| 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 (Marten, 2005), 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 were five or six other counselors
sent there and the director of FOFF, Nancy Carbone,
was dissatisfied with the others. Either they
were too passive in their approach or they didn’t
understand the guys, or they didn’t understand
the subculture, or she didn’t like them
personally. Maybe they were debating with her
about the clinical aspects 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; a musician and a daughter
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 strongly guiding me on 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 giving 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 – Try not to 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 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 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 would often
say, “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, during the
occasional downtime there, 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 f--k 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, no 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 if 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 many objections and rarely went against
the grain, Nancy cooperated with me as opposed
to the 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 Dade County, Florida 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, survivor guilt, nightmares,
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 refer to, 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 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 because 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 because they might have trouble
verbalizing it themselves, “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 the average man 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. It was frustrating hearing many
men describe the same pain medications, the
same steroid or cortizone injections, and 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, unless he can prove he
is currently receiving treatment. 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
by 9/11 stories.
Professional Mistakes
One of the most 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 (consciously or unconsciously) 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 are
alleviated and 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 occasionally 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 is 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.”
That was not my priority. 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 a great
number of the clients I dealt with. I felt I
was failing them and that is why the article
is entitled “my failures…”
Any psych professor should warn you that mental
health professionals tend to 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 common
difficulty with firefighters. I recognize rushing
into burning buildings takes great courage,
however I also 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 a--hole,
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 conditions would have had a chance
to improve. However, as 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 the executive director 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 he 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, often 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 such
as: medication, anger, marital affairs, 9/11
benefits and entitlements, or the way some 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 vacations
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. 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, most 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 witnessed
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 husbands 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 some wives considered to be
appropriate mourning behavior.
Client Issues
Although it was rare that 9/11
firefighters were physically 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 older, if they were to
broach 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 firehouse. 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 decides, ‘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 other parents.
Many 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 memorial in honor of the
men in their firehouse, 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 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 a 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.
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