What Can 9/11 Teach Us About Mental Health for COVID-19?

Disaster mental health experts share learning in the wake of coronavirus.

Posted Apr 22, 2020

by Jonathan DePierro and Craig Katz, Guest Authors

The COVID-19 pandemic presents one of the largest collective traumas in recent memory, emerging among the still-ongoing global AIDS pandemic and conflict-related refugee crisis. As of April 22, 2020, over 2.34 million people across the world have been infected with COVID-19 and there have been approximately 178,000 deaths (Johns Hopkins University, 2020). In New York State, one of the global hotspots for this tragedy, there have been more than 258,000 infections and 19,000 deaths, far exceeding the number of lives lost there on 9/11/01. Yet, several clear lessons learned from the mental health response to 9/11 may be applied to this pandemic. 

Prevention efforts

Adverse mental health effects following trauma are often proportional to the intensity of exposure. Many 9/11 responders and survivors had toxic exposure to the “dust cloud” from the collapse of the WTC buildings, compounded by seeing loss of life and encountering human remains. Particularly for emergency responders, there was inadequate monitoring of this “dosing,” especially the duration of their time at Ground Zero in rescue and recovery work. Likewise, it is essential that efforts be made now to ensure that the exposure of healthcare workers is monitored, given that both the risk of COVID infection and the exposure to loss of life and human suffering rise with every work shift.

At the same time, consistent social support provides a buffer against even a high degree of trauma exposure. Following 9/11, workers who were part of traditional uniformed first responder populations likely had the mental health benefit of robust social networks provided by their affiliation with colleagues and unions. Non-traditional responders, including volunteers from all walks of life, had this support available to them less reliably (Pietrzak et al., 2014).  Creating or bolster social support, therefore, is particularly important for the essential workers now (e.g. food delivery workers), who may not have built-in and easily accessible networks via their occupation. Technology that was not widely available at the time of 9/11 supports this essential social connectedness. We now see religious services, gatherings of family and friends, and even weddings, occurring over video conferencing platforms, and these efforts will certainly mitigate distress.

Treatment needs

Natural and manmade disasters in recent memory have been followed by a high-volume response from mental health professionals. Soon after 9/11, mental health professions flooded makeshift family support centers and responder aid stations.  These workers created a “trauma tent,” a safe, supportive space surrounding affected individuals (Katz & Nathaniel, 2002). Now, in the midst of COVID-19, again thousands of providers have volunteered to provide support services. 

These heroic efforts are likely to be of great help. However, the 9/11 experience has highlighted several important barriers that need to be considered when offering services. Many affected individuals may not engage with care, due to mental health stigma, denial, compartmentalization, and practical limitations on their time. Widely-disseminated personal testimonials (e.g. in the form of social media posts or TV ads) addressing the impact of COVID-19 on mental health may decrease mental health stigma (Pinfold et al., 2005), a particular concern among health professionals and uniformed emergency responders. A model for this can be found in the first-person accounts of trauma-related symptoms on the Veterans Health Administration’s YouTube channel

The eventual federally-subsidized consolidation of treatment of World Trade Center rescue, recovery and cleanup workers and survivors serves a model for how similar long-term services may be made available to individuals affected by COVID-19. Within the United States in particular, a nationally-organized health effort is particularly important given that many individuals have now lost their income and health benefits in the context of this pandemic.

Some groups with elevated risk

High rates of mental health distress are anticipated among health care workers on the front lines of the COVID-19 pandemic. The potential for moral injury, engaging in an action contrary to one’s moral compass, is a strong concern and is associated with an increased risk of psychiatric disorders and suicidal thinking (Bryan et al., 2018; Williamson et al., 2020). Workers may be making guilt-inducing choices regarding rationing care, including resuscitation efforts and ventilators. This issue recalls the internal conflicts for 9/11 uniformed responders: Many felt as if they failed in their mission to serve the public because only a small number of people were rescued from Ground Zero.

There is also reason to believe that distress will be high among less visible non-medical “essential personnel,” including governmental employees, healthcare support staff, and delivery workers. Non-traditional 9/11 responders (e.g. construction, cleanup, asbestos workers) have been found to have higher rates of chronic PTSD than uniformed responders (e.g. police). Potential risk factors for this group include greater life stressors and lower social support around the time of 9/11 (Pietrzak et al., 2014). Further, not unlike many workers now, these 9/11 responders mostly lacked disaster experience and found themselves taking on tasks well outside the scope of their jobs, often not by choice but due to economic necessity.

Points of departure

While we may learn from 9/11, COVID-19 poses unique challenges that may engender even more profound mental health consequences. First, the acute impact of 9/11 proved to be more or less limited to the day itself whereas that for COVID-19 is so far unfolding over several months.  Second, the political and social divides across the globe may convey additional stress, whereby mixed messages from leaders regarding paths to safety and recovery sew confusion and anxiety. Finally, following 9/11, there were countless images of crowded funerals and memorials, and physical comforting via embraces. Yet, these collective mourning and healing rituals are now mostly disrupted by social distancing.

Conclusion

The emotional reverberations of the 2020 COVID-19 pandemic will likely be felt for many decades. Rather than the sudden jolt of fear and horror that accompanied the 9/11 attacks, the COVID-19 pandemic has brought a mounting wave of anxiety, anger, hopelessness and grief. Widely-accessible short-term and long-term treatment services are necessary to respond to this need, which may outstrip even what we encountered after 9/11.

References

Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 36–45. https://doi.org/10.1037/tra0000290

Johns Hopkins University. (2020, April 11). Coronavirus Global Cases by the Center for Systems Science and Engineering. https://coronavirus.jhu.edu/map.html

Katz, C. L., & Nathaniel, R. (2002). Disasters, Psychiatry, and Psychodynamics. Journal of the American Academy of Psychoanalysis, 30(4), 519–529. https://doi.org/10.1521/jaap.30.4.519.24188

Pietrzak, R. H., Feder, A., Singh, R., Schechter, C. B., Bromet, E. J., Katz, C. L., Reissman, D. B., Ozbay, F., Sharma, V., Crane, M., Harrison, D., Herbert, R., Levin, S. M., Luft, B. J., Moline, J. M., Stellman, J. M., Udasin, I. G., Landrigan, P. J., & Southwick, S. M. (2014). Trajectories of PTSD risk and resilience in World Trade Center responders: An 8-year prospective cohort study. Psychological Medicine, 44(1), 205–219. https://doi.org/10.1017/S0033291713000597

Pinfold, V., Thornicroft, G., Huxley, P., & Farmer, P. (2005). Active ingredients in anti-stigma programmes in mental health. International Review of Psychiatry, 17(2), 123–131. https://doi.org/10.1080/09540260500073638

Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and experiences of moral injury in front-line key workers. Occupational Medicine. https://doi.org/10.1093/occmed/kqaa052