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The scope and magnitude of the September 11, 2001, attacks on the World Trade Center and the Pentagon were unprecedented in US history. It was arguably the most serious trauma to beset Americans on US soil. The twentieth anniversary of 9/11 will take place during another crisis, not only in American history but also in world history — the COVID-19 pandemic.
Firefighters at the scene after the 9/11 attack on the World Trade Center.
"As different as these two events are, there are obvious points of comparison," Jonathan DePierro, PhD, assistant professor of psychiatry, Icahn School of Medicine at Mount Sinai, New York City, told Medscape Medical News. "Both were unprecedented life-threatening situations, presenting threats to individuals' lives and profoundly traumatizing not only society as a whole but also first responders."
DePierro, who is also the clinical director of the Center for Stress, Resilience, and Personal Growth at Mount Sinai, thinks there are many lessons to be learned from the mental health response to 9/11 that can inform our understanding of and response to the mental health needs of today's first responders in the COVID-19 crisis, particularly healthcare professionals.
"Every one of our hospitals became a 'ground zero' early during the pandemic, and we see the numbers rising again and hospitals again overwhelmed, so our institutions need to design interventions to meet the needs of our healthcare professionals," he said.
Placing Trauma Within a New Framework
According to Priscilla Dass-Brailsford, EdD, MPH, professor of psychology, Department of Psychiatry, Georgetown University, Washington, DC, September 11, 2001, "placed trauma within a new framework."
"Prior to 9/11, crisis protocols and how to manage stress in the aftermath of violent events were uncommon," Dass-Brailsford, a clinical psychologist with expertise in trauma who also chairs a clinical psychology program for the Chicago School of Professional Psychology, told Medscape.
As a first responder, she was involved in early interventions for survivors of 9/11. On September 11, 2001, she had just resigned her position as coordinator of the community crisis response team — the first of its kind in the United States — through the Victims of Violence Program in Cambridge, in Cambridge, Massachusetts.
The program responded to communities in which there were high rates of drive-by shootings and similar acts of violence. Because of her crisis experience, Dass-Brailsford was asked to conduct debriefings in Boston in the area where the 9/11 terrorists had stayed prior to boarding the planes that were used in the terrorist attacks. She subsequently went to New York City to conduct similar psychological debriefings with affected communities.
"What we've learned is that we had no crisis protocol on how to manage the stress in the aftermath of such a violent event, no standard operating procedures. There were very few people trained in crisis and trauma response at that time. Partially spurred by 9/11, trauma training programs became more prolific," she said. Dass-Brailsford developed a trauma certification program at Lesley University in Cambridge, Massachusetts, where she began to teach after 9/11. "I saw the importance of having clinicians trained to respond in a crisis, because responding to a crisis is very different from conducting regular mental health interventions."
Short- and Long-term Interventions
DePierro said that Mount Sinai has a 20-year history of responding to the physical and mental health needs of 9/11 responders.
"We saw a number of first responders experiencing clinical depression, anxiety, a lot of worry, symptoms of posttraumatic stress disorder (PTSD), and an increase in alcohol and/or substance use," he recounted. In some, these responses were immediate; in others, the onset of symptoms was more gradual. Some responders had acute reactions that lasted for several months to a year, whereas for others, the reactions were prolonged, and they remained "chronically distressed long after the immediate exposure to the event," he said.
Mental health care professionals who provided interventions for workers involved in recovery and cleanup at the World Trade Center have highlighted the need for long-term monitoring of people on the front lines during the COVID-19 pandemic — especially healthcare workers, other essential personnel (eg, delivery, postal, and grocery store workers) and surviving family members. "Health monitoring and treatment efforts for 9/11 survivors and responders were put into place soon after the attacks and continue to this day," using funding provided through the James Zadroga Act, DePierro said.
"Without similarly unified health registry and treatment services, many individuals — especially from underserved groups — will likely experience chronic mental health consequences and will be unable to access high-quality healthcare services," he stated.
"Psychological First Aid"
"Although many people who go through a crisis — whether as a result of terrorism, such as 9/11, or a medical crisis, such as the current pandemic, or a natural disaster, such as Hurricane Katrina — experience PTSD, it's important to note that not everyone who goes through a crisis and is traumatized will go on to develop PTSD," Dass-Brailsford emphasized.
"To me, 9/11 placed psychological first aid on the map. Even if you are not a clinician, you can be trained to provide psychological first aid by becoming familiar with people's reactions to trauma and how you can support them through it," she continued.
For example, if a co-worker is agitated or "seems to be having a meltdown, you can be there by offering support and getting them the appropriate help." Research has suggested that having social support before and after a traumatic event can be helpful in determining vulnerability to the development of PTSD and in modulating the impact of the trauma.
Psychological first aid is helpful as an interim measure. "If you see a co-worker holding their head in their hands all day and staring at the screen, identifying whether the person might be having a dissociative episode is critical. Providing some support is important, but if more intensive professional support is needed, determining that and making a referral becomes key," Dass-Brailsford stated.
DePierro added, "One of the most important messages that I want healthcare workers to know from my years of working with 9/11 survivors is that feeling distressed after a traumatic event is very common, but with effective care, one doesn't necessarily need to be in treatment for years."
Danielle Ofri, MD, PhD, clinical professor, Department of Medicine, New York University Grossman School of Medicine, New York City, agreed. "It is important to continue keeping tabs on each other and remaining sensitive to the collateral struggles of our colleagues. Some have children who are struggling in school, others have parents who have lost a job. Continuing to check in on others and offer support is critical going forward," she told Medscape.
Cohesiveness and Volunteerism
One of the most powerful antidotes to long-term traumatization is a sense of community cohesiveness. This was the case following 9/11, and it is the case during the COVID-19 pandemic, according to Ofri, an internist at Bellevue Hospital, in New York City.
"There was an enormous mobilization. Bellevue is a city hospital with a level I trauma center, and we expected to be swamped, so the whole hospital shifted into gear," said Ofri. "What would have been terrifying seemed tolerable because we felt that we were in it together. We discharged the inpatients to make beds available. Within hours, we had converted clinics into emergency departments [EDs] and ICUs. We worked seamlessly, and the crisis brought us together...but then, of course, no patients showed up."
She described her relationship with her colleagues as "feeling almost like a family, especially during the pandemic, when so many others were in lockdown and feeling isolated and useless."
She and her colleagues saw each other daily. Although the content of their tasks and responsibilities changed and people were redeployed to other areas, "our workday didn't really change. It would have been overwhelming if we hadn't had our daily meetings to regroup and assess where we were. Each day, everything we had learned or implemented the day before — treatment protocols, testing protocols, our understanding of how the virus was communicated — would change and need to be reevaluated. Those morning meetings were critical to staying centered. It felt as though we were building a plane and flying it at the same time, which felt both scary and heady. Luckily, it took place within the fraternity of a committed and caring group."
Ofri recounted that after 9/11, as well as during the pandemic, "professionals kept jumping in from the sidelines to volunteer. Within hours of the collapse of the towers, the ED had filled with staff. People came out of retirement and out from vacation and out of the woodwork. It was very heartening."
Even more inspiring, "all the departmental barriers seemed to break down. People were willing to step out of their ordinary roles and check their egos at the door. Seasoned physicians were willing to function as medical interns."
This generosity of time and spirit "helped keep us going," she said.
DePierro agreed. "One of the things I've seen on medical floors is that COVID actually brought some units together, increasing their cohesion and mutual support and increasing the bonds between people." These intensified bonds "increased the resilience of everyone involved."
Commitment to the Community
Ofri recalls families gathering at the hospital after 9/11, watching posters of missing people going up all over the hospital as well as on mailboxes and lampposts. Because the center for missing people was located right next door to Bellevue, there were long lines of families coming in to register. The chief medical office was there, and a huge tent was built to accommodate the families. The tent took up the entire block. "We felt a lot of ownership, because families were coming here," she said.
The street remained closed even as the days, weeks, and years stretched on, and the tent remained. It was used as a reflection area for families. During the pandemic, that area was used for refrigerated trucks that served as temporary morgues.
"Both logistically and emotionally, we had a feeling during the pandemic of, 'We've been here before, we'll do it again and be there for the community,' " Ofri said.
She noted that the sense of commitment to the community carried her and fellow clinicians through the toughest parts of 9/11 and of the COVID-19 pandemic.
"People look to the medical system as a lodestar. 'Where's my family member? What should I do? Should I be tested? Vaccinated?' We were there to be a steady presence for the community physically, psychologically, emotionally, and medically, which helped center us as well," Ofri said. "If we didn't have that, we might have all given in to existential panic."
She added, "Although we had to work twice as hard, often amid great personal risk, we had the good fortune of having a sense of purpose, something to contribute, plus the community of colleagues we cared about and trusted with our lives."
Crisis and Personal Growth
DePierro said that participants who went through 9/11 have been coming to Mount Sinai's World Trade Center Health Program for care for nearly two decades. "Many are doing quite well, despite the emotional trauma and the dust and toxin exposure, which has given us a window into what makes people resilient."
Social and community support are key factors in resilience. Another is recognizing opportunities for personal or professional growth during the crisis, according to DePierro.
During the pandemic, hospital staff were redeployed to departments where they didn't typically work. They worked with new colleagues and used skills in patient care that they hadn't needed for years or even decades. "Although this was stressful and distressing, quite a number said they came through with more medical knowledge than before and that they had forged relationships in the trenches that have been lasting and have become important to them," he reported.
He noted that during both crises, for first responders and healthcare practitioners, religious or spiritual faith was a source of resilience. "During the peak of the pandemic, chaplains provided an exorbitant amount of staff support as clinicians turned to the chaplain to help make sense of what they were going through and connect to something greater than themselves." Similarly, during 9/11, police and fire department chaplains "played a huge role in supporting the first responders," DePierro said.
He said that Mount Sinai holds resilience workshops "where we focus on these topics and teach healthcare workers how to build resilience in their lives, heal day-to-day stressors, and even grow from the experience."
Ofri, who is the founder and editor-in-chief of the Bellevue Literary Review , added that the arts played an important role in bolstering resilience and providing a creative outlet for clinicians after 9/11 and again during the pandemic.
The publication is celebrating its twentieth anniversary ― its first issue went to press in September 2001. The cover contained an acknowledgement of 9/11.
Ofri said that a gala event had been planned for October 7, 2001, to celebrate the inaugural issue of the publication. She assumed no one would show up, given that the United States had invaded Afghanistan only hours earlier. To her surprise, over a hundred people attended, "which made me realize the role of the arts during trauma. People were seeking to come together and hear poetry, fiction, and creative nonfiction."
Ofri has been "impressed by the amount of incredible creative writing of all sorts that has been submitted [to the publication] during the pandemic, an unexpected flowering of the arts."
Unique Challenges, Unique Opportunities
All three experts pointed to several noteworthy differences between the experiences of first responders following 9/11 and those of today's healthcare professionals during the pandemic.
"What happened on September 11 was one discrete event, and although it obviously led to years of recovering body parts and cleaning up Ground Zero, and on a national level it led to a war, it nevertheless was a single event," DePierro observed. By contrast, the COVID-19 pandemic is ongoing, and for healthcare practitioners, "it's by no means over. Again and again, they are being thrown back into battle, dealing with fatigue, weariness, and loss of life."
Moreover, "it is my understanding that immediately following 9/11, there was a general coming together in our country, but it's obvious that today, there's a great deal of fractiousness, contention, disagreement, and disunity in our country when it comes to COVID-19," DePierro continued.
"This takes a great toll, particularly on healthcare workers who are dealing with COVID-19 on a daily basis and experience a disconnect between what they see on their floors and ICUs of the hospital, experiencing loss of life they've likely never encountered in their careers, and what people are saying when they downplay the seriousness of COVID-19," he said.
Ofri agreed. "The fragmentation of our country and the failure of leadership at the highest level to provide even the basics, such as PPE [personal protective equipment] for healthcare professionals, left us baffled, profoundly hurt, and angry," she said.
A positive difference between the COVID-19 pandemic and the aftermath of 9/11 is the development of sophisticated technology that allows interventions for traumatized individuals — both healthcare professionals and the general public — through telehealth, DePierro pointed out.
"I would say that these resources and technologies are a silver lining and should continue to be expanded on," he said. "Now, busy healthcare workers can access all manner of supportive services, including teletherapy, right from home or between shifts."
Another "silver lining" is that the pandemic has shone a spotlight on an issue that predated the pandemic — the mental health of healthcare professionals. Opening a discussion about this has reduced stigma and hopefully has paved the way for improved treatments and for providing resources.
Dass-Brailsford added, "it is important, going forward, for all of us to be trauma informed, to know how trauma and trauma-related stress unfolds in both other people and yourself, and to know what coping skills can be used to avoid crises from developing — a task that extends across all types of disasters."
Batya Swift Yasgur MA, LSW, is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).
Where were you during the 9/11 attacks and how did it impact your life? Please share your experiences as we reflect on that day 20 years ago.
Lead Image: Mario Tama/Getty Images
Image 1: Jonathan DePierro, PhD
Image 2: Priscilla Dass-Brailsford, EdD, MPH
Image 3: Danielle Ofri, MD, PhD
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Cite this: The Trauma and Healing of 9/11 Echo in COVID-19 - Medscape - Sep 03, 2021.