When Crazy Is Normal

Portrait of a Grieving City

Last Friday night was the first time in a while Lauren Buchter had a good night's sleep. By Sunday, though, her sweet slumber, which had fallen victim to the terrorist attacks, was once again disrupted by anxiety-filled nightmares. The gritty video footage of bombs going off in Afghanistan made Buchter, a senior at Manhattan's La Guardia High School, sick to her stomach. But while the nausea wore off rather quickly, her emotional distress lingers on. "I have a helpless feeling," says Buchter, who's been dreaming of being trapped on planes and buses. "All these things keep happening and there's nothing I can do."

On September 11, as the financial district was cloaked in chaos, a formidable army of psychologists, social workers, and psychiatrists emerged to offer the talking cure. By 5 p.m., more than 200 had gathered at the Red Cross offices on Amsterdam Avenue in midtown, eager to counsel. There were, however, no patients at that point, so the volunteer mental health workers ended up watching CNN and comforting one another.

At Bellevue, Dr. Joseph Merlino, director of community and ambulatory psychiatry, was also preparing for a flood of traumatized patients seeking mental help. Distraught visitors did come to the crisis center set up in the hospital's chapel, but they didn't want to talk about their feelings. "They didn't even want to sit down," says Merlino. "They just wanted to know if their loved ones were there." Nor did Merlino's seriously ill patients seem to be showing much distress. In fact, he says, "They all seemed to be handling it rather well."

Trauma experts have a name for the emotional calm that overtook the city in the first few days after September 11: the honeymoon period. The shocked and bereaved summoned their resources to deal with practical matters. The usually self-obsessed rose above their personal problems. Mixed in with the raw terror and massive grief, many felt an unprecedented connectedness. Somehow, despite the overwhelming loss, it felt for a fleeting moment as if the whole city were on Ecstasy: Coworkers hugged, passersby radiated love.

Four weeks into the crisis, there is no question that the honeymoon is over. As war begins and the period of emotional clarity draws to a close, the city is bracing itself for the true psychic aftermath of the attacks. Already, pharmacies are reporting an increase in the number of new prescriptions for anti-anxiety, anti-depressant, and sleep-inducing drugs. Some psychiatrists say they have upped the doses for patients already taking these medications. LifeNet, the city's 24-hour mental health hot line, which at first held steady at its usual average of 110 calls per weekday, had roughly twice that number last week.

In a Bronx elementary school, Kari Collins has been seeing a significant jump in the number of kids arriving at her office with physical complaints. "They come in complaining of a stomachache or a headache," says Collins, who is director of mental health services for the School Based Health Program at Montefiore. "But when you talk to them a little bit more, they start talking about the World Trade Center."

A preliminary tally shows the city's suicide rate holding steady during these extraordinary last few weeks, but it's clear that emotions have taken center stage. NY1 even cut away from the president's press conference to showcase the city's volatile moods on its new call-in therapy program. But no matter—many city dwellers could identify more with callers' tears than with the forced optimism and military lingo of Bush.


Beyond Psychiatry

The old border between sanity and insanity was hardly tidy, but psychiatry did its best to distinguish between the pathologically problem-ridden and the rest of us: Before September 11, mood swings, crying jags, a change in sleep patterns, and loss of interest in pleasurable activities signaled depression. People who thought others were out to get them were paranoid. Those whose worries interfered with their daily functioning had anxiety disorders. They were sick. But what's the diagnosis now, when an entire city feels these things? What's the prescription when one passenger on a City Hall-bound bus begins to cry, and then another and another until everyone aboard—the bus driver included—is weeping?

"We know that there is not one New Yorker who isn't affected by this," says Health Commissioner Neal Cohen. What the commissioner doesn't know—what no one knows—is whether New York's surreal emotional state will balloon into a full-fledged mental health crisis. The Coalition of Voluntary Mental Health Agencies estimates that 2.3 million people in the New York City area will need counseling as a result of the World Trade Center disaster. A Pew Research Center poll reported that more than two-thirds of Americans were depressed in the weeks after the attacks.

The situation resists such numbers and definitions. Trauma experts agree that between 20 and 25 percent of people exposed to traumatic events typically develop significant psychological problems, most notably post-traumatic stress disorder (PTSD). But according to the official psychiatric manual, the disorder can only be diagnosed if the symptoms—including recurrent nightmares, heart palpitations, irritability, and difficulty concentrating—persist more than a month after the original trauma. So, though thousands of people have already had these symptoms for weeks, they technically can only begin having PTSD on October 11.

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.

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."


Normal?

One of Garfinkel's patients tripped over a severed foot while evacuating the stock exchange. Several others saw the first plane pass right next to the big windows of their conference room. He has the same message for all of them: "It's normal to be absolutely terrified out of your mind," he says. "It's normal to be more shaken than you've ever been before. It's normal to replay the event in your mind again and again. It's normal to be dreaming of dead bodies next to you."

At the Family Assistance Center on Pier 94, psychologist Judy Kurianski has also been trying to assure people they're traumatized rather than crazy. Sometimes she holds their hands, other times she just listens—to the woman who can't stop regretting her last fight with her husband, for instance, or to the man who was on the 77th floor and is still waiting for his son to descend from the 102nd. When she was down at the site of the collapse, she lent her ear as a Con Edison worker blurted out a detailed description of how burning bodies appeared when they hit the ground. "As horrific and morbid as that sounds, he needed to say that because it got it outside of himself," says Kurianski. "Afterward, he said, 'Gee, thank you for letting me say that. That is such a relief to get rid of that ugly thought in my head.' "

While this kind of emotional off-loading clearly serves a purpose, a minority of psychologists think people would do better to keep their misery outside the medical context. "If a loved one dies and we have grief and we go through all of the pain of that loss, we don't talk about having an illness or disorder that needs treatment," says Gerald Rosen, one of a group psychologists who signed an open letter cautioning against what they called the "rush to therapy" after September 11. Rosen, who used to provide immediate counseling, known as debriefing, to those who had survived bank robberies, rapes, and other traumas, points to some recent studies indicating that debriefing increases victims' chances of experiencing more distress down the road. Instead, he recommends seeking "natural supports" from family, friends, and church.

Many who have seen the worst of it don't want to rehash with anyone at all. "When I'm not working, the last thing I want to do is talk about it," said one policeman, who, like many of the city's uniformed officers, is still working a grueling schedule of 12 hours on, 12 hours off.

For Kim Sanders, a staff member for the National Development and Research Institute who was four blocks away from her office on the 16th floor of tower two when the second plane hit, the solution is somewhere in the middle. Sanders doesn't want to go over the horror she saw on her way to work anymore. "I've said that 100 times already," she says. "Sometimes it's just to satisfy someone's curiosity rather than to help with what you're going through in that moment." What does help, she says, is talking to others who have shared the experience about their progress—how much easier it is to leave the house for the first time and what it feels like to ride the train.

While Sanders has also found comfort shooting pool in a bar—"getting back to the normal things," as she puts it—others have little stomach for their old routines. When the planes struck, one woman who works for a local elected official was campaigning in the West Village. But now, "I don't give a shit about the election," says the woman, who asked not to be named. "I'm so filled with loathing for my boss and anyone asking me to do stuff, I feel like my head's going to explode."


The Existential Fallout

The Chinese character for crisis combines two ideograms, one meaning danger and another meaning opportunity. Having glimpsed their and others' mortality, many are finding themselves suddenly emboldened to change their lives. Jen Nessel quit her job as communications director for the Coalition for the Homeless on her first day back in the office, which is five blocks from the blast. The event—and the loss of a coworker, who had an asthma attack and died after being caught in the dust and smoke from the towers—made an ongoing quest for job satisfaction that much more urgent. "I was unhappy on a moderate level, and I realized that the only way I was going to change that was to just do it."

For Richard Taylor, a bus driver who was on his way into the Battery Tunnel when the second tower came down, change came in a smaller form. "I shaved my hair," says Taylor, who had worn it past his ears for years. After abandoning his bus and fleeing for his life during the collapses, he buzzed his dust-caked hair close to his scalp—something he had long considered trying. Says Taylor, "I don't worry about the small things anymore."

Indeed, the big things looming—or, in the case of the towers, no longer looming—have induced a psychic shift that has dwarfed the usual concerns of New Yorkers, regardless of where they were when the planes hit. The new war is further eroding the sense of control so damaged by the terrorist attacks, intensifying the fears that had already sparked a run on gas masks and Cipro. And for some, the uncertainty of whether and when we would launch a military attack has been replaced by other fresh anxieties about the fate of our troops, the extent of U.S.-inflicted civilian casualties, and when and how this war will end.

These are questions that have cropped up in previous wars, though we may never have felt them so deeply before. "You always think you're outside of history," says Eric Stover, professor of public health at the University of California at Berkeley. "What happened with the towers being hit is, the train of history slowed down and we were looking into those gaping holes." Not only does that force a sense of community in the present, according to Stover, it sensitizes us to past collective traumas: "The bombing of Dresden, Hiroshima, and Nagasaki all of a sudden become that much more real."

Ironically, though, the vast significance can sometimes only be felt by bringing loss down to a more comprehensible scale. Steve Auerbach, a physician who works for the Health and Human Services department, was at his office on Duane Street when the first plane hit. He witnessed the impact close up—an image that later looped in his head. And when he was providing medical services at the collapse site, he saw dismembered parts, an experience he says is "emotionally different" from handling corpses as a doctor.

In the midst of the crisis, he learned that a coworker, a 71-year-old woman named Naomi, had died of unrelated causes. "I didn't cry about any of it until I was on the phone with Naomi's son," says Auerbach. He worries that her family is not receiving due attention because of the greater picture. But to Auerbach, marking the loss of Naomi, whom he describes as "everyone's grandmother," is a path to sanity in an insane situation. "Life goes on," he says, "and death goes on."

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