Dedication

2. Dedication This book is dedicated to those who lost their lives attempting to save others and to the families who have endured so much as a result of their sacrifice.

3. Firefighters, Police & EMS went from being first responders to victims Firefighters, Police & EMS went frombeing first responders to victims

4. Introduction • On September 11th the New York City Fire Department (FDNY) community lost 343 of its members. This represents the largest loss of life of any emergency response agency in history. • They left behind wives, fiancés, and girlfriends; mothers, fathers, and siblings; children young and old and yet to be born. They also left behind the more than 13,000 surviving members of the FDNY community.

5. About FDNY: Crisis Counseling • This text is about the CSU response to the needs of the FDNY community. • It is about reaching out to those who risked their lives that day to help others and as a result suffered the loss of roughly three percent of the workforce and six percent of command staff in less than one hour.

6. Decision Tree for Program Development Figure 1.1

7. Repeating Themes in FDNY: Crisis Counseling • Terrorism is about fear • it isolates people. • Generally, the most effective mental health response supports the inherent connection people have with one another. • Teamwork, works.

8. The Most Utilized Programs • Support and strengthen interaction • Communication • Emotional connections • Encourage safety and acceptance • Identify natural strengths among and within people • Services are made easily available and accessible

9. Guiding Principles • Innovation and adaptability of services • Inclusion • Multiple service locations • Normalization • Education • Collaboration • Pre-planning

10. Helping a Community in Crisis Figure 2.1

11. Coping with Chaos • The Counseling Services Unit Pre-9/11Merging with EMS – Two Different Cultures • The CSU Response to 9/11 • Assessing the Community • Receiving Outside Help • CSU Expansion • Connecting with the Firefighting Community • Connecting with Families • Family Liaisons • Moving Forward • Defining a Timeline for your Community

12. Understanding Culture • Cultural Identity • Exploring the Culture of the Brotherhood and the Impact of 9/11 • Firefighting History and Tradition in New York • Politics and Defiance • Modern Firefighting in New York City • The FDNY as a Paramilitary Organization

13. Understanding Culture (continued) • Everyday Life in the Firehouse • Rituals and Rank • EMS Culture • Common Bonds • Family Ties That Bind • Heroics, Media & Politics • The Brotherhood and Its Loss • Applying Cultural Identity to Intervention

14. Checklist for Understanding the Culture of a Community • Understand the history and traditions • Process of enculturation • Understand everyday life • Understand ethnicity, economy, gender • Understand interaction of cultural influences with other groups, communities • Understand cultural influences that affect individual behavior

15. Shaping Services to Meet Emerging Needs • Factors Influencing Initial Assessment • How history informs service delivery • The Role of Program Assessment • How the nature of the event shaped the response • When loss is catastrophic • When mission is ongoing • Listening and responding to emerging needs • Getting the word out: the importance of multiple methods of outreach

16. Program Development Program Development Outreach Service Delivery Outreach Service Delivery Shaping Services

17. Shaping Services to Meet Emerging Needs • Strengthening the CSU Identity • Establishing provider networks • Independent Practitioners • Special Projects

18. Building partnerships • Do’s and Don’ts for Consultants • Do wait to be invited in • Don’t assume there is nothing in place • Do be clear on what you can offer and why you think it is of value • Do respect boundaries; don’t do end runs around the appropriate people because you are impatient or think you know better what is needed • Do create a feedback loop with the designated representative and use that person consistently to make your needs and observations known • Do see yourself as a representative of the organization • Do anticipate termination

19. Establishing a network of private practitioners • Consult with an expert to set up your system. • Identify needed expertise and create a user-friendly data base for ready access. • Establish clear limits based on time frames, not clinical information. • Establish a single point of entry into the system; this avoids splitting and reduces the potential for internal conflict. • Meet regularly to identify systemic problems and address them immediately. • Set up an e-mail link with providers to communicate non confidential material quickly and efficiently. • Identify the team players and use them when referrals are requested.

20. Critical Aspects in shaping the FDNY/CSU 9/11 response: • Longevity and ongoing nature of the recovery effort • Scope of direct, FDNY losses • Inability to recover remains of the lost • Public and media attention to all aspects of FDNY • Ongoing threat of additional terrorism

21. Building a staff: both peer and professional… • Care for the Caregivers • The rewards of the work • The need for self care is undisputable • Education and training • Professional and Peer Supervision • Additional Supports • Keeping the machinery going: issue of funding and resource development • Thoughts for the future

22. Guidelines for Education

23. Components of the Self-Care System Education & Training Supervision Resources for Wellness Services Components of Self-Care System Individual Social Outlets Figure 4.2

24. Caution: Generalizing from one disaster to another can be dangerous so too from one fire department to another …and one firehouse to another ...and from one firehouse clinician to another …and yet certain experiences were consistent across the board.

25. Providing Help in the Workplace: The Firehouse Clinician Project • The Mindset of FDNY Firefighters • The mission and history of the unit  • The nature of the emergency • Training and experience of the individuals

26. The Intervention: Placing Clinicians in Firehouses • Genesis of the Project • The Population: • defining who needed services • The Site: • Five Boroughs of Firehouses • 62 firehouses suffer direct losses • Theoretical Orientation • Generalizing Lessons • Caution is advised when generalizing from one event to another • Intervention Goal • Make mental health services accessible • Match available services to the needs of the firehouse • Identify individuals having extreme reactions, very depressed or isolated

27. Be more careful not to confuse group statistics with prejudiced stereotypes One firehouse clinician said,“Perhaps you would have anticipated working with men who were not receptive to the language of emotional expression, and you would have been as wrong as I was when I began my stint as a Firehouse Clinician.” “You are going into somebody’s home, not just their place of business.”

28. Onsite Skills • Trust develops when an onsite mental health clinician • Has relevant experiences • Is honest • Knows what he/she has to offer • Is willing to be a resource rather than a psychotherapist

29. The Firehouse Clinicians Project • Selecting Firehouse Clinicians • Initial Training to be a Firehouse Clinician • Learning about the FDNY culture • The Best Advice: “You are going into someone’s home, not just a place of business.” • Phase One: Pairing the Firehouse Clinician with a Firefighter • The First Visit to the Firehouse • The Challenges of the Early Months • Ice breakers • Informational materials, handouts

30. Techniques • Icebreakers • Food • Information • Use of internal structure • Conceptualizing the Role • Resource rather than therapist • Educating and normalizing • Consistency and availability

31. The Firehouse Clinicians Project • Revamping Professional Boundaries • Group Dynamics • Personalities and Relationships in the Firehouse • Understanding Therapeutic Relationships: Transference • Parking lot therapy • Meeting everyone, different times, shifts • Preparing to be a Firehouse Clinician • Listening to Fear and Bravery • Prerequisite Skills for Onsite Mental Health Workers • Flexibility in Theory and Practice Relating to Firefighters • Relationship of Counseling Services Unit to the Firehouse Clinicians • Termination Countertransference: the time to leave the firehouse • Firehouse Clinicians Post 9/11

32. Working With a Group You Never Meetdifferent from other clinical experience where the members of the treatment team meetto discuss clients… in this setting, the clients are first responders who are often together and sometimes talk about the clinicians • Group Continuity • Different groups are present through the 24 hours/7 days per week work cycle • Use of Language • Being Tested, Being Trusted • Inclusion • Gender Bias

33. Preparing to be a Firehouse Clinician • Learn about disasters and survivor guilt • Determine as best you can if you can listen to stories about horrible conflicts and hold indelible, horrific images • Ask yourself if you are prepared to be moved in ways that will surely affect you and your family. You might want to discuss this choice with your spouse. • Are you willing to modify your ideas about your profession so you can be therapeutic?

34. How the CSU Aided the Firehouse Clinicians • Paired professional mental health clinicians with peer counsellors • Maintained open, two-way communication • The CSU was always available to answer questions • Hosted meeting for the firehouse clinicians to share experiences • Said “Thank you” often, freely, and sincerely • Demonstrated commitment to the goal of helping the first responders

35. CSU Intakes 9/01 – 6/05

36. Modifying Psychotherapy for Individuals (1) • Individual Psychotherapy with Firefighters • Pre-treatment Conditions • The Parameters of Individual Treatment • The context, the disaster • The individual charateristics • Choosing Individual Psychotherapy • Personal preferences • Issues related to shame

37. Modifying Psychotherapy for Individuals (2) • Treatment Considerations • Treatment Goals • Pre-trauma levels of functioning • Attain functioning at a level considered healthy • Implications for Psychotherapy Technique • Time in Relation to Treatment and Process • Appointment times may vary with the workers schedule • Interventions • Normalizing and depathologizing • Boundaries • Public crisis versus private trauma • Termination

38. Transference and Countertransference • For some of the firefighters, a firehouse clinician may have represented an ideal parent and to others, a useless parent. • Some seemed to react to a mental health professional with fear and suspicion, perhaps the fear of a rejecting parental object. • How can these issues be addressed in a firehouse with many people and outside of the privacy of a quiet, safe therapy office?

39. Finding Comfort in Groups (1) • Why Group Intervention? • The healing power of groups cannot be overemphasized • Therapy Groups vs. Support Group • Trauma Groups: Temporal Considerations • Issues of Membership Selection • Structural Considerations

40. Finding Comfort in Groups (2) • Acute/Emergency Phase On-site Interventions • Early/ Post-Impact Phase On-site Groups • Kitchen-Table Groups • Middle and Later Phase Office-based Groups • Importance of Homogeneity in Group Formation • Traumatic Bereavement Groups • Process of Grief and Bereavement • Meeting the Families of the Missing • Beginnings

41. Process of Grief and Bereavement • Accepting the reality of the loss • Experiencing the feelings related to the loss • Adjusting to the environment • Emotionally relocating the deceased in memory in order to go on with life

42. Finding Comfort in Groups (3) • Different Voices of Grief • The Work of the Group • Differences • Reconstitution • Single Session Groups: the use of activities and education in community building • A final word about groups

43. Providing a Home-Based Therapeutic Program for Widows and Children (1) • Understanding the Experience for Mothers and Children • Traumatic Elements • The Long Search • Deaths of Multiple Friends and Acquaintances • Media Scrutiny • The Special Role of the Firefighter Father

44. Providing a Home-Based Therapeutic Program for Widows and Children (2) • Developing CSU Services for Bereaved Families • Developing a Program for Individual Families • Challenges to Developing Appropriate Services • The Family Assessment and Guidance Program • Four bi-monthly, then monthly interviews in home during the first two years. More frequent contacts provided as needed or requested. • Two or more interventionists meet with family members in their own home • Year three and later flexible interview and measures schedules, frequency based on family needs • Mother and children over age seven complete battery of measures twice during the first year, annually after that. • Provide feedback to families on measures and evaluation

45. Assessment Domains for Children • Psychological state and behavior • mourning, separation reactions, self-esteem, internalizing and externalizing symptoms • Functioning in the home with parent and siblings • School competence and overall cognitive functioning • grades and academic functioning • Behavior • in relation to teacher and classmates • After school activities and hobbies • Peer and classmate relationships

46. Providing a Home-Based Therapeutic Program for Widows and Children (3) • Preliminary Trauma, Grief, Reconstitution Model • Definitions of the Process Depicted in the Preliminary Loss and Reconstitution Model • Restoration Identity Restructuring TRAUMA↔GRIEF↔RECONSTITUTION

47. Preliminary Model of Loss and Reconstruction

48. Providing a Home-Based Therapeutic Program for Widows and Children (4) • Implementing for the Family Program • Intervention Goals for Children and Adolescents • Intervention Goals for Adults • Therapeutic Approaches • Finding Focus • Engaging the Population • Interviewing in the Home • Assessment • Lessons Learned

49. Strengthening the Connections Within the Family at Home • Firefighters have two families • After 9/11, the firehouse family dominated the lives of the firefighters • “What’s said here, stays here” • Protecting the family at home from the dealing with the daily dangers of the job • After 9/11, the public nature of the event broke through the shield that protected the family by not talking at home about the job

50. The Impact of Trauma on Relationships • No one goes through trauma alone. When an individual is dramatically affected by an event, that event will impact those closest to him or her as well. The classic symptoms of trauma each create an understandable disturbance in intimate connections • Avoidance: • the necessary numbing where one can’t cry, can’t feel, can’t talk about it, precludes intimacy and involvement through constriction of feelings. • Re-experiencing • the presence of intrusive recollections of the traumatic event in thoughts, images, nightmares and flashbacks takes one away from participation in the here and now. • Hyper-arousal: • reacting physically, neurologically and psychologically as if still in danger makes the normal routines of family life nearly impossible to tolerate. The sound of children’s chatter, infant crying, sibling squabbles et al often lead to angry outbursts, overreactions and ultimately to isolation.