New York Turns to Oklahoma for Guidance

Two Terrorist Acts: The Past Is Prologue

by John V. O'Neill, MSW, News Staff
November 2001

Many weren't functioning very well before the bombing.

One of the first acts of NASW's New York City Chapter after the Sept. 11 terrorist attack was to contact the Oklahoma Chapter to gain insight into problems the city might expect in its social services delivery systems, how to best use chapter resources to help, what New Yorkers might expect in the way of emotional and mental health problems in the short term and long term, and how best to prepare practitioners for the challenges they would face.

Six and one-half years earlier, Oklahoma City's peace was shattered by a terrorist's bomb that ripped apart the Alfred P. Murrah Federal Building, killing 168 people and injuring 490.

The scale of the losses and trauma in New York City is so much larger than anything else in the nation's recent history that it is bound to be different from other traumatic events. "Here in Oklahoma City, we are just a pinhead compared to what happened in New York City," said Sue Settles, executive director of the Oklahoma Chapter. Nonetheless, New Yorkers felt there were lessons to be learned from the experiences in Oklahoma.

"What you have to realize is that 100 percent of the people weren't functioning that great to begin with," said Settles in an interview. Those with severe reactions "didn't fall into clear categories," she said. "People who had post-traumatic stress syndrome from the Vietnam War relived their experiences, and many went into a day treatment center."

It was especially hard for people with mental problems resulting from the bombing to reach out, said Settles. The mental health centers were taking care of people who already had a diagnosis, so it was hard for them to take more people. That problem was partially solved with a grant from the Federal Emergency Management Agency earmarked for "new people" affected by the bombing.

Licensed social workers are trained to deal with individuals and their families, and many hadn't considered trauma part of their practice, said Settles. When 80 of the approximately 350 social workers in private practice in Oklahoma City asked to volunteer, the chapter set up skill-building workshops on trauma.

For about two months, the chapter personnel and volunteers in Oklahoma City were involved almost exclusively in crisis-oriented responses and helping match volunteers with areas of need. Thereafter, they began to focus on long-term issues. "The effects on people and their needs don't go away just because the cameras turn to something else," said Settles.

NASW, with other organizations like mental health centers, schools, nonprofit agencies and faith-based agencies, set up a long-term recovery planning group that met for years on a regular basis to discuss how resources could best be used to ease the disaster's effects. For instance, most of those killed at the Murrah building were federal employees with life insurance, health insurance and retirement plans. But there were families whose sole provider was killed or injured in the bombing, and more resources were directed to the most needy.

It will be up to the chapters in New York and the other disaster sites to decide what their priorities are, said Settles. "It's not just the one-on-one counseling that's important. There are roles for all kinds of social work skills. Communities need to be rebuilt, groups need to be convened and meet objectives, administrative skills are vital, programs and work plans need to be put together, research needs to be done."

People's need for mental health services was intermittent, said Settles. "Many were in such shock and denial at the beginning that they wouldn't admit they needed help, but problems came up later." For instance, one crane operator had problems on the first anniversary as replays were shown on television, and he brought in his whole crew for counseling offered by the Fire Fighters Association, she said.

Getting back to something approaching normal has taken us "a long, long time," said Settles. "We are still not over it."

There were some benefits to the chapter and social work from participation. The Salvation Army, the city, the state legislature and NASW's national office honored them.

"I was told by the Salvation Army that social workers make great volunteers," said Settles. "They will be the ones who will be around long after the other volunteers have left town."

Since the bombing, NASW entered into an agreement with the American Red Cross that established ground rules for close cooperation between the two organizations in the delivery of mental health services to people affected by disasters and provided a focus for NASW chapters' relationships with the organization. The agreement, said Settles, "needs to be executed in every state. Chapters can get incorporated in state disaster plans as providers of service."

Experiences of disaster mental health providers in Oklahoma and at many other sites show strong reasons why social workers need training before doing this sort of work. Lesson number one in any training is that disaster work is very different from psychotherapy.

Fortunately, there is a fair amount of literature on disaster mental health to give clues as to the effects on those who survived the disasters, on their families, on the nearby population and on rescue workers.

Several readily available models for crisis intervention are available for study, and the American Red Cross, among others, offers training. One helpful book from the Center for Mental Health Services (CMHS) is Disaster Response and Recovery: A Handbook for Mental Health Professionals.

From it, providers learn that most of the problems and symptomatology are normal reactions of normal people to abnormal events. Few require traditional psychotherapy unless they persist. Few disaster survivors seek out mental health assistance, so providers who simply wait in clinics will have little to do.

For these reasons, outreach to the community is essential. Outreach means mingling with survivors, rescue workers and others in shelters, at meal sites and in devastated neighborhoods. Interventions must be appropriate to the phase of the disaster. For instance, it may be counterproductive to probe for feelings while shock and denial are shielding individuals from intense emotions. During later phases of their adjustment, people may be feeling frustration and anger and could resent being asked if they can find something "good" coming out of the disaster.

There are two types of disaster trauma, both of which could greatly benefit from social work expertise. These are individual trauma and collective trauma, according to CMHS. Individual trauma is the stress and grief people feel with such force they can't function effectively. Collective trauma can sever ties of survivors with each other and the locale.

"People will find it difficult, if not impossible, to heal from the effects of individual trauma while the community around them remains in shreds and a supportive community setting does not exist," said CMHS. "Thus, mental health interventions such as outreach, supportive groups and community organization, which seek to reestablish linkages between individuals and groups, are essential."

Many social workers have become experts in disaster mental health. Among them are John Weaver of Pennsylvania and Robert Chazin and Sheila Berger of Fordham University's social work school.

Weaver's book Disasters: Mental Health Interventions and Web site received much attention after the terrorist attacks.

The question, "How do you feel?" or similarly intrusive questions are perceived to be the stereotypic pyschobabble that television and movies use as shorthand for all mental health counseling or what media representatives use to get sound bites from traumatized people, wrote Weaver. "Once you begin opening up a dialogue about the facts, the feelings will follow, without having to ask for them."

He suggests several questions to open a conversation with those who have lost loved ones. Among them: When did you and your family get the news? What have you learned about the circumstances of the death? What do you have to do next? What happened during your last contact with the lost loved one?

Fordham's Chazin and Berger have developed a four-part guide for crisis counseling that they used in debriefings around the New York City after the Sept. 11 attack. It is called SANE, and the four parts are story, assessment, new interventions and evaluation.

In their model, first the counselor elicits the person's "story" — what he or she experienced then and are experiencing now — and accepts the pain without trying to fix it.

Next there is an assessment of the person's difficulty and trauma reaction. Is it a normal grief reaction or one that is more serious, with ongoing counseling or other interventions needed? What coping mechanisms are being used, and what would be helpful now?

With "new interventions," the person's reactions are interpreted as being normal, to be expected after loss and trauma, and there is a review of the stages of grief: shock, denial, anger, guilt, fear, depression, acceptance and reintegration. Also, there is an education component, which includes:

• Explaining grief as an ongoing process that can emerge and subside more than once.
• Pointing out that use of substances may numb out bad realities, but it delays or stops healing.
• Encouraging self-care and nurturing.
• Encouraging mutual aid with family, co-workers, neighbors, children, the community, rescuers and aid organizations.
• Instilling hope and trust that the pain will subside with time.
• Teaching relaxation techniques, such as breathing exercises.

When finished, an evaluation is done of what was helpful and might continue to help, and individual plans for continued healing are made.

For a copy of Disaster Response and Recovery: A Handbook for Mental Health Professionals: (800) 789-2647, document number (SMA) 94-3010; John Weaver's Web site: http://ourworld.compuserve.com/homepages/johndweaver/; for the SANE model: chazin@fordham.edu.