When Crazy Is Normal

Portrait of a Grieving City

The enormity of the disaster can make diagnosis seem absurd as well as arbitrary: Do the officially traumatized include just the people who were in the area? Or also their immediate family members? Or everyone who saw the burning towers from a distance? Or even those who saw them on TV, in which case the number of likely PTSD cases could shoot into the tens of millions? (Disturbingly, the American Psychiatric Association says the likelihood of PTSD increases if the trauma was unanticipated, if it could recur, and if people were exposed to maimed bodies or lost a loved one.)

"Right now, we just don't know what it will look like," admits Phillip Saperia, executive director of the Coalition of Voluntary Mental Health Agencies. "But there is every indication that this is a continuing problem that in some short-range time is going to increase. And our mental health system is already incredibly stretched."

In the coming months, the system will be stretched much further. In anticipation of a flood of crisis-addled patients, the Federal Emergency Management Agency has already issued the State Office of Mental Health a $14 million grant to pay for counseling done in New York City in the first 120 days after September 11. Health Commissioner Cohen hazards that, together with contributions from private sector and charitable organizations, the amount of funding for city mental health services may climb to $50 million in the coming year, though some estimate the total cost of these services could be as much as $250 million.

Illustration by Max Grafe

Much of the burden will fall to managed behavioral health companies, which often handle psychiatric care and substance abuse treatment for big HMOs. Magellan, a behavioral health company that has some 6 million customers in the area, insists it has enough qualified trauma specialists to handle the need, according to company spokesperson Erin Somers. Saul Feldman, executive director for United Behavioral Health, also feels confident about his company's ability to meet the coming need—whatever it may be. Already UBH has seen a slight increase in both outpatient and in-hospital visits in the area, as well as about a 25 percent jump in calls. But depending on the employer, plans may limit the number of mental health visits. The norm is somewhere around 20, but some plans don't cover mental health at all.

The poor will likely suffer the worst. The significant number of low-wage workers who didn't have health insurance before September 11 is sure to increase as a result of lost jobs and a worsening economy. And though there is, for now, a surfeit of volunteer mental health workers who speak English, not enough are available to counsel Spanish-, Russian-, and Chinese-language speakers who have been showing up at the Red Cross centers and other sites looking for counseling. In Oklahoma City and other disaster sites, rescue and recovery workers, like the thousands downtown still digging around the clock, have suffered most, slipping into addiction, isolation, and obsession with the event for years afterward.

Therapy May Never Be the Same

For those who are getting it, psychological help is not what it once was in the reigning therapy capital of the world. After seeing tower two collapse while she stood alongside one of her patients on the street and subsequently learning that a close friend of hers had died in the incident, Judith Alpert says her relationships with all her patients are more reciprocal. "I now tell them I have a dear friend who died and that I, too, saw a building fall," says Alpert, wearing a black suit in her West Village office. "I tell them we are all affected."

Indeed, not only does the trauma that has rained loss on all New Yorkers close the artificial distance usually imposed by therapy, but mental health workers are even more likely than most to be traumatized. Though he was uptown when the planes hit, psychologist Eric Garfinkel has absorbed some of the most brutal experiences vicariously, through counseling workers at the American Stock Exchange and other downtown businesses. "I now know more about what happened that day than any human being should know," Garfinkel said during a recent interview, his voice trailing off.

Bellevue's Merlino, too, seems as waylaid by the events as any of his patients. He has been providing counseling to sobbing spouses of the missing and firemen who have been taking out their stress on each other. He's also been working at the office of the medical examiner, where truck after truck arrives with refrigerated crates of body parts. Working upward of 65 hours a week since the 11th, Merlino has been gamely advising people about the importance of eating right, exercising, sleeping enough, and not resorting to substance abuse. But the haggard doctor admitted he himself has stopped going to the gym, has been working through the weekends, and has been drinking "a glass of wine a night more than I should."

Under the circumstances, such reactions are, of course, perfectly understandable. To make this point, several hospitals, including Bellevue, have dispersed mental health workers throughout the building, rather than risking driving off patients with the stigma of psychiatry. Similarly, Health Commissioner Cohen says he's gearing up to bring counseling into churches, schools, and offices across the city rather than wait for the needy to seek help. He's also hoping to expand on an existing "peer counseling" program within the fire department. "We have to be sensitive to the fact that uniformed officers don't readily open their doors to outside therapists," says Cohen. "Those groups can be very insular."

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