December 7th, 2018

First-responders are those rescuers that are first to arrive at any catastrophic event – whether “natural” (such as a flood or earthquake) or man-made (such as mass school-shootings or terrorist attacks).

The knowledge obtained by studying enduring psychological reactions among rescuers has far-reaching public health implications.

Following the spate of deadly mass-shootings over the past year, I decided to revisit some of my discussion-points addressed by Dr. Steven Friedman and myself pursuant to the continued work with several firemen over an extended time-period.

The purpose of this report is to highlight a group of oft-neglected hero`s – first responders, using data collected prospectively over a 10-year period. Such studies are difficult to find in the literature since our observations are based on repeated interviews with this group of firemen (and often their spouses).

Our observations were based on direct clinical observation of those original remaining in treatment from a larger group of referrals who shrunk over time due to relocation, and stress-recovery.

This report describes persistent symptoms within a sub-group of 14 First-Responders remaining from the original group of 22 referrals who continued to suffer from significant symptoms related to the original trauma-event.

The data probes the long-term psychological effects during which Dr. Friedman, the Director of the Anxiety Disorder Clinic at S.U.N.Y. Downstate, recorded interviews over a 10-year period from those New York Fire Department (FDNY) First-Responders who were sent into the mayhem and chaos of the W.T.C. at enormous personal risk, performing countless acts of heroism.

During the event, the firemen witnessed death by burning of dozens of trapped fellow citizens, Fellow – FDNY First-Responders, as well as their own near-death experiences.

They all, by DSM-4 and ICD-9 met the Criteria A threshold required for PTSD.

It is worthy of noting that the term PTSD has become popularized, to the extent that a wide range of subjects exposed to traumatic-events, by virtue of having been psychologically “traumatized”, assume the diagnosis of PTSD for purposes of litigation.

All the subjects described here met the more – stringent criteria of “shock and horror” required by the DSM -4: The dread associated with personal threat or the witnessing of injury of such magnitude whereby death or terrible injury would be a likely outcome.

Following the event, they were then faced with additional issues of the bereavement resulting from the loss of innocent civilians or fellow-first-responders.

Given the increased frequency of hate-motivated and politically-motivated mass-shootings within soft-targets in the U.S., those in the field of Public Health and National Safety should need consider the devastating psychological trauma not only to the victims of these catastrophic attacks, but the potential risk to first-responders: Those already at the scene as well as the first to arrive and provide rescue-functions to fellow citizens, often under perilous conditions.

Given the chaotic circumstances at the time, the assigned mission has been to stabilize trauma-victims. By contrast, the delayed onset of trauma-related psychological symptoms are often ignored, or when they do occur, lack the methodological rigor required for publication by most academic journals.

Since Firefighters at Engine 54, Ladder 4, and Battalion 9 were among the hardest-hit first-responders during the 9/11 attacks, I will touch on some longitudinal observations of “life beyond rescue” for this particular cohort – the first to arrive at the scene of the disaster.

Issues of Loss

For the firefighters who survived the collapse of the W.T.C., one of the most poignant issues was to deal with the loss of so many colleagues on a single day.

As one responder stated in his initial session, “How can anyone understand? On that day our battalion lost 30 to 40 guys that I knew very well. I was very close to them. We went through the Academy and served in the same house together. These were guys I would call if I wanted to see a movie or go out for a beer.”

The loss of so many colleagues on one day felt like a complete fracture of their social support system.

Many firefighters continue to feel a deep sense of loss.

One rescuer conceded that he had endured the experience completely unsupported and had become progressively socially isolated.

The loss of close ones is known to play an additive negative role with worsening of PTSD, confirmed by studies of other traumatized populations (Savjak, N. “Multiple Traumatization.” PSIHOLOGIJA (2003): 32).

Among first-responder groups who have close fraternities resembling the firefighters of FDNY, a massive loss of good “attachment objects” may overwhelm the psyche’s self-soothing functions, further hampering the ability to synthesize this volume of traumatic material.

While cognitive behavioral therapy is the traditional treatment modality in trauma treatment, first-responders like these who experience catastrophic trauma combined with multiple interpersonal loss may require additional intense emotional support for their bereavement.

For other clients, shame and guilt was the dominant theme. One fireman suffered from a recurrent flashback of running away after the initial collapse and failing to rescue a civilian who needed help. This fireman had symptoms both of PTSD and major depressive disorder.

However, one might also describe recurring “unwanted thoughts” as “morbid ruminations.” Distinguishing between “flashbacks” and “morbid ruminations” may depend on whether the primary diagnosis is PTSD or major depressive disorder.

This distinction is important since the case for anti-depressants and neuroleptics is only established with major depressive disorder. Flashbacks, on the other hand, can respond to cognitive therapy alone.

Unique Personality and Cultural Factors

It is important for the therapist to acculturate with the unique nuances of any distinct trauma-group, as these often provide the “hooks” for engagement into therapy with any traumatized group. This has already been published by others working with firefighters following trauma and emerged in our group early in the recovery process (Kirshman, 2004).

An example of a distinct cultural nuance was well-captured by one of the firefighter victims in a trauma-recovery group as follows: “We are that group of true Americans that live and die by our beliefs. We are those simple folks that don’t have patience for analyzing a situation which calls for action.

Firefighters tend to be people who thrive in environments involving risks and challenges. They are not risk-aversive. They embrace action as a form of self-validation when others seek safety or even emotional flight; even in situations that others describe as dangerous and whose reflexive actions are risk-aversive.

Like other groups of self-responders, Firemen tend to be individuals who react instinctively, and have little patience for analytic self-reflection.

An important by-product of this action-orientated (“extroverted”) method of problem-solving, is that this population shows less concern about the psychological dimension of their experiences.

One firefighter reported in therapy that upon safely returning home, he realized that he had witnessed a momentous day in American history. He reported that “I wrote down all the events of the day in a diary, knowing that I would one day show this to my children.”

When his therapist asked to see his diary, it consisted of less than two pages of unemotional factual detail. Perhaps first-responders score higher on visuospatial and non-verbal performance. But this fireman continued to suffer from high levels of arousal (with symptoms of insomnia, irritability, an inability to tolerate noise); as well as avoidance symptoms.

His response was typical of the temperament often seen among first-responders: action-oriented and emotionally avoidant.

He could not accept the notion that recalling memories of the trauma and reconstructing memory fragments into a “trauma narrative” could serve any value.

When trauma victims are less verbally or emotionally reflective (“extroverted, rather than introverted”), any form of psychotherapy tends to be alien to their usual coping experience and comfort level.

In other words, by temperament these first-responders appeared to respond to crises through an action modality, possibly indicating a higher performance IQ (non-verbal) at the expense of “emotional intelligence.” Action-responders are more likely to perform efficiently in situations requiring “instrumental skills,” but delayed in their emotional “working through” the crises when the rescue effort ends traumatically.

These issues highlight the need for trauma therapists to be innovative in certain groups of traumatized first-responders.

In addition to issues around engagement, there is the challenge to evoke sufficient verbal expression to compile a trauma narrative in a client who is action-orientated.

An example of an innovative trauma-exposure technique known as “Virtual Reality Exposure” (VRE) was presented by Rothbaum at the Lake George Research Conference on PTSD in 1998.

Computer-generated visual-displays of specific trauma-scenes, were coupled with soothing audio-responses, delivered by earphones to a group of Vietnam Veterans suffering from chronic PTSD and alcoholism.

Significant symptom-improvement was noted following fourteen 90-minute exposures, during a seven-week period of “exposure-therapy”.

This form of Cognitive-Behavior Therapy should be considered as the primary modality in psychotherapy among trauma-survivors with PTSD when culture or temperament are antithetical to conventional psychotherapy.


The author gratefully acknowledges the contributions made by Dr. Steven Friedman, Ph.D. Professor of Clinical Psychiatry and Director of the Phobia & Anxiety Disorders Clinic, at the State University of New York, Downstate Medical Center, for his tireless efforts assisting the firefighters who survived the collapse of the World Trade Center.

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