| 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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