"I never thought I'd be saying this, but I'm gonna get therapy. After the shit I've seen? Lots and lots of therapy." So said an ash-covered rescue worker in a hard hat the other day, sipping from a can of Bud on his break from picking through the rubble of what was the World Trade Center.
His buddies -- standard-issue tough guys, ironworkers all -- nodded their heads in agreement. "Straight to the headshrinker's," said one of them, staring south down Sixth Avenue. "I'm gonna be there a long time. No kidding." He shook his head and popped open a new can. "And I know I won't be the only one. You can't believe the things we've seen, we keep seeing. We're gonna be needing all the help we can get."
The subdued mood that cloaked New York in uncharacteristic serenity for the first few weeks after the attacks is gradually cracking apart. These trembling psychic aftershocks continue to resonate as time plods on. And while New York's reputation is hardly one of civility, bursts of rage have begun to pierce the quiet public mourning. The incidents feel extreme, even for this robust population: Two women incited a pushing fight on the F train from Brooklyn last Friday. A passenger on a different train that day began screaming in rage, and the rest of the car joined in. Nerves ran so high at a usually collegial workplace that a fistfight broke out between co-workers.
New York, has, of course, long been a world capital of psychotherapy, famous for its neurotic, analysis-seeking denizens. Vienna may have Sigmund, but we have Woody. "It's the temperament of this city," said Ronald Fieve, a professor of psychiatry at Columbia University with his own practice. "New Yorkers are stimulus-addicted, high-energy. That gets into mild manic or manic-depressive disorders, bipolar types. We've always been that way, far more than other places."
But in the aftermath of the terrorist attacks, the field is no longer reserved for Upper West Side yentas and self-absorbed downtown hipsters who feel more comfortable on their analyst's couches than on their own. Since the first hours after literal fire and brimstone struck, teams of triage psychiatrists set up shop at ground zero to deal with psychic fallout. More arrived in the days that followed, counseling at the family center, the armory, wherever the grieving gathered.
Since the second week, crisis counselors have flooded workplaces all over the city, some visiting daily to offer individual grief counseling in cubicles, and to lead group sessions in glass-walled conference rooms. This week, psychologists and psychiatrists, already feeling the strain of high demand before the terrorist attacks, are braced for thousands of new clients, many of whom will be seeking counseling for the first time.
Meanwhile, drugstores all over the city say they've had a surge in demand for antidepressants since Sept. 11. Prescription requests for Ambien (a sleeping aid) and Klonopin (for panic attacks) are flooding pharmacists' phone lines. "I don't think there's a pharmacy out there that hasn't seen it go up," said Dino Papoutsis, at Bigelow Pharmacy in the West Village. "Anxiety level is high right now. Who's sleeping? A lot of people need all the help they can get."
And for perhaps the first time in this headshrinking city, therapists are sharing in the trauma of their patients, unable to function at a remove from the crisis under discussion. "I had a psychotherapist in my office this morning telling me he had been in tears a number of times this week, and I mean during sessions," says Ari Kiev, director of New York's Social Psychiatry Research Institute. "People are coming in with tremendous, horrific stories about things that have affected us all." One therapy patient reported how a recent session opened with the tables turned: Her therapist told her she had lost a patient of 10 years in the attacks. "My first question was, do you have someone to talk to?" she said.
Immediately after the attacks, people who had been in precarious mental states were in many cases forced beyond their already shaky limits into mental turmoil. "We had many patients go right into the hospital," said Fieve. "Borderline manic-depressive or schizophrenic patients, anyone with a psychotic disorder, they've all been hospitalized. Just think of the paranoia, the fear, the pictures of gas masks. It's enough to put anyone over the edge."
And Fieve said it is a particularly bizarre time for some deeply paranoid or phobic patients who have felt exonerated -- though not necessarily relieved -- by the sudden reality of their delusions. "The people who have paranoid personality traits feel a great sense of vindication. It's the ultimate I told you so."
For New Yorkers suffering from varying levels of depression and anxiety, the tragedy has plunged many of them into clinical states. And therapists say there are new challenges for relationships here -- couples, families, friendships -- that were already strained by percolating anger, distrust and dissatisfaction before the crisis, as preexisting problems have intensified in its aftermath. "This is all felt more profoundly by people who already feel vulnerable. More people are already coming into therapy, and increasing or beginning use of antidepressants. People already seeking help may be looking for more frequent visits. I know I've been full up," said Joyce McFadden, a therapist whose SoHo office is in what was once the shadow of the towers.
And the worst, according to all sources, is certainly yet to come. Even Mayor Giuliani expressed uncharacteristically grave concern recently during an off-camera moment at an Upper West Side temple's Rosh Hashanah services. He told the congregation he was terrified of the anguish coming when the dust literally clears and New Yorkers realize the true magnitude of the devastation. The words he did not speak, which have been on the lips of therapists and news anchors for weeks, are "post-traumatic stress disorder."
"We're gearing up for an onslaught," said Dr. Fieve's secretary. "We're expecting people suffering from PTSD to start calling in droves -- it'll take a couple of weeks." According to standard psychiatric diagnosis manuals, it takes a month before PTSD sets in. Not coincidentally, a national depression screening day has been set for Oct. 11. Many of the symptoms already have plagued people across the country since catastrophe struck. The symptoms include nightmares, insomnia or prolonged exhaustion and sleep, deep and unshakable sadness, feelings of isolation, heightened sense of fear and paranoia, jumpiness, weakened appetite and a continuous mental replay of the images some people saw firsthand and others saw repeated on television.
"People will keep thinking about the event, keep seeing bodies flying through the air -- those images will keep intruding on our consciousness," said Kiev. "You see it over and over again, imbedded in the memory -- a person can be repeatedly traumatized hundreds, thousands of replays of those images." For the time being, this experience has been classified as a symptom of acute stress disorder. But next week, that diagnosis will slide over to PTSD.
"Our phone lines have already been deluged," said Elizabeth Vermilyea, who is the training director at the Sidran Traumatic Stress Foundation in Baltimore. For some callers, she said, the symptoms already qualify for PTSD. For example, the Sidran Foundation has been helping hundreds of people phoning in from Oklahoma City, whose symptoms have been reactivated by the recent events. "They've had a real resurgence of their fears, their flashbacks, their need for safety and predictability," said Vermilyea. "But for others, we just can't call it that yet. And, frankly, it doesn't sit well with me that Americans can freak out for a month before it's diagnosable."
Her concern applies not just to New Yorkers and Oklahomans, but to people all over the country who have been traumatized by what they've witnessed through news coverage. "This was a national assault against safety and identity," said Vermilyea. "People are struggling everywhere, calling here for help. It's uncanny how universal this is across the country, these same acute traumatic stress responses."
For an estimated 15,000 children whose parents -- one or both -- disappeared in the rubble, the trauma has carried with it the devastation of identity and the obliteration of their sense of safety. For the most part, child psychologists say, these children are playing at school, but grieving silently at home. Their anguish and bewilderment are held in check by fear and disbelief; but long-term effects, say therapists, are inevitable.
"These kids know if they bring up stuff about the deceased parent, it upsets the surviving parent," said Robert Abramovitz, the chief of psychiatry and director of the trauma center at the Jewish Center for Family and Children. "They're nervous that the surviving parent is so upset it will kill them, so they keep their own grief quiet. Because their biggest fear right now is about the parent who is still living -- as in, are you gonna die?"
Abramovitz said that at his center, and in quickly established drop-in centers for kids across the city, "there's an eerie quiet." Like PTSD specialists, his therapists are preparing for a belated deluge of stricken, bereaving children. He says that children's silent grieving and attempts to feign normalcy will not last. They will begin, he says, to digest the unthinkable in gradual doses -- and they will need help.
"This is a complicated trauma," he said. "We know it's hard enough to get used to never seeing somebody and accept that you'll only have them in memories, not real life. But the task is to feel safe enough about those memories. Every time kids think about their deceased parents, they're flooded with images imagining how they died. They see every night on TV how massive that rubble pile is. And it will be hard for kids to imagine beyond that for a while." It could take between three to six months, he said, for kids to get past these gruesome mental obstacles to deal with their losses.
Given the enormity of the predicted onslaught, some therapists are worried about the ability of the mental health community to cope. "I'm most worried about Social Services," said McFadden. "They're underfunded. There will be a real strain, I think. Even long-standing private practices or inpatient psychiatric units that have been up and running will be facing problems in dealing with this different situation. It's just all so new to all of us." Kiev is concerned about the level of expertise of the many counselors who will be pitching in to support the afflicted for the first time. "I'm worried that people who aren't completely or properly trained will be getting in over their heads," he said.
In anticipation of overwhelming need, out-of-state mental health experts already are streaming into New York, a city that entered the crisis with the greatest number of mental health workers per capita. Trauma experts from the International Society for Traumatic Stress Studies arrived soon after the attacks to help both on the ground and with implementing administrative plans. One member of the group, who was on hand in the Oklahoma City aftermath, immediately prepared a CD-ROM to help mental health workers in New York. The National Mental Health Association has established a crisis response fund to assist in the effort, focusing attention on New York and Washington, D.C., and coordinating local public health response throughout the country.
"It's a bereavement of the whole city, of the whole country, and it might last for years. This is just the beginning," said Fieve. "It will be intense, and we can't predict what's going to happen, but we'll be all right because we're the greatest city with the greatest doctors."
One can only hope he's right. As we prepare for this ambiguous and mysterious "war" against terrorism, we enter an even murkier indefinite era: the process of grieving and recovery. Perhaps therapists and mental health workers will form our next battalion of heroes, caring for the rescuers we have honored already, and mending those people who ripple out from the ruins in concentric circles of distress.