the Aftermath of 9-11-01: A European Perspective?
Buus Jensen, MD, Ph.D.
a significant historical event happens, most people will keep
in their memory, what they did, where they were and how they spontaneously
reacted on that day, even if they were not directly affected.
September 11, 2001 became one of those days. A global event instantly
reported by the media throughout the world. Images repeated over
and over on TV-screens overruled our disbeliefs of a reality disguised
was in Kosovo preparing a lecture for the next day to psychiatric
residents on the theme of "Public Mental Health Interventions
Related to War and Post-War Contexts". A phone call from
Africa urged me to switch on the only working German TV-channel.
The screen twisted colors and lines into a surrealistic nightmare.
Next mornings lecture was quite different than first planned.
Later that day, I joined a spontaneous peace walk in Pristina
with the crowd waving American flags in solidarity. I asked myself,
when I last saw a demonstration abroad in favor of the US.
week later traveling on a half-empty transatlantic flight I watched
the downtown smoke rise from the changed skyline as I arrived
in New York scheduled long ago to teach at the International Trauma
Studies Program (ITSP/NYU) about "Early Mental Health Interventions
in Large-Scale Disasters". My usual downtown hotel was open,
but now located in a war zone behind barricades of police and
military. Windows were intact but covered with dust as a reminder
of last weeks debris storm that terrorized downtown streets.
Walking through the streets I was reminded of my days in Sarajevo,
remembering the feeling of a war zone, but in the wrong context.
Men in Wall Street suits hurried by silently with masks over their
Western trauma professionals try to apply their skills in contexts
of the developing world or in countries in "transition".
Suddenly this was a journey in the opposite direction. Coming
from my work in war-torn areas of Africa, through post-war Kosovo
to a still smoking war-zone in downtown Manhattan.
disaster has its own uniqueness yet lessons from other global
emergencies are often valuable for planning early interventions
in any cultural context. The aim of this paper is to illustrate
how a general structured framework used around the world for planning
comprehensive emergency response may also apply to New York. Our
further challenge is about the European perspective on preparedness.
What are the unique and shared elements of effective response
if a similar emergency situation happened in Paris, Copenhagen
A STRUCTURED RESPONSE
world watched in amazement at New Yorks response. The speed
and dedication of the helping forces and the compassionate spontaneous
efforts by survivors to assist each other. The mental health professionals
eagerly joined the helping efforts. Uncertain of their role, but
believing this was their field and feeling responsible to help.
following presents a structure for creating early interventions
that seeks to prevent or minimize psychosocial and mental health
consequences of exposure to potentially traumatic events. It suggests
that practical early interventions can be organized into 3 phases
(Jensen & Baron 2002).
1: Needs Assessment Leading to Emergency Response
begins with immediate emergency aid and a quick assessment of
overall need. Fire fighters, policemen, health workers and emergency
services personnel are the first at the site to offer immediate
care. As they give crisis aid, these emergency workers compassionately
interact with survivors and assess their needs. These workers
are knowledgeable about potential helping resources and map needs
and resources as the basis of the first immediate plan for interventions.
Initial interventions concentrate on survival needs like safety,
shelter and treatment of injuries.
do mental health professionals assist during the crisis? Immediately
following 9-11, a spontaneous volunteerism spread among New Yorkers.
Lay people and professionals offered assistance. Psychoanalysts
reportedly stood in line in front of a downtown hospital pleading
to be let in to assist the traumatized. The desire to help was
commendable. For mental health professionals, their help was most
needed as common human beings, not at that early stage, as therapists.
2: Preventive Brief Interventions
the immediate crisis the following interventions are brief and
intend to prevent or minimize exacerbation of emotional and practical
problems caused by the crisis. Target populations are survivors
and their families, witnesses, emergency workers and affected
communities. Interventions seek to reduce or dissipate emotional
distress, advice participants about how to cope and promote resiliency
through family and community support. Helpers try to identify
survivors who are more deeply distressed and require onward referral
for additional care.
of the New York University students in my class on September 18
were directly affected by the 9-11 tragedy. One useful helping
technique is to bring a group with similar experiences together
to share their personal narratives. Through a group process they
bring order, understanding and support to each others experiences
and feelings. In the NYU classroom, we used the technique as a
personal self-help exercise and to facilitate the students
skills in using this technique with others.
3: Early Clinical Interventions
clinical interventions target individuals, families or small groups
of distressed survivors unable to return to normal functioning
in a timely way and in need of more specialized assistance.
after 9-11, NYC therapists were overwhelmed by their existing
and old clients asking for extra sessions for emergency support.
NY is unique in the world for the numbers of people seeing therapists.
Therapists were confused by who needed therapy and why. Clients,
like the therapists, were frightened and stressed by the events.
Was it necessary to have extra therapy or better to seek out friends
and family for normal sharing and support? Knowledge about how
to implement community-oriented interventions was limited. Therapists
were pulled into an emergency response with little forethought,
training or preparation.
FOR ORGANIZING EMERGENCY INTERVENTIONS:
7 Cs are suggested as one framework for organizing the 3
phases of early emergency interventions.
Culturally sensitive and contextually appropriate interventions
2. Coordination of all services
3. Community oriented public mental health approach
4. Capacity building: training, support and supervision
5. Clinical services
6. Care for the Caretakers
7. Comprehensive data collection, analysis and evaluation
Culturally sensitive and contextually appropriate interventions.
to ask ourselves:
What are the culturally specific elements of NYC relevant to
planning a sensitive emergency response?
What resources are available within existing health and social
welfare structures and families and communities?
helped to facilitate a mental health planning workshop for 80
NYC professionals on September 23. We tried to grasp the cultural
specifics of New Yorkers from the corporate Wall Street type,
to the world of modern artists to the immigrants from around the
Sub-cultures of more than 5 million people separated by social
and economic class, multitudes of ethnic groups and religious
diversity. Some with strong traditional families and communities
others far from their original homes and totally isolated. All
sharing a universal belief about New Yorks invulnerability
as the center of the world with a tradition for "heroes"
and of course a "Mecca of Psychotherapy".
Coordination of all services
to ask ourselves:
Is there a coordination body with a clear, authoritative leadership
for the psychosocial/ mental health response that involves all
there clear maps of needs, resources and gaps?
the planned interventions cost effective?
the emergency interventions lead to effective mid and long-term
most parties agree on the importance of coordination, few want
to be coordinated. In NYC, competition for who knew best and for
power, control and money began quickly. Some NYC professionals,
who were previous veterans of work in foreign cultures, complained
about the "fly-in" experts from outside of NYC coming
to their city to tell them what to do without knowing their culture,
and not respecting those in their home turf. A professional from
Connecticut or Denmark was just not a New Yorker.
Community oriented public mental health approach
to ask ourselves:
Do interventions mobilize family and community resiliency and
existing community support structures ie: community leadership,
religious leaders, local institutions and associations, neighborhood
networks etc. optimally utilized in the emergency and ongoing
self-help? Are grassroots organizations for family and network
support ie: Rotary Clubs and church, and womens groups
the media systematically involved in providing community education
and appropriate information more than sensationalism?
clinical interventions promote a comprehensive public mental
health and human rights perspective?
Capacity Building: Training, Support and Supervision
to ask ourselves:
Is training available in advance about the mental health issues
of emergency response to health professionals, support helpers
like school teachers, religious and other community leaders
and firefighters, policemen and other emergency service workers?
systematic training available in universities and professional
schools so that all mental health professionals are prepared
to provide effective crisis interventions in a emergency?
Is specialization training available to interested mental health
professionals for the treatment of trauma?
illustrated that many mental health professionals did not have
training in crisis intervention. In this large-scale crisis, their
usual methods of psychotherapy were not most useful and many did
not know how to respond. Mental health workers were often looking
for individual problems and therapeutic solutions rather than
offering emotional support and compassion, promoting self-help
and resilience and encouraging family and community networks.
Critical also in the immediate aftermath in NY was large-scale
efforts at community education about normal responses to trauma
and stress to potentially vulnerable groups i.e.: clean-up workers,
Wall Street companies, journalists etc to prevent the exacerbation
of expected distress.
to ask ourselves:
Are mental health professionals encouraging public understanding
about normal responses to trauma, natural resilience and the
necessity of using family and community systems for self-help?
Are they avoiding pathologizing what is normal response to trauma?
Is mental health crisis intervention available to the severely
Are existing mental health clinics and private practitioners
trained to provide the needed service in this context rather
than just do what they always do?
Care for the Caretakers
to ask ourselves:
Is there a mentality that recognizes the personal vulnerability
of helpers and encourages them to seek support when needed?
Are there mental health crisis and ongoing services accessible
to relief workers?
Is there sufficient support, supervision and training for mental
Comprehensive data collection, analysis and evaluation
to ask ourselves:
Is there an ongoing system for collecting information?
Is there ongoing systematic monitoring of needs, resources and
quality assurance systems integrated into interventions to assess
effectiveness from the beginning?
Are mechanisms established to ensure that future research honestly
portrays the problems and the interventions?
disasters have permanent social and psychological effects. Lessons
learned internationally confirm a need for long-term healing perspectives
beyond the immediate emergency situation.
to NY and similar to other contexts are steps towards establishing
"Truth, Justice and Reconciliation" as means
of psychological and social healing. Trying to clarify the true
narrative of what really happened cleansed of the pollution of
lies, guesses and wishes. Finding justice, where violators are
held responsible, convicted and punished within a judicial context
and respect for human rights. Balancing the wish for blind revenge
with reconciliation to avoid vicious circles of new violations.
All major issues needing resolution to bring collective healing.
IS THE EUROPEAN PERSPECTIVE?
natural question to ask from a European perspective is: Are we
prepared if a similar event like 9-11 happens in Paris, Copenhagen
European countries have substantial disaster preparedness plans
but are the psycho-social and mental health components comprehensively
developed and ready for action? It would be a challenge country
by country to analyze potential large-scale traumatic events through
a systematic analysis using the 7 Cs structure to challenge
the potential effectiveness of our pre-planned interventions.
A comparison of ideas and models could become a theme for a future
months later, while NYC is still recovering, humanitarian workers
are heading towards Afghanistan. Hopefully bringing with them
lessons learned about guiding principles of emergency interventions
that can make it in New York, so they "can make it everywhere".
A new context, a different war zone, a series of special events
yet similar basic guidelines of where to begin in our helping
efforts. Our question, using these same guidelines, are we ready,
if necessary, here in Europe?
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Psychosocial Policy and Practice in Social and Humanitarian Crises:
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J. de Jong, B. Green & S. Solomon). UN, New York. (In press).
S.B. and Baron N. (2002) Training Programs for Building Competence
in Early Interventions Skills. In: Oerner R. & Schyder, U.
(Eds.) Reconstructing Early Interventions after Trauma, Oxford