This is a great and exciting book; a volume filled with stories of endeavor, achievement, appraisal and learning; stories of heroism, challenge and hope. It will become a handbook for all who would research the impact of disaster and terrorism on mental health and well-being. It is a courageous contribution to the science of this field in giving testimony to the research that was done to assess need, to study reactions over time, and to provide and evaluate the best possible care. It is also courageous in that the research is presented openly, with its challenges, its successes, its imperfections, and with critical appraisal provided by “outside” experts. It is all the more powerful for this. It is the most comprehensive drawing together of the wide range of initiatives that followed a specific incident, initiatives that were implemented in the times of chaos and uncertainty. It was instigated by researchers and clinicians who were, at the time, themselves also experiencing the multiple, acute and subsequent stressors of the attack and its aftermath. It is a further contribution in terms of the universal wish to make meaning of what has happened. As mental health professionals and scientists, this surely, is one of our ways of making meaning.

A number of themes thread their way through this book: The enormity, unexpectedness and uniqueness of what happened; not only was America assaulted, but the world saw, and felt what happened.

The traumatic exposure

The dramatic effect of the pictures notwithstanding, the physical and mental effects of being at “Ground Zero” were described by many “Ground Zero workers” as only able to be understood through direct experience of it. The site occupied 16 acres in lower Manhattan, with buildings grouped around a 5-acre central plaza. The site is bounded by Vesey Street on the north, Church Street on the east, Liberty Street on the south, and West Street on the west, about three blocks north of the New York Stock Exchange. The Twin Towers were 110 stories, 1353 feet (412 meters) tall. In total, there were about 10,000,000 square feet of rentable space. About 50,000 people occupied the buildings. There were 43,200 square feet (4020 square meters) – about an acre of rentable space – on each floor. The seven buildings were made up of 95% air by volume, and contained 15 million square feet of space. Commercially, the seven-story mall beneath the World Trade Center (WTC) was America's third most heavily trafficked mall (Tomasky, 2003). In the aftermath of 9/11, the site continues to be an object of much interest, discussion and meaning for droves of visitors.

Whatever else “Ground Zero” may have been, it was also the workplace for a large number of workers and volunteers. In addition to the firemen and policemen whose volunteer, rescue, and recovery efforts have been chronicled in the media, “Ground Zero” also provided employment for at least 50 other professions, as well as a host of volunteers.

Introduction

Mass violence disasters, especially terrorist events in urban areas, are hypothesized to have greater impact on mental health than either natural or technological disasters due to their intentional nature (Norris et al., 2002). The density of the urban environment, its ethnic diversity, and expected support deterioration, might exacerbate the disaster effects (Norris, 2002). Studies focused on the exposure to terrorist events in recent years: the 2001 World Trade Center (WTC) disaster (Schuster et al., 2001; Galea et al., 2002; Schlenger et al., 2002; Silver et al., 2002; Vlahov et al., 2002), and the 2000–2002 terrorist attacks in Israel (Bleich et al., 2003), have documented significant psychological problems, in the short term, in both directly and indirectly exposed individuals.

A recent review concluded that the health effects of disasters are wide and adversely affect several aspects of health including generalized distress, psychiatric disorders, physical illness, and interpersonal problems (Norris et al., 2002). Mass violence was found to have greater psychosocial impact than natural or technological disasters, due to its intentional character (Norris et al., 2002). For example, 6 months following the Oklahoma bombing (North et al., 1999) adults injured in that event had markedly elevated rates of post-disaster mental health disorders (45%), including post-traumatic stress disorder (PTSD, 34%).

Political terrorism, and especially suicide terrorism, has emerged as a highly detrimental international problem. As a well planned and executed violent event, suicide terrorism is deliberately intended to cause massive destruction and gruesome death; induce fear and helplessness; diminish safety and stability; weaken crucial social bonds; and disrupt the economic, political, and social order (Kaniasty & Norris, 2004; Neria et al., 2005).

On the morning of September 11, 2001, with the attacks on the World Trade Center (WTC) and the Pentagon, the world that many of us thought we knew, was altered. While thousands of people were directly exposed to or witnessed the attacks from close proximity, millions around the globe watched the events in real time or repeatedly over time on news channels. The attacks of 9/11 will likely be the most witnessed terrorist acts in modern history.

The events that unfolded on and after 9/11, and the subsequent terrorism around the globe have created a climate of fear and anxiety. These are the psychological outcomes that terrorists seek to inflict. Terror can only be effective if it leaves lingering concerns about safety; if it disrupts the most basic ways citizens manage and control their lives.

The overall goal of this volume is to document and critically examine the comprehensive and wide-ranging mental health response after 9/11. Specifically, this volume aims to examine:

1. Whether the research on the psychological consequences of 9/11 suggest a unique and substantial emotional and behavioral impact among adults and children.

2. In what way the impact of these attacks exceeded the individual level, affected communities and specific professional groups, and tested different leadership styles.

3. How professional communities of mental health clinicians, policy makers and researchers were mobilized to respond to the emerging needs post-disaster.

4. What are the lessons learned from the work conducted after 9/11, and the implications for future disaster mental health work and preparedness efforts.

The visibility and the political import of the collapse of the World Trade Center Towers made it an extraordinary event even in a world replete with disasters and wars. These massive buildings symbolized the financial center of the world. Their dramatic collapse was witnessed directly by millions of people in New York City, and indirectly on television by countless others around the globe. Thousands died, tens of thousands narrowly escaped death, and the effects rippled across communities of a wide region.

The chapters in this part of the book are concerned with the way in which this event affected the mental health of people in New York City and elsewhere in the USA. The authors of three key studies of the mental health effects describe the way in which their research was conceived and executed, and some of their most striking results. Leading psychiatric epidemiologists were invited to critique these studies, and comment more generally on the nature of research on mental health effects of disasters. In addition, one of the study authors was invited to respond to the critiques. We are indebted to all of the authors for their contributions.

By design, therefore, the chapters present divergent viewpoints about the nature and the magnitude of the mental health effects of September 11th. This approach results in a lively exchange, and enables readers to appreciate the ongoing debate and form their own opinions about it. But readers also have a right to know what the editors perceive to be the main lessons of this work. We will highlight five which have clear implications for future studies of the mental health effects of large scale terrorist attacks and other disasters.