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20 Years Later: How 9/11 Shaped ‘Disaster Psychiatry’

The World Trade Center burns as the USNS Comfort arrives in New York harbor September 14 at sunset. (USCG photo by PAC Brandon Brewer) https://www.dvidshub.net/search?q=1082244&view=grid

By Sarah Marshall


Two decades ago, Sept. 11th changed our world. Among the many lasting impacts of that tragic day, mental health providers and researchers broadened their perspective on psychiatric issues related to disasters, galvanizing the practice of disaster psychiatry like never before.

“Disaster psychiatry focuses not only on psychiatric illness, but also distress, and altered behaviors in the face of disasters … It brings together psychiatry and the principles of public health in the context of a large-scale trauma event,” explains Dr. Robert Ursano, director of the Uniformed Services University’s Center for the Study of Traumatic Stress (CSTS).  

Dr. Robert Ursano gives a presentation.
Dr. Robert Ursano, professor of psychiatry and
neuroscience at USU, gives a presentation during a
NATO meeting in 2019. Ursano and Dr. Joshua
Morganstein, assistant director for USU's CSTS
have been instrumental in the field of disaster 
psychiatry, which has broadened like never before in
the wake of 9/11. (Courtesy photo)
Ursano credits Dr. Elissa Benedek for first bringing an awareness of the practice of disaster psychiatry to modern American psychiatry in the early 1990s, nearly a decade before 9/11. Benedek (mother of USU’s present Department of Psychiatry Chair Dr. David Benedek) was serving as president of the American Psychiatric Association when she created a Task Force on Psychological Dimensions of Disaster, that became the Committee on Disaster Psychiatry in 1992. The committee, which Ursano later chaired for many years, provided support for psychiatrists, educating them on the psychological impact of disasters. Ursano was chair of USU’s Department of Psychiatry on Sept. 11, 2001, and subsequently developed as senior editor The Textbook on Disaster Psychiatry, now in its second edition.

After 9/11, a greater awareness was placed on responding to the community impacted by a disaster, Ursano adds, which meant not just where the event took place, but the community impacted, which can spread across a nation. The disaster community for 9/11 was the entire United States as evidenced, for one, by all of the nation’s phone lines being tied up that day -- everyone across the country was trying to reach loved ones who were either traveling, in New York, at or near the Pentagon, or near Shanksville, Pennsylvania. 

“The community was affected by the meaning of the event, not just the direct exposure to the events,” Ursano says.

It also became even more evident that human behavior is impacted in various aspects after a disaster, and the focus should not just be on disorders caused by such an event, he says. While psychiatric disorders, like post-traumatic stress disorder (PTSD), are still a concern in the wake of a disaster, there are also distress responses, and health risk behaviors -- and all of these are the focus of psychiatry. For instance, in New York City’s emergency rooms after the attacks, he explained, the most common problem was trouble sleeping, and not PTSD.  

“In order to respond to disasters, 9/11 highlighted the importance of the breadth of these distress responses,” Ursano says.

Coast guardsmen from Activities New York look on from Staten Island as the USNS Comfort arrives in New York harbor, with the World Trade Center complex burning in the background days after the September 11th attacks. (USCG photo by PAC Brandon Brewer)
Coast guardsmen from Activities New York look on from Staten Island as the USNS Comfort arrives in New York harbor, with the World Trade Center complex
burning in the background days after the September 11th attacks. (USCG photo by PAC Brandon Brewer)

Researchers also became more attune to the psychological impact of disasters on a population, in the wake of 9/11. For instance, if one were to look at downtown Manhattan -- a population of about 500,000 -- and how many of those suffered from PTSD after 9/11, that would be about 100,000 people, if the rate was about 20 percent, Ursano explained. However, if one were to look at the greater New York population -- about 8 million people -- and the rate was about five percent, that would be about 400,000 people. The most broad group exposed would be missed, even though their risk is lower. This reminds us it’s important to be cautious about assuming who is at risk after a disaster, Ursano adds. Broad community health surveillance better informs us who has been impacted and where risk is concentrated, which allows for resources to be more effectively distributed.

“We began to think about the impact in a population, and not just the impact of a population,” he says. 

Bringing all of these facets of psychiatry to public health, in a large-scale trauma event, ultimately transformed disaster psychiatry into a practice area, Ursano continues. 

U.S. Public Health Service Capt. (Dr.) Joshua Morganstein, assistant director for USU's CSTS, gives a presentation on crisis leadership during a symposium. (Courtesy photo)
U.S. Public Health Service Capt. (Dr.) Joshua
Morganstein, assistant director for USU's CSTS, gives
a presentation on crisis leadership during a symposium.
(Courtesy photo)
“It is the intersection of psychiatry with public health and traumatic events that creates the practice of disaster psychiatry,” he says. 

In turn, disaster psychiatry further emphasized its presence not only as a mode of practice, and a partner with public health care, but also an area of intense research focus.

“This was an important transition for the field, and it occurred in a gradual way over time,” Ursano says.

The lessons learned from 9/11 have fostered the development of principles for public health leadership, and interventions, which can be tailored to the unique aspects of each disaster, explained U.S. Public Health Service CAPT (Dr.) Joshua Morganstein, assistant director for USU’s CSTS.  The attacks shed light on how the impact of disaster unfolds over time, and how beneficial it is to have community cohesion early on, he added. 

“Eventually, many people find a way to make meaning of the difficulties and move forward,” Morganstein said. “Anticipating and planning for the frequently observed ‘phases of disaster’ also allow resources to be allocated more effectively and tailored interventions to be delivered in a more timely manner.” 

Morganstein, who also serves as chair of the APA’s Committee on Psychiatric Dimensions of Disaster, said it’s also been shown that by enhancing a sense of safety, social connectedness, and hope, can reduce some of the disaster-related distress in the wake of a tragedy. 

“This framework continues to inform our approach to protecting public mental health after disasters, including the pandemic,” Morganstein said.

Over the years, CSTS has been recognized nationally and internationally for its contributions to disaster psychiatry research and care. The CSTS has produced numerous resources to help support healthcare providers, service members and families, responders and emergency workers, community leaders, and the general public in the wake of disasters, including the present pandemic, which can be found here.