My Failures and Successes in Treating 9/11 Firefighters
by Sam Kedem

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.

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. Ithica, 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.