My Red Cross service at Ground Zero

In my last post I wrote about my first tour (with my wife, Maria) as a Red Cross Disaster Mental Health Volunteer  in Manhattan, weeks after the 9-11 attacks. In 2001 Maria was employed, and I was between jobs. She’d been given two weeks leave to serve in New York, but couldn’t get an additional two weeks for a second tour. So, after my first tour ended, I was in a position to apply for a second tour and was again assigned to Manhattan. By this time luxury hotels were filling their rooms again, and I was given a shoebox of a room at the Pennsylvania Hotel – which happens to be my preferred lodging when I visit The City. And this time, when I in-processed  at the Red Cross headquarters in Brooklyn, I was given a prized assignment. I would be working at a Red Cross Respite Center at Ground Zero.

Ground Zero was fenced-in, and access was restricted to those who worked there. The sacred ground where the World Trade Center towers had stood was now known as the Pile by those who worked on it. Two weeks earlier, superstructure was still being torn down by giant machines resembling metal dinosaurs, and the wreckage could still be seen from outside the fence. Now operations were mostly subterranean, and Ground Zero was a vast pit, crawling with activity. The Respite Center I was assigned to at Ground Zero was there to serve anyone who worked on the Pile. The cafeteria operated 24/7 and free services were available for off-duty workers. Our clients included police and firefighters, demolition workers, engineers, telecommunications workers, machine operators, and National Guard troops.

Outside at Ground Zero, everyone had to wear a hard hat. The Respite Center was housed in a college student union building with a large atrium, a cafeteria and big rooms on the ground floor, and two more stories of smaller rooms, behind wide balconies  overlooking the atrium. Serving at the Respite Center was a very different experience than serving at a Family Service Center. It was where people working on the Pile went for meals, and when they were off-duty. Everything was free, from the cafeteria to a supply store with batteries, towels, work clothes, boots, gloves, etc. Workers who had long commutes could stay to sleep in dormitory rooms, without going home after each shift. There were also showers and darkened nap rooms with recliner chairs. There was a big media center where off-duty workers could play cards, or watch TV, or use a computer to play games, send e-mails, or surf the Web.  They could sign up for free massages or attend twelve-step meetings.

All Red Cross volunteers were there to pamper our clients and to help them deal with  the stresses of working on the Pile. We disaster mental health volunteers were there to listen to those who wanted or needed to talk, to be available and accessible. We knew not to ask intrusive questions or to initiate conversations about working on the Pile. We ate with the clients in the cafeteria and we schmoozed. We took snacks and coffee out to the cops and the National Guard troops providing security around the perimeter of the Pile. We filled in for other volunteers, washing dishes or making sandwiches, so they could take a break.

As with my first assignment in Manhattan, I was there to serve as a facilitator and troubleshooter – but in a different context. Our primary job was to provide respite to people doing stressful work. Bodies and body parts were still being found in the rubble. At one point I heard a local Salvation Army volunteer at a cafeteria table with firefighters ask a question about finding body parts. I took her aside and told her why her question was inappropriate at a Respite Center, where workers went to get away from their work on the Pile. She caught on.

There’s no telling how many New Yorkers developed Post Traumatic Stress Disorder (PTSD) due to the events of 9-11, but in my two Red Cross tours in Manhattan I encountered quite a few. Some had seen bodies falling from the burning towers; others had run for their lives when the towers fell. I was asked time after time if what the person was going through was “normal.” The people asking that question might be experiencing depression, anxiety attacks, fear reactions, anger, and other PTSD symptoms. I don’t know how many times I said something like this to trauma victims: “What you’re experiencing used to be called ‘shellshock’ or ‘combat fatigue’. It’s not just soldiers in combat who have the kind of symptoms you’re having. You’re a civilian who suddenly found yourself in a war zone. What you’ve described to me is a normal reaction to an extremely abnormal experience. You’re not going crazy.”

Another question I got a lot from people experiencing symptoms of PTSD was, “Will it always be like this?” While I had to tell them that I couldn’t answer their question, my replies included positive suggestions about recovery: “Everybody’s different. Some people keep re-opening the wounds, or convince themselves that they’ll never get better, and don’t. Some people just get better over time. If your symptoms don’t begin to diminish, and disable you in some way, you should consider counseling..  But the important thing is to keep an open mind about your recovery. Trust in your ability to heal, and get help if you need it. Nobody has the right to tell you that you should have already gotten over it by now.”

Police (“New York’s Finest”) and firefighters (“New York’s Bravest”) were especially hard-hit by the 9-11 attacks, as they were mourning the loss of so many colleagues. All human remains found in the Pile were turned over to a special squad of policemen and firefighters, to be removed with ceremony and respect; so people were still being traumatized, weeks after the attacks. I felt privileged to be in the company of the men and women of the police and fire departments, and to play a small part in New York’s healing. I’d visited Manhattan before, but this time I felt a part of it. I fell in love with it.

 

Exposure Therapy

Most everybody knows what you’re supposed to do if you’re thrown by a horse. If you want to keep on riding, you get back up on horseback right away, to overcome your fear of being thrown again. The only way to get over your fear of drowning, if you swim in the deep end of the swimming pool, is to leave the shallow end and swim in water over your head.

The clinical term for this principle in psychology is exposure. Exposure is the antidote to avoidance, our very human tendency to reduce anxiety by avoiding activities and situations that tend to trigger anxiety. Avoidance is like a drug that immediately and reliably reduces anxiety or fear. For example, Tom is attracted to his high school classmate Jane, and wants to ask her out. He’s told himself that today’s the day he’ll get up his nerve and approach her, but he avoids doing it as the day goes by. As the end of the school day nears, he gets more and more anxious. But the moment he decides to postpone it until tomorrow, his anxiety dissipates. Avoiding and postponing work in the short-term, but serve to entrench our anxieties and fears in the long-term. Avoidance is one of the defense mechanisms  identified by Freud.

According to Dr. Marsha Linehan,  whose Dialectical Behavior Therapy (DBT) treatment of Borderline Personality Disorder has been empirically shown to be highly effective,, exposure is a necessary component of all effective cognitive behavior therapies. Two of the skills training modules in DBT, emotion regulation and distress tolerance, help to prepare clients for exposure to things they typically avoid.

Exposure therapy can be effective in treating Generalized Anxiety  Disorder, Social Anxiety Disorder, Obsessive-Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTSD), and phobias – irrational fears. It involves habituation to the feared stimulus/situation. Imagining exposure to successive approximations of the stimulus/situation (imaginal exposure) and teaching heightened awareness of physiological responses such as heartrate and muscle tension (interoceptive exposure) can be accomplished in the therapist’s office. Exposure to the actual stimulus/situation “out in the world” (in vivo exposure) is often the third step of exposure therapy. Being aware of the thoughts, emotions, and physiological responses involved prepares the client for in vivo exposure. Gradually working your way from the shallow end of the pool to the deep end involves exposure to “successive approximations” of the thing most feared. Jumping – or being thrown – into the deep end is an example of “flooding.”

The therapeutic method known as systematic desensitization was pioneered by South African psychologist Joseph Wolpe. After doing a behavior analysis of thoughts, feelings and physiological responses involved in a phobic reaction, he did relaxation training until the client felt some degree of control over his typical responses. Then he worked with the client to develop a hierarchy of fears, from the least fear-inducing to the most fear-inducing thoughts/experiences. Using this hierarchy, he would work with the client on relaxing as they went through successive approximations, leading up to the thing most feared.

Here’s an example of how I might use this method with a client who had never flown in an airplane, due to her phobia about flying. (Because flying is statistically much safer than driving, fear of flying is considered  an irrational fear, or phobia.) Having assessed Louise’s typical thoughts, feelings, and physiological responses/anxiety symptoms, and having trained her to relax, I might start a session with a relaxation induction, leading to a guided fantasy based on her hierarchy of fears. Louise has been instructed to close her eyes, to raise her right index finger whenever she felt an increase of anxiety, and to lower it when the anxiety decreased.

“You’re in your apartment and you’re packing for your flight . . . . Now you have your bags packed and you’re waiting for a taxi to the airport . . . . And now you’re at the airport and you hear the boarding call . . . . Now you’ve stashed your carry-on and are seated, buckling your seatbelt, etc.” Whenever Louise would raise her finger, I’d switch from the guided fantasy to the relaxation induction: “And as you breathe slowly and deeply, you can feel your muscles relaxing, and your anxiety is replaced by a calm feeling . . . . ” When the finger went down, I’d pick up where I left off on the guided fantasy.

Over time, Louise learns that she has increased control over her response to fearful thoughts, getting gradually closer and closer to the thing she fears most. Once she can imagine herself staying in control as the airplane takes to the skies, we might go on to in vivo exposure therapy, which might involve me accompanying her – at least at first. Some private practice therapists specializing in the treatment of phobias might even accompany his client on his first flight, coaching and encouraging him.

People with severe OCD often engage in compulsive rituals to reduce their anxiety. Exposure therapy can help them to learn that they don’t have to rely on these rituals to reduce their anxiety. People with anxiety disorders can use the principles of successive approximation to gradually desensitize themselves to stimuli/situations that used to trigger anxiety. Exposure therapy can similarly help people with PTSD to control physiological arousal in response to stimuli/situations that used to trigger fear. But in order to overcome an irrational fear, you have to eventually face it.

Post-Traumatic Stress Disorder

In the course of my career I worked with many people who had experienced significant trauma. Something I heard from many of them was along the lines, “What’s wrong with me? I think I’m going crazy! I can’t stop crying (worrying/ having panic attacks/having nightmares/having flashbacks/losing my temper/thinking about suicide, etc.) I didn’t used to be like this!” Once I was confident in my diagnosis, I’d respond in this manner: “You’re not going crazy. You’re having a normal reaction to an abnormal, traumatic life event. Your symptoms are consistent with something called post-traumatic stress disorder (PTSD) – the same thing that affects some soldiers who’ve been in combat. In World War I it was called shellshock and in World War II it was called combat fatigue, but it doesn’t only happen to soldiers.”

I’d go on to explain what happens in the brains of some people who’ve had traumatic experiences. The amygdala – which helps us to process emotions and is linked to the fear response – can be activated by trauma and sensitized to react to triggers: things that the brain has come to associate with the original traumatic event. A sudden loud noise might trigger an instant fear response in a combat veteran. Seeing a depiction of an assault on a cop show on TV might trigger a flashback in an assault victim. Sights, sounds and sensations reminiscent of the trauma can re-stimulate the amygdala and trigger symptoms. Thoughts can also be triggers.

Two people might experience the same traumatic event, only one of whom will develop PTSD; and science can’t predict which one. You can’t put a timetable on recovery from trauma, but all too often people suffering from PTSD are blamed for the persistent changes in their behavior. Many get told things like “Just get over it!” and “What’s wrong with you?” – as an accusatory statement in the form of a question.

PTSD can be caused by a single event or by serial traumas, such as ongoing child abuse. It can result from physical or sexual assault, surviving a terrible accident, or witnessing bloodshed and/or death. It can be caused by weeks or months spent in combat zones, even if there was no single major traumatic event. Soldiers are often reluctant to admit to symptoms of PTSD, as the military culture tends to stigmatize the diagnosis as a sign of weakness. But it isn’t; it’s a brain disorder.

My wife Maria and I served as Red Cross Disaster Mental Health Volunteers at a Red Cross Family Service Center near Ground Zero after 9-11. Although we were both licensed mental health professionals, as disaster mental health workers we weren’t there to do therapy. We were there mostly to listen, and to help people understand and process  what they’d gone through on the day when the twin towers fell. We also provided referral information to those we met who might need therapy from local practitioners. One thing I remember saying to a number of trauma victims I encountered was, “You’re not going crazy. You’re a civilian who suddenly found yourself in a war zone. Nothing in your life has prepared you for that. Your (symptom/symptoms) is/are a normal reaction to an abnormal circumstance.”

Hundreds, perhaps thousands, of Manhattanites were traumatized to a greater or lesser degree by the events of 9-11. You didn’t have to be near Ground Zero to be affected, and it seemed that the whole city was on edge, anxious about the possibility of another attack. I met a woman who had watched the falling bodies of people who’d jumped from the burning towers, transfixed by the horror of what she was witnessing. I spoke to a young man who’d ridden the subway his whole life,  ashamed because he was terrified to do it again. I heard story after story from people who wondered if their lives would ever be the same again. Another thing I said to several people I encountered was, “Nobody’s qualified to tell you when you ‘should’ get over this. It may get better as time goes by, or it may not. There’s no guarantee that you’ll completely recover, but don’t give up on the likelihood that you will, in your own time. You may need professional help.”

There are highly effective treatments for trauma victims. Just as physical wounds can heal over time, so can the “invisible wound” of PTSD.