America’s Heroes One Year Later: Researchers Learn From New York’s 9/11 Survivors

By Barbara A. Gabriel, bagabriel@aamc.org

In New York City, psychiatrist Charles Marmar, M.D., is having disaster workers who responded to the World Trade Center attacks a year ago repeatedly re-live their experiences at Ground Zero, helping them reconstruct in their imaginations each detail of that fateful day. “Imagine you are walking toward the World Trade Center,” instructs Dr. Marmar. “What do you see? What do you feel? What do you smell?”

Helping the helpers: Rescue workers administer fluids to hydrate one of the most important members of the rescue team, a search dog, on Sept. 19, 2001.

This exercise, called “cognitive behavioral treatment,” is being used by Dr. Marmar to treat police officers, firefighters, EMTs, paramedics, and other emergency workers who responded to the Sept. 11, 2001, attacks or who were involved in highly stressful components of the cleanup effort, such as body recovery.

Dr. Marmar, professor and vice chair of the Department of Psychiatry at the University of California’s San Francisco Medical Center and associate chief of staff of mental health at the San Francisco VA Medical Center, has been studying the treatment of stress-induced mental disorders in police officers in New York and California for several years. He has become an expert on psychiatric symptoms brought on by stressful, often life-threatening events. Dr. Marmar and a collaborator at the New York Weill Cornell Medical Center have been funded by the National Institute of Mental Health (NIMH) to test an eight-session treatment strategy aimed at responders to the World Trade Center attacks who are manifesting symptoms of post-traumatic stress disorder (PTSD).

Such symptoms include disturbing memories and dreams, edginess, and sleep and concentration difficulties. “The overarching idea of this treatment is to secure homeland defense by ensuring that all emergency services personnel are able to do their jobs and remain healthy in the event of a large-scale disaster,” explains Dr. Marmar.

The cognitive behavioral therapy Dr. Marmar is offering to the 56 emergency responders who have enrolled in his study involves imaginal exposure, in which individuals are encouraged to repeatedly imagine reliving the event; “exposure in vivo,” in which responders confront feared situations resulting from their experiences at Ground Zero, such as a fear of elevators, tall buildings, or planes; and “cognitive reprocessing,” in which individuals examine their thinking about their experiences with a psychiatrist who helps them correct mistaken beliefs, such as the fear that any tall building could collapse on them or that any plane is headed for a crash.

A control group will be offered “treatment as usual” for disaster response workers, such as debriefing and occasional supportive counseling. After results for the patients chosen for Dr. Marmar’s cognitive behavioral therapy are compared with those in the control group, all responders will be offered the opportunity to participate in the psychiatrist’s eight-session strategy.

“Study volunteers will have a reduction in their rescue-related stress symptoms such as bad dreams, pictures of the event popping into their minds, and physical reactions including heart racing, sweating, and shaking when they remember the event,” predicts Dr. Marmar. “They will have less avoidance of the things that remind them of the event because they will be able to tolerate reminders better. They will be freer to resume their lives and engage in normal work and life activities and hobbies. They will sleep better, concentrate better, and be free of the stress of being on guard all the time.”

Dr. Marmar explains that his treatment strategy is designed to be a tool that psychiatrists can take onto the scene of large-scale disasters to help rescue workers and emergency personnel quickly contain, manage, and reduce post-traumatic stress. He also suggests that the skills his cognitive behavioral therapy teaches patients may be used as “immunizations,” meaning that emergency responders could apply the treatment to themselves in future life-threatening events.

“We want to contribute to the civil defense of the United States by developing a safe, effective, and easily transportable treatment that can be taken to the field in the event of another large-scale terrorist attack,” says the psychiatrist.

He adds that police officers and firefighters who repeatedly face life-threatening situations in their daily line of work may also use the experimental therapy. “We know that people in certain occupations face frightening crises every day,” he says. “You don’t have to wait for a terrorist attack. We want to develop a system that will allow us to get to people as soon as bad things happen to them in order to put out the psychic fire right there.”

Helping the helpers

Two psychologists have also been funded by the NIMH to assess stress disorders in disaster relief workers. But their work differs from Dr. Marmar’s in that they are specifically interested in the effects of trauma on relief workers who have also been trained as clinicians. “The 110 clinicians who are involved in our study are people affiliated with fire departments working in critical incident stress management teams,” explains Rose Zimering, Ph.D., assistant chief of psychology at the VA Boston Healthcare System, who is conducting an assessment through the Boston University School of Medicine.

“Our subjects include firefighters, EMTs, clergy, social workers, and psychologists who are trained in critical incident stress management, a type of clinical service delivery. Their role in the disaster was to work with surviving firefighters and the family members of firefighters who did not return home.”

The study, which seeks to assess the presence of secondary trauma reactions in disaster relief mental health clinicians working with WTC survivors, involves assessments six months after the attacks and on the one-year anniversary of Sept. 11. The first assessment included a face-to-face interview as well as a self-report. The second assessment will involve only self-reporting instruments.

“It’s an assessment study that should really help us develop some hypotheses about the potential for secondary trauma,” explains Suzy Gulliver, Ph.D., a staff psychologist at the VA Boston Healthcare System who is the co-principal investigator for the project.

“What we hope to find is an indication of the factors that predict whether people are resilient when they’re faced with the stress of assisting survivors or whether people are struggling with problems that result from doing that kind of work. We want therapists to be able to take good care of themselves when they’re exposed to traumatic events.”

Dr. Zimering says preliminary results from analyzing the initial interviews reveal that very few disaster relief clinicians meet the full criteria for PTSD. “Rather, we found that many of these individuals had a profoundly positive experience with their work,” she explains. “They felt it was extremely meaningful to be able to assist in some way after the terrorist attacks when the country was torn apart. They felt honored to be called upon to help the firefighters.”

Others had some negative reactions involving re-experiencing the narratives told to them by survivors or having emotional responses to triggers in their environments that reminded them of the work they had done. But Dr. Zimering says that, in general, negative reactions were temporary, subsiding a month after their work was done. “We predict this study will be a first step toward assessing how it is that people cope well when they’re in professions that expose them to high levels of trauma,” says Dr. Gulliver.

Treating clinical fallout

While much attention and funding has been directed toward assessing and relieving the traumatic emotional fallout of the events of 9/11, physical health risks have also been a concern for the responders to America’s largest homeland attack. William Rom, M.D., professor of medicine and environmental medicine at the New York University School of Medicine, has obtained a grant from the National Institute of Environmental Health Sciences to conduct a clinical study of respiratory symptoms in 300 New York firefighters who were exposed to Ground Zero for significant amounts of time. He is studying a syndrome that clinicians who are working with survivors of the attacks are calling “World Trade Center Cough,” especially prevalent in firefighters who were the first responders to the disaster.

Dr. Rom is conducting “limited lung washes” in firefighters displaying the cough to obtain cells in the lungs’ air sacs and thus determine what particles have been inhaled. “WTC Cough appears to be an upper-airway irritation that probably reflects the large size of the particles inhaled and the fact that they’re highly irritating to the airways,” he explains. “We’re trying to identify the particles that got down into the lower part of the lungs, particularly the fly ash, fiberglass, and any asbestos particles, and we’re looking to see if this cough is associated with new onset asthma. Our goal is to characterize WTC Cough Syndrome and identify its mechanisms.”

Additional grants are helping Dr. Rom and his colleagues perform an epidemiological study of a larger cohort of people living in lower Manhattan to assess the danger of acquiring new onset asthma as a result of inhaling the massive amounts of debris that accompanied the fall of the twin towers. Another study will examine the potential for asthma development in telephone workers who were exposed to Ground Zero several days after 9/11 to restore power to the surrounding area.

Other clinical studies include one at the Mt. Sinai School of Medicine in which researchers are con- ducting a health evaluation of 200 ironworkers who dismantled the remains of the World Trade Center and comparing those evaluations to ironworkers elsewhere.

In addition, Johns Hopkins University is developing a registry of the estimated 3,000 to 4,000 workers involved in cleanup at Ground Zero for study by questionnaire and function tests as well as for outreach initiatives. Columbia University will study pregnancy outcomes and subsequent child development in a sample of exposed women compared with other women unexposed to the attacks.

New contracts set

In August, the Health and Human Services Department announced an $11.4 million contract with Mt. Sinai to determine whether rescue and recovery workers and volunteers who worked at the WTC disaster site are experiencing related illnesses or injuries. The contract will fund free standardized clinical examinations to workers and volunteers involved in Ground Zero rescue and cleanup efforts. Under the contract, the Mt. Sinai School of Medicine and a consortium of occupational health clinics in New York, New Jersey, and other locations will provide examinations to eligible workers and volunteers.

In a study combining the evaluation of both psychological and clinical fallout from Sept. 11, Cynthia Pfeffer, M.D., professor of psychiatry at Weill Cornell Medical College and attending psychiatrist at New York-Presbyterian Hospital’s Weill Cornell Medical Center, is attempting to determine the emotional and physiological effects of bereavement on children who lost parents in the attacks.

She will follow 50 children, aged 6 to 12, through in-depth interviews at intervals of about six months. The study will also measure the children’s levels of cortisol, a hormone affected by stress. And Dr. Pfeffer will track the children’s growth in height and weight, comparing all of these measurements against a control group of children who did not lose parents on 9/11.

Dr. Pfeffer shares the enthusiasm of her colleagues for helping those who risked their lives for others on 9/11 and those who remain victimized as a result of that day’s terrible events. “The effects of Sept. 11 can be very variable,” she says. “We think it’s very important to find out the impact of the attack on the [individuals] most severely affected, to understand the emotional and physiological changes they are going through, and to provide all the support we can to them in this difficult time.”

Contact Us    © 1995-2008 AAMC    Terms and Conditions    Privacy Statement