In the days and weeks following the attacks, 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 family survivors from Oklahoma City who lost loved ones in the Murrah Federal Building bombing. The Community Assistance Unit from the mayor 's office and the New York Police Department's Community Affairs Section coordinated the delivery of services. The services included assisting family members in the preparation of the missing persons   report, DNA sampling, release of patient and deceased lists, distribution of death certificates and memorial urns, and escorting families to Ground Zero. The eventual impact this would have on the workers would not be realized until months after the work had been completed.

McCann and Pearlman (1990) described how providers' own cognitive assumptions and beliefs about safety and power can be disrupted in the face of client trauma. This indescribable trauma triggered an array of emotions in crisis intervention professionals. From clinician to police officer, feelings of grief, loss, fear, and the questioning of one's own mortality were evident (Dick, 1996).

Many families refused to let go of the notion that their loved one would be rescued while 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 rage that she wanted to go and dig her baby brother out of the rubble. Questions abounded.

"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 wristwatch 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 his name is here." Those fourteenhour days were filled with tears, unanswered questions, shock, denial, disbelief, thousands of photos, toothbrushes, dental records, and extraordinary hope that a missing relative was not dead and might be "the unconscious one 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, families turned from premourning to mourning. Comfort rooms were set up at the center, where we could offer support privately and provide crisis intervention. Spiritual care providers also gave support to those who often turn to faith in times of grief.

Most of all, people wanted their questions answered and neither the police nor the mental health practitioners could offer a resolution, In many cases, those in crisis screamed in frustration, and active listening was the only appropriate intervention. Family members cried in fear of the worst and crisis workers listened with quiet support and empathic connection. Those of us who were aware that people's worst fears had been realized, gently and compassionately broke the news to one person at a time.

The volume of clients, some of whom continued to come back daily to check lists despite the fact that the lists remained unchanged, slowly began to wear on the crisis workers. For those of us in leadership positions, the juggling of territorial jurisdiction, authority, and political objectives became the quintessential bureaucratic nightmare.

Challenging aspects of the work also centered on issues of organizational development. Initially, there was no plan of action, and the resultant lack of designated leadership created confusion over authority. Unclear roles and responsibilities led to frustration and stress for crisis workers, who were already at risk for vicarious trauma. Ordinarily, the Red Cross maintains jurisdiction over the initial mental health response at disaster sites and will thus take the lead; however, the City Department of Mental Health also assumed jurisdiction because of their responsibility for the mental health of the New York City community. This jurisdictional struggle, the enormity of the crisis, and the looming fear of another terrorist attack created an ad-hoc mental health response that put my police community affairs mental health team at the center of the coordination.

The emotional energy necessary to balance the needs of the clients with the political objectives of each of the agencies involved was often more frustrating and painful than the actual work itself. Many of us had become "overprotective" of the families and felt it was our responsibility to shield them from the political and bureaucratic processes.

 

"Take Care of My People"

Figley (1995) and others describe compassion fatigue as a deleterious effect of helping others in trauma. Others define the psychological effect on workers who offer assistance to those in trauma and grief as vicarious traumatization or vicarious bereavement (McCann & Pearlman, 1990; Rando, 1997; Saakvitne & Pearlman, 1996). 1 believe that one of the most important factors that contributes to compassion fatigue is found in the empathic response itself. In order to intervene effectively, it is necessary to make a genuinely empathic connection with the individual in need. Figley (1995) maintained that the interpersonal competence of the caregiver is one characteristic of compassion fatigue. In letting suffering individuals into the inner depths of one's self, and by feeling their pain as your own, you create a connection that is at the very center of effective intervention. I listened to some of the cops who worked at the pier say, "I can't let them in, because once I do that I'm finished. I don't want to know their story because it will hurt too much."

On September 22 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 were to be escorted to a memorial site nearby, where they could pay tribute to their loved ones by leaving flowers, cards, and bears donated by Oklahoma City families. 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 Ken Thompson and Diane Leonard, Oklahoma City family survivors, 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, the New Jersey Special Operations group, city mental health practitioners, pet therapy dogs, and family survivors from Oklahoma City.

Our plan was to make three trips a day, taking fifty people by ferry to the World Financial Center and walk them reverently and gently to the burial place of their loved ones, known to the world as Ground Zero. The mission was to provide emotional, spiritual, and physical support to families as they witnessed the incomprehensible destruction and said their good-byes. Family members' safety was of grave concern to us, particularly in light of the heightened alert and the possibility of another attack, so law enforcement professionals from all over the tri-state area provided additional security. Because the integrity and dignity of the process was critical to me, I established a policy prohibiting the photographing of families.

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

We could not be fully aware of the effect this work would have on us until many months later. One of the factors that I believe contributed to compassion fatigue for many police crisis workers was the fact that they "went the distance." Most mental health volunteers, whether they were sponsored by the Red Cross or by the city's Department of Mental Health, were limited to one ferry trip per day, twice a week.

Out of necessity, however, our officers were assigned to a minimum of two trips per day for two months. Lacking empirical evidence to support limiting the number of trips to moderate deleterious effects of vicarious grief for the providers, we can only report anecdotally on the effect on the officers who were consistently involved in the intervention.

Despite efforts to prevent vicarious traumatization and compassion fatigue by conducting regular debriefings with these officers, negative psychological outcomes have been observed. At a recent follow-up with officers who were directly involved with families at the pier, conducted six months after September 11, symptoms of posttraumatic stress, depression, vicarious trauma, and compassion fatigue were clearly evident. These officers were vessels within which thousands of people deposited their grief, and they were full. Very few of us know how the families we assisted are currently functioning, For most of us, our memory is of their despair.

During formal and informal debriefing sessions, officers talked about the importance of the work. For most of us it was a ministry. We were answering a call to serve and take care of the families of thousands who had died. We saw ourselves as serving the many victims by trying to take care of their loved ones. We had to let the stories in and care for these families as if they were our own. As a result, some of us -"crossed the line." We psychologically adopted those families and for that interpersonal competence, as Figley (1995) labeled it, we now pay the price with remnants of grief that remain in us.

 

Moderating Outcomes of Compassion Fatigue

As the leader of the mental health team, in addition to the responsibility I felt to the thousands of families, I was continually concerned about the team members. I worried that the officers were taking in too much, working too hard, staying too long, taking too many trips each day, and not taking enough time off. I limited the number of trips per day to two and insisted that officers take off at least once a week. I convinced my chief to prohibit officers from working seven days straight and, although they grumbled because they wanted to be there, it was beneficial to their psychological well-being in the end.

In attempting to moderate the deleterious effects of the work and prevent vicarious traumatization and compassion fatigue, I conducted daily check-in sessions with my officers. Each morning at 7:00 A.M., we would gather in what we called "the circle of trust" and share our fears, frustrations, sadness, nightmares, despair, and sometimes, humorous stories of the prior day's events. Utilizing an indigenous spirituality version of the "talking stick," we would pass an Oklahoma City bear around the circle and officers would share their feelings when the bear made its way to their lap.

Some officers described dreaming of hundreds of people waiting to view hospital lists in their living rooms, 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. Because they trusted each other, their team leader, and the process, they felt safe enough to freely share their feelings. We conducted these "circles of trust" daily for three months until our work at the pier was completed. On the day of our last ferry trip to Ground Zero, the "family" that had become known as the mental health team and, to some, the "boat people," had an informal termination session at an Italian restaurant where we shared food and emotions and ceremoniously marked the end of our "ministry."

Concerned that there would be ongoing negative effects, I arranged a followup retreat for the officers who had been assigned to the mental health team to be conducted by an outside clinician from Safe Horizon. In a beautiful and peaceful setting, far from the devastation of Ground Zero and the pain of Pier 84, we assembled for a day of healing and emotional recovery. A six-month follow-up retreat was also conducted to "check in" once again. Many shared that they could not sleep, were feeling sad, had a hard time getting the pain out of their psyche, and that the suffering of the families was still with them. It was amazing how easily these feelings could be stirred up. Six months later, it was still very close to the surface.

                                               No Pain, No Gain

In the worst of times, it is through pain that we see the greatness in humanity and in the capacity of humans to do good work (Foa & Rothbaum, 1998). It is in this light that officers shared how proud they were to do such important work. Some officers described it as the best work of their careers and as the "most painful, yet most fulfilling." It was difficult to leave it behind and go back to routine assignments. All else seemed meaningless by comparison. The families were not the only ones who benefited from our work. We also received a tremendous, once-in-a-lifetime gift that would forever change each of us-as individuals and as mental health service providers.

When caregivers reflect on the importance of a particular crisis intervention, particularly a traumatic crisis, you realize that effective intervention does not come cheaply. The emotional exhaustion that is its aftermath can be the cost of good caring (Figley, 1995; Kinzel & Nanson, 2000; Saakvitne & Pearlman, 1996). This idea was a recurring theme at the six-month follow-up discussion with the police mental health team. Officer after officer shared how they believed they had accomplished an incredible feat in holding the families of thousands of souls in their arms, and what a privilege it was to have been able to serve them. To a person, we would not have wanted to be anywhere else. And believing we made a difference enabled us to begin to restore our sense of meaning and personal control.

 

Self-Care Plan

As anniversaries of September 11 approach, there are several ways we can take care of ourselves and "transform the pain of vicarious traumatization" (Saakvitne & Pearlman, 1996). Following are some of the suggestions that were made at the six-month anniversary retreat for the officers of the mental health team that seem to relieve and lessen the symptoms of compassion fatigue and vicarious traumatization:

• Avoid the "physician, heal thyself" syndrome.

As mental health practitioners and clinicians, we sometimes avoid seeking help and believe that we know what is best for ourselves. The intensity of intervening with those in crisis or trauma can take its toll, however, and professional help to deal with personal responses can be helpful.

• Sleep deprivation is dangerous.

For those of us who were engaged with the crisis work of September 11 or for those engaged in any other work involving victims of a traumatic incident, sleep may be difficult. Knowing that this is normal and to be expected is not enough. Your body, mind, and spirit require sleep. You may need a sleep aid or other medication. Some herbal teas may help as well as meditation exercises, but you may need a prescription drug to help you get a good night's sleep while you talk out your feelings with a professional clinician.

• Identify your personal issues.

Critical incidents can stir up personal feelings of loss, grief, depression, and anxiety. It is important to recognize that your own issues may be triggered and thus you need to also identify and utilize the personal coping strategies that normally work for you as they relate to those issues and losses.

• Ritualize the work.

To remember the work in its detail is important to healing. Preparing a scrapbook or journal that documents and ritualizes the work may help to put some sense of closure on the incident so that the healing can begin. For some, the ritual of going to the river or ocean and letting the ','pain and suffering" go seems to be helpful.

• Find some distance.

It is important to leave the work behind. Let go of helping for a bit and acknowledge that others will be OK and will get along without you. Realize that "they need to do for themselves and now you need to do for you." To continue to feel responsible for clients, coworkers, and "the work" can become destructive. Even just to leave it for a while and then come back to it later may be emotionally and spiritually beneficial.

• Relax.

Meditate, exercise, pray, play, take a vacation, go to the beach, or visit the ocean.

Whatever it is that gives you comfort in a positive and constructive way is what you need right now. Alcohol, substance indulgence, and poor nutrition, despite the false feeling of pleasure and comfort they can provide, are destructive and should be avoided. Engage your personal "tried and true" coping skills.

• You are not alone.

It is important to remind yourself that what you are feeling is a consequence of excellence and that other crisis workers are feeling the same effects of a job well done. Now is the time for you to engage in therapeutic exercises of self-care.

Conclusion

As the nation, the cities affected directly and indirectly, and the families of the victims begin to heal and move on in their recovery process, so too must we, the caregivers, begin our healing. First we must give ourselves permission to feel and then to enter into the journey of healing. Failing to do this makes the tragedy of these events and traumatic incidents like it that much more disastrous. We then become victims rather than survivors who are healthy and whole caregivers.

 

SMALL-GROUP OR CLASS DISCUSSION QUESTIONS

1.   How would you know if you were experiencing burnout or compassion fatigue? How would you respond?

 2.   If you were working in a setting where you routinely worked with people in crisis (e.g., a rape crisis or battered women's program or a hospital emergency room), how would you take care of yourself on a day-to-day basis? If you were a supervisor or manager, how would you ensure a psychologically safe environment for your staff?

 Foa and Rothbaum (1998) regard their experiences in working with trauma survivors as "gifts" that are only available to those who work in the trenches. What do they mean by this? Can you give examples of how such difficult professional work might be considered a gift?

 

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