The American Psychiatric Nurses Association (APNA) is the largest membership association for psychiatric nurses of all levels of education and practicing in a variety of settings. The members are both national and international, and there are 33 state chapters. APNA provides leadership to promote psychiatric-mental health nursing, to improve mental health care for culturally diverse individuals, families, groups and communities, and to shape health policy for the delivery of mental health services.

In the year that has passed since September 11 (often referred to as 9-11), we have begun to develop an organized review of our response to this tragedy. This article describes APNA's response to the 9-11 tragedy and highlights some of the specific disorders that psychiatric nurses may encounter and assess in individuals because of this trauma.

APNA's Response to 9-11

APNA responded to the tragedy of 9-11 at several levels. Association members from around the country reached out to those in need, the National Association provided many services, and nurses in New York offered generous assistance to those around them. These responses will be described below.

Members Reach Out

For the first few days immediately following the attack, APNA's telephone lines, e-mail, and list serve were flooded with messages from Psychiatric-Mental Health Nurses (PMHNs). The resounding message was "what can we do?". For many, this plea was for information on the organization's plans to respond; for others, removed from New York, Pennsylvania and Arlington, the questions related to what an APNA state chapter could do to assist and in what ways individual members might participate. As with many health care professionals, these tragic events brought out in our members a sense of powerlessness and frustration, and sometimes anger. Often the anger was misdirected because immediate answers were not available. Organizing a national effort seemed impossible for APNA, as it was for many other organizations of health care providers totally unprepared for such a catastrophe. In addition, many members called with concern and fear for the APNA staff's safety because its headquarters is in close proximity to the Pentagon in Arlington, Virginia.

APNA Responds

Within a day the Board of Directors agreed to respond in three main ways. First, the board made plans to partner with the American Red Cross (ARC) in their national efforts. Second, the board agreed to encourage members to work locally with the ARC chapters in their areas. And third, APNA decide to use its website (www.apna.org) as a place to provide information about emotional problems and their symptoms that may occur when such an event takes place.

In the month that followed September 11, the American Red Cross's national efforts involved a national "hot line" and here, in Washington, DC, a "Comfort Center." PMHNs from APNA responded immediately when notified of the need to help and called the scheduler to volunteer time answering calls placed on this "800"number. In particular, ARC needed advanced practice nurses skilled in assessments, and especially child-adolescent mental health, to respond to callers, to provide some intervention by support and grief counseling, and in some cases to make referrals for additional counseling.

Children's reactions were reported to be the focus of many calls, and responses to requests for information from providers attempted to help families deal with the aftermath of 9-11.

Members from our Washington, DC, chapter were especially positioned to participate at this local site established for hot line callers. Crisis intervention skills were needed; many callers wanted to discuss symptoms and what might happen in the next few days. Some callers requested information about how to explain the events to their children, what they could expect, and what to watch for with regard to symptoms that might require treatment. Children's reactions were reported to be the focus of many calls, and responses to requests for information from providers attempted to help families deal with the aftermath of 9-11 (Gurwitch, Silovsky, Schultz, Kees, & Burlingame, 2002). This type of traumatic event, mass violence, ranks among "disasters" as the most disturbing type when compared to technological or natural disasters (Solomon, 2002).

During this initial period of about two weeks after 9-11, few resources, especially web-based ones that could be easily accessed, had been developed. Word of mouth, the "old way," was the only method immediately available for providing needed education/information. Thus both the hotline and the Comfort Centers where individuals might go for support and counseling were helpful ways in which one-to-one interaction could take place, support and information would be provided, and a competently trained mental health provider was available.

Later some of APNA's member-experts collated information about anxiety responses and PTSD for our website and identified links to other websites that provided information about anxiety disorders and their symptoms. Some of these useful sites are listed in Table 1. Also as an organization with a large New York State chapter, APNA was in dialogue with our colleagues in New York facing the worst of the tragedy.

Table 1:

Online Resources on Trauma, Terrorism, and the Aftermath

American Academy of Experts on Traumatic Stress www.aaets.org American Psychological Association www.apa.org American Red Cross www.redcross.org/services/disaster/keepsafe/childtrauma.html The Center for Mental Health Services www.mentalhealth.org/cmhs/Emergency Services/terrorism.html National Center for Post Traumatic Stress Disorder www.ncptsd.org/disaster.html National Institutes of Mental Health http://www.nimh.nih.gov/

New York Nurses Respond

Dr. Judy Haber, a long time member of APNA, psychiatric nursing leader, and columnist for the Journal of the American Psychiatric Nurses Association (JAPNA) outlined in a recent editorial the role nurses played in New York (Haber, 2002).

What we know as psychiatric-mental health nurses about violence, trauma, and the resultant emotional disorders had not been tested by most of us in this overwhelming and far-reaching way.

For example, she related that for New York University, it was the first day of clinical experience for many of their students. Both faculty and students worked instead as volunteers at hospitals near the Twin Tower site, offering immediate treatment for minor injuries such as abrasions and lacerations. Some of the work consisted of showering people to rid them of mud and providing them with clean clothes. However, the immediate noticeable skin abrasions and lacerations were without a doubt the "tip of the iceberg" for many directly and indirectly involved in these events. What we know as psychiatric-mental health nurses about violence, trauma, and the resultant emotional disorders had not been tested by most of us in this overwhelming and far-reaching way. The most common disorder, anxiety, can be experienced immediately following a traumatic event and/or symptoms may appear for the first time months or even years after the exposure to a traumatic event such as with Post Traumatic Stress Disorder (PTSD). Preventing re-exposure to aspects of a traumatic event is an important intervention for treatment post trauma. However, in New York, the continued exposure to the sight and smell of the wreckage posed a particular problem for these individuals; repeated exposure to aspects of a trauma or catastrophe may increase the risk of such symptoms as guilt and powerlessness, which in turn may then lead to such disorders as low level depression.

Synopsis of Stress Disorders

The most common stress disorders associated with 9-11 are Acute Catastrophic Stress Reaction, Acute Stress Disorder, and Post Traumatic Stress Disorder. Risk factors for these disorders and the treatment of PTSD are described below.

Stress Disorders and 9-11

At first, many individuals on the hotlines, and those who appeared at the Red Cross centers, as well as in individual practices and emergency rooms, experienced what is termed Acute Catastrophic Stress Reaction (ACSR) in which symptoms occur within a few hours or days of a catastrophic happening and are resolved within 4 to 6 weeks. Table 2 lists these symptoms.

Within 4 weeks of a catastrophic event, symptoms of an Acute Stress Disorder (ASD) may appear. These anxiety symptoms, more severe than ACSR, are also listed in Table 2. Advanced practice registered psychiatric nurses throughout the country reported that many of their clients, who were already in treatment for mental health difficulties, relayed such symptoms. Moreover, individuals began to be referred from their primary care physicians and others providers for mental health counseling related to ASD. If ASD is not resolved, individuals may be at risk for developing PTSD, other anxiety disorders, and even suicidality (Haber 2002). Medications and psychotherapy are used in conjunction to treat these disorders.

The most familiar and serious of the anxiety disorders related to trauma is Post-Traumatic Stress Disorder (PTSD). This syndrome was recognized as a diagnosis in 1980. Prevalence rates for PTSD are estimated to be between 5 to 13 percent; rates are different for specific traumatic events, such as rape or witnessing murders or violent crimes (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). The symptoms, in Table 2, may not be evident until 3 months after the trauma, and perhaps even years afterward. Similar to what occurred with Viet Nam War veterans, PTSD may later present itself in the form of depression, substance abuse, or somatic disorders. Many psychiatric nurses who work with the "veteran" population began to note increased symptoms and "relapses" as a result of the September 11 tragedy. APNA members who work with substance abuse populations also related that many from this population had "relapses" directly associated with the tragedy. PTSD can also be accompanied by such physical symptoms as pain or irritable bowel symptoms. PTSD is considered a chronic condition if the duration of symptoms is three months or more.

Table 2:

Anxiety Disorders Post Trauma: A Comparison of Symptoms Onset *
Disorder Onset	Post Event
Acute Catastrophic Stress Disorder(ACSD) Worry, insomnia, heightened startle response, and difficult concentrating and coping with work	Few hours to days
Acute Stress Disorder (ASD) Nightmares, flashbacks, hypervigilance, avoidance of reminders of event, loss of interest in significant activities, and intrusive thoughts related to the trauma	Four weeks or more
Post Traumatic Stress Disorder (PTSD) Symptoms present for at least one month and include: re-experiencing the trauma through a nightmare or flashback, routine avoidance of reminders of the event, increase sleep disturbance, irritability, poor concentration, startle reaction, and regressive behavior	Three months to years
*Adapted from: APA. (1994). The Diagnostic and Statistical Manual of Mental Disorders, IV-R.

Individuals at Risk for Mental Health Problems

Since 9-11, a wealth of information, especially on the web, has explained hypotheses and theories about which individuals may be more at risk for the development of severe outcomes following exposure to these traumatic events. Such factors as displacement, relocation, separation from family, extensive loss of property, and horror can all play a role in the development of mental health disorders. Those who have experienced a past trauma have also been at greater risk for PTSD following 9-11. Developing this profile has assisted psychiatric nurses by providing clearer information for targeted assessments. In addition, two instruments that measure PTSD have been updated to incorporate information about exposure and the extent of this exposure to the 9-11 tragedy (Tuma, 2002).

Treatment of PTSD

The most common treatment of PTSD is a combination of therapy and psychopharmacology.

Messages given by skilled therapists such as "you are not to blame" and "you are not alone" are important for clients during the therapy.

The therapy usually focuses on Cognitive Behavioral Therapy (CBT) and exposure-based therapy. The goal of this therapy is to help individuals confront emotionally painful aspects through re-exposure of the events in imagination, or sometimes in reality, if this is possible and appropriate (Yehuda & Davidson, 2000). Clients are helped to identify dysfunctional thoughts and perceptions of themselves and the world; and these thoughts are then challenged by the therapist and replaced with functional or healthier thoughts about the events. Messages given by skilled therapists such as "you are not to blame" and "you are not alone" are important for clients during the therapy. Positive outcomes, or symptom relief, can occur over a three-month period of intensive work. Left untreated, PTSD can result in more serious emotional difficulties, loss of work, poor relationships, and changes in character.

Because the neurobiological basis of many of the PTSD symptoms relates to serotonin, the selective serotonin reuptake inhibitors, such as Sertaline, and Fluoxetine, have been found to be particularly effective for PTSD. In combination with psychotherapy, the improvement resulting from psychopharmacologic treatment usually occurs in the first three months for most clients; still others will improve following these three months (Connor, Sutherland, Tupler, Malik, & Davidson, 1999).

Mental Health and Economic Issues

Beyond the psychiatric care and the cost of this care that individuals must assume as the result of this tragedy, Haber (2002) highlights what our nation must face.

The cost of mental health care that may be needed for years as a result of this tragedy, may far outweigh the cost of the physical rebuilding that will take place.

Any illness, physical or emotional can be costly in terms of employee productivity, absenteeism, lateness, and the use of health benefits. The cost of mental health care that may be needed for years as a result of this tragedy, may far outweigh the cost of the physical rebuilding that will take place. While there are few studies that address the cost of PTSD, some information exits in particular for criminal victims. For example, the direct cost of personal crime is estimated by Miller, et.el. (1996) to be $105 billion annually. This cost includes medical costs, lost earnings, and public support, such as programs that address victimization. Miller et al. estimated that in 1991, approximately 4.7 million criminal victims received mental health care for an estimated total cost of $8.3 to 9.7 billion. When the number of individuals who were exposed to the trauma of 9-11, whether directly or indirectly, is considered, the costs to the nation in mental health care will be exorbitant. It is estimated that more mental health providers are needed who can treat PTSD.

APNA leaders have been extremely concerned about the specialty of psychiatric-mental health nursing in light of the nursing shortage that we all now face. Now, even more, with the increase in mental health needs of the population resulting from September 11^th, the shortage concerns have been heightened. Indeed, much of the powerlessness that we all experienced during the days following the attack was evident at APNA's 15^th Annual Meeting that occurred in October of 2001. Awareness of the shortage leads to a feeling of powerlessness when we confront what is needed and yet what is within the realm of possibility for us to achieve.

One of the purposes of a specific membership organization is to provide individuals with a sense of identity, esprit de corps, and support around issues that are important to the specific group.

We realized that action was needed to help us overcome this sense of powerlessness, just as we often assist our patients with their sense of powerlessness.

At the annual meeting in 2001, members requested time to talk about the tragedy and how they felt as nurses, as psychiatric nurses, and as citizens. Tearfully we struggled as we sang "America the Beautiful" at our opening ceremony. We realized that action was needed to help us overcome this sense of powerlessness, just as we often assist our patients with their sense of powerlessness. Action for APNA meant political action.

APNA Plans for the Future

A plan involving three important issues took shape as the Board of Directors and other APNA leaders grappled with the future of the nation's mental health and the role of the psychiatric nurse in this future. Three significant questions directly related to September 11 needed to be addressed: How can we be better prepared for future tragic events as a specialty? What can we do to recruit the numbers of psychiatric nurses needed to address the long term effects of this tragedy? and How can we promote mental health in a preventative way for our citizens?

The American Red Cross Disaster Training has always been an invited and welcomed part of our annual meeting. Encouraging our members via our state chapters to consider this training now to increase those available to respond in the future is necessary. Our Government Relations staff has been working with federal agencies that are addressing bio-terrorism to include PMHNs, and specifically the APNA, in report language that would address the need for more education and training of psychiatric nurses as "responders" to future potential attacks. As with other nursing organizations, we continue to lobby for funding for nursing education and research. Especially needed are funds to incorporate terrorism, and its aftermath, in all nursing curricula and to promote psychiatric research that addresses the sequelae of 9-11 and tests the effectiveness of mental health promotion programs.

APNA has incorporated recruitment and retention into our organization as a priority in this year's strategic plan. Recruiting into nursing continues to be a priority for us; and APNA serves as a member of the steering committee, along with 19 other major nursing organizations, for Nursing's Agenda for the Future (NAF) (ANA, 2002).

Mental health promotion has always been at the forefront of APNA's goals (APNA, 2002). For example, last year APNA worked with the three other mental health disciplines (psychiatry, social work, psychology) serving on a task force funded by the Center for Mental Health Services (CMHS) to develop a monograph on Mental Health Promotion. For such trauma as the events of 9-11, prevention may mean intervening in acute distress early enough to prevent the development of PTSD. Plans are in process to further address mental health promotion with respect to the potential effects of terrorism in future educational materials for our members.

Conclusion

As we confronted the one-year anniversary of our nation's tragedy, we are more aware of our need to analyze our organizational response to the events of September 11, 2001, our response to our consumers of mental health, and what we need to have in place for the future of our nation's mental health.

One important lesson that the APNA leadership and members have learned is that membership in one's professional organization, an entity with an agenda and strategies, can, has, and will help to alleviate individual frustration and powerlessness.

Analyzing these issues, we are comforted because we have a plan. Developing strategies has helped us to resolve some of our overwhelming feelings of powerlessness that we all experienced, cried about, and discussed when attending our annual meeting last October. One important lesson that the APNA leadership and members have learned is that membership in one's professional organization, an entity with an agenda and strategies, can, has, and will help to alleviate individual frustration and powerlessness. Just as many of us are increasing our connectedness to our families; our members are connecting with each other and the mission of APNA. As Haber (2002) so aptly wrote, speaking with a united and powerful voice will make sure our agenda is heard. Moreover, because APNA was called upon, responded, and has a viable agenda to address our nation's mental health in light of 9-11 and potential future tragedies, we are proud to be counted among those who stepped up to the plate at a time of national need.

Authors

Jane H. White DNSc, RN, CS, Executive Director APNA
E-mail: jwhite@apna.org

Jane H. White assumed the position of APNA's first Psychiatric Nurse Executive Director in June 2001. She received a diploma from Hartford Hospital School of Nursing, a BSN from Purdue University, an MSN in Psychiatric-Mental Health Nursing from the University of Alabama, and a DNSc form the Catholic University of America in Washington DC. Prior to assuming the position as the Executive Director of APNA, Dr. White was on faculty for 22 years at Catholic University where she directed the Psychiatric-Mental Health program and achieved the rank of full professor. She continues to maintain a psychotherapy practice part-time, working with women with eating disorders. She has numerous scholarly publications, presentations, and research projects on bulimia and anorexia nervosa and is especially interested in prevention and mental health promotion. She serves on the Editorial Review Board of three journals.

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