In the Aftermath of 9-11-01: A European Perspective?
Soeren Buus Jensen, MD, Ph.D.


When a significant historical event happens, most people will keep in their memory, what they did, where they were and how they spontaneously reacted on that day, even if they were not directly affected. September 11, 2001 became one of those days. A global event instantly reported by the media throughout the world. Images repeated over and over on TV-screens overruled our disbeliefs of a reality disguised as fiction.

I was in Kosovo preparing a lecture for the next day to psychiatric residents on the theme of "Public Mental Health Interventions Related to War and Post-War Contexts". A phone call from Africa urged me to switch on the only working German TV-channel. The screen twisted colors and lines into a surrealistic nightmare. Next morning’s lecture was quite different than first planned. Later that day, I joined a spontaneous peace walk in Pristina with the crowd waving American flags in solidarity. I asked myself, when I last saw a demonstration abroad in favor of the US.

A week later traveling on a half-empty transatlantic flight I watched the downtown smoke rise from the changed skyline as I arrived in New York scheduled long ago to teach at the International Trauma Studies Program (ITSP/NYU) about "Early Mental Health Interventions in Large-Scale Disasters". My usual downtown hotel was open, but now located in a war zone behind barricades of police and military. Windows were intact but covered with dust as a reminder of last week’s debris storm that terrorized downtown streets. Walking through the streets I was reminded of my days in Sarajevo, remembering the feeling of a war zone, but in the wrong context. Men in Wall Street suits hurried by silently with masks over their mouths.

Usually Western trauma professionals try to apply their skills in contexts of the developing world or in countries in "transition". Suddenly this was a journey in the opposite direction. Coming from my work in war-torn areas of Africa, through post-war Kosovo to a still smoking war-zone in downtown Manhattan.

Each disaster has its own uniqueness yet lessons from other global emergencies are often valuable for planning early interventions in any cultural context. The aim of this paper is to illustrate how a general structured framework used around the world for planning comprehensive emergency response may also apply to New York. Our further challenge is about the European perspective on preparedness. What are the unique and shared elements of effective response if a similar emergency situation happened in Paris, Copenhagen or Athens?


The world watched in amazement at New York’s response. The speed and dedication of the helping forces and the compassionate spontaneous efforts by survivors to assist each other. The mental health professionals eagerly joined the helping efforts. Uncertain of their role, but believing this was their field and feeling responsible to help.

The following presents a structure for creating early interventions that seeks to prevent or minimize psychosocial and mental health consequences of exposure to potentially traumatic events. It suggests that practical early interventions can be organized into 3 phases (Jensen & Baron 2002).

Phase 1: Needs Assessment Leading to Emergency Response

Help begins with immediate emergency aid and a quick assessment of overall need. Fire fighters, policemen, health workers and emergency services personnel are the first at the site to offer immediate care. As they give crisis aid, these emergency workers compassionately interact with survivors and assess their needs. These workers are knowledgeable about potential helping resources and map needs and resources as the basis of the first immediate plan for interventions. Initial interventions concentrate on survival needs like safety, shelter and treatment of injuries.

How do mental health professionals assist during the crisis? Immediately following 9-11, a spontaneous volunteerism spread among New Yorkers. Lay people and professionals offered assistance. Psychoanalysts reportedly stood in line in front of a downtown hospital pleading to be let in to assist the traumatized. The desire to help was commendable. For mental health professionals, their help was most needed as common human beings, not at that early stage, as therapists.

Phase 2: Preventive Brief Interventions

After the immediate crisis the following interventions are brief and intend to prevent or minimize exacerbation of emotional and practical problems caused by the crisis. Target populations are survivors and their families, witnesses, emergency workers and affected communities. Interventions seek to reduce or dissipate emotional distress, advice participants about how to cope and promote resiliency through family and community support. Helpers try to identify survivors who are more deeply distressed and require onward referral for additional care.

Many of the New York University students in my class on September 18 were directly affected by the 9-11 tragedy. One useful helping technique is to bring a group with similar experiences together to share their personal narratives. Through a group process they bring order, understanding and support to each other’s experiences and feelings. In the NYU classroom, we used the technique as a personal self-help exercise and to facilitate the students’ skills in using this technique with others.

Phase 3: Early Clinical Interventions

These clinical interventions target individuals, families or small groups of distressed survivors unable to return to normal functioning in a timely way and in need of more specialized assistance.

Days after 9-11, NYC therapists were overwhelmed by their existing and old clients asking for extra sessions for emergency support. NY is unique in the world for the numbers of people seeing therapists. Therapists were confused by who needed therapy and why. Clients, like the therapists, were frightened and stressed by the events. Was it necessary to have extra therapy or better to seek out friends and family for normal sharing and support? Knowledge about how to implement community-oriented interventions was limited. Therapists were pulled into an emergency response with little forethought, training or preparation.


The "7 C’s"

The 7 C’s are suggested as one framework for organizing the 3 phases of early emergency interventions.

1. Culturally sensitive and contextually appropriate interventions
2. Coordination of all services
3. Community oriented public mental health approach
4. Capacity building: training, support and supervision
5. Clinical services
6. Care for the Caretakers
7. Comprehensive data collection, analysis and evaluation

1. Culturally sensitive and contextually appropriate interventions.

Questions to ask ourselves:

  • What are the culturally specific elements of NYC relevant to planning a sensitive emergency response?
  • What resources are available within existing health and social welfare structures and families and communities?

Glimpses from NYC:

I helped to facilitate a mental health planning workshop for 80 NYC professionals on September 23. We tried to grasp the cultural specifics of New Yorkers from the corporate Wall Street type, to the world of modern artists to the immigrants from around the world.
Sub-cultures of more than 5 million people separated by social and economic class, multitudes of ethnic groups and religious diversity. Some with strong traditional families and communities others far from their original homes and totally isolated. All sharing a universal belief about New York’s invulnerability as the center of the world with a tradition for "heroes" and of course a "Mecca of Psychotherapy".

2. Coordination of all services

Questions to ask ourselves:

  • Is there a coordination body with a clear, authoritative leadership for the psychosocial/ mental health response that involves all major players?
  • Are there clear maps of needs, resources and gaps?
  • Are the planned interventions cost effective?
  • Will the emergency interventions lead to effective mid and long-term plans?

Glimpses from NYC

Although most parties agree on the importance of coordination, few want to be coordinated. In NYC, competition for who knew best and for power, control and money began quickly. Some NYC professionals, who were previous veterans of work in foreign cultures, complained about the "fly-in" experts from outside of NYC coming to their city to tell them what to do without knowing their culture, and not respecting those in their home turf. A professional from Connecticut or Denmark was just not a New Yorker.

3. Community oriented public mental health approach

Questions to ask ourselves:

  • Do interventions mobilize family and community resiliency and self-help?
  • Are existing community support structures ie: community leadership, religious leaders, local institutions and associations, neighborhood networks etc. optimally utilized in the emergency and ongoing self-help? Are grassroots organizations for family and network support ie: Rotary Clubs and church, and women’s groups mobilized?
  • Is the media systematically involved in providing community education and appropriate information more than sensationalism?
  • Do clinical interventions promote a comprehensive public mental health and human rights perspective?

4. Capacity Building: Training, Support and Supervision

Questions to ask ourselves:

  • Is training available in advance about the mental health issues of emergency response to health professionals, support helpers like school teachers, religious and other community leaders and firefighters, policemen and other emergency service workers?
  • Is systematic training available in universities and professional schools so that all mental health professionals are prepared to provide effective crisis interventions in a emergency?
  • Is specialization training available to interested mental health professionals for the treatment of trauma?

Glimpses of NY:

9.11 illustrated that many mental health professionals did not have training in crisis intervention. In this large-scale crisis, their usual methods of psychotherapy were not most useful and many did not know how to respond. Mental health workers were often looking for individual problems and therapeutic solutions rather than offering emotional support and compassion, promoting self-help and resilience and encouraging family and community networks. Critical also in the immediate aftermath in NY was large-scale efforts at community education about normal responses to trauma and stress to potentially vulnerable groups i.e.: clean-up workers, Wall Street companies, journalists etc to prevent the exacerbation of expected distress.

5. Clinical Services

Questions to ask ourselves:

  • Are mental health professionals encouraging public understanding about normal responses to trauma, natural resilience and the necessity of using family and community systems for self-help? Are they avoiding pathologizing what is normal response to trauma?
  • Is mental health crisis intervention available to the severely affected survivors?
  • Are existing mental health clinics and private practitioners trained to provide the needed service in this context rather than just do what they always do?

6. Care for the Caretakers

Questions to ask ourselves:

  • Is there a mentality that recognizes the personal vulnerability of helpers and encourages them to seek support when needed?
  • Are there mental health crisis and ongoing services accessible to relief workers?
  • Is there sufficient support, supervision and training for mental health professionals?

7. Comprehensive data collection, analysis and evaluation

Questions to ask ourselves:

  • Is there an ongoing system for collecting information?
  • Is there ongoing systematic monitoring of needs, resources and gaps?
  • Are quality assurance systems integrated into interventions to assess effectiveness from the beginning?
  • Are mechanisms established to ensure that future research honestly portrays the problems and the interventions?


Large-scale disasters have permanent social and psychological effects. Lessons learned internationally confirm a need for long-term healing perspectives beyond the immediate emergency situation.

Important to NY and similar to other contexts are steps towards establishing "Truth, Justice and Reconciliation" as means of psychological and social healing. Trying to clarify the true narrative of what really happened cleansed of the pollution of lies, guesses and wishes. Finding justice, where violators are held responsible, convicted and punished within a judicial context and respect for human rights. Balancing the wish for blind revenge with reconciliation to avoid vicious circles of new violations. All major issues needing resolution to bring collective healing.


The natural question to ask from a European perspective is: Are we prepared if a similar event like 9-11 happens in Paris, Copenhagen or Athens?

Most European countries have substantial disaster preparedness plans but are the psycho-social and mental health components comprehensively developed and ready for action? It would be a challenge country by country to analyze potential large-scale traumatic events through a systematic analysis using the 7 C’s structure to challenge the potential effectiveness of our pre-planned interventions. A comparison of ideas and models could become a theme for a future European Conference.

Now months later, while NYC is still recovering, humanitarian workers are heading towards Afghanistan. Hopefully bringing with them lessons learned about guiding principles of emergency interventions that can make it in New York, so they "can make it everywhere". A new context, a different war zone, a series of special events yet similar basic guidelines of where to begin in our helping efforts. Our question, using these same guidelines, are we ready, if necessary, here in Europe?


Baron, N., Jensen, S.B. & de Jong, J.T.V.M. (2002). Mental Health of Refugees and Internally Displaced People. In Guidelines for Psychosocial Policy and Practice in Social and Humanitarian Crises: Report to the United Nations (Eds. J. Fairbanks, M. Friedman, J. de Jong, B. Green & S. Solomon). UN, New York. (In press).

Jensen, S.B. and Baron N. (2002) Training Programs for Building Competence in Early Interventions Skills. In: Oerner R. & Schyder, U. (Eds.) Reconstructing Early Interventions after Trauma, Oxford University Press.

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