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Witnesses to Terror -- One Year Later: April Naturale

The lingering effects of 9/11, with Project Liberty's trauma stress expert.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only. This event was sponsored by Project Liberty.

Moderator: Hello, members, and welcome to 9/11: A Day to Remember, A Day to Heal, on WebMD Live. Joining us now is trauma stress expert April Naturale from Project Liberty, a program that provides free crisis counseling services to persons, families, and groups most affected by the Sept. 11 World Trade Center disaster. She will talk with us about the lingering effects of 9/11 on New Yorkers and all Americans. Welcome, April. Thanks for being our guest today. How are you holding up one year later?

April Naturale: Well, I have done what I suggest that a lot of people do and have used cognitive restructuring to check myself. What I realized is that I am tired more than anything else. But I am stable. Thanks for asking about me. How are you?

Moderator: Well, we are holding up by holding on and being gentle with each other.

April Naturale: An excellent thing to do. I often hear people tell me that when they think they're at the end of their rope, they find there is a knot at the end that helps them to hang on. If I might suggest, also make sure you are not isolated today, and connect up with those you care about, so you can take care of each other. Find some ritual or activity that may give you comfort and strength. Also please know that Project Liberty continues to be available and you can call even if you just want to talk.

Moderator: Tell us about Project Liberty and what you have been doing to help New Yorkers over the past year.

April Naturale: Project Liberty is the mental health response to the WTC disaster that's run by the New York State Office of Mental Health with the funds from FEMA (Federal Emergency Management Agency).

April Naturale: Project Liberty is trying to reach 2.5 million New Yorkers we believe have in some way been affected by the disaster. Our commercials, and subway and bus ads send the message we are not alone, and some of the distress symptoms people have been feeling are actually quite normal after a disaster. These symptoms can include sleeplessness, flashbacks, nightmares, anxiety, depression, and some other distress responses. Project Liberty offers crisis counseling and public education to let people know that talking about these symptoms can be a great source of relief and help people begin to feel better. We have sent out about 10 million pieces of literature letting people know we are out there for them, what the distress symptoms are, how to talk to children, and how to cope with special events such as anniversary dates like today.

Member: We are listening from a psychology class in Alabama. Today's topic is PTSD. We are concerned about secondary PTSD from today's news events.

April Naturale: Thanks for the inquiry. It's an important question. PTSD, or posttraumatic stress disorder, is a type of mental distress that can develop when one has experienced trauma of some kind. This can include becoming a victim of crime, experiencing the death of a loved one or close friend, or even witnessing a traumatic event such as the WTC disaster. PTSD has a number of symptoms that make up the disorder. These can include an increased startle response, severe anxiety, panic attacks, episodes of depression; disassociation or feeling outside of one's self, and a general inability to function well. We usually identify PTSD a number of weeks after an incident has taken place. That's why we believe that crisis counseling can assist people to help reduce the possibility of them suffering with PTSD after such an incident. But your concern is shared by all of us in the mental health field. We know that visually our minds take in information and our emotions are highly impacted by what we see. And so our message has been to victims' families and to parents of children and to other individuals who have been distressed by the WTC disaster to either limit their exposure to the media images or, if they do plan to watch television and review pictures of the disaster, to do so in an environment in which they are not alone and can have the support of family, friends, or a counselor to discuss what thoughts, emotions, and concerns come up after viewing the images again. Our advice has been for many people to turn the television or the radio off and do something more healing or therapeutic.

Member: My wife and I worked in the federal building that was surrounded by the north tower and 7 WTC. We heard the incredible roar of the jet as it passed over us and felt the vibration and sound of the impact as it hit the north tower. We watched debris and then bodies falling from the tower. We watched as the second plane hit the south tower and the building exploded in an orange ball before our eyes. We ran for our lives across the Brooklyn Bridge and turned to see the south tower collapse. We had no close friends or relatives die in the disaster. Our lives have gone on and we probably recognize the importance of enjoying each day. We're happily planning our retirement. But... will we ever be able to see a plane in the sky and not think of that day or of the plane crashing into a building? Will we ever be able to watch a building being razed without thinking of that day? Will we ever lose that small gnawing feeling of guilt for running for safety while watching all the police, fire, and EMS personnel rush toward the disaster? Will our response to "regular things," such as looking at a tall building, ever not trigger a thought of that day? I don't want to forget what happened, but I'd like to not have to remember it so frequently.

April Naturale: First, let me say I am so glad you took this opportunity to let me know how you are doing. I would like to address a number of things you brought up. I think it's very important that you don't invalidate how directly involved you and your wife were in this disaster. Just because you didn't get injured or lose anyone you love does not mean you don't have a right to be feeling the distress responses you are. Please know that it is people like you that Project Liberty would like to have the opportunity to assist so you don't continue to suffer with the symptoms you talked about. Running for safety is something that was necessary for the majority of people who were in the area when the towers were collapsing. You certainly would not have been able to help anyone had you become injured or lost your life. You will hear police, fire, and safety personnel always tell the general public to move to safety. So you did the right thing. You must allow yourself to accept that. For all of us, it's important to recognize what we are able to do in the event of an emergency. If you were not trained to respond to a disaster or to provide medical services, then the best thing you could have done was to get yourself and your wife to safety and allow the professionals to do their job, sparing them from having to take care of you, too.

In answer to your question about whether you will ever be able to look at a plane or a building and not think about the horrific experience that you had, I can only say that what we do know is that over time, the intensity of the emotions around these memories can decrease if you have given yourself the opportunity to process with a counselor what your experience was. As with most Americans and certainly those like yourself who were at the disaster site, the memories are more intense and it may take longer for you to be relieved of the severity of the emotion around them. It's my own belief that we always hold a small piece of these experiences in our memories and will probably always hold a piece of this disaster in our hearts as well. But I also believe that it's a gift to give oneself, to take the time to tell your story and your experiences, your emotions, and your perceptions about what your experience was, to a counselor, either individually, with your family member, or in a group so you can begin to let go of some of these distressing emotions. I hope you will take the opportunity to accept the free crisis counseling that's being offered through Project Liberty.

You can call 1-800-LIFENET; that's 1-800-543-3638. A LIFENET operator can hook you up with Project Liberty services in your neighborhood.

I hope you are kind enough to yourself to give yourself time to heal. Know that even one year after this event, many people are still feeling the distress symptoms that are natural after such an awful incident. You are not alone and hopefully you can allow yourself to begin to heal. So reach out and talk to someone at LIFENET, so you can begin the process. My best to you and to your wife.

Member: I was doing OK until the last couple of weeks.

April Naturale: I have heard many people tell me those exact same words. They thought they were doing OK, and now, in the past couple of weeks, are starting to feel some of the distress signs that they experienced right after the disaster. Know that it's not unusual for anyone to start to feel a rise in the emotions as we approach today, the anniversary of the WTC disaster. We are a society of rituals. We celebrate birthdays, holidays, and other special dates like anniversaries. So it's not unusual that a particular date like today would begin to set off intense emotional responses. Also, there has been a large increase in media coverage around the anniversary and discussions about anniversary events have had everyone talking about the disaster, more so than in the previous couple of months. Hearing these discussions and seeing the images of the towers over and over again can be traumatizing for some people. So it's not unusual that you may start to feel emotional stress at this time. Also, because of the scope of this disaster and the many implications -- the deaths, the terrorism, the anthrax scare, and the threat of war -- many individuals were in what I refer to as a "healthy denial." This means we were trying to go about our daily business and not become debilitated by all of the concerns that this disaster set off. In order to do that, we used a very helpful defense mechanism to protect ourselves. Now that it's one year later, many people are feeling that they can start to take a look at what happened. Some are just beginning to recognize their emotions around the events. So again, it's not unusual that only recently you started to feel distress symptoms of anxiety or depression or had nightmares, flashbacks, or the sleeplessness so many complain about. That's why Project Liberty services will continue through the next nine to 12 months. We understand that many people are just beginning to get in touch with their emotions and we continue to be available in over 100 sites throughout New York City and the 10 counties that have been declared disaster areas by the president. So if you have not already called, I would recommend you pick up the phone. You can call LIFENET 24/7, and ask to be hooked up with Project Liberty services in your neighborhood.

Member: I moved to New York about six days before the attacks and I totally uprooted ... I mean I lived in Texas for 29 years and moved here to live. I was having a difficult time with my move and then that happened and everything else afterward and I just don't feel safe no matter how tough the security may be. How can I be so sure? Everyday my husband gets on the train for work and I pray that he'll return safely. I hear airplanes and watch them sometimes to be sure they are going to their destinations. My depression is a bit overwhelming sometimes. I don't know what to do or what I should be doing. This is all just too much for me and it's been a year ... help!

April Naturale: How unfortunate for you to have moved to New York City just before the WTC attacks. Moving in itself can be a very traumatic event. And if you couple that with an incident like the WTC disaster, it can certainly set off some very distressing symptoms for you. You have obviously associated your lack of feeling secure with the move. The issue of security has become a great concern for all of us. It's really the first time in recent history that we as a country have felt so violated. The best defense is to continue to participate in your normal activities because none of us can anticipate the future. It may also be helpful to address what sounds like anxiety around the disaster. It might be very useful for you to discuss this anxiety with a crisis counselor so that you may learn ways to initiate some coping mechanisms that will allow you to do the things you normally need to do as you move through your day, and not be hindered by the memories of the event. I don't know exactly what would work for you individually, but a crisis counselor can help you identify what some of those coping skills may be. They will ask you what's worked for you in the past, what types of activities give you comfort, and when do you feel most relaxed. They can also teach you relaxation techniques and stress management activities in addition to other coping skills. It sounds like it would be worth your while to call 1-800-LIFENET and start that process for yourself. I wish you well.

Moderator: Is the counseling offered by Project Liberty one-on-one, group sessions, or both?

April Naturale: It can be either one-on-one, a family meeting, a group, or even public education sessions to larger groups. The whole idea of Project Liberty is to reach out to the general public as well as those who have been directly affected, and to provide services where you are most comfortable receiving them. Some do not like the one-on-one environment and prefer to meet with family members or to be part of a support group with members who have shared the same experience. There are close to 50 support groups around the city and the 10 counties addressing issues specifically related to the WTC disaster. That may be a group for victim's families, women with depressive symptoms, a group of parents concerned about their children, or a group of survivors with guilt. It would be worthwhile to call and find out if you can hook up with one of these Project Liberty services to address whatever concerns you have.

Member: Are there any activities that help?

April Naturale: I think so. What we know is that it's very important for people not to isolate themselves or to stop doing those things in their lives that they would normally do and that bring them comfort, peace, or joy. So we certainly recommend that you reach out or accept support from family, friends, or counselors. Other things we know that can be helpful are stress management exercises. Some of these are actual physical activities like walking, stretching, yoga, and relaxation techniques. Other things may include leisure activities you would normally participate in, like reading, going to the movies, praying, meditating, or visiting with those you know understand how you are feeling and who are supportive. There are also specific techniques of cognitive structuring that can help one alter the way one thinks, to help insert positive messages, memories, and images that many also find helpful when they have been suffering with serious distress symptoms around a traumatic event. These types of cognitive structuring activities are best performed by professional counselors. What we also know is that many people go to their creative side to help them cope with traumatic events. As you have seen, there are examples of artistic creativity all over the city and all over the state. We have seen artwork, poetry, heard music, and read letters that many children and adults have exhibited as an expression of their thoughts and emotions around the WTC attacks. We highly encourage these types of activities, especially journaling, which many find healing on a daily basis. Others have also told us that volunteering, especially with children, has been an incredibly therapeutic activity, which helped them to cope with distress. While everyone has their own idea of what's helpful to them, these are just suggestions. You might explore more by thinking about them on your own or discussing them with a counselor. You may also want to call 1-800-LIFENET and ask for Project Liberty services.

Moderator: There are many folks in our room today who are from the NY area and still feel as if they cannot get the assistance they need ... such as proper medications. Can Project Liberty help in that area as well as with counseling?

April Naturale: Some people find that their distress symptoms are quite severe and intolerable to them, and that crisis counseling alone is not giving them enough relief to be able to get through their days and function well. In those cases, we refer people for formal mental health treatment. Part of the assessment of one's symptoms may involve exploring whether medications can help. There are some antidepressant and anti-anxiety medications that have minimal side effects and many report relief from taking these physician-prescribed medications. While Project Liberty does not provide formal mental health treatment, or medications, they will refer you for such an evaluation. More recently, the 9/11 Fund and American Red Cross have joined in an effort to offer mental health services, which may include referrals for medication when appropriate for identified individuals with the eligible criteria for this benefit program. If you believe you may be eligible for the 9/11 Fund and American Red Cross Extended Mental Health Benefit Program, you can apply through LIFENET. They will give you the details of who is eligible and how to apply for and access this benefit.

While I am not a physician I can tell you that some people report relief after having worked with a physician and taken the recommended medication. There are others who prefer not to use medication and it's certainly their choice. But if you are having severe symptoms without relief from counseling, you may want to access a mental health evaluation.

Moderator: Can we ask what you are doing today, besides sharing with us? How are you marking the anniversary?

April Naturale: Sure. I was privileged enough to be able to witness the moment of silence and the reading of the names of the victims of the WTC disaster at the site this morning. I was grateful to see all the concerned New Yorkers coming together to participate in this anniversary event to mark the day in hopes that we don't forget those who lost their lives and their family members who are suffering with grief. People were quiet and respectful and there was an air of community grieving as well as a peacefulness that I think signaled the community's readiness to begin to heal. Family members, rescue and safety workers, counselors, and community members all came together in a respectful, thoughtful way to mark the anniversary. I was grateful to participate in this ritual and will do so again this afternoon at another memorial service. There are many small community-based anniversary events going on throughout the city, state, and country. We have encouraged people to participate in these events, as they can be healing and are certainly supportive of those suffering the most. So I thank you for asking and hope you are all able to participate in whatever activities will help you to begin healing from this horrific event, and that you are able to feel all of the support and the caring from all of those outside New York and the rest of the country. Project Liberty continues to receive daily communications from other states and many other countries, even, offering their support, thoughts, and prayers. So we continue to try and share all of that information with New Yorkers by our presence in the communities, throughout the city, and the 10 counties. All of the Project Liberty Staff are deployed to these areas all day and all evening and we'll be back again tomorrow. I would like to thank everyone who continued to give us positive feedback about the work that's been done, and those selfless with their time and energy to help with the support after the disaster. We are so proud to be part of a community that responded so well to such an awful event.

Moderator: Thank you, April.

April Naturale: Thank you.

Moderator: Unfortunately, we are out of time. Thanks to April Naturale for joining us this hour. For information about Project Liberty, visit

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