrated firefighter being seen in the emergency room began to shake and cry as he confided to me that he had just carried the headless body of his commander out from the rubble."

In the days since the terrorist attack on New York, Saint Vincent's family support center staff has provided information and counseling to more than 7,000 people. Additionally, Saint Vincent's established a telephone counseling service that has received more than 10,000 calls since the disaster, according to Eth, who is also medical director of Saint Vincent's Behavioral Health Services and professor of psychiatry at New York Medical College.

The family support center also has become a respite place for hospital staff.

"We thought it would be for families," Eth told PT, "but we find that our colleagues really need it as well. We have offered massage, acupuncture, and a quiet place to relax and get away from the heavy physical and emotional burdens of responding to this disaster. People are working longer hours, and the work is more intense."

Initially, the disaster was a medical/surgical emergency, Eth said. But within 12 hours it evolved into a mental health crisis.

"The New York hospitals and community mental health agencies are trying to coordinate efforts to provide mental health services in concert with the City Department of Mental Health, Mental Retardation and Alcoholism; the New York State Office of Mental Health; and various federal agencies. It is a huge task to plan for mental health services, to coordinate the services, to train clinicians, and to provide the services and outreach that [are] necessary. That process is underway, but has a while to go before we are able to meet the need," he said.

At the same Senate hearing, Cynthia Pfeffer, M.D., professor of psychiatry and director of the Childhood Bereavement Program at Weill Medical College of Cornell University and New York Presbyterian Hospital, discussed her involvement in helping families and children.

"I had many responsibilities during the aftermath of this tragic event to assist schools, corporations, community leaders and affected families to process and develop plans to cope with the emotional, behavioral, physical and social consequences of this tragic episode. I met many children and their parents who revealed concerns with profound implications," she told the committee.

"Some parents reported that they were overwhelmed with fear, crying and helplessness. They could not easily communicate with their children and wanted support and guidance. Teachers were not sure about what to tell their students, how to interact with parents and how to cope with their own feelings. Parents debated with each other about how to explain what occurred fearing that their children would be traumatized."

At New York University's (NYU) Bellevue Hospital Center, Carol A. Bernstein, M.D., who supervises the nation's largest psychiatric residency training program (72 residents), has had her own share of daunting challenges since Sept. 11.

"We have been centrally involved right from the beginning," she told PT. "It's been hard to cope with all the personal issues that come in a situation like this at the same time [that] we are charged with providing the mental health services in the disaster and trying to train the next generation of psychiatrists."

Within two hours after the World Trade Center collapsed, Bellevue Hospital was running in full disaster mode, with several hundred doctors and medical students prepared to deliver care, according to a New York Times report.

"We discharged a lot of people from psychiatric services in order to provide beds for the expected injured and set up all sorts of extra staffing for psychiatric emergencies, but nobody came," said Bernstein. Only about 100 patients from the disaster were treated at Bellevue that morning, a telling sign of the later massive loss of life.

When Bernstein came in to Bellevue the next day (Wednesday), she was absolutely staggered by the fact that all of the residents had gotten there, despite the city being clamped shut and every access closed.

"I went to every group of residents that I could find -- at Bellevue, at the clinic, on the unit, in the emergency room -- and talked with them. Everybody was really quite shaken up but determined to help in whatever way they could," said Bernstein, associate professor of clinical psychiatry at NYU School of Medicine.

By Wednesday, families of those missing in the disaster were starting to check hospitals for their loved ones and go to a designated assistance site in the children's services building, located between NYU and Bellevue Hospital.

"A lot of psychiatry residents were actually out with lines and lines of people helping them go over what, at the time, were handwritten lists of people who had been admitted to various emergency rooms around the city," she said.

In the beginning, mental health care services were disorganized, Bernstein said, and "every day there was a new plan of what types of psychiatric services might be necessary."

Later in the week, some of the psychiatry residents were enlisted to help major corporations address the emotional devastation. Cantor Fitzgerald Partners, the brokerage house that lost some 600 employees from their World Trade Center location, arranged for a meeting with families and friends of the missing at the Pierre Hotel.

"Some of my residents went out to try to help the families. There were several PGY2s involved and, for them, it was an overwhelming experience. When people realize that family members have died tragically and suddenly, there is a lot of emotion," she said, adding that survivors in the firm also experienced intense emotions.

Throughout that first week following the terrorist attack, Bernstein did what she could to reduce the anxieties of the residents.

"Everybody was so frightened," she said. "All of the disaster literature talks about workers going to a disaster situation, but they don't talk about a situation where the workers are traumatized themselves," she said. For Bernstein, everyone in Manhattan was at "Ground Zero," and the experience was "off the chart."

"I was meeting pretty much every single day with as many residents as I could gather together. On Thursday, I was able to meet with all of my PGY3 residents to debrief them and talk about what was going on. And at noon, we had a resident-wide journal club that was led by several of our attendings, including one who was cofounder of a disaster psychiatry outreach group at the morgue. We used some materials that the American Psychiatric Association put up on its Web site and any material I could get my hands on," she said. "Yet, there isn't much written on a disaster of this magnitude in a major urban area It must have been like the Blitz in London during World War II, but people were not writing about posttraumatic stress disorder then."

By Sept. 17, Bernstein asked her residents seeking to participate in volunteer activities to talk with her. She explained that studies indicate psychiatric patients are at particular risk in a disaster situation. "The residents really needed to be there for their patients and to conserve their energies for the long haul."

She explained that some of the residents are currently helping at the New York City Family Assistance Center on Pier 94, located at 54th Street and 12th Avenue. "It looks kind of like an exhibit hall at an annual meeting. There are places for people to go to get death certificates, to get unemployment benefits, to see about housing, and, of course, there are counseling services," she said. "NYU is now sending a team on Mondays and Tuesdays during the day-one attending and one resident-to the pier to provide counseling services for anyone who needs help. To me, this is good, because it is structured. There is attending supervision, and we will relieve the residents of their regular responsibilities during the day to do this."

Beyond counseling families, the residents are also helping professionals working with families. For example, they are debriefing lawyers who are providing legal assistance to families filing death certificates.

Because the city's medical examiner's office is located at NYU, some residents have volunteered to provide counseling to individuals involved in identifying body parts and working with victims' personal effects.

Looking at her own contribution, Bernstein said she is linking traumatized people around the country with psychiatric resources -- individual practitioners, clinics and the like. And she is also looking after the residents. "The challenge for me on my job is to try to hold them together, teach them and also give them the opportunity to volunteer if they want to. Everybody feels so helpless when something like this happens, so you want to do something to make it better."

Asked about the ongoing effects of the disaster on herself, the staff and the people of New York City, Bernstein said that seeing the Wall of Prayer -- photos and flyers about the people who are still missing in the disaster -- on a construction barrier outside the entrance to Bellevue Hospital impacts "us, the residents and our patients." She added, "There is a hole in lower Manhattan. Subway service is still out. Access to hospitals is restricted. There are police everywhere...For myself, each week is a little better, but I wouldn't say each day is better. Some days are good, and some days are bad. There is a gradual movement in the return to normalcy as it were, but it is not the same."