New York Firefighters – A Sample of First-Responders 10 Years Following the Collapse of the World Trade Center

March 30th, 2011

“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 a terrorist attack).
The knowledge obtained by studying enduring psychological reactions among rescuers has far-reaching public health implications.
It was actually President Obama’s visit to Engine 54 that prompted me to revisit my discussions with Dr. Steven Friedman about his continued work with firemen who have suffered to the extent of engaging in treatment for periods ranging from several months to ten years. Some of these firemen are still in treatment.
Steve and I were recently discussing various unique aspects among those firemen who required treatment following the WTC collapse during the 9/11 terrorist attacks.
At the time, as Attending Psychiatrist at SUNY Downstate, I would stabilize any patient admitted to the E.R. with one of the acute traumatic stress disorders and then refer them to Steve’s Anxiety Disorder Clinic at the Department of Psychology at SUNY Downstate.
Steve has continued to treat firemen since those tragic attacks.
Over a ten year period Dr. Friedman gathered a collection of vignettes of the FDNY, which is unique in probing the long-term psychological effects among a specific group of rescuers who were sent into the mayhem and chaos of the WTC.
During the rescue operation, and at enormous personal risk, they performed countless acts of heroism.
During the event, the firemen witnessed the death by burning of hundreds of trapped fellow citizens, as well as their own near-death experiences.
Following the event, they then were faced with the additional bereavement resulting from the loss of many close friends.
Those in the field of Public Health and National Safety should consider the potential risk to first-responders, since they are the first to arrive and provide rescue-functions to fellow citizens, often under perilous conditions.
Given the chaotic circumstances at the time, our assigned mission was to stabilize trauma victims and our observations lack the methodological rigor required by most academic journals.
Following our conversation, I emailed Steve a summary of some salient issues which he reviewed, and approved its release.
As I watched Obama visit with firefighters at Engine 54, Ladder 4, and Battalion 9 on May 5, I took pause to look at those first-responders through a different prism; as someone knowing more about their unique predicament. 
I will touch on some of these observations to provide a window into life beyond rescue for this cohort of first-responders arriving first at the scene of a natural disaster.
Issues of Loss
For the firefighters who survived the collapse of the WTC, 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 become familiar with any distinct psychological or culturally-specific quality characterizing any group of first-responders; a point well demonstrated among the group of firefighters (Kirshman, 2004). 
One firefighter put it as follows, "We see ourselves as blue collar, simple, unemotional, true Americans. Firefighters tend to be action-oriented people who thrive in environments involving risks and challenges." They are not risk-aversive. They embrace what others may see as "dangerous/aversive" situations. 
While first-responders often tend to be individuals who react instinctively, they don’t necessarily have much patience for analytic self-reflection.
An important by-product of this normally highly adaptive action-orientated ("extroverted") method of problem solving is that this population tends to be less concerned 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. 
Using a computer-generated head-mounted visual display of the trauma scene while stereo earphones provided the audio cues, a Vietnam Veteran with chronic PTSD and alcoholism was successfully treated following fourteen 90-minute exposures over a seven week period.
This type of exposure therapy should be considered when trauma survivors with PTSD symptoms are resistant to more conventional therapies.
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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