| My
name is Sam and I am a therapist for the World
Trade Center Permanency Project. That is the
New York Council On Adoptable Children’s
(COAC) 9/11 program developed immediately following
the September 11 attacks. The following is an
account of how I was introduced into counseling
firefighters, techniques of building rapport,
common misconceptions about firefighters, post-traumatic
symptomology, and treatment effects. The following
material is based on my work at Friends of Firefighters
(FOFF) and my current clientele at WTCPP. I
will refer to all firefighters and my firefighter
clients in the masculine, because they were
all men. Currently, the FDNY has only 26 female
firefighters (Houtlyn, 2007), about .2% of the
department. Also, when I refer to 9/11 firefighters,
this will include FDNY and the many volunteer
firefighters who responded to the attacks and
worked the mountain of rubble at Ground Zero.
How I Got In.
I was involved in 9/11 counseling from the
ground floor, when the New York Mental Health
Association (MHA) and Federal Emergency Management
Agency (FEMA) developed a network of crisis
counselors called Project Liberty. When I was
with Project Liberty, under Safe Horizon, there
were about forty part-time and full-time counselors.
Almost all of them were women. One other gentleman
there was named Ron. He had his own private
practice and he was in charge of a government
domestic violence program, so he did not have
a lot of free time for Project Liberty, which
was largely a volunteer effort. We were sent
to various corporations and agencies affected
by the attacks; anywhere from multi-million
dollar brokerage firms to public schools in
order to provide supportive counseling in a
group setting, and individual assistance if
necessary. The reason I bring up gender is because
this is what largely played a role in my being
selected to work at Friends Of Firefighters
(FOFF), an organization dedicated to providing
supportive services to firefighters affected
by 9/11.
Why did Project Liberty send me? Because they
figured I was a guy and I would connect better
with the firefighters. In hindsight, my gender
had some advantages and some disadvantages.
Because it is true, men feel more comfortable
around other men and talk to them more –
regarding most topics (XXX). Not regarding all
topics. They are not willing to discuss some
subjects with men that they might be willing
to share with women. So in hindsight; sending
me was a wise decision regarding some aspects
of rapport-building and bonding and a poor decision
in other aspects. The reason I remained was
because there was five or six other counselors
sent there and the director of FOFF, Nancy Carbone,
was dissatisfied with the others. Either they
had a soft approach or they didn’t understand
the guys, or they didn’t understand the
subculture, or she didn’t like them personally.
Nine times out of ten, she just didn’t
like them personally. Maybe they were arguing
with her about the clinical facets of their
work. Sometimes, I can get along with my female
colleagues better than they can get along with
each other. I guess I’m lucky in that
regard. What was the problem with counseling
firefighters?
The Executive Director
For one, Nancy knew pretty much about cars,
a stereotypically guy subject, so she connected
with them in that way. You get firefighters
talking about their first car, or the old muscle
cars, and that’s it – it’s
off to the races. Second, she was a neighborhood
girl, she grew up in various areas around Brooklyn
and she lived there a long time. She married
a Brooklyn man, who is an Art Professor at a
Brooklyn university. By the way the guy is,
without a doubt a saint, and we used to refer
to him as the saint. She has two beautiful kids;
Kye a musician and Kia, who wants to study environmental
law. Of course, she raised them in Brooklyn.
So besides telling you the secrets about every
single store owner and block, she could remember
when this neighborhood was bad until the so
and so’s moved in, and this neighborhood
was great until the so and so’s moved
in. Together she and the officers would weep
over the gentrification of many of Brooklyn’s
neighborhoods.
Not only did Nancy know about cars, and was
a neighborhood girl, she knew about music. She
was a musician who played many of the blues
clubs in the West Village, back in the seventies.
The older officers, not the younger guys, connected
with that. If they connected with the music
from that era, they connected with her the same
way. They would talk endlessly about old albums
and live concerts, a perfect avenue for reminiscing
over fond memories. Once she would connect with
the officers, that would provide her access
to the firehouse, then she could reach out to
the younger firefighters.
Nancy knew what they were going through, she
bonded with them, and she was a Brooklyn resident,
affected by that toxic soup that blew in from
Ground Zero, affecting Brooklyn Heights, Williamsburg,
and her neighborhood Carol Gardens. Friends
of Firefighters had a beautiful view of downtown
Manhattan, because it was located in a storefront,
just across the East River in a neighborhood
called Red Hook. Red Hook is where they filmed
Brando’s On the Waterfront, and it still
had that old Italian, warehouse and docks kind
of style. So Nancy was connected through, cars,
music, and community. She wasn’t really
an executive director so much as a concerned
citizen and strong woman driven to help. If
she sat in on an officers meeting, she would
not have missed a beat in understanding everything
they were speaking about. She knew firehouse
lingo, she knew the politics regarding the upper
echelons of the FDNY, and she knew the mood
and subtleties of the firehouse. She knew when
visitors were welcome, when the house was sullen
and closed off, when the house was in trouble,
and when they were relaxed. She sensed, in two
seconds, when the atmosphere was different because
a brother was hospitalized, an outside officer
was in the house, or they were in hot water
for conduct that would most likely make the
newspapers in a few days.
I had a very unassuming style. She was literally
trying to tell me how to counsel, and I never
confronted her about that. Plus I had a sense
that she was not trying to boss me around, but
getting me a feel for things. She was cluing
me in and I am always keeping an open mind and
am willing to learn new things. I never had
the attitude of, “I’m the clinician,
what does she know?” She had very good
ideas about how to counsel firefighters and
how to get in good with them. And I did use
most of those ideas.
Rules for Getting In
It’s easier to give a cougar a bubble
bath than to begin counseling with a firefighter.
One example of Nancy’s ideas – Don’t
call yourself a counselor. If you want to get
in good with firefighters, and don’t want
them to clam up, don’t call yourself a
counselor. According to the Center for Disease
Control about 20% of rescue workers met the
threshold for Posttraumatic Stress Disorder
(PTSD), yet only three percent accessed mental
health services (Smith, Katz, Holmes, Herbert,
Levin, Mozine, Landsbergis, Stevenson, &
North 2004). Ethically, not identifying yourself
as a mental health worker is not the best thing
to do, however I told myself that these men
were not yet clients, so that’s fine.
Perhaps I was deceiving myself, but that was
the logic I used. I learned from volunteering
at the respite centers that they didn’t
want to talk to anyone about the work, especially
another able-bodied male who they felt should
be working the pile. So now, when I met them,
I would say I work with FOFF. I am just helping
out, I am an intern, I help with the clerical
stuff. They would take me in and accept me as
part of the setting. I am also a bit of a physical
guy. Although I am bookish, I don’t appear
so. I am heavy set, in as good physical condition
as most firefighters, and the first thing they
would usually ask me is “What house are
you with?” As they grew to know me, they
learned of my position and my training.
The second great idea Nancy had was “dress
down”. No business casual, which is the
standard in social services. Now you don’t
have to tell me twice to dress down, I love
my jeans, T-shirts, and ball caps. I hope I
can wear jeans till they day I die, and when
I was told I can wear sneakers, I thought I
was in Heaven. That made me more accessible
to the clients.
“Let them talk about what THEY want to
talk about.” This third piece of advice
was a key element. If they want to talk about
sports, I will try to keep up. I love the Miami
Dolphins, so let them pick on me for that. That
was the segue into more important topics. The
average clinician would not be willing to begin
each session discussing mundane topics for the
first half hour, in order to get into richer
material. However, I looked at it as cracking
the shell to get to the walnut.
The other thing Nancy said - assist them, as
in – be an assistant. She was trying to
literally build up her office and a wellness
center next door. The firefighters, out of the
goodness of their hearts, would help her build
it. They knew it was for them in the end, anyway.
They helped lay down floors, pull up old floors,
tear down walls, build up new walls, plaster.
With my vast engineering and technological skills,
I was able to help them. Actually, if I built
a bird house, the city would condemn it and
board it up. I was able to assist and help with
the menial labor work. Nothing is a better catalyst
for getting guys to chat than working on something
together and that’s what we did. I was
like an apprentice and I helping them build
things. However, clinically I was on 24/7. This
wasn’t casual or fun for me. It was not
a joke. Nancy was actually pushing me onto them
by saying, “Why don’t you have Sam
help you pull up the floors.” That is
not something that too may clinicians, male
or female, were willing to do at the time. However,
there was so much downtime there, that I welcomed
opportunities to be productive. I was (and she
was) right, it helped me gain tremendous insight.
Nothing makes a man less self-conscious than
when he is physically working on something.
Because it is the least similar to a clinical
setting, it is the most advantageous for uncovering
essential subject matter. We were building everything
and talking about all kinds of things: their
family, their relationship with their wives,
their relationship with the guys, prior relationships,
their children, their parents, or even relationships
with “other” women. Father dying,
mother becoming senile, kids misbehaving in
school, and of course a firefighter’s
favorite subject in 2003 – the problems
with the department and 9/11.
Nancy also warned me not to go in the firehouses.
You do not know them, you are a new face, even
if I had a flyer for free trips. We had a lot
of free fishing trips and hunting trips. I thought
these flyers were great opportunities - Program
Outreach 101. The first time I walked into the
firehouse, I don’t think the words “hello”
ever escaped my lips when a firefighter yelled
“Get the fu-- out of my house!”
Some mental health professionals already made
themselves unwelcome by attempting bilateral
stimulation with a house full of guys laughing
at the recipient, or even by using therapeutic
techniques with no scientific merit. So Nancy
had a lot of good ideas and a lot of smart suggestions.
That’s how I got to counsel firefighters
in a non-descript sort of fashion and I had
the opportunity to counsel many of them. Then
when I transferred to the World Trade Center
Permanency Project, my skill with rescue workers
carried over and they constituted 43% of my
clientele.
Another great idea Nancy had, something every
clinician dreams of – no paperwork. No
intake interviews, no psychosocial assessments,
no depression inventories, no stress inventories,
not trauma scales, and most importantly - no
progress notes. At first this was a true blessing.
However, after you build up a clientele, you
have to write something so you don’t confuse
your cases. Many of them were very similar.
I always scribbled down some things on scratch
paper, after the client left the session. That
way if a firefighter stopped by the next day,
in two weeks, or a month later, I would still
remember his mood, his symptoms, the details
of his case, and what needed to be addressed.
I always asked myself is this the ethical way
to do things? Am I harming the clients by counseling
in a less than professional environment? Nancy
of course always had the same answer, this is
not therapy. So do not hold it to the same standards
as therapy. This allowed me to ease my conscience
most of the time. But when I was alone with
a client, the work was intense, focused, directed,
and therapeutic. That is essentially how it
was done. Forget credentials, forget titles,
this guy is just a counselor, and we’re
just doing some counseling. That is how the
work was accomplished throughout my service
there. Because I did not have too may objections
and rarely went against the grain, Nancy decided
she liked me as opposed to the many other clinicians
assigned there. That helped me gain a lot of
insight into what I was doing. From there, I
was able to strengthen the relationships that
I created, establish therapeutic goals, and
maintain treatment with the client, whether
they felt welcome at FOFF or not.
Fire Talk
I have never counseled firefighters before
this time. I have several friends on various
fire departments in Miami. I have never counseled
a mass disaster before either. My father was
a chief mental health professional during Hurricane
Andrew. He helped develop some of the post-trauma
psychology protocols for FEMA. He was at the
site of devastation in the very southern end
of Miami for months in 1992, so he was very
good at it and I sought his advice and support
often.
The most prominent physiological post-traumatic
symptoms that most firefighters display is that
they do not sleep. Most symptoms among men have
to do with sleep. They either have trouble falling
asleep, wake up several times a night and have
trouble going back to sleep, or wake up way
too early. They suffer from obsessive thoughts,
heavy survivor guilt, nightmares, and flashbacks.
The real reason they do not sleep is because
of their intrusive thoughts of the traumatic
event, in this case 9/11. Haslam and Mallon
(2003) discovered that one-third of traumatized
FDNY suffered sleep disturbance, but 65% suffered
rumination over the traumatic event. In my cases,
9/11 haunted most of their waking moments and
their sleep.
Common misnomer: firefighters talk with each
other about everything. This is not always the
case. They do not talk with each other about
their own issues, but they need to. I don’t
care what kind of research you throw out, the
more you talk about the traumatic experience
you went through, the less likely you are to
suffer from traumatic symptoms in the future
(Cowman, Ferrari, Liao-Troth, 2004). I am not
saying it has to be stress debriefings (CISM
or CISD), or psychoanalysis. I do not advocate
mandatory debriefings, though debriefings may
help firefighters with a propensity for mental
illness (Harris, Baloglu, Stacks, 2002; Haslam
& Mallon, 2003). For example, World War
II veterans were sent home with their entire
company, by ship. Therefore they had sometimes
had weeks to discuss their experiences with
their comrades. Vietnam Veterans were often
flown home individually, plucked from their
platoon, they would find themselves back in
the United States, sometimes the very next day.
This is believed to be one of the principal
reason why Vietnam Veterans suffered more posttraumatic
symptoms than WWII veterans (Grossman, 1995).
Stereotypically, guys don’t talk about
their feelings or their emotions. Firefighters
develop a need early in their career to manage
their emotions and therefore manage the emotions
of younger firefighters and even their client
at the scene of an emergency, in order to administer
aid and gain coherent and employable information
(Scott & Myers, 2005). One of the clues
to counseling men, in particular firefighters
is not to use the word “feelings”.
This makes EMDR difficult it demands you give
them the directions verbatim. Alternatively,
you can present the question as, ‘What’s
going through your mind?’ or ‘What
were you thinking at the time?’ Or you
could spell out for them what they might have
been feeling, “That must’ve hurt.”
Or “You must’ve been down after
that.” or “That’s a lot to
carry.” But you don’t use the word
feelings, unless you want to compromise the
therapeutic relationship, because it implies
mental weakness.
People love to talk about the firehouse culture.
Although FDNY is referred to as New York’s
bravest, it is uncertain whether braver men
are drawn to the profession or the profession
trains them and forces them to be brave (Martens,
2005). It is true that together they eat, sleep,
breathe, sh--, and put their lives on the line
for each other. It is true they develop a very
strong bond, like brothers in arms. You ask
any firefighter wife, they might admit jealousy
of the firehouse activities, firehouse community,
and firehouse subculture – that second
family their husband belongs to. Wives and girlfriends
are both jealous of that (Kelly, 2004). The
real truth of the matter is: just like there
are things firefighters would never talk to
their wives about, there are things they would
never talk to each other about. I know they
gather around the firehouse kitchen table all
the time. They discuss, after a hairy incident,
what happened, what went right, what went wrong,
where they were, who was there. They go through
every second in their mind; checking mistakes,
procedure, and what was the logic of a move
or an action at the time. However, that does
not necessarily involve what they were feeling,
what they were personally going through, or
the traumatic things that took place. Feelings
of shock, horror, fear, or thoughts of family,
and death, are not usually discussed at the
table (Regher, Dimitropoulos, Bright, George,
& Henderson, 2005).
Naturally, my job was to get them to talk about
things they do not ordinarily talk about. What
would that be? What their nightmares consist
of, what they worry about the most, what they
like about the department, and what they hate
about the department, things they want to forget,
and ideals they want to remember. I believe
FDNY are the most loyal firefighters in the
world. I believe there is no one who loves their
job more than the firefighters. Police officers
are considered traditionally the loneliest profession,
even if you have 38,000 of them uniformed in
NYC. Even NYPD officers transfer over to become
firefighters, not the other way around (Kaprow,
1991). Firefighters love their profession, love
their job, and love being on duty. One would
think that the danger is the greatest drawback,
yet that is what they like most of all and they
request firehouses that receive the most calls.
I have heard a few chaplains or mental health
personnel say, “I think they accept me
as a figure in the firehouse community, because
they feel comfortable enough to discuss women
and curse in front of me.” This is a poor
measure. When explicit sexual details, racial
jokes and epithets fly before you, then you
are beginning to become a fixture.
A Lack of Support
Despite all this, the chief complaint of 9/11
firefighters is the FDNY administration. One
of the factors contributing to the posttraumatic
symptoms of Vietnam Veterans is the lack of
support from the government and from the American
public (Litz, 2005). A lack of support will
either augment traumatic symptoms, or make the
symptoms endure longer (Herman, 1992; Grossman,
2005). What the firefighters had was a lack
of support from the department, itself. For
example, many clients complained of fire department
doctors who reported that what a lot of firefighters
suffered from has little to do with 9/11. Firefighters
are bound to suffer a certain amount of respiratory
difficulties after so many years on the job.
It was argued that they are supposed to have
bad backs, bad lungs, bad knees and bad shoulders.
Although injuries are part of the nature of
firefighting, this did not explain why many
of those injury rates doubled and tripled immediately
after 9/11 (McArdle, 2003). This is something
their medical board was not always ready to
recognize. Thirty percent of the firefighters
received three-quarters retirement (where they
would receive ¾’s of their salary)
and the city told the department to stop these
decisions because the city could not afford
these settlements. For the first time in the
men’s careers, they were suspicious of
their own department and loyalties began to
waver.
Here we are going on six years later and the
men are suffering from more severe medical diagnoses
like Sarcoidosis - a scarring of the lungs,
liver difficulties, upper respiratory infections,
lower respiratory difficulties, pancreatic infections,
toxicity in the blood system, and various kinds
of cancer. Now the New York Committee On Safety
and Health (NYCOSH) and the Association for
Occupational and Environmental Clinics (AOEC)
have comprised a list of medical symptoms that
they know to be related to 9/11. They have disseminated
the medical profiles to occupational clinics
all over the nation. These symptoms are much
more difficult to chalk up as part of the pitfalls
of an everyday firefighter. When the doctor
works for FDNY, it is not usually in his best
interest to diagnose a firefighter disabled
due to 9/11. The doctor wants to relate the
injuries to typical line of duty things or a
smoking habit, or various pre-9/11 difficulties.
The “independent” doctors the department
sent them to also failed to recognize their
illness as relating to 9/11. Although young
firefighters are twice as likely to suffer physical
injuries than their male non-firefighter equals
(Lee, Fleming, Gomez-Marin, & LeBlanc, 2004),
there is a double standard. When it comes to
physical symptoms, I have heard the gamut: from
lumps in the scrotum, he called his third testicle
to tuberculosis in non-smokers; skin rashes
to heart palpitations. These were strong, healthy
men. Of course most guys can stand to lose weight,
can stand to eat better and exercise more. But
these were healthy men that used to run marathons
and participate in sports and coach little league.
Now they have liver problems when they never
drank or even took aspirin. They have lung problems
when they never smoked. Now, all of a sudden,
they get tired climbing a flight of stairs.
They are fatigued most of the time, or it hurts
when they breathe, or it hurts when they lay
on their back, or on their side. I grew tired
of hearing men describe the same pain medications,
the same steroid or cortisone injections, the
back surgeries that didn’t work. They
would all become excited when they hear about
a kind of prosthetic disc implant that will
come to America, pending approval. They couldn’t
wait till it was approved and paid for by GHI
so they could be the first ones to receive it.
Poor Candidates for Therapy
Now we discuss psychological disabilities since
I am not truly qualified to discuss physical
symptoms. After 9/11, firefighters are bound
to suffer more traumatic experiences than the
average person in the everyday world (Bachman
& Zelko, 2004). They are more likely to
experience the symptoms of trauma and depression:
fatigue, poor energy, poor motivation, intrusive
thoughts and images, flashbacks, more likely
to argue with their wives, their children, and
each other; more likely to abuse substances,
to be irritable, to lose their patience, to
be short-tempered (North, Tivis, McMillin, Pfefferbaum,
Cox, Spitznagel, Bunch, Schorr, & Smith,
2002), and above all, the least likely to seek
out a mental health professional. The longer
they worked the mountain, pile, pit, bathtub,
Ground Zero, the more likely they were to develop
PTSD, be disappointed in their careers, and
turn to substances (North, Tivis, McMillen,
Pfefferbaum, Spitznagel, Cox, Nixon, & Smith
2002; Van der Kolk, 2002). Nevertheless, they
were still averse to seeking treatment. As a
matter of fact, if any of them specifically
requested psychological counseling, it was for
one of two reasons: either they were two steps
away from losing their job, or two steps away
from getting a divorce. The rumor was, if you
had documented proof that you were seeking professional
help when the department finds drugs on your
person, in your area, or in your system, you
may still be able to save your career. As for
the second reason; most guys are not ready to
go through divorce because they’ve learned
from friends it will be ugly, costly, damaging
to their children, and they will probably be
held at fault. Those are the only reasons firefighters
purposefully sought me out for therapy.
Counseling at CSU?
The department created another genius way of
cutting off the gangrened limb. They developed
a no-tolerance policy. This means if a firefighter
is found with any illegal substances in his
system, he will immediately get fired and lose
his pension. This means no second chance, no
appeal, no recuperation, no demotions. This
is the furthest thing from supporting and nurturing
a collection of men who had to attend several
funerals a week for about a year. School bus
drivers, commercial airline pilots, and carnival
ride operators can all test positive and still
maintain their job through a series of penalties
and treatment compliance. However FDNY could
not. Although this is a city-wide policy, no
other city department enforced the policy like
this, including FDNY, until after 9/11. NYPD
had the POPPA program which maintained patient
confidentiality. FDNY’s Counseling Services
Unit (CSU) could not be trusted to do the same.
Firefighters felt like the department was out
to get them and CSU was just a branch of the
department. Cops felt protected when they visited
POPPA program, like they were being taken care
of by one of their own. Firefighters, on the
other hand, felt like a kid in the principal’s
office when visiting CSU, because most of CSU’s
counselors were civilians, not firefighters.
If they were peer counselors like in the POPPA
program, they would have a more successful program.
There are about 14,000 firefighters in NYC;
roughly 11,400 firefighters and 2,800 EMS workers.
CSU had all of 14 counselors run by Malachy
Corrigan before 9/11 and about 100 afterwards
(Corrigan to AP, 2004). While I never heard
any good things about him from our executive
director, I could not really judge his decisions
because I did not know him well or the politics
of his position. I did not hear repeated complaints
about him from my clients the way I heard about
other fire commissioners and administrators.
The guys would have been served properly by
trained peer counselors who can say ‘I’ve
been there and I know what you are going through.’
Before 9/11 nobody voluntarily went to CSU,
they went because they were in trouble. It was
their sentence, their penance. Traditionally
a substance abuse problem was handled by the
other guys sitting you down and holding their
version of an intervention, or an officer doing
it one on one. Personally, I advocate for any
kind of counseling: firehouse chaplain, deacon
doing marital exercises, hot line, or anonymous
support group. If you went to CSU, odds are
your firehouse would be “randomly”
tested in the next few days or weeks, several
times. Meaning an investigator walks into the
house and demands a urine sample from everyone
present, on the shift, and a brief search would
take place. If you can’t trust your own
department for professional services and confidentiality,
where can you go? They came to us. At FOFF the
person counseling you can be me or it could
be another firefighter. At CSU the female therapists
were accused of flirting and taking the husbands’/firefighters’
side by many of the wives. Here that would not
happen. We were all men and not morbidly engrossed
in 9/11 stories.
Professional Mistakes
One of the unhealthy things you could do was
develop a fascination with the actual terrorist
attacks or recovery efforts through the firefighter’s
first-hand experience. Whether the story is
sad or amusing, they will love telling the story
as much as some one will love hearing it. However,
repeated ‘tales from the pile’ will
not serve anyone in improving their mental health.
Many firefighters try to bully the clinician
with their trauma. They try to intimidate with
the deaths of their brethren and the 110 story
skyscraper that fell on them. They will describe
grim, gruesome, tragic details about 9/11 in
the hopes that their nightmares become yours.
Perhaps the counselor will be overwhelmed and
stop treatment, which would be fine with the
client. The firefighter will intimidate you
by saying, “I spent 15 hours a day in
the burning mountain of rubble, with the smell
of death, and the hopes of finding just a small
piece of my buddy. I’ve seen legs impaled,
found bones in the dust, and I cough up my guts,
while you sit in your pretty little office with
your notepad.” Therapists inexperienced
with trauma become paralyzed by this frontal
assault by men who are already physically intimidating,
let alone armed with their 9/11 experience.
In any therapy, strong emotions from the client
are not supposed to be a sign of failure. As
professionals, this is supposed to be expected.
I doubt a cardiologist is intimidated by a large
patient who says, “You don’t know
what I’ve been through. You’ve never
had a chest pain that brings you to the floor
with your children crying over you.” He
or she merely replies, “If you want to
get healthy, listen to me and I will help you
get through this.” My job, in a manner
of speaking, was to say, “The last twenty
guys I treated went through what you went through
and saw what you saw. But this isn’t about
them, it’s about you. Their lives have
gotten better. Would you like your life to improve?”
Some firefighters weren’t willing to work
and just left. Sometimes, in my weaker moments,
I would take that personally. That was an amateur
mistake I did succumb to. But some firefighters
were willing to do what it takes to get better.
Confronting the Client
Once the firefighters realized that you were
not here to listen to their tales, that this
was going to be raw and emotionally difficult
work, and they would have to come on a regular
basis - they quit therapy. They realize - This
going to be hard work and I don’t want
to work on my symptoms anyway. Fifty-five percent
become emotionally upset when even reminded
of a traumatic event, like 9/11 (Haslam &
Mallon, 2003). My current supervisor would advise
me - don’t work harder than the client.
Meaning: don’t demonstrate more effort,
energy, and motivation towards the client’s
goals, than the actual client. Participants
avoid thoughts and feelings associated with
the traumatic event. However, avoidance is a
poor coping mechanism and a good way to develop
PTSD later on down the line (McFarlane, 1992).
Most mental health professionals were so honored
to have recovery workers as clients that they
were willing to do anything to keep the client
and have him say “I feel better.”
To Hell with that. If firefighters are not willing
to recognize and work on their problems or their
relationship, do not try to make them. Let them
go. That was the case with the majority of the
clients I dealt with and that is why the article
is entitled “my failures…”
Any psych professor should warn you that mental
health professionals tend personalize the client’s
successes in therapy, with “Look how much
I’ve helped him.” However when the
client does worse, we blame the client with,
“He did not listen to me”, “he
was not ready to change”, or “his
issues were too severe.” The bottom line
is that the client should get all the credit
for pursuing therapy through difficult sessions,
or the blame for dropping therapy when things
become intense. This is a big problem with firefighters.
I don’t care how many burning building
they go into, I measure courage by their willingness
to stick to the work it takes to fix their marriage
and themselves. When it comes to dealing with
their own issues, their own depression, their
own anger, many become scared or lazy and suddenly
they don’t have time to do anything.
Then their problems get worse and they become
the firehouse jerk, the as--ole, the guy that
all the other ones make fun of, and all the
other ones want to beat up. Unfortunately, this
was the case with many of my clients. There’s
one guy in every firehouse who argues with everyone
about music, or argues with everyone about politics,
or about how to do things, or what the best
motorcycle is. They become a bully at work,
just like a kid is a bully on the playground.
Then newspapers have a field-day with headlines
like 35th Bravest Arrested [this year] For Driving
Drunk (amNY, 2004). It was a problem after 9/11
and it continues to be a problem today.
If our executive director allowed me to confront
them about what they are going through, their
issues would have been addressed and their condition
has a chance to improve. However, like with
any non-profit, social service, grass-roots
agency, our funding depended on grants. Our
grants depended on numbers. And you do not keep
firefighters coming back by confronting them
on their psychological issues. So Nancy was
limited in that she would not permit a firefighter
to be challenged on his conflicts, even if a
sense of self-awareness was what they needed.
Now comes the double-edged sword. I work in
an agency, so I have an advantage over those
in private practice because I come into contact
with many firefighter clients. Unfortunately,
I am also disadvantaged because I have to answer
to someone who does not necessarily have the
best clinical judgment or the clients’
progress at heart. In private practice you can
say, ‘Look if you are not willing to take
therapy seriously, perhaps you are not yet ready
for the work involved.’ I, on the other
hand, mostly had to let clients get away with
directing the conversation wherever they wanted,
and hope they would come back for the next session.
Unless I developed a really good strong relationship
with them, then I could challenge them without
threatening the continuity of sessions.
Cracking a Walnut
Even if you were friends with someone for ten
years, guys do not want to talk with guys about
how they want to improve things with their wife,
impotence, temper, or fear. They are not the
most sharing, verbal, emotional gender. Doctors
Klein and Taylor (2000) noted that women tend
to congregate and share when stressed. This
is due to the release of the hormone –
Oxytocin, meanwhile men tend to isolate, because
their testosterone blocks the hormone. So why
would any guy, let alone a firefighter, want
to share with me? That takes the building of
a rapport and an introduction to the notion
that I am a different kind of guy. I am more
sensitive, I am more open, and I am not afraid
to bring things up. Mental health professionals
are trained to bring up the subject of suicidality,
of outside voices, of peculiar thoughts; not
to dance around it. That’s what I would
do with all 9/11 clients. So after I would bring
up a firefighter’s more sensitive subjects,
either he would feel relieved in finally being
able to discuss it, or he felt uncomfortable
and did not return (to talk to me). Then, of
course, I would be in trouble with our executive
director. Finally, I was able to address issues
with my clients like: medication, anger, marital
affairs, like 9/11 benefits and entitlements,
or the way they took advantage of 9/11. Although
there were not many ways to take advantage of
a city-wide disaster, it was done by a few.
Intercontinental vacation were offered to the
men, as well as scholarships for their kids,
banquets in their honor, politicians desired
photo-ops with them (only in uniform), and sexual
favors were abundant. The years 2002/2003 were
either the best or the worst to be a firefighter,
depending on the kind of person you are. It
could be the worst of times because they complained
about the obsolete radios, the Bronx firefighters
dying because the department no longer issued
emergency ropes, the closing of six firehouses
due to budget cuts, and open-season for hunting
of FDNY by police officers who were sick of
their glorification and were finally permitted
to act on it.
FDNY is the largest fire department in the
world, equivalent to that of Tokyo, yet with
more experience than Tokyo, because the famed
orange-panted men in Tokyo do not go into burning
buildings (XXX). They only put out fires from
the outside. The FDNY have a right to be proud
of their tradition and heritage. However, firefighters
are as cliquey as the high school cheerleading
squad. Anyone can attest to this. They can run
into each other in the middle of the Saharan
desert and only want to talk fire-talk. FDNY
snub their noses at NJ firefighters, at LI firefighters,
and at volunteer fire departments that may get
just as many calls as an FDNY house. Then FDNY
is also stuck up, surprisingly, within the department.
If you have been retired or on light duty, come
back to the firehouse and see how you are treated
then. You will be considered out of the loop.
Brooklyn houses laugh at Queens houses and Bronx
houses laugh at both of them, and Manhattan
houses laugh at all of them. They laugh because
they all believe the other borough has less
frequency of calls, less dangerous calls, and
they are more poorly organized. Engine companies
make fun of ladder companies and ladder companies
make fun of engine companies, each thinking
that they are more important than the other.
Of course, if a firefighter defects from one
to the other, he is viewed (in jest) as a traitor.
Strangely enough, they all have a tremendous
amount of respect for their commanding officers.
Officers are rated very high on a satisfaction
level (Bacharach & Zelko, 2004). Fire Commissioners
are an appointed position and that is another
story. You do not have to be a firefighter to
become a commissioner.
The Families
If you found out your spouse was in a burning
building today or saw a tragic injury, it would
probably be the first thing he told you about
when he got home. You may be more thankful at
having dinner together and count your blessings
as you hold each other extra tight before going
to sleep. FDNY firefighters report to 6-10 calls
per day, over 50% report to 11-15 calls per
day (Bacharach & Zelko, 2004). When a firefighter
returns home, he makes it a point to not tell
his family about the excitement he witnessed
for two reasons. He does not want to burden
his spouse with the gory details and he does
not want his wife to constantly worry about
his safety (Wagner, Heinrichs, Ehlert, 1998;
Kelly, 2003; Regehr, Dimitropoulos, Bright,
George, & Henderson, 2005). However, not
talking about his days only serves to alienate
the firefighter from his wife. Many of the wives,
who were being treated, started off complaining
of their husband spending all hours working
at Ground Zero. However, out of respect for
the deceased and the job their husband were
doing, they did not want to verbalize their
complaints to them. Then the wives slowly grew
impatient with the growing number of funerals.
Their husbands attended the funerals for the
men they worked alongside in their firehouse.
Then they attended funerals for the men they
trained with and worked with in the past. Then
the same army of firefighters attended funerals
for the firefighters they did not know or work
with. The wives were losing patience with this
continuous grieving process. With 343 dead,
there was a funeral or memorial services to
attend practically every day, for the following
year. Then the late night drinking and carousing
in official uniform, after the services, is
not exactly what the wives considered to be
appropriate mourning behavior.
Client Issues
Although it was rare that 9/11 firefighters
were healthy while working at Ground Zero. Some
of them were healthy enough to disrupt their
own life. September 11 often brought about a
mid-life crisis where none existed earlier.
Men who were twenty years happily married began
to explore the possibility of an extra-marital
affair. Some got tattoos for the first time,
usually memorial badges to brand the event that
had changed their lives. Some tried drugs and
one client bought a Harley Davidson motorcycle
without even knowing how to ride it. It was
the kind of behavior one would see in a teenager,
only being expressed in middle-aged men who
suddenly felt like something was missing from
their lives. While I was able to recognize the
deeper questions of self-identity and existentialism,
many of the clients preferred to explore these
issues with some one wiser, if they were to
breach the subject at all.
I was quite shocked while I took a support
group to a movie called “Reign O’er
Me” with Don Cheadle and Adam Sandler.
Sandler’s fictional character lost his
family on 9/11. While he displays a range of
symptoms excellently, one surprising symptom
is the constant, never-ending renovation of
his kitchen. I have had a few clients work on
the same construction project for years after
9/11; constantly re-renovating, or adding onto
an addition to an addition to the home, or even
taking on the Sisyphean task of building a home
without screws or nails.
The most terrifying symptom of the healthy
firefighters was recklessness. Some firefighters
felt the need to be the first to run to the
scene of a blaze, the first to kick down a door,
and the first to rush into a dangerous structure.
As a probationary firefighter (probie) this
might be expected. As an experienced man, this
was ludicrous and endangered the lives of others.
Yet the 9/11 firefighter suffering from survivor’s
guilt often felt that he did not do enough for
his deceased brethren, that he should have died
that day, and subconsciously, he is still trying
to join them. What Freud (1961) described as
the death instinct (Thanatos) needs to be explored
before it results in something tragic.
However, the conduct slowly eroding a firefighter’s
marriage or family isn’t always so apparent
after 9/11. Negative symptoms were much more
common than positive symptoms. By this I mean
what the firefighters did not do caused as many
problems as what they did do. For example, it
is common for members of the firehouse to assist
the widow of someone from their house. This
could involve taking up a collection, dropping
by their home, making some repairs, taking the
kids out, or even finishing up a summer project
the deceased never got a chance to complete.
Now imagine having five or even ten widows in
the firehouse. A lot of wives of the surviving
men felt their home and children were being
neglected by their husbands, who were only keeping
up the time-honored traditions of taking care
of their own. One wife became upset because
her husband used to nag her to exercise, as
he ran three miles on the weekend. Now, the
same man is embarrassed because he gets winded
taking a lap around the track, so he does not
even try to exercise anymore. The same holds
true for sexual activity. Not maintaining the
same endurance or paralyzing pain in his back,
not only disrupts sex, but inhibits intimacy
from even taking place. The firefighters’
logic and low self-esteem decide, ‘Why
start something I am incapable of finishing.’
This discourages him from exploring the intimate
things he is capable of, while he ruminates
over the things he used to be capable of. His
wife, once married to a symbol of courage and
masculinity, is confronted with a powerless
side to her husband, a side full of self-doubt
and shame.
Most parents are aware that teenagers can be
difficult and usually brace themselves for this
troublesome time. Firefighters had greater trouble
with this than most parents. Most of their teens
knew a firefighter or two who died as “Uncle
Tony” or “Brother Steve”.
The initial shock of thinking their father has
died, for some, lasted agonizing hours before
the good news came, for others – days.
When teenagers did not see their fathers for
weeks, or months at a time, they reverted to
the time-tested technique for getting his attention
– by getting in trouble. To date, I have
not read any studies examining the conduct of
the children of recovery workers (although Columbia
University’s Mailman School of Public
Health has a children’s study). However,
I will say that I have never heard so many parents
eager to get their adolescents out of the house.
Even if they were teenage daughters, who were
just as bad, they were no longer viewed as Daddy’s
little girl. Public schools and private schools
all over NYC and Long Island have suffered alcohol
abuse, substance abuse, aggressive behavior,
violence, sexual misconduct, and even arson,
at the hands of teenagers of firefighters. For
the most part, school administrators went to
incredible lengths to bend the rules regarding
disciplinary action. Where expulsion would have
been the standard protocol, schools gave these
teenagers “time off” to give the
school a break and let the teens re-bond with
their family. I have attended more than one
meeting designed to keep the teenager’s
behavior out of the city newspapers, drawing
unwanted attention to the school and the family.
Suicide
Depressive symptoms were not uncommon among
some of the 9/11 firefighters. Although these
symptoms would probably be more accurately classified
as extended bereavement or survivor’s
guilt. The worst culmination of these thoughts
is the suicidal behavior. Aside from the recklessness
of charging into dangerous situations mentioned
earlier, there was the more overt suicidal behavior.
I have heard officers report to me the countless
times they counseled one of their men who contemplated
suicide, or fielded phone calls from nervous
wives who trusted them enough to tell them,
“John just hasn’t been himself.
He acts like this is his last day on Earth.”
This happened so often, that some officers set
up an informal suicide watch in the firehouse.
Every firehouse has a shrine in honor of the
men they lost on 9/11. Although this is more
than deserved, it is essentially a permanent
reminder of death and the horrors of 9/11 every
time they report to work. One captain had to
talk his man down off the roof of a firehouse
before passers-by called the police, i.e. it
would hit the media.
I recall three different clients. One firefighter
was drunk, on the roof of his own Brooklyn apartment
building, in the middle of the night, planning
to end his life. A homeless man sleeping on
the roof, they startled each other, talked him
out of it. Another firefighter decompensated
after 9/11; was home alone, going through divorce,
and was afraid of losing custody of his children.
He was also inebriated when he pulled the gun
down from his closet shelf and unlocked it.
The sound of his children paying him a surprise
visit interrupted his plans. He took this as
a sign and took steps to work with me. Alcohol
in the firehouse is never an alarming sight.
It is against the rules, though it was once
a staple of the New York firehouse. Another
client, a Queens’s firefighter, had swallowed
a handful of barbiturates before heading upstairs
to chase it with his fifth of Jack Daniels.
The house alarm and announcement for a call
to action went out before he could continue
with his goal. He spent the night using his
adrenalin to battle the effects of the sedatives.
Upon returning to the firehouse he collapsed
in his bed without showering, almost sleeping
through into the next shift. Unfortunately not
all stories have happy endings. I have heard
reports of three senior firefighters who committed
suicide after 9/11. None of their deaths were
leaked to the media, even though one was married
to two women.
Recommendations
To say that I recommend mental health counseling
for firefighters suffering from posttraumatic
symptoms would be a gross understatement. The
recommendation is futile and simplistic at this
point in time. It would be like handing out
napkins to clean up a spill from a jackknifed
oil rig on the Brooklyn Bridge. Therapeutic
progress depends on too many factors, including
the firefighter’s attitude and motivation.
I hold firm to the belief that an ounce of prevention
is worth a pound of cure. The FDNY, and fire
academies in general, need to incorporate training
emphasizing the prevention of posttraumatic
stress symptoms through development of a social
support system and engaging the system. The
training would incorporate recognizing the seed
of familial difficulties and how to treat them
immediately before they grow into an oak tree.
It would discuss the onset of common posttraumatic
symptoms and how to prevent their exacerbation.
Finally, the training would warn firefighters
of poor coping strategies and how to avoid them.
I believe if firefighters employ the skills
they learn in a Preventing Posttraumatic Stress
class, much like they incorporate the lessons
from their Hazardous Materials, Building Structures,
Water Supplies, and Thermodynamics classes,
posttraumatic stress symptoms will be reduced
in frequency and intensity throughout the whole
department.
References:
Associated Press Release http://www.nyc.gov/html/fdny/pr/2004/060204_6604.shtml
Bacharach, S. and Zelko, H. (2004) On the front
line: The work of first responders in a
post 9/11 world. Ithaca, NY: Cornell ILR.
Bryant, R. and Guthrie, R. (2005) “Maladaptive
appraisals as a risk factor for posttraumatic
stress.” American Psychological Society,
16 (10), 749-752.
Cowman, S., Ferrari, J., and Liao-Troth, M.(2004)
“Mediating effects of social support on
firefighters sense of community and perceptions
of care.” Journal of Community Psychology,
32 (2), 121-126.
Drown, J., Mulhern, G., and Joseph, S. (2002)
“Incident-related stressors, locus of
control, coping, and psychological distress
among firefighters in Northern Ireland.”
Journal of Traumatic Stress, 15 (2), 161-168.
Freud, S., transl Strachey, J.(1961) Beyond
the Pleasure Principle. New York, NY: Norton
& Company Press City.
Grossman, D. (1996) On Killing. New
York, NY: Bay Books, Little, Brown, and Company.
Grow, S.(2002) “End of session.”
The Toronto Star, 9/3/02, A6.
Guthrie, R. and Bryant, R. (2005) “Auditory
startle response in firefighters before and
after trauma exposure.” American Journal
of Psychiatry, 162, 283-290.
Harris, M., Baloglu, M., and Stacks, J. (2002)
“Mental health of trauma-exposed firefighters
and critical incident stress debriefing.”
Journal of Loss and Trauma, 7, 223-238.
Haslam, C. and Mallon, K. (2003) “A preliminary
investigation of posttraumatic stress symptoms
among firefighters.” Work and Stress,
17 (3), 277-285.
Herman, J. (1992) Trauma and Recovery.
New York, NY: Basic Books.
Houtlyn, C. (2005) Conversations with personnel
department of FDNY.
Hutton, A.(2004) “35th bravest arrested
for driving drunk.” am New York,
9/27/04, 3.
Kaprow, M. (1991) “Magical work: Firefighters
in New York.” Human Organization,
50, 97-103.
Kelly, L (2003) Conversations with counselor
of firefighter spouses at CSU and FOFF.
Larkin, M. (2002) “Mixed response to
9/11 anniversary among NYC’s first responders.”
The Lancet, 360, 730.
Lee, D., Fleming, L., Gomez-Marin, O., and
LeBlanc, W. (2004) “Risk of hospitalization
among firefighters: The national health interview
survey, 1986-1994.” American Journal
of Public Health, 94 (11), 1938-1939.
Litz, B. (2005) “The Unique circumstances
and mental health impact of the wars in Afghanistan
and Iraq.” (www.ncptsd.va.gov)
Martens, J. (2005) “Definitions and omissions
of heroism.” American Psychologist,
60 (4), 342-343.
McFarlane, A. (1992) “Avoidance and intrusion
in posttraumatic stress disorder.” Journal
of Nervous and Mental Diseases, 180, 439-445.
Murray, J., Ehlers, A., and Mayou, R. (2002)
“Dissociation and posttraumatic stress
disorder: Two prospective studies of road traffic
accident survivors.” British Journal
of Psychiatry,180, 363-368.
North, C., Tivis, L., McMillen, J., Pfefferbaum,
B., Cox, J., Spitznagel, E., Bunch, K., Schorr,
J., and Smith, E. (2002) “Coping, functioning,
and adjustment of rescue workers after the Oklahoma
City bombing.” Journal of Traumatic
Stress , 15 (3), 171-175.
North, C., Tivis, L., McMillen, J., Pfefferbaum,
B., Spitznagel, E., Cox, J., Nixon, S., and
Smith, E. (2005) “Psychiatric disorders
in rescue workers of the Oklahoma City bombing.”
Presented in lecture by Dr. Pfefferbaum.
Regehr, C., Dimitropoulos, G., Bright, E.,
George, S., and Henderson, J. (2005) “Behind
the brotherhood: Rewards and challenges for
wives of firefighters.” Family Relations:
Interdisciplinary Journal of Applied Family
Studies, 54 (3), 423-435.
Richardson, C. (2004) “City beat: 9/11
aftershocks.” NY Daily News,
6/21/04. (www.ufalocal94.org)
Schorr, J. (2005) “Responding to terrorism
in the USA: Firefighters share experiences in
their own words.” Journal of Aggression,
Maltreatment & Trauma, 10 (1-2), 577-589.
Scott, C. and Myers, K. (2005) “The socialization
of emotion: Learning emotion management at the
fire station.” Journal of Applied
Communication Research, 33 (1), 67-92.
Smith, R., Katz, C., Holmes, A., Herbert, R.,
Levin, S., Moline, J., Landsbergis, P., Stevenson,
L., North, C., Larkin, G., Baron, S., and Hurrell
Jr., J. (2004) “Mental health status of
WTC rescue and recovery workers and volunteers
– NYC, July 2002 – August 2004.”
Morbidity and Mortality Weekly Report,
53 (35), 812-814.
Van der Kolk, B. (2002) “In terror’s
grip: Healing the ravages of trauma.”
Cerebrum, 4, 34-50. (www.traumacenter.org)
Wagner, D., Heinrichs, M., and Ehlert, U. (1998)
“Prevalence of symptoms of posttraumatic
stress disorder in German professional firefighters.”
American Journal of Psychiatry, 155,
1727-1732.
Witt, H. (2005) “Firehouses and police
stations brace for 9/11 trauma.” Chicago
Tribune, 4/18/05, 15.
|
