On the Ground After September 11: Mental Health Responses and Practical Knowledge Gained

This book is excellent and unique among the many publications in mental health related to September 11, 2001, including others by the same editors. Some of the contributors are my close friends and colleagues. The book is a testament to the outpouring of caring and services that followed the devastating terrorist attacks. It provides a relatively long view of almost three years. The range of human responses along the postdisaster timeline are eloquently presented, including fear, courage, resilience, stress, grief, avoidance, rage, posttraumatic stress disorder (PTSD), depression, exhaustion, and secondary traumatization, with varying durations and degrees of severity. The writing ranges from clinical, scientific, and administrative to poetic and spiritual. A full range of interventions are presented, from pastoral counseling, to hospitals' provision of food to the homebound elderly, to grief counseling, to play therapy and more. Among the national responders to September 11, the Federal Emergency Management Agency, the American Red Cross, the uniformed services, and other organizations were preeminent, and you can learn here about how they achieved so much after September 11.

On the Ground After September 11 is organized in brief sections that are easily read on their own. The book is a fine source of first-person narrative, including many of the leaders of the immediate and long-term relief efforts and many others. It chronicles some of the experiences in New York, at the Pentagon, and in Pennsylvania at the Flight 93 crash site. The range of expertise and experience is very broad, from clergy to policy makers, clinicians, survivors, their loved ones, and others. The editors engage your curiosity so you can't be sure what you'll read about in the next chapter. The many affected groups reflect our nation's diversity: children, adults, the elderly, rich and poor, gays, Christians, Muslims, Jews, Native Americans, African Americans, firefighters, medical examiners, nonprofit organizations, corporations, mental health programs, hospitals, government agencies, the military, educators, all mental health disciplines, and more. It is a fine source of clinical and research references by key authors. Although it is not academic, many of the chapter contributors are academicians.

The goals are succinctly presented. "This book is intended to provide the mental health community and the American public in general the understanding and the texture of what happened in the mental health response to the terrorist attacks, the range of reactions to these traumatic events, the lessons learned, and what will help us be prepared in the future for possible attacks similar to the devastation and emotional trauma of September 11." Also, since it was conceived just after September 11 and was assembled near September 11, 2004, another goal seems to have been to encourage contributors "to put their experiences on paper," which the editors have achieved beautifully.

Many keys to understanding are contained here. The editors write, "Regardless of the weapons used, terrorist attacks are psychological warfare and, as such, are primarily mental health emergencies." Neal Cohen, commissioner of both health and mental health in New York from 1998 to 2002, shares much of value that emerged from his many contributions to the response to September 11. "One important lesson learned from this is that terrorism creates health impacts that reach far beyond the immediate boundaries of a disastrous event, because people will, whenever possible, seek to leave the immediate area and return to their homes…. Despite decades of neglect, our national public health infrastructure is now increasingly recognized as our first line of post 9/11 defense," and it is important to place mental health "squarely into the mainstream of our public health agenda."

Community activist Adem Carroll writes that "for the diverse Muslim community in New York, the shock waves have never ended. The heavy net of suspicion that came down upon the community has never lifted. We Muslims have been ensnared by the politics of fear, sensationalist media, hate crimes, detentions, investigations, and surveillance."

Dorry Tompsett's poem "The Empty Space" eloquently shares feelings linked to her experience of loss of her husband:

Walking downtown

trying so hard not to look at

The Empty Space

the immense immeasurable

hole in the sky

the hole in my heart, my life.

As a child psychiatrist, I was deeply impressed by "The Towers," which is a narrative by Kay Stritzel Rencken about play—actually play therapy—with kindergarten-aged children in Pasadena. She sensitively describes the fear, grief, and recovery of several children and how she aided their working through their feelings from the time of seeing the World Trade Center fall on TV, through a year later. Their play in school—much of it nonverbal—focuses on their use of blocks and building towers and other structures, their early inhibitions about changing what they made, saving and photographing their creations, and remembering and talking together about them. Finally, some children become able to take down or even knock down their towers again, as they had done before September 11 and as children normally do.

Military psychiatry and mental health services have been under great stress from the terrible injuries, deaths, and strains on servicemen and servicewomen from the wars in Afghanistan and Iraq. It began on September 11 when military and some civilian mental health teams had to both respond to the attacks and simulataneously prepare for war, which is made clear by Thomas Grieger, Cmdr. John Knowles, Col. Cameron Ritchie, Col. Stephen Cozza, and Howard B. Smith. Colonels Ritchie and Cozza conclude a very useful review of the work they did by explaining the toll on their personal lives simply and clearly. "The tragedy at the Pentagon totally absorbed our lives for months. We dressed in battle dress uniforms each morning at 5, and returned home very late at night. Our kids did not always appreciate the magnitude of the disaster and sometimes complained when we were unable to be home in ways that they had been accustomed to…. Deployments in wartime tend to take one away. But this was a wartime deployment in our hometown, which made balancing the demands of work and home more difficult. Ultimately, one needs to be able to live with one's own choices."

I regret that there is not space in this book review to address each selection individually, because each one is worthy of that.

My reservations about this substantial volume are few. Although it can be challenging to determine when each contribution was written, the quality is so high and the diversity of contributions is so great that this is not so important, and the timing of the writing is often indicated by the authors. Also, the book would be easier to use if the helpful clinical and research references had been placed at the end and alphabetized, because they are hard to find quickly.

Overall, this book should be used regularly by disaster planners around the world and by those preparing and working to relieve the acute and long-term suffering of those affected by disasters, terrorism, and war. The sequelae of Hurricane Katrina suggest that we have a long way to go.