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Extremist Terrorism, Trauma, & Complex PTSD:
Implications for Rescue Workers
By Laurie A. Trachtenbroit, MA, LPC
Georgia Certified Emergency Manager (CEM)
Certified Homeland Security Level-V (CHS-V)
Certified Forensic Consultant (CFC)
Diplomate American Board of Forensic Examiners (DABFE)
Diplomate American Board of Forensic Counselors (DABFC)

Abstract

Extremist terrorism profoundly affected the lives of Americans when the World Trade Center Twin Towers were attacked on September 11, 2001. On that date, 2,631 civilians and 343 heroes, who responded to help, lost their lives as a result of the attacks—with another 24 people missing and presumed dead. A 2008 research study found that 11.1 percent of rescue workers responding to the attack exhibited probable PTSD 10-61 months after the event, far exceeding the American adult lifetime prevalence for PTSD of 6.8 percent. The whole world witnessed death and destruction on America’s soil, with media sensationalism generating mass trauma. The uncertainty of future terrorist attacks created a powerful psychological weapon against society. Some have suggested that living with the threat of terrorism may result in the kind of prolonged trauma that leads to Complex PTSD. There is a need to provide early intervention, 1-8 weeks post-trauma, for large groups of high-risk persons directly and indirectly affected. Research indicating limitations and potential harm with Critical Incident Stress Debriefing requires exploration of alternatives. A new early intervention is proposed for large groups of high-risk individuals addressing pre-trauma, peritrauma, and post-trauma needs, with a special focus on rescue workers. The proposal focuses on acquisition and effective use of coping strategies over several sessions, as well as family group work to ensure sufficient support both at home and on the job. The need to develop and implement effective stress inoculation and early intervention is particularly critical for rescue workers, who are relied upon to immediately respond and effectively function in the horrific events that extremist terrorism creates. The cumulative effect of rescue worker trauma is significant and cannot be ignored in trauma event preparation.

Key Words: Terrorism, Extremist Terrorism, Trauma, Post-traumatic Stress Disorder, PTSD, Complex PTSD, Rescue Workers


Trauma & Post Traumatic Stress: A Brief History

Stressors that are very sudden, intense, dangerous, and which are perceived as uncontrollable and unpredictable are most likely to be experienced as traumatic (Cash, 2006, p. 57).

Prospective research has indicated that a large majority (94 percent) of traumatized individuals will evidence symptoms consistent with PTSD in the immediate aftermath of trauma. However, most individuals exposed to traumatic stressors do not subsequently develop PTSD. Evidence suggests that the normative response to trauma is to initially experience a range of PTSD symptoms, which remit naturally (Follette & Ruzek, Eds., 2006, p. 6). The literature indicates high rates of emotional numbing, reduced awareness of one’s environment, derealization, depersonalization, intrusive thoughts, avoidance behaviors, insomnia, concentration deficits, irritability, and autonomic arousal in the weeks after a traumatic experience (Follette & Ruzek, p. 201). Berger (2004) contends that pathologizing these responses by characterizing them as symptoms ignores their adaptive function and may be harmful (Knafo, Ed., 2004, p. 238).

Berger (2004) further states that the survivors’ task, in the immediate aftermath of trauma, is to accept and tolerate these early stress responses as normal, and that if they successfully do so, then the stress reactions will dissipate (Knafo, Ed., 2004, p. 243).

Diagnosing Post Traumatic Stress Disorder:

The diagnosis of PTSD is made based on post-traumatic symptoms that persist for more than one month. DSM-IV requires one re-experiencing symptom, three avoidance symptoms, two increased arousal symptoms, and evidence of significant distress or impairment.

Cash (2006) defines PTSD as:

a maladaptive reaction to a traumatic event in which a person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others and experienced intense fear, helplessness, or horror. Afterward the person developed symptoms of re-experiencing the traumatic event in various forms, avoidance of stimuli that are associated with the event, emotional numbing, and hyperarousal to a degree that is disruptive to his or her functioning (p. 15).

Herman (1992) stated:

Traumatic reactions occur when action is of no avail. When neither resistance nor escape is possible, the human system of self-defense becomes overwhelmed and disorganized. Each component of the ordinary response to danger, having lost its utility, tends to persist in an altered and exaggerated state long after the actual danger is over. Traumatic events produce profound and lasting changes in physiological arousal, emotion, cognition, and memory (p. 34).

Symptoms of Post Traumatic Stress Disorder:

Intrusion/Re-experiencing: Recurring and intrusive recollections; recurrent dreams; acting or feeling as if the event is being relived; intense psychological or physiological distress at exposure to internal or external cues that symbolize the trauma (Cash, 2006, p. 16).

In summarizing intrusion, Herman (1992) stated, “Long after the danger is past, traumatized people relive the event as though it were continuously recurring in the present. They cannot resume the normal course of their lives, for the trauma repeatedly interrupts. It is as if time stops at the moment of the trauma” (p. 37).

Constriction/Avoidance: Avoiding thoughts, feelings, and conversations associated with the trauma; avoiding activities, places, or people that arouse recollection of the trauma; inability to recall important aspects of the trauma (Cash, 2006, pg. 16).

In summarizing constriction, Herman (1992) stated:

When a person is completely powerless, and any form of resistance is futile, [they] may go into a state of surrender. The system of self-defense shuts down entirely. The helpless person escapes from [their] situation not by action in the real world but rather by altering [their] state of consciousness…These detached states of consciousness are similar to hypnotic trance states…But while people usually enter hypnotic states under controlled circumstances and by choice, traumatic trance states occur in an uncontrolled manner, usually without conscious choice (p. 42-44).

Hyperarousal/Increased Arousal: Diminished interest; feelings of detachment, restricted range of affect; sense of a foreshortened future; difficulties with sleep, irritability, and concentration; hypervigilence and exaggerated startle responses (Cash, 2006, p. 16).

In summarizing hyperarousal, Herman (1992) stated:

After a traumatic experience, the human system of self-preservation seems to go onto permanent alert, as if the danger might return at any moment. Physiological arousal continues unabated. In this state of hyperarousal…the traumatized person startles easily, reacts irritably to small provocations, and sleeps poorly (p. 35).

The Importance of Subjective Experience:

Trauma is a near universal human experience (Cash, 2006, p. 139). However, not everyone who survives a traumatic experience will develop a diagnosable condition. Some people can experience an event as stressful, while others who experience the same event may not. The National Comorbidity Survey Report, published in 2005, indicates that the lifetime prevalence of PTSD among adult Americans is 6.8 percent (National Center for PTSD).

The subjective experience of the traumatic event is critical to development of pathological reactions.

Individual Risk Factors for PTSD:

An individual’s prior history, reactions during the traumatic event, and reactions following the traumatic event will have a significant impact on the potential for the development of PTSD.

Pre-Trauma Risk Factors: Previous trauma exposure and occupation as an emergency worker such as firefighter, paramedic, law enforcement officer, or rescue worker are among the identified pre-trauma risk factors (Cash, 2006, pg. 59).

Peri-trauma Risk Factors: Perceived life threat; intense negative emotional response during the traumatic event such as fear, helplessness, horror, feelings of guilt and shame; dissociation (Cash, 2006, p. 63).

Post-Trauma Risk Factors: Loss of resources (economic and social); perceived low levels of social support; inability to tolerate and cope with the normal post-trauma symptoms of PTSD (re-experience, avoidance, and increased arousal); feelings of guilt and shame (Cash, 2006, pg. 64).

Note: Brewin, Andrews, and Valentine (2000) conducted a meta-analysis and found that risk factors that occurred during and after a trauma had the greatest impact (Cash 2006 pg. 63).

Features of the Traumatic Event:

Herman (1992) stated, “The most powerful determinant of psychological harm is the character of the traumatic event itself. Individual personality characteristics count for little in the face of overwhelming events…With severe enough traumatic exposure, no person is immune” (pg. 57). Those with the closest proximity to the traumatic event, the severity of the traumatic event, duration of the traumatic event, and whether one suffered injuries as a result of the traumatic event are the most at-risk for PTSD (Dattilo & Freeman, Eds., 2007, pg. 405).

Treatment of PTSD in Individuals: Three Stages of Recovery

Stage 1: Re-establishing Safety

Herman (1992) stated, “Survivors feel unsafe in their bodies. Their emotions and their thinking feel out of control. They also feel unsafe in relation to other people. The strategies of therapy must address the patient’s safety concerns in all of these domains.” She notes that medication may be helpful in reducing reactivity and hyperarousal; behavioral techniques, such as relaxation, may be helpful in managing stress; cognitive-behavioral techniques may be helpful in reducing confusion and disorder; interpersonal strategies, such as psychotherapy, may be helpful in re-establishing trust; and social strategies that mobilize natural support systems may be helpful in re-establishing social attachment (p. 160).

Stage 2: Remembering & Mourning

Herman (1992) stated, “All of the classic writings recognize the necessity of mourning and reconstruction in the resolution of traumatic life events. Failure to complete the normal process of grieving perpetuates the traumatic reaction” (p. 69).

Remembering:

Herman (1992) stated, “The survivor tells the story of the trauma…completely, in depth and in detail. The therapist plays the role of witness and ally, in whose presence the survivor can speak of the unspeakable” (p. 175). This process involves developing and refining a narrative that includes the things leading up to the traumatic event; the traumatic event itself, including what the survivor saw, heard, and smelled, as well as what the survivor thought and felt; the survivor’s response to the trauma; and the responses of the important people around him or her to the trauma (Herman, 1992, p. 177). Herman (1992) stated, “In the telling, the trauma story becomes a testimony” (p. 181). This process also involves defining the meaning of the event to both survivors and the important people around them—in a new way that dispels shame and humiliation and restores dignity and value.

Dealing with Survivor’s Guilt:

Herman (1992) stated:

In the aftermath of traumatic events, as survivors review and judge their own conduct, feelings of guilt and inferiority are practically universal…feelings of guilt are especially severe when the survivor has been witness to the suffering or death of other people (p. 53-54).

Guilt, or feelings that one should have felt, thought, or acted differently at the time of the trauma has been positively and significantly related to the severity of PTSD. Research indicates that feelings of guilt in trauma survivors may contribute to the development of PTSD, especially in the absence of social support. Trauma-related guilt is a common problem for survivors of many different kinds of traumatic events (Follette & Ruzek, Eds., 2006, p. 258-259). Many trauma survivors experience guilt and shame that have little or no rational basis (Follette & Ruzek, p. 260) because of a common thinking error called “hindsight bias” in which one believes that unforeseeable outcomes were foreseeable and preventable (Follette & Ruzek, p. 264). To correct hindsight biased thinking, it is critical to identify negative outcomes that were unforeseeable and therefore unpreventable (Follette & Ruzek, p. 284). The resolution of guilt depends upon developing a full recognition of how what one knew and believed resulted in actions that made sense at the time of the traumatic event (Follette & Ruzek, p. 285).

Mourning:

Herman (1992) stated:

The descent into mourning is at once the most necessary and the most dreaded task of this stage of recovery…The survivor frequently resists mourning, not only out of fear but also out of pride (refusing) to grieve as a way of denying victory to the perpetrator” (p. 188).

Reclaiming the ability to feel a full range of one’s emotions, coming to terms with the impossibility of ever getting “even,” and giving up fantasies of revenge are all part of the mourning process (Herman, 1992, p. 188-189).

Reconnecting:

Herman (1992) stated, “Helplessness and isolation are the core experiences of psychological trauma. Empowerment and reconnection are the core experiences of recovery” (p. 197). Reconnecting involves taking a renewed interest in the present and the future, actively rebuilding one’s life, restoring social bonds, and re-establishing intimacy in relationships.

Complex Post Traumatic Stress Disorder

Herman (1992) discusses a complex form of PTSD that is not adequately addressed in the current DSM-IV conceptualization of PTSD. Complex PTSD involves survivors of prolonged and repeated trauma in contrast to a single traumatic event: Prolonged and repeated trauma amplifies the symptoms of PTSD to the point that survivors have no recognizable baseline of calm or comfort (Knafo, Ed., 2004, p. 38).

Terrorism and Complex Post Traumatic Stress Disorder

Some have suggested that living with the threat of terrorism may result in the kind of prolonged trauma that leads to Complex PTSD. While we have traditionally understood PTSD in terms of an individual’s stress reaction, there are those that conceptualize terrorism as trauma for the group: which functions in much the same way as trauma for the individual (Knafo, Ed., 2004, p. 533).

Trauma from terrorism affects large-group-identity based on ethnic, national, or religious affiliation in ways that are entirely different from the effects of natural or accidental disasters (Knafo, Ed., 2004, p. 481). After ethnic, national, or religious hostilities, whole societies change (Knafo, p. 496).

Bergmann (2004) stated, “An unexpected terrorist attack, by virtue of the uncertainty of its potential repetitiveness, creates additional powerful psychological weapons against its victims and constitutes social trauma (Knafo, 2004, p .449).

The aim of terrorist attacks is to create widespread fear (Knafo, Ed., 2004, p. 371). The goal of terrorists is to cause death to a large number of people perceived as enemies and to cause horror and interruption in the lives of enemies who remain alive (Knafo, p. 226). Netanyahu (1997) stated, “The terrorist’s underlying message is that every member of the society is guilty, that anyone can be a victim, and therefore, no one is safe” (Knafo, p. 236). Successful terrorist attacks result in fears that our leaders cannot protect us (Knafo, p. 226).

Extremist Terrorism is creating maladaptive behaviors in the daily lives of increasing numbers of people worldwide (Knafo, 2004, p. 87). Media reports and sensationalism of terrorist events perpetuate the sensation of being unsafe and trapped (Knafo, p. 92). Regarding the attack of American’s World Trade Center Twin Towers on September 11, 2001, Storezier & Gentile (2004) stated, “At National and even international levels…outside the areas of actual attack, the vicarious experience of the disaster through television generated its own kind of trauma” (Knafo, p. 415). Berger (2004) further stated, “Attacks against the United States on September 11, 2001, have profoundly affected the lives of Americans, as well as millions around the world” (Knafo, p. 233).

Treatment of Trauma from Terrorism

Treatment of trauma from terrorism must involve intervention with a large group of people. The tendency to treat only those directly affected by disaster has potentially serious future implications (Knafo, 2004, p. 96). The need to identify the high-risk individuals who are vicariously affected by geographical proximity to the site of the incident or social proximity to the victims, as well as address the trauma-related symptoms of those indirectly, but seriously, affected witnesses is also critically important (Knafo, p. 175).

The resulting target group for mental health intervention to prevent PTSD shortly after the mass trauma from terrorism is staggering to consider:

  • Those whose symptoms remains the same or worsen over time (Knafo, 2004, p. 248)
  • Directly and indirectly affected rescue workers
  • Indirectly affected families and friends of the deceased, estimate 10 per deceased person (Federal Emergency Management Agency Training Manual for Mass Fatalities, 2006, p. 6-10)
  • Indirectly affected civilians in close geographical proximity to the trauma site. (Datillo & Freeman, 2007, p. 405)

Rescue Workers Are At High-Risk

Rescue workers are frequently exposed to direct and indirect trauma. They may directly experience violence or the threat of violence, see grotesque and horrifying things, and conduct their work in the same challenging day-to-day living conditions that victims face (Knafo, 2004, p. 372-375). Therefore, it is imperative for command leadership to prepare proactively for the potential of severe stress reactions of rescue workers on their team.

Stress Inoculation & The “Survivor Personality”

Stress Inoculation programs are those aimed at preventive mental health before a traumatic event occurs. A review of research regarding resilience to trauma may be instructive, relative to development of stress inoculation skills prior to terrorist events. Siebert (1996) uses the term “Survivor Personality” to describe someone who “has survived a major crisis or challenge, surmounted the crisis through personal effort, emerged from the experience with previously unknown strengths and abilities, and afterwards finds value in the experience (Knafo, 2004, p. 319). Siebert (1996) identifies three components to the “Survivor Personality,” including optimism, resilience and hardiness. Optimism refers to a person’s expectation of success despite circumstances; resilience refers to a person’s adaptation to changing circumstances; and hardiness refers to a person’s commitment and level of self-control (Knafo, p. 319). The qualities of optimism, resilience, and hardiness are thought to differentiate survivors from victims (Knafo, p. 318).

Other researchers have found that resilient individuals function calmly under pressure, find purpose, accept fear in themselves and others, and avoid engaging in excessive violence or other guilt-arousing behavior (Knafo, p. 161-166).

Krystal (2004) stated, “In order to improve one’s chances of survival, one [has] to favor the… preservation of love, hope, and faith under the most difficult of circumstances” (Knafo, 2004, p. 76).

Protective strategies for trauma stress workers include preserving social connections, continued active coping in the face of extremity, and the focus on preserving a sense of judgment based on a foundation of morals.

Future research must focus on identifying specific methodologies to effectively train resilience, using an early-intervention approach.

Stress Inoculation & Avoiding the Media

Regarding the media, De Becker (2002) stated, “The rush to be first appears to have eclipsed the rush to be accurate” (p. 144-145). De Becker further states, “Exaggerated reports amount to nothing more than an advertisement to extremists and madmen, and electronic terrorism for the rest of us” (p. 144). De Becker (2002) urges the media to “stop providing information in a way that is itself hurtful to the general public and is helpful to our dangerous enemies” (p. 148). De Becker (2002) likewise urges Americans to avoid sensationalized media and notes the special vulnerability of children to media and adult discussions about disturbing news. De Becker’s (2002) advice is salient for both rescue workers and other helping workers providing shelter to the public.

The Critical Role of Social Support

Social support is a term to describe various types of helping, including: assistance with problems, understanding and acceptance, normalizing one’s experience, and related stress reactions after a trauma (Follette & Ruzek, 2006, p. 445). Berger (2004) discusses the importance of social support in the early recovery phase from trauma. The task for survivors at this phase of recovery is to tolerate and accept their stress reactions (Knafo, 2004, p. 244).

Family and friends can also help by tolerating the survivor’s stress reactions and supporting the survivor’s process of mourning. Berger (2004) suggests that family and friends can demonstrate social support by accommodating temporary physical and emotional limitations, responding with sensitivity, and providing encouragement (Knafo, 2004, p. 245). Actual and perceived decline in social support have been identified as risk factors for PTSD (Follette & Ruzek, 2006, p. 446).

Ruzek (2006) suggests that individuals may be trained to more effectively support one another by developing interventions for groups (p. 446). Critical Incident Stress Debriefing has been in vogue for several years. It generally involves bringing together a group of people, who have been affected by a common event, for the purpose of education, normalizing stress reactions, and support (Follette & Ruzek, 2006, p. 448). Despite its widespread popularity, research has suggested that one-session-psychological-debriefings, such as CISD, may actually cause harm to some survivors (Knafo, 2004, p. 235).

Ruzek (2006) proposes early group interventions that combine verbal presentations with opportunities to learn and practice coping behaviors; suggesting they take place among peers who have experienced the same traumatic event, with facilitation by skilled clinicians and over multiple sessions. Such an approach would allow recovery behaviors to be acquired and reinforced in a socially supportive environment over time.

This author would like to expand upon Ruzek’s concepts and propose a proactive intervention program that contains the following components, with a focus on rescue workers:

  • A web-based, early intervention program, which targets each type of high-risk group separately
  • An assessment tool to measure pre-intervention stress reactions and symptoms in individuals
  • Facilitator teams, pairing skilled clinicians with individuals like the victim, who have survived a previous trauma (peers)
  • Intervention program which presents information and specific cognitive behavioral interventions over several sessions between 1-6 weeks post-trauma
  • Outcome assessment using same assessment tool referenced above, to reassess stress reactions and symptoms at regular intervals eight-plus weeks post-trauma.

PTSD & Co-Occurring Disorders

PTSD has a high rate of co-morbidity. Therefore, it is critical that psychological and substance abuse problems be ruled out. According to Cash (2006), the most common co-occurring disorders include Alcohol Abuse/Dependence, estimated at 51 percent, and Substance Abuse/Dependence, at 48.5 percent (p. 50).

Subgroups with especially high rates of trauma and Substance Use Disorders (SUD’s) include rescue workers. Those with co-occurring PTSD and SUD have worse outcomes than those with either disorder alone (Follette & Ruzek, 2006, p. 229).

The development of PTSD typically precedes Substance Abuse or Dependence. Some research suggests that those highly sensitive to anxious symptoms are more likely to cope with substances to decrease arousal. Although alcohol and drugs are sought to decrease anxiety symptoms, they have a paradoxical effect of actually worsening other symptoms (Cash, 2006, p. 125).

Prior Trauma History Creates Higher Risk

Research has established that a current trauma tends to serve as a trigger for traumatic events from one’s past becoming reactivated. Therefore, it is critical to identify prior trauma(s). The Post-traumatic Stress Diagnostic Scale (PDS) is the most widely used self-report measure to assess trauma exposure history. The PDS has 49 items and takes 10-15 minutes to administer. Parts I and II of the PDS specifically address trauma exposure history (Follette & Ruzek, 2006, p. 46).

Self Report Measures of PTSD Symptoms

Self-report measures of PTSD symptoms that have adequate psychometric properties may be helpful in providing continuous measures of PTSD to reflect symptom severity at intervals during the course of treatment.

The PTSD Checklist (PCL) is a self-report measure that has a military and civilian version (PCL-M and PCL-C). The PTSD Checklist has 17 items and takes 5-10 minutes to administer.

Clinician Administered Measures of PTSD:

In 1995, the International Society for Traumatic Stress Studies developed standards for assessing PTSD. Structured clinician administered diagnostic interviews were recommended.

One of the most widely used structured interview tools for diagnosing and measuring the severity of PTSD is the Clinician Administered PTSD Scale (CAPS). The CAPS creates a severity score for each symptom. The CAPS takes approximately 30 minutes to administer 17 core symptoms only, or 60 minutes to administer in its entirety: with items geared toward measuring guilt and dissociation. The CAPS has been used successfully with a wide variety of trauma populations (combat veterans, victims of rape/incest and other crime, Holocaust survivors, cancer survivors, and those involved in motor vehicle accidents, among others). The CAPS has served as the primary diagnostic outcome measure in more than 200 empirical studies of PTSD and has been translated into at least 12 languages (Weathers et al., 2001).

Early Intervention for Groups with PTSD:

Van der Kolk (2004) stated, “Effective therapy needs to help survivors tolerate the sensory reminders of the trauma and to physically experience efficacy and purpose in response to stimuli that once triggered feelings of helplessness and dependence” (Knafo, Ed., 2004, p. 273).

Baranowsky et al. (2005) discuss the importance of pairing exposure to traumatic memories and relaxation, until relaxation occurs in the face of exposure and symptoms subside (p. 7). They provide an excellent and very detailed description of various relaxation techniques (p. 19-31).

Berger (2004) discusses the importance of facilitating the transformation of trauma memories from a confusing, fragmented, and disorganized narrative into a coherent, logical, and organized story in order to reduce initial adverse reactions and perhaps prevent the development of PTSD (Knafo, Ed., 2004, p. 265).

Berger (2004) proposes an exposure intervention called “Traumatic Memory Restructuring” (TMR) in the early recovery phase of treatment. He suggests that TMR should be used in the course of group debriefing as an alternative to Critical Incident Stress Debriefing, and he has found it to be helpful with survivors of terrorist attacks in Israel (p. 266).

The basic steps involved in Traumatic Memory Restructuring (TMR) with individuals include:

  • Teach survivor basic relaxation techniques
  • Ask the survivor to recall experiences before the traumatic event
  • Ask the survivor to recall the traumatic experience and monitor for physiological changes. Use relaxation techniques as needed to help the survivor self-regulate his of her body.
  • Facilitate better organization of trauma narrative by asking the survivor to make logical connections between fragments, using cause/effect reasoning (Can you better explain what happened there?), and asking survivors to fill in the gaps of what could have happened
  • Facilitate reconstruction of pathological narratives (faulty attributions and misinterpretations), helping the survivor to realize their behaviors at the time of the traumatic event were normal and necessary.
  • Ask the survivor to retell the new constructed trauma narrative and then write it down to share with support resources
  • Ask the survivor to place the traumatic experience within the overall context of their lives, both to date and into the future (What were the lessons learned and what are their meanings to the survivor and those persons important to the survivor).

Cognitive Behavioral Therapies are considered to be the most effective treatments for Post Traumatic Stress Disorder in individuals. The treatment elements of Cognitive Behavioral Therapy also lend themselves well to a group therapy model (Follette & Ruzek, Eds., 2006, p. 393). Group therapy is designed to help survivors of trauma cope with the isolation, alienation, shame, and restricted or diminished feelings by bonding with others who have similar histories in the context of a supportive environment (Follette & Ruzek Eds. 2006 p. 389).

Future research must focus on:

  • Quickly and accurately identifying the high-risk groups for intervention during the early recovery phase (1-8 weeks post-trauma)
  • Assessing whether the cognitive behavioral approaches known to be effective in individual therapy are also effective within groups for those affected by terrorist attacks
  • Exploring the use of web-based interventions to facilitate large-group intervention delivery following terrorist attacks
  • Evaluating mixed gender vs. single gender groups, mixed trauma vs. same trauma groups, civilian vs. rescue worker groups, and varying lengths of treatment for those affected by terrorist attacks
  • Providing evaluation from up to one year to several years post-trauma.

Summary: Implications for Rescue Workers

Rescue workers have direct and indirect exposure to trauma, and are at high-risk for post-traumatic stress reactions. Research has indicated that following the terrorist attacks of September 11, 2001, 11.1 percent of rescue workers were diagnosed with PTSD, exceeding the 6.8% prevalence rate of PTSD in the general American population. Existing interventions such as Critical Incident Stress Debriefing have proven to be limited and potentially harmful to some. The need to be proactive in ensuring the continued mental health of rescue workers cannot be stressed enough.

Training and reinforcing resilience, increasing social support at work and at home, providing effective leadership and command in the field, and routinely using early interventions specifically designed to prevent PTSD within the work group and among peers are critical. Command staff and their response teams have a good handle on individual resilience, within team support, and leadership requirements. However, effective post-trauma intervention is lacking, primarily due to lack of proven and available interventions within the mental health field.

One improvement for command leadership to consider is to have a trained trauma clinician within the department, to work with rescue workers and their families pre-trauma, peri-trauma, and post-trauma on at least a part-time, continuous basis. Pre-trauma work with the families of rescue workers to provide information, develop or enhance within family support, and ultimately to develop or enhance the support the family can provide to the rescue worker is a critical need. Post-trauma early intervention with rescue workers within their team, facilitated by the mental health team member and a peer who has survived a similar trauma—with a focus on acquiring and effectively using specific coping strategies such as TMR— over several sessions within 1-8 weeks is another critical need.

In times when budgets cuts are being made to rescue worker teams around the country, it may seem cost-prohibitive to suggest that a specially trained mental health clinician be hired at least part-time as part of the response team continually, and not just on a per-event basis. However, the continued availability of effective rescue worker teams depends on a proactive and comprehensive approach to maintaining mental health both at home and at work. The cumulative effects of trauma over time, and the necessity of a network of social support in the community, at home, and at work cannot be underestimated for rescue workers. Society has a responsibility to make sure rescue workers get the assistance they need prior to, during, and after traumatic events, so that our heroes will be there and healthy when we need them.

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Stellman, J.M., Smith, R.P., Katz, C.L., Sharma,V., Charley, D.S., Herbert, R., Moline, J., Luft, B.J., Markowitz, S., Udasin, I., Harrison, D., Baron, S., Landrigan, P.J., Levin, S.M., & Southwick, S. (2008). Enduring Mental Health Morbidity and Social Function Impairment in World Trade Center Rescue, Recovery and Cleanup Workers: The Psychological Dimension of an Environmental Health Disaster. Environment Health Perspectives (www.ehponline.org)

Storezier, C. B. & Gentile, K. (2004). Responses of the Mental Health Community to the World Trade Center Disaster in Knafo, D. Ed. (2004) Living with Terror, Working with Trauma: A Clinician’s Handbook pp. 415428. Maryland: Rowman & Littlefield Publishers.

Weathers, F.W., Litz, B.T., Herman, D.S., Huska, J.A., & Keane T.M. (1993, October). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility as referenced in Follette, V.M. & Ruzek, J.I Eds. (2006). Cognitive Behavioral Therapies for Trauma p. 46. New York: Guilford Press.

Weathers, F.W., Ruscio, A.M., & keane, T.M. (1999). Psychometric Properties of Nine Scoring Rules for the Clinician-Administered PTSD Scale (CAPS) referenced in Follette, V.M. & Ruzek, J.I Eds. (2006). Cognitive Behavioral Therapies for Trauma p. 40. New York: Guilford Press.

Weathers, F.W., Keane, T.M., & Davidson, J.R.T. (2001) The Clinician Administered PTSD Scale (CAPS): A Review of the First Ten Years of Research referenced in Follette, V.M. & Ruzek, J.I Eds. (2006). Cognitive Behavioral Therapies for Trauma p. 40. New York: Guilford Press.

Author Biography

Laurie A. Trachtenbroit, MA, LPC, CEM, CHS-V, CFC, DABFC, DABFE, is a Georgia Licensed Professional Counselor with Certification in Emergency Management, Homeland Security, and Forensics. Trachtenbroit is also a member of the ABCHS National Emergency Response Team. Trachtenbroit currently serves as the American Red Cross Georgia State Emergency Management Program Manager where she facilitates the recruitment, development, and deployment of Government Liaison Teams across the state.

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