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