Coping with the mental impact of the USA attacks

MSF - Kaz de Jong

Kaz de Jong is an expert in the psychological impact of mass traumatic events. As mental health advisor for Médecins Sans Frontières (MSF) in Amsterdam, Kaz has set up mental health programs in Bosnia, Kosovo, Rwanda, Poland, Tajikistan, Sierra Leone, Sri Lanka, Lebanon, Kashmir and Colombia.

After the September 11 attacks on the United States, Kaz was asked to come to New York to help MSF office staff deal with the psychological effects of the tragedy and to assess what assistance MSF could offer to the emergency mental health services already mobilized in the city.

Soon after arriving, Kaz and his colleague Marleen joined forces with Safe Horizon, New York's leading victim assistance agency, in responding to the World Trade Center tragedy. They used their expertise in mass trauma to advise the organization on what to expect in the New York community and to prepare appropriate responses for the immediate mental health needs.

They trained staff on the use of debriefing techniques for people who were victims of and witnesses to the tragedy, conducted debriefings with outside organizations alongside Safe Horizon as part of the training process, and presented Safe Horizon with a model for supervision of those conducting these debriefings. Kaz and Marleen also helped to debrief and develop models for debriefing the emergency room staff at several Manhattan hospitals. MSF also provided support at an Arab-American family health community center in Brooklyn.

We spoke with Kaz after he had spent a week in New York City.

What did you expect to accomplish when you were invited here?

We weren't really sure what we would be able to do. We came to support the MSF office and to assess what we might be able to help with as far as mental health needs in the city. We had previous contact with several excellent mental health agencies in New York and knew that it would not be necessary for MSF to mount an independent program in the city. But we wanted to do anything we could to support the emergency relief work, whether it meant talking with people in the office or on the streets or subways.

What did you find when you first arrived?

We took a bus into the city from the airport and arrived the Sunday morning after the attack. We decided to walk through the city and visit the memorial in Union Square Park. We wanted to make contact with people as quickly as possible to get right to the core of the problem.

Life looked like it had returned to normal in some places, but the closer we walked to the site of the tragedy, the more you could feel the anxiety level. Some people were still just dealing with what was going on in their immediate environments. Some were more grounded and others clearly felt panic, sadness, and anger. At the site of the disaster downtown, you see it even more closely. When we got closer to Fulton Street, people were just staring at the site with their hands covering their mouths.

This initial shock is a very normal kind of reaction to see in the aftermath of a traumatic event, like the one New Yorkers had just experienced. People were feeling a sense of disbelief and shock - their most fundamental beliefs and trusts had been shattered. At this point, they were down at the bottom of the mountain and just beginning to look up.

You've worked with victims of violence in places like Rwanda and Kosovo. How different or similar was the World Trade Center tragedy from other traumatic events you have worked on?

It is unique only in its setting. If you go to the human level of individual emotions, however, people are the same all over the world. The situation was different and yet very familiar. Normally we don't walk around freely in the places we work and see so many of the basic resources, like cars and shops, available. There is a huge contrast in New York between a mass traumatic experience and the normalcy of daily life. There is an abundance of goods, safety, and transportation. If you need ten psychologists to help with the work, you can just call them. That is not what we are used to.

On the other hand, emotionally, people are the same. Despite all the available resources, people are still looking for the right way to use them. They are working on their own coping processes. Some are shocked and disorganized. Others are calm and organized. They are all busy with the personal.

The other difference is that one way that people deal with suffering is to recall coping mechanisms they have used to get through past traumatic events. People in many of the cultures where we have worked, like Colombia or Sierra Leone, have more of a history of trauma and coping than many people do here in the United States. In that sense, people here are more vulnerable.

What did you do to support the mental health response to the emergency here in New York?

Primarily we worked with Safe Horizon to help with their staff training and some debriefings. They requested help in developing an appropriate debriefing model. They have mainly worked with victims of domestic and urban violence, but not such a mass traumatic event as the city experienced last week.

This was a massive event - the counselors were victims of the violence themselves.

We basically just reassured the counselors that what they were doing was right. We told them, don't forget what you already know about mental health. You have a treasure of experience inside yourselves and you just need to use it. These are seasoned mental health professionals. They just needed time to debrief and download their own feelings and then they could start to work. We were extremely impressed with the organization and response of the mental health professionals in New York.

We had the advantage of coming from the outside and not being immediately affected by the event. Our heads were clear. We didn't need to be taken care of so we could help them take care of themselves and others.

Reassurance is always part of the training we do for mental health workers, in Rwanda, New York or anywhere. As well as talking about models and guidelines, we tell them, you need to think about what you yourself need as a victim. Think about your own coping mechanisms. If you can identify what you need, then you will know how you can give it to others. You have it all inside of you; you just need to mobilize it.

What kind of psychological symptoms are common in people who have experienced or been touched by a mass traumatic event such as the World Trade Center attacks?

Some common symptoms are disbelief, shock, anxiety, fear, feelings of guilt, loss of control, anger, profound sadness, concentration problems, sleeping problems (including nightmares), emotional numbness and fear for the future, and avoidance of everything that reminds them of the event.

What advice would you give to people who are experiencing any of these feelings?

Most importantly, you must always remember that all of these feelings and thoughts or behaviors are normal. It is the event that is abnormal.

These symptoms might persist in varying degrees for about a month or so - this is also very normal. If they are especially severe or continue longer, you might consider visiting a mental health professional.

How can people help themselves and each other deal with the psychological effects of this traumatic event?

First of all, they should remember that expressing what you've experienced in one way or another is very important. No one is suffering alone. Everyone will have coping mechanisms to deal with what they are feeling. They will find a way to process and cope with the event, a way to put the event in a certain place and regain control. 80 to 90% of people can cope with traumatic experiences without mental health support. That in itself is proof of the strength and ability people have or can mobilize within themselves. It is good to realize that the event cannot be undone, but once it is given a place in their minds, people can go on with their lives.

Expressing oneself verbally is one way of regaining control. Other ways include resuming normal activities, and repeating behavior that was helpful to you in the coping of sad events in the past.

You can help others get through this by being patient, understanding their ups and downs, and listening to them. Take the time not to immediately try to solve their problems, but to listen and understand them. Undertaking activities with others is also a good thing, especially when one sees that someone is becoming withdrawn. At the same time, you must also respect the fact that although expression is an important coping mechanism, there are moments when people might not want to speak. Pushing someone to share or digging for emotions is not correct and might even be harmful.

Most importantly, you must remember that the processing of such an event takes time and energy, and everyone must take the time to relax. In the beginning, do not expect to be as productive as before. Try to distract yourself and your friends and loved ones with activities. You won't be able to change the event, but you can help yourself and your friends to cope with it. By helping others one can re-establish a sense of self-esteem and worthiness.