Some 500,000 people are believed to have developed post-traumatic stress disorder in New York following the fall of the World Trade Center, according to the Journal of the American Medical Association. This rate is nearly three times the national rate per capita. Thousands were directly affected - either having fled the building or the immediate vicinity or having lost a loved one or worked on recovery efforts.
So what are the best ways to cope with the anniversary? Whether you have been severely or moderately affected, experts agree that there are several key considerations to keep in mind in order to reduce stress and maintain optimal mental health. The entire month of September this year will be filled with reminders of the attack, so it is important to pay close attention to how you and those close to you are coping not just on the date itself, but during the weeks surrounding it. As the anniversary approaches, calls to 1-800-LIFENET, the helpline for mental health services which people can call to access Project Liberty, a free counseling and referral service for New Yorkers affected by the attacks, have steadily increased. "We've had a hundred additional calls a week for at least three weeks," statewide director April Naturale said in late August, when there were about 500 calls a week. "And it's climbing every day."
On the anniversary itself, experts say that there is no single best way to spend the day, whether you stay at home or participate in any of the planned ceremonies or events. "Trust your gut," says Dr. Richard Shadick, assistant director of Pace University's Counseling Center. "If you are already feeling very nervous, it might be good to have quiet reflection. But if you are craving information and connection with your community, it makes sense to find a way to participate." Shadick, who witnessed the attack and has provided pro-bono 9/11 therapy throughout the year, agreed to participate in Gotham Gazette's live chats on the day of the anniversary to counsel readers about how to cope. Naturale recommends keeping things "low key, because the emotions themselves may be overwhelming." Small community memorial ceremonies, private rituals like saying prayers or lighting candles, religious services, or just spending time with loved ones and friends can help. "We don't recommend isolating yourself," she adds.
Media attention to the anniversary, in this world capitol of media, will be nonstop and hard to escape entirely. "If you have been traumatized," says Naturale, "We recommend avoiding the images of the planes flying into the towers." For Project Liberty's tips on viewing 9/11 related TV, click here.
Dr. Nancy Smyth, Associate Professor at the University of Buffalo School of Social Work, is an expert on psychological trauma. "We have reason to suspect that the more people watch the images on TV, the more likely they are to have psychological symptoms of post-traumatic stress disorder including anxiety and depression." she says.
Smyth says the research can't determine whether people who are more traumatized are more likely to seek to watch the replays or whether the replays themselves are producing extra stress -- and some experts believe that repeated viewing could lead to desensitization, which might help in some cases. But, Smyth adds, "I have informally collected a lot of anecdotal data and people who have experienced a great deal of sleep disruption report that when they turn off the TV, they feel better."
Smyth advises minimizing exposure to the images of the disaster on television, particularly those which are most gruesome and explicit. She stresses particularly that people should not feel obligated to watch. "Many people felt they had to watch to show that they cared, and felt guilty turning it off. They felt relieved to have permission to stop watching." she says.
New Yorkers seem to be doing more of everything in their attempts to cope: While drinking, smoking and drug use have increased, so have gym memberships. Equinox is reporting a 25 percent increase in profits since 9/11 and New York Health and Racquet Club is also seeing increased demand, according to Crain's New York Business.
Exercise is one thing all the experts agree on as an excellent way of dealing with stress, and the time surrounding the anniversary is no exception. Whatever type of activity appeals to you - from rollerblading, rock climbing and running to dancing, swimming or even just walking -- moving your body can help you feel better.
One reason this is true is because focusing on your physical experience in the moment helps shift attention away from disturbing memories. Smyth cites research showing that traumatic memories seem to be stored in the brain differently from other memories; unlike ordinary recall, traumatic memories seem to involve an actual physical replay of previous events as experienced emotionally through sensations like elevated heart rate and heightened anxiety.
If you can calm those sensations from the past with physical activity now and focus on the current physical activity instead, this can help you overcome them. Therapy for traumatic stress often involves this kind of refocusing -- as well as trying to translate the memories from being disconnected physical and emotional snapshots into a coherent story, like normal memory.
"If you find yourself coming across images that are upsetting or intrusive, take time to sit down and write out what you feel and then go do something soothing." says Smyth. Both writing and talking with others can help people make sense of the traumatic experience and integrate it into normal memory. If you have intrusive memories, trying to put them out of your mind without giving them this kind of context tends only to produce more flashbacks and increased symptoms.
It's kind of like those thought experiments where people are told not to think of a certain subject, for example, white cats, say experts. Trying not to do so almost always fills your head with thoughts of pale felines; similarly, trying to suppress memories of an event that has upset you often calls up more of them until you can make sense of it and it no longer stands out so much.
Both Smyth and Naturale emphasize doing something that is meaningful to you personally to mark the anniversary, whether it be as short as observing a moment of silence, or whether you want to attend a memorial or plan a get-together with people close to you.
Finally, if you feel you need help, don't be afraid to seek it. Smyth says that the time to seek help is when talking to friends or taking other self-support measures aren't working and you continually feel low or have flashbacks. Project Liberty's hotline offers access to free, licensed mental health care services through 1-800-LIFENET, and the hotline can be accessed 24/7.
Tanya Keys never noticed the four smiling babies dressed in furry angel wings. Yet these spokesbabies are part of a multi-million dollar advertising campaign out to enroll city kids into Child Health Plus, the state insurance program that offers coverage to all children under 18. The free or low cost program came as a total surprise to Keys, a mother of six. She did not learn about it until she went to the Riverside Child Health Clinic last year with her children.
"I didn't know about Child Health Plus or that we could even get health insurance," said Keys, revisiting the West 100th Street clinic for check-ups for Davon, 10, and Shanice, 7.
The word is not getting out about Child Health Plus. Although there are 735,000 New York City children currently enrolled in the insurance plan, an additional 370,000 kids remain uninsured. Many parents are equating the program with welfare and do not believe their children are entitled to coverage. Others, particularly immigrants and working parents, are afraid or ashamed of public programs.
The number of American children without health insurance has increased steadily in the last decade, totaling about 11 million in 1999, the latest date when statistics are available. In an effort to reduce these numbers, Congress passed the State Children's Health Insurance Program in 1997. Billions of dollars were made available to states for the sole purpose of insuring children.
With an annual budget of over $250 million, New York State launched Child Health Plus. Child Health Plus is actually a dual program that joins Children's Medicaid (now called Child Health Plus A) with the new Plan B, primarily for children from better off families; a family of four is eligible if it earns up to about $41,000 a year.
Child Health Plus has a lot going for it. Both plans offer emergency, preventive and routine physical and dental care, and prescription drugs, at no charge, or premiums of no more than $15 a month per child. Families with incomes above the cutoff can also buy into the program at slightly higher rates. And with life around the poverty line routinely accompanied by depression, substance abuse, and eating disorders, mental health is an important part of the program. Child Health Plus A, however, offers additional Medicaid benefits, while Child Health Plus B operates more like a private insurance program through a range of sponsoring insurance providers.
Against this backdrop of differences stands the program's single biggest barrier: lack of information. "A lot of parents know about Medicaid and that it pays for everything," said Ruth Santana, a social worker with the Morris Heights Health Center in the Bronx. "But very few working families that don't have insurance know that Child Health Plus is a good option for them."
According to a recent report, "Addressing the Barriers to Covering Kids", funded by the Robert Wood Johnson Foundation, the nation's largest health care foundation, many parents are like Tanya Keys and are unaware of Child Health Plus. "Because they work, earn a living, probably pay taxes, and equate government programs with welfare only, they tune out messages promoting State Child Health Insurance Programs," the report found.
A number of community roundtables sponsored by the New York Academy of Medicine found that children eligible for Child Health Plus aren't signing up because families aren't getting adequate information from sources they rely on. "The information is not out there, it's not in the places parents need to be," said one participant. Moreover, trusted messengers such as clinicians, schools and community groups are often just as confused as parents about the program and eligibility of children from working families.
According to the New York Academy of Medicine, this ignorance is creating a host of false impressions and unfounded fears. Medicaid still carries the stigma of dependency and charity, despite the de- linking of welfare from Medicaid in the 1996 federal welfare laws. And all too many parents think Child Health Plus is Medicaid. "My suspicion is they lump the two together and question its value," said Santana.
But behind the surplus of confusion and inconvenience, lies a sharp reality: most uninsured children come from families in which the parents are themselves uninsured. In New York City, more than 70 percent of the uninsured have an employed adult in the family but still have no coverage. "The fact that parents are delaying care for their uninsured kids because of financial worries is tragic," said Dr. Risa Lavizzo-Mourey of the Robert Wood Johnson Foundation. This fall Child Health Plus is scheduled to expand into Family Health Plus, and allow some parents to enroll with their children.
The city has started to address some of these barriers. Mayor Rudy Giuliani announced a back-to-school enrollment drive with the popular children's clothing stores Modells, Cookies and Sears. So far, 1,000 children have signed up for Child Health Plus through this partnership. Under a plan unveiled this spring by the mayor, schools that successfully enroll uninsured students will receive bonuses ranging from $25,000 to $50,000. Dr. Diane Stump from the Riverside Health Clinic said she has seen information about Child Health Plus on the new school enrollment forms. These initiatives are part of the larger HealthStat program, which targets uninsured New Yorkers who are eligible for Child Health Plus, Medicaid or Family Health Plus. HealthStat initiatives have enrolled more than 151,000 adults and children since it began in 2000.
But signing kids up for insurance does not necessarily guarantee they'll use it. There are a number of other obstacles, such as lengthy Medicaid interviews, Child Health Plus re-enrollment procedures, immigrant fears about deportation, limitations on providers and inconvenient office hours. Medical treatment for many children is limited to the school nurse or emergency room. In a study reported by the American Academy of Pediatrics, researchers found that, "Simply extending health insurance coverage to low-income children is not enough to ensure access to care."
"It's time we encourage eligible New Yorkers to take advantage of existing coverage programs," said Mark Green, the public advocate, in a August speech. "My proposal rests not on making a new bureaucracy, but instead on making the most of existing programs." Like Green, the other candidates have suggested building greater awareness through aggressive advertising, simplified enrollment and more extensive outreach with churches, and community groups in low-income neighborhoods. "It's the city's responsibility to guarantee access, remove barriers, and make the process family- friendly," said Judy Farrell, a policy analyst for Bronx Borough President Fernando Ferrer.
Peter Vallone, the City Council speaker, has proposed that the city pick up all premiums on Child Health Plus B, which would cost the city an additional $147 million. "It's a way to get to those for whom the premium would be a factor," said Vallone spokesman Mattis Goldman. Green, Ferrer and Alan G. Hevesi, the city comptroller, have been critical of this plan. "Why should the city pay if state and federal already pay for those who need it," said Farrell. Moreover, Ruth Santana, the Bronx social worker, said that many parents want to pay premiums. "Parents want insurance for their children," said Santana. "But they also want to maintain dignity."
Yobanna Genao was a 36-year old court reporter earning an impressive salary and raising three children on her own when, in 1997, she contracted a chronic illness that eventually made it impossible to work. She lost her job, her house, her car, her health insurance, and was forced to turn to public assistance. She began thinking of suicide.
This was not the first time in her life Genao had thought of killing herself. Suicidal thinking descended in her late teens, while attending college, after the death of a treasured aunt and the painful break-up of a relationship. Fortunately, a notice on a bulletin board at school about a counseling program caught her eye and she was able to get help. After a few weeks of therapy, the suicidal thoughts left, although it took months for the depression to entirely lift.
Her suicidal thoughts returned at the age of nineteen, when she was living at home with her mother who was herself depressed and threatening to kill herself if her daughter didn't stay with her. This time Genao did not seek help, but escaped the situation by getting married. Today she sees that decision as a symptom of the depression. "It was a bad choice," she said.
The marriage didn't work out. But Genao went back to school, got a better job, was given promotions, bought a house on Long Island for her and her children, and was graced with a positive attitude of just focusing on today, which helped her through the next fifteen years.
But the latest series of losses and financial strains have made for rough going. The depression returned, and so did the thoughts of suicide. "It's like when all the problems start coming at me at the same time I feel powerless, with no way out," she said, "and as I analyze the situation, it seems at times that everybody would be better off without me, especially my children... ."
A social worker referred Genao to a program for depression at the Payne Whitney Clinic. With the help of therapy, medication, and her therapist interceding on her behalf in matters relating to the physical illness (fibromyalgia), she has been able to counter the "naughty voice," as she calls it, that urges her to kill herself, with voices that offer reasons to live. For example, this voice says, her children need her.
Before entering the program at Payne Whitney, Genao says she "looked like a bag lady. My life was a mess." Her daughter had been out of school for five months. Now she is back in school and has won many awards. Her 17-year old son is getting ready to go away to college and Genao has the clarity to be able to help him. Untreated though, "I didn't have the energy to deal with any of that."
"If you can treat the depression, you can prevent suicide," said Sue Matorin, former Director of Social Work, and now Treatment Coordinator for the Affective Disorder Team at the Payne Whitney Clinic of New York Presbyterian Hospital. "I've never seen anybody suicidal who wasn't severely depressed," said Ms. Matorin. "But depression is an illness that can be treated. There is something you can do about it."
Common roadblocks to treatment, however, are the stigma attached to having a mental illness, and the lack of coverage for treatment. People are ashamed to talk about depression or suicidal behaviors, and when they seek professional help, they often find their insurance won't cover mental health treatment in the same way it would a medical ailment.
"If you hear someone has leukemia," said Ms. Matorin, "you make a fund-raiser. But if the family didn't have enough money to treat depression, people are too embarrassed to mention it." Yet mentioning it, talking about it, is a crucial element in getting help. "Suicidal thinking has to do with feelings of hopelessness. If you get people to talk, you create arenas of hope. Different things can be done."
In the last year in which figures are available (1999) from the Chief Medical Examiner, 494 people committed suicide in New York City, with the youngest age group listed as between 10 and 14, and continuing on up to ages 75 and above. These figures are down slightly from the previous year when 524 New Yorkers killed themselves. Men outnumbered women in every age group except 10 to 14, where the girls outnumbered the boys.
Suicide is the eighth leading cause of death in the United States (up from ninth in 1996) and the third leading cause of death for young people ages 15 to 24. More people die of suicide than homicide. In the last fifty years, suicide rates among adolescents have tripled.
To deal with this crisis, Dr. David Satcher, the Surgeon General, recently outlined a national strategy for suicide preventionthat includes:
"Suicide is a preventable problem," said Dr. Satcher at a news conference in May when he announced the plan. "We should make it clear that suicide prevention is everybody's business."
There are populations that have been found to be at special risk for suicide. These include teenagers, especially gay, lesbian, bisexual and transgender teens; the elderly, particularly elderly men; those who have experienced trauma (for example, veterans, and also victims of sexual assault or physical abuse); people with problems of depression, or mood disorders; those with drug or alcohol dependence; people in trouble with the law; those who have made previous suicide attempts; compulsive gamblers; and Native Americans.
One in ten college students considers suicide, according to recent data, and researchers at the Centers for Disease Control and Prevention find that college students have a 50 percent greater chance of suicidal behavior with alcohol or drug dependence. On the plus side, resources to help with depression are generally very good at colleges, if the students in need are steered towards them.
Suicide is the third leading cause of death in prisons, following natural causes and AIDS. The vast majority of these suicides occur among mentally ill prisoners, and over 50 percent within 24 hours of incarceration. Youth suicide in juvenile detention centers and correctional facilities is four times greater than the general population. Promising suicide prevention initiatives have begun in jails and prisons, but continuing suicides among newly committed mentally ill inmates suggests that more needs to be done.
One successful suicide prevention program highlighted by the Surgeon General is the U.S. Air Force program. Alarmed by the finding that one in four deaths of Air Force personnel was the result of suicide, the Air Force set up the program in 1996. An analysis of the suicides showed that the service men and women were more likely to kill themselves following a break-up with a spouse or if they were in trouble with military court. So they started a program to make everyone more aware of suicide warning signs and made it easier to get help. For example, one rule was changed so that Air Force personnel with legal problems can seek psychological counseling without worrying that anything they say can be used against them. In just three years, the Air Force cut its suicide rate by two-thirds. Other branches of the military had no program and their rates remained the same.
A local suicide prevention program, the Suicide Hotline (212-673-3000) run by the Samaritans of New York receives over 100 calls a day, approximately 40,000 calls a year. Executive Director Alan Ross has been on the hotline for ten years now, starting as a volunteer himself. Although the number of daily calls has doubled in that time, the issues behind the calls, the feelings, he says, remain the same. "The issues are pretty universal," said Ross. "They haven't changed with time and they are the same whether you are in New York or Brazil or Sri Lanka: social isolation and feelings of hopelessness."
The main tool used by the all-volunteer staff is active listening, allowing the caller to bring feelings about suicide out into the open, without judgment, which can be a great relief. The Samaritans do not counsel. "It's pure support," said Ross. Occasionally they will make a referral.
Although they have a web page, the hotline does not have on-line access for help. "It's hard enough to run a 24-hour phone hotline" said Ross. But their web page does provide information on warning signs for suicide, and what to do if you or someone you know is feeling suicidal. They also run a program for survivors of suicide.
Ross was very upbeat about the Surgeon General's prevention strategy. "It is significant," said Ross. "It puts suicide on the national agenda. It acknowledges mental health as an issue, and depression as an illness."
The city also has a 24-hour hotline called Lifenet (800/543-3638 or 800 LIFENET) and Lifenet en Espanol (877/298-3373 or 877 AYUDESE) which offers referrals to resources for mental health emergencies, including suicide, and alcohol and substance abuse. And the American Association of Suicidology has a 24-hour National Hopeline (800/SUICIDE).
A suicide prevention program in the city with a different focus is CARES (Children's Attitudes, Responses and Emotions to Suicide), a clinical and research program for children who have had a death in the family from suicide, most often a parent or sibling, but sometimes a grandparent. Developed and run by Dr. Cynthia Pfeffer, author of The Suicidal Child (Guilford Press, New York), CARES helps children, from infancy through late adolescence, understand the illness aspect of suicide, and that they were not purposely abandoned.
"Children who have had a suicide in the family are very high risk for suicide themselves or for psychiatric disorders such as depression and substance abuse," said Dr. Pfeffer "So this is very much a preventative program."
Significantly, Dr. Pfeffer explained, children who survive a suicide are faced not only with the stress and the stigma, but may also be having thoughts of joining the family members who committed suicide.
CARES is part of the Childhood Bereavement Program at Weill Medical College of Cornell University with offices at the Payne Whitney Clinic on East 68th Street (and in Westchester). Dr. Pfeffer also runs a program for adult survivors, and continues her work with children who are themselves suicidal.
Most people who attempt suicide do something to let people know their intentions, but too often these warning signs are ignored by family, friends, coworkers, teachers, and doctors. Warning signs for suicidal thinking include:
If someone exhibits these warning signs, talk directly to them about it. Watch for statements like "nobody cares," or "everyone will be better off without me." Ask them if they are thinking of suicide, and if they say yes, ask if they have a plan. Get help from people or agencies specializing in crisis intervention and suicide prevention, such as a community mental health agency, private therapist, school counselor or psychologist, family physician or suicide prevention center.
And if you are feeling suicidal yourself? "Get help immediately," says Yobanna Genao. "Go to the nearest emergency room. Call somebody."