In this narrative the author reflects on the effective and counterproductive elements of the mental health response provided by the Family Assistance Center in New York City.

I write this paper as a retrospective analysis and critique of the mental health response to the families of the victims of the World Trade Center attacks, coordinated by the New York Police Department's Community Affairs Mental Health Team under my leadership. My analysis focuses on the uniqueness of the response following the disaster and the eclectic collaboration of the crisis workers. In the analysis, I place an emphasis on the integral parts of the intervention and describe what made them effective, as well as identifying the elements that seemed counterproductive. This paper takes the reader through the days and weeks following September 11th at the Family Assistance Center where over 5,000 families were offered services and crisis intervention.

A large part of the response centered on providing crisis intervention to families and individuals. The term" mental health response" was more of a misnomer than an accurate description of the actual services provided by crisis workers and clinicians because traditional mental health services were not offered, nor were they appropriate. One of the most important lessons that I learned during those ten critical weeks was the importance of remaining nonintrusive, nonjudgmental, and empathetic and of responding in a way that helped to restore dignity, power, and security for those individuals who were at various stages of the crisis spectrum.

The individuals and families who fled, first to the morgue in the early hours following the attack, later to the armory, and ultimately to Pier 94 at the Family Assistance Center, displayed various characteristics of crisis behavior. In the first few weeks, I watched the reactions of individuals: desperation, frustration, denial, shock disbelief, and anger. A classification of "premourning" was probably the most fitting during this time. As time moved on, despair and grief became more evident as people began to move into deeper stages of mourning when no word came of any survivors.

Individuals' shock, anger, disbelief, denial, and grief were spoken through words of many languages and in the tears, gestures, and body posture that surpassed the barrier that language can sometimes be to effective communication. A sea of humanity, displayed in the photos held in the hands of thousands representing the missing and the dead, symbolized the severity of the enormous tragedy. On a cognitive level, the crisis workers and service providers knew this was an enormous task before them and one that would require a unique and eclectic response. On an emotional and spiritual level, there is no training to prepare the practitioner for such an assignment.

In the days and weeks following the tragic events of September 11th, various agencies and organizations became part of a unique support team. This team consisted of law enforcement medical personnel, mental health practitioners, spiritual care providers, pet therapy professionals, and people from Oklahoma City who had lost loved ones in the Murrah Federal Building bombing on April 19,1995. The Community Assistance Unit from the Mayor's office and the New York Police Department's Community Affairs Section coordinated the delivery of a variety of services. These services included preparation of the missing persons reports, DNA sampling, release of patient and deceased fists, distribution of death certificates and memorial urns, and ultimately escorting the families to Ground Zero. Many social services were provided at the Family Assistance Center by various agencies and organizations; however this analysis focuses specifically on the mental health response.

The agency responsible for the safety, security, and coordination of service delivery was my unit in the New York City Police Department the Community Affairs Section. As a police lieutenant with a doctorate in the mental health field and extensive background in crisis intervention, I coordinated the interagency mental health response along with a team of officers chosen because of their expertise in crisis intervention.

The response began for us on September 11th at approximately 1:30 P.M. at the city morgue, where my police mental health team, consisting of only five officers at that time, was involved in assisting hundreds of families with the preparation of the "missing persons report." That first day's response seemed to never end and in a surreal way just became the next day and the next day and the next day Those first few days following the attacks, prior to the arrival of the Red Cross, clinicians volunteered their services, offering support to the police mental health team and assisting in crisis intervention for the families who came to the morgue en masse. The team helped families negotiate a traumatic and chaotic bureaucratic process. In the days that followed, a Family Center was set up at the Armory on Lexington Avenue in Manhattan and was later moved to Pier 94. The police mental health team, with the assistance of volunteer Red Cross mental health service providers from all over the country, and city department of mental health practitioners provided support and crisis intervention. A spiritual care team representing various faiths was also on hand to offer support. At this point in the process a more formalized mental health response was in place and the police mental health team continued to take the lead and coordinate the intervention.

Early on in the premourning phase, some individuals pleaded with us to be allowed access to Ground Zero so they could help find their loved one; others hoped to find them wandering disoriented in lower Manhattan; still others believed that their friend, mother, lover, partner, son, or daughter, whose "missing person" photo they carried with them, was unconscious and unidentified in a hospital. One woman was screaming in a rage that she wanted to go and "dig her baby brother out of the rubble."

Most of all people wanted their questions answered and neither the police nor the mental health practitioners could offer a resolution. In most cases, those in crisis screamed in frustration and active listening in silence was the only tool of intervention. The people cried in fear of the worst, while we just listened. Those of us who were aware that the worst of fears had been realized, gently and compassionately broke the news to one person at a time.

We did not pathologize the acute stress symptoms that were being presented. Instead it was answering questions: " How current is this hospital list?" "If she was disoriented she wouldn't be able to spell her name correctly. Can I check again for a different spelling?" "Is this list really all inclusive?" "Is this deceased list as of this morning?" "I have his photo and dental records, should I give it to you?" "She was wearing a red shirt that morning and she has a wrist watch engraved with her initials." "How do I fill out this nine page form?" Unsure of how to respond, crisis workers would answer, "I'm sorry, it doesn't look as though her name is here."

Those fourteen hour days were filled with tears, unanswered questions, shock, denial, disbelief, thousands of photos, tooth brushes, dental records, and extraordinary hope that the missing were not dead and were one of "the unconscious ones in the hospital."

As the days and weeks went on and the term "rescue effort" was gently changed to "recovery" with very few bodies being recovered and no one being rescued alive, the families' emotional state turned from premourning to mourning. Comfort rooms where we could offer support privately and provide crisis intervention were set up at the center. Spiritual care providers offered support to those who often turn to their faith in time of grief. Some psychiatrists assessed the need for medication in cases where a person's reaction was interfering with his or her physical well being, while other clinicians tried to draw upon their training and background for the appropriate intervention.

The most challenging part of this work for me centered on issues of organizational development. No plan of action and a lack of leadership from any particular mental health agency created confusion over hierarchical authority. Unclear roles and responsibilities led to frustration and stress for the crisis worker, who was already at risk for vicarious trauma. Ordinarily, the Red Cross maintains jurisdiction over the mental health response at airline disasters and will take the lead; however the City Department of Mental Health also assumed jurisdiction because of its responsibility for the mental health of the New York City Community This jurisdictional struggle, the enormity of the event, and the looming possibility of another terrorist attack created an ad hoc mental health response that put MY police community affairs mental health t eam at the center of the coordination.

On September 22nd, the Mayor's office asked my police mental health team to lead an ongoing collaborative effort to escort families by ferry to the sacred place of Ground Zero in order for them to view the site and see the place where their loved ones were last alive. In addition to the Ground Zero visit families would be escorted to a memorial site nearby where they could pay tribute to their loved one by leaving flowers, bears, cards, etc. There was no plan to follow and little direction given, yet the police mental health team, with the guidance of Jeannie Straussman, C.S.W., from the State Office of Mental Health and Mr Ken Thompson and Ms. Diane Leonard from Oklahoma City, put together an initiative that would prove to make the difference in the lives of thousands of mourners. The support team would consist of community affairs officers assigned to the mental health team; Red Cross mental health practitioners; spiritual care providers, including Coast Guard chaplains; paramedics; New York State troopers; New Jersey Special Operations group; city mental health practitioners and social workers; pet therapy dogs; and people from Oklahoma City.

We would take fifty people, three times a day, by ferry to the World Financial Center and walk them reverently and gently to the burial place of their loved one, known to the world as Ground Zero. The mission was to provide emotional, spiritual, and physical support to the families as they witnessed the reality of the incomprehensible destruction and said their goodbyes. The safety of the people was of grave concern to us in light of the heightened alert and likeliness of another attack, so law enforcement professionals from all over the tristate area provided additional security. The integrity and dignity of the process was critical to me and, therefore, photographing the families was strictly prohibited.

The grieving process is a personal one, and mourning rituals in most cultures and religious faiths are particularly private events, created and developed individually. However, because of the vast numbers of people who were deceased, grieving families were forced into a situation where their mourning became a matter of public view and the nonsectarian ritual that was created for them was to be simultaneously conducted with hundreds of strangers. Strangers to each other before the trip, these families from various races, ethnicities, and cultures ultimately shared a ritual that bonded them as a group and would not bring closure, but rather help them to begin their process of recovery.

Team Preparation and Communication

Each morning I would gather the sixteen police officers and sergeants in a circle to talk about how they were dealing with the stress, how they were feeling, and how to plan for selfcare. These officers were carefully selected by me and assigned to the mental health team because of their expertise, background, or education in mental health. A sense of surprise came from some of the mental health practitioners who found it interesting and perhaps even a little "odd" that police officers, sergeants, and a lieutenant could also be mental health practitioners. Ironically, by placing the community affairs officers in charge of the coordination of services at the Family Assistance Center, the notion that police work is social work became more of a reality than any of us would have imagined.

The police mental health team would check in with each other about their fears, pain, acute stress symptoms, nightmares, frustration, grief, loss, and feelings of helplessness as it applied to the families. These cops worked twelvehour days for ten weeks, with little or no time off. Some officers described dreaming of hundreds of people in their living rooms waiting to view hospital fists, spilling over into their bathrooms and hallways. Other officers cried as they shared their personal grief and loss relative to the incident. Still others talked about the effects of witnessing the horrific devastation of Ground Zero. These officers were at risk for vicarious trauma and therefore this daily morning debriefing in the "circle of trust" as it was named, was critical for their mental health.

The Red Cross volunteers were not allowed to work more than two weeks, and the city clinicians and social workers also rotated their services frequently. The police mental health team worked continuously and directly without a break for ten weeks, providing crisis intervention for thousands of families and individuals. A lot was asked of the police mental health team. They would take a minimum of two boat rides each day. They were heroes in the true sense of the word, helping families in their recovery.

Prior to each boat trip, I would brief the support warn, reminding them to meet families where they were at, not to pathologize grief, to allow people the space and privacy they deserve, and cautioning them about the likelihood that they themselves may get caught up in the crisis of the site. Three times a day, before different members of the team each time, my briefing reiterated how critical it was to keep in mind that the families had not invited us to the grave site of their loved one. All the providers had to remember that grief and mourning are private and to resist being intrusive. "lf people cry, that's okay. It's part of the grieving process. Offer them a tissue." Despite the briefings, it was still necessary to remind members of the team to step away from the family and give them some breathing room during the visit. Those providers who were getting caught up in their own crisis because of the devastation were encouraged to move along and stay with the families. Time and again it was necessary to remind each other not to pathologize grief and that it was okay for families to react hysterically. Crisis is contagious.

Effective Communication and Intervention

What worked best was active listening, allowing long periods of silence, and empathetic body posture. Words of encouragement or suggestions were few and awkward. Many people looked to the officers of the mental health team for answers to heartbreaking questions: "When will they find her body?" "Will I be able to see her body at the morgue?" " If he had a tattoo on his arm, will that help to identify him?" Most of these questions had no answers, only compassionate responses with hypothetical conjecture.

In Native American spirituality, "dog medicine" is that of service and unconditional love. The pet therapy provided by groups like the Delta Society, Therapet, TDI, and the Good Dog Foundation, under the direction of Ms. Rachel McPhearson, provided one of the most effective forms of intervention at the center. Coordinated by Dr. Stephanie LeFarge from the ASPCA, the pet therapy dogs instinctually knew how to meet the families where they were emotionally. The dogs did not have an agenda and were never selfserving. They were never intrusive, never pathologized grief, and it was in their service, sincerity, nonpretentiousness, and unconditional love that an extraordinary miracle of healing power was brought to the lives of over 4,000 people and clearly made the difference in their recovery process.

Where language may have been an issue, the dog's presence communicated love, acceptance, and understanding. When a mental health practitioner's presence, although well meaning, hampered conversation, the dog's spirit, patiently waiting at the side of their owner/handler broke through the barrier of awkwardness for so many families.

An elderly Latino woman stricken with grief was with her family on one of the trips to Ground Zero and was inconsolable. Neither the officers from the mental health team, the Red Cross volunteers, or the spiritual care providers were able to make a connection with this woman, who chose to remain alone in her pain. On that trip was a pet therapy dog named "Fidel." He was a sweet, adorable, loving Papillion, one of the favorite and most effective dogs, and the only provider who was able to break through and make a connection. She held Fidel in her arms and cried and sobbed uncontrollably. Fidel took it all in, as was his duty to do so. Fidel had been instrumental in helping that woman's catharsis, a first step in her recovery. Fidel's gift was his selflessness, unconditional intervention, and nonintrusiveness. After the trip, the woman thanked Fidel, who exhaustedly fell into a deep sleep in the arms of his owner Rachel McPhearson.

As the dogs gave the gift of unconditional love, the people from Oklahoma City gave the gift of empathy and care that was unexplainable. The true expert and living proof for the families that they will survive this nightmare was a miraculous testimony over and over again. Before each trip, I would address the families and prepare them for what was about to take place and what they were about to experience. I assured them that although it would be painful, "we would get through it together." The support team would then be introduced. The look on the faces of the people would dramatically change when the people from Oklahoma City, who, like them, also lost loved ones, were introduced. Families would gravitate toward them and sometimes no words were exchanged, similar to the service that the dogs provided.

Words were not necessary. Counseling techniques, crisis intervention strategies, and credentials were less than important. It was the recognition of the true expert and the nonintrusive service provided by people like Diane Leonard, who lost her husband in the Oklahoma City bombing, and Ken Thompson, who lost his mother, that made the difference to the families of this tragedy. They had "walked in their shoes," and this was what made the difference. I made a special request through the Red Cross to have the people from Oklahoma City be included as an ongoing and integral part of the support team Ultimately breaking through a frustrating bureaucracy, fifteen people from Oklahoma City joined the support team for a tenweek period. At my request, Diane Leonard and some of the others returned for a memorial in November and were instrumental in helping to provide unique support for the thousands of people who attended that event. Many of the families made connections with the people from Oklahoma and maintained contact months after the memorial, offering support to each other.

Conclusion

The families were not the only ones who had benefited from this work. The support team had received a tremendous, onceina lifetime gift that would forever change them and make them better people, polishing their skills as mental health service providers. This experience is rich with lessons.

One of the lessons for us in the mental health field is to serve unconditionally, putting aside our own "agendas." Additionally, it is critical for us to recognize that sometimes the mental health "expert" may not be the professional with the credentials but rather the provider who has a less traditional background and a more lived experience, as in the case of the peopIe from Oklahoma City. We can also learn from this experience that effective communication and intervention is sometimes more powerfully conveyed in silence. Animal beings can teach us how to serve unconditionally and nonintrusively in times of grief and that the most unexpected minister is not always dressed in cleric's garments.

My officers and I benefited greatly from this work and most of us describe our work at the morgue, the Armory, and Pier 94 as the greatest work of our careers. However, we are at serious risk for vicarious trauma despite preventative measures that were taken to moderate its effects. We were defused, debriefed, and attended a daylong retreat and a stress management conference. However, at a recent "stress management reunion" conducted six months after September 11th, the risk for Post Traumatic Stress, depression, and vicarious trauma were evident. We had been vessels where thousands of people could deposit their grief and now we were full. Very few of us know how the "families" are currently doing. For most of us, our memory of them is of despair, grief, and crisis. As Ground Zero, currently a very different scene, remains open for viewing to all "ticket holders," some members of my team are still providing escorts there and for them, it is perhaps only September 12th.

The police department, often under the fire of justified criticism, became overnight heroes after September 11th, a distinction often held by the fire department and somewhat unfamiliar territory for the police. All rescue workers were classified heroes because of their efforts. The unknown police heroes were those that worked with me directly in the emotional and spiritual rescue and recovery of the families at Pier 94. They proved that police work is in fact social work and they made the difference in the lives of thousands. It was a privilege to work with them every day for ten weeks, and I know that the families are eternally grateful to them.