The staff of Mt. Sinai Medical Center on New York City's Upper East Side, like those at many mental health clinics here these days, is stretched thin.
Since Sept. 11, about 20 Mt. Sinai staffers are fielding a growing number of calls to a special World Trade Center mental health hotline. They're counseling more clinic visitors than their usual 60,000 a year. They're preparing brochures and organizing conferences about trauma. And, with the help of about 60 physicians deployed into the field, they're training thousands of teachers and guidance counselors about how to spot kids in distress.
"The staff has put in thousands of manpower hours," said Mt. Sinai's medical director Dr. Deborah Marin. "There's tremendous demand."
And this is only the beginning. Mt. Sinai's clinic, like others across New York, is gearing up for a flood of need as the city approaches a potential mental health crisis.
The scope of the trauma is unprecedented in the United States, and some counselors question whether the system here can handle the numbers of New Yorkers who may eventually need help.
Using formulas derived by the federal government following disasters like the 1995 Oklahoma City bombing, the New York State Office of Mental Health estimates that as many as 1.5 million New Yorkers could need some kind of mental health help in the aftermath of Sept. 11.
New York psychologists say they are already seeing shock, depression and anger in many individuals — the early stages of grappling with trauma. Predictably, those who are closest to the disaster — survivors, witnesses, and those who lost family members, friends and co-workers — are suffering the most.
"We are seeing problems with sleeping, low mood, increased startle response, a sense of foreshortened future, and a sense of doom," said Dr. Gabriella Centurion of the Cabrini Mental Health Center in lower Manhattan, which has seen a 10 percent increase in its clinic population since Sept. 11. Many of Cabrini's clients live in high-rise buildings, and many saw the twin towers burn and collapse after being rammed by hijacked jets.
But mental health experts say it often takes months, or years, for some traumatized individuals to notice troubling symptoms or to seek help.
‘We Haven’t Yet Seen What the Impact Will Be’
"Everybody I know in the mental health community in New York is gearing for later this year, or months from now, for the suicides and nightmares," said Harold Takooshian, a psychologist at Fordham University.
Several months after a mass trauma, people who managed their emotions earlier on may find themselves unexpectedly depressed, irritable, unable to sleep, fighting with partners, unable to enjoy everyday pleasures or filled with a general sense of malaise.
Many may ignore early signs of distress, are not aware of mental health services, or only come forward later as assistance from family and friends, intense in the immediate aftermath of a disaster, begins to wane.
"I think we haven't yet seen what the impact will be," said Dr. Alan Siskind, executive vice president of the Jewish Board of Family and Children's Services, which has dispatched 160 crisis teams so far to corporations, schools and synagogues.
Neal Cohen, the New York City health commissioner, warned Congress a few weeks after Sept. 11 that despite the city's massive effort to extend immediate mental health relief, the region's long-term needs would be daunting. "The task before us is enormous," Cohen told a Senate panel. "Virtually every New Yorker is experiencing high levels of stress."
The recent anthrax scares only add to the stresses of already shaken New Yorkers, and complicates the work of mental health counselors. "How the specter of bioterror feeds into this is something we're struggling with," Marin said.
Concern About PTSD, Children, and Vulnerable Populations
Trauma experts say up to one-third of those closest to the World Trade Center disaster could suffer from post-traumatic stress disorder, a condition characterized by a persistent re-experience of traumatic events.
"What we know about PTSD is it is long-lasting," says Carol North, a psychiatry professor at the Washington University School of Medicine in St. Louis, who has studied dozens of disasters, including Oklahoma City. "But it is eminently treatable, so it's important to get mental health treatment."
The mental health needs of children also pose a unique challenge for the system. As many as 10,000 children may have lost parents in the World Trade Center disaster, which killed an estimated 4,500 people, and an unknown number of kids were witnesses.
Even children with no direct connection to the terror attacks could show symptoms of trauma, and part of the challenge will be educating teachers, school administrators and parents about recognizing children in distress.
Dr. Steven Marans, who heads the National Center for Children Exposed to Violence at Yale University's Child Study Center, spoke to a mother recently whose 15- and 16-year-olds didn't want to talk about their feelings about Sept. 11. But they were becoming more mesmerized with the HBO series Band of Brothers about World War II. The teens' mother realized this was their way of giving expression to what was going on around them, Marans said.
Reaching children will involve "screening [them] across different dimensions to get a very basic notion of where they're at in terms of psychological adjustment," he said, "not just once but to be able to follow up and see how they're doing down the road so we're not just waiting for the most dramatic symptoms to emerge indicating the need for intervention."
There is also reason for concern, some experts say, about at-risk populations who were already under-served by mental health services. Immigrants with language barriers, the unemployed, those who already had serious mental illnesses and the socially isolated may be more difficult to reach.
Don’t Underestimate This Hard-Hit Community
In the short term, a $22.7 million grant from the Federal Emergency Management Agency is funding mental health outreach programs for up to 60 days after Sept. 11, and the state is applying for more money that should fund services for up to nine more months. This money will largely be used for mental health education and referral services, not for traditional psychological counseling.
Even with the millions in short-term aid, some experts say the system may not be equipped to handle the psychological needs of New Yorkers down the road.
"The system that's in place can barely handle the severe and persistently mentally ill," North said. "Add to that the new needs [from Sept. 11], and the system can't possibly do it."
Although Siskind believes the city mental health system has been doing a "remarkable" job in handling the initial response to the crisis, he is wary of how the system will handle coming demand. Due to the economic downturn, city and state agencies are expected to face budget cuts, and financial troubles will make philanthropic support less reliable as well.
"There needs to be more thinking of long-term mental health needs," says Siskind, who is on the executive committee of the board of directors of the Coalition of Voluntary Mental Health Agencies Inc.
Despite much concern for the mental health of New Yorkers, though, trauma experts say it's important to remember how hardy communities can be. Indeed, New York has already shown the world its resilience.
"I am always amazed at what these horrible adverse events do to bring out people's strength, the altruism, the heroism," North said. "Most people after these events heal. They don't forget, they heal."