Compassion fatigue following the September 11 terrorist attacks: a study of secondary trauma among New York City social workers

Experience suggests that individuals working in the caring and psychotherapeutic professions are among those to provide mental health services to disaster victims suffering from psychological trauma following catastrophic events. Yet, few studies have focused on the emotional exhaustion from working with such clients, referred to as compassion fatigue (CF) in this study, and how CF differs from other occupational hazards, such as secondary trauma (ST) and job burnout. In the present study, we used recently validated scales to predict ST and job burnout related to providing services to those affected by the World Trade Center (WTC) attacks. Our study data were based on a random survey of 236 social workers living in New York City (NYC), over 80% of which reported being involved in post-WTC disaster counseling efforts. Our analyses indicated that controlling for demographic factors, years of counseling, and personal trauma history, ST was positively associated with WTC recovery involvement (p <. 001) and negatively associated with having a supportive work environment (p < . 01). In contrast, job burnout was negatively associated with having a supportive work environment (p < .01), but not associated with WTC involvement or WTC counseling efforts. We discuss these results in light of future conceptual and empirical research needs.     

Post-9/11 helpseeking by New York City parents on behalf of highly exposed young children

This study examines factors related to helpseeking among New York City parents on behalf of their young children after the September 11th terrorist attacks. Data were gathered from 180 parents about their children (under age 5) through in-depth parent interviews 9-12 months postdisaster. Parents were asked to describe their children's disaster-related experiences, their own and their children's mental health status, and post-9/11 helpseeking behavior for their children. Predictors of parental helpseeking for children's services included the emergence of new fears in children since 9/11, parent symptoms of depression, and parents' own helpseeking. The strongest predictor was children's direct exposure to the attacks. Fifteen percent (n = 27) of parents sought services for their very young children. Findings suggest that following 9/11, a familial orientation to helpseeking combined with children's specific disaster-related experiences may provide a basis for seeking services for young children, rather than children's apparent mental health status.     

The parent-rated social skills of a sample of New York City preschool children 8-10 months after September 11, 2001

This study compared the Social Skills Rating System-Preschool Parent Version ratings of two groups of New York City preschool children 8-10 months after September 11, 2001. One group of children was within 1 mile (1.61 km) of the World Trade Center (WTC) during the attack and exposed to one or more traumatic events. The second group was 2.04 to 14 miles (3.28-22.54 km) away from the WTC and not exposed to traumatic events. The social skills ratings of the comparison groups did not significantly differ These outcomes were consistent after statistically adjusting for the potentially confounding influence of parental PTSD, anxiety, and depression symptoms.     

Mental health service and medication use in New York City after the September 11, 2001, terrorist attack

OBJECTIVE: A survey assessed use of mental health services and psychiatric medications in New York City four to five months after the September 11, 2001, attack on the World Trade Center. METHODS: A telephone survey using random-digit dialing was conducted among 2,001 adult householders. RESULTS: During the interviews, 7.6 percent of respondents reported use of mental health services in the past 30 days and 7.7 percent reported use of psychiatric medications. Factors associated with service use included experiencing four or more lifetime traumatic events, experiencing two or more stressful life events in the past 12 months, having posttraumatic stress disorder (PTSD), and having depression. African-American and Hispanic respondents were less likely than white respondents to use services. Greater service use after the attack was associated with a graduate education, increased alcohol use after the attack, and depression. Factors associated with medication use included being in either of two age groups (25 to 44 years and 45 to 64 years), having a primary care physician, experiencing two or more stressful life events in the past 12 months, and having depression. African-American and Hispanic respondents were less likely than white respondents to be taking medications. Greater use after the attack was associated with having depression. Mental health visits in Manhattan appeared to decrease compared with the first two months after the attack. However, among respondents with PTSD or depression, those who were nonwhite, younger, without a primary care physician, or without health insurance were less likely to use postdisaster services. CONCLUSIONS: Service use after the terrorist attack was related to mental status and to the amount of trauma and stress experienced. Overall, white respondents, those aged 25 to 64 years, and those with a primary care physician were more likely to use services.     

Alcohol use disorders and drinking among survivors of the 9/11 attacks on the World Trade Center in New York City

Research on the relationship of alcohol and disasters has yielded mixed conclusions. Some studies investigate alcohol consumption but others examine alcohol use disorders in relation to disaster. Alcohol consumption and alcohol use disorders have not be studied concurrently in relation to specific disaster trauma exposures. A volunteer sample of 379 individuals from New York City agencies affected by the September 11, 2001 (9/11) attacks on World Trade Center were assessed approximately 3 years postdisaster for alcohol consumption and alcohol use disorders relative to specific disaster exposures. Increases in alcohol consumption were relatively small, eventually returning to pre-9/11 levels, with few cases of new alcohol use disorders or alcohol relapse. The findings suggest that postdisaster alcohol use has negligible clinical relevance for most of the population. Scarce disaster resources should be focused on those at identified risk of excessive alcohol use, that is, those with pre-existing alcohol or other psychiatric disorders.     

Outreach and peer-delivered mental health services in New York City following September 11, 2001

OBJECTIVE: Following the tragedy of September 11, 2001, the Federal Emergency Management Agency (FEMA) funded Project Liberty, an umbrella program operating from multiple sites throughout New York City to provide free crisis counseling and other assistance. One particular Project Liberty site provided peer support services for individuals with pre-existing psychiatric disabilities. This article reports on the outreach efforts undertaken by Project Liberty's Peer Initiative. METHODS: As part of a broader qualitative study, face to face interviews were conducted with Project Liberty Peer Initiative staff and service recipients. CONCLUSIONS: Outreach was found to be a key strategy used to identify and connect with psychiatrically disabled individuals in need after disasters. Implications for the use of similar outreach strategies in future disaster planning and service delivery are described.     

Acute stress disorder, depression, and tobacco use in disaster workers following 9/11

Early posttraumatic psychiatric disorders have not been well studied in disaster workers. This study examined the rates of probable acute stress disorder (ASD), probable depression, increased tobacco use, and their associated risk factors in 9/11 World Trade Center disaster workers. Surveys were obtained from 90 disaster workers (e.g., medical personnel, police, firefighters, search and rescue) 2-3 weeks after 9/11. Nearly 15% of disaster workers had probable ASD and 26% had probable depression. Probable ASD and depression were highly related to functional impairment. The risk for ASD was increased for those with 9/11-specific disaster exposures, more pre-9/11 trauma exposures, and the peritraumatic dissociative symptom of altered sense of time. Disaster workers who were younger, non-White, or who had increasing numbers of peritraumatic dissociative symptoms were more likely to have probable depression. More than half of tobacco users increased their tobacco use after 9/11. Additionally, all tobacco users with probable ASD and almost all tobacco users with probable depression increased tobacco use. Rapid mobilization of resources for early screening and intervention and health promotion campaigns aimed at improving adverse health-related behaviors may be helpful for this high-risk group.     

Compassion fatigue and psychological distress among social workers: a validation study

Few studies have focused on caring professionals and their emotional exhaustion from working with traumatized clients, referred to as compassion fatigue (CF). The present study had 2 goals: (a) to assess the psychometric properties of a CF scale, and (b) to examine the scale's predictive validity in a multivariate model. The data came from a survey of social workers living in New York City following the September 11, 2001, terrorist attacks on the World Trade Center. Factor analyses indicated that the CF scale measured multiple dimensions. After overlapping items were eliminated, the scale measured 2 key underlying dimensions--secondary trauma and job burnout. In a multivariate model, these dimensions were related to psychological distress, even after other risk factors were controlled. The authors discuss the results in light of increasing the ability of professional caregivers to meet the emotional needs of their clients within a stressful environment without experiencing CF.     

Probable cigarette dependence, PTSD, and depression after an urban disaster: results from a population survey of New York City residents 4 months after September 11, 2001

Disaster exposure may exacerbate psychopathology and substance-related disorders. Four months after September 11, 2001, using random-digit dialing to contact a representative sample of adults (N = 2001) living in New York City, we assessed cigarette smoking and symptoms of probable cigarette dependence using measures from the National Survey on Drug Use and Health. A total of 36.8% of smokers reported increased cigarette use; 10.4% of respondents reported three or more symptoms of cigarette dependence and were considered cases of probable cigarette dependence based on DSM-IV criteria. Cases were more likely to report an increase in cigarette use since September 11 than non-cases (69.4% among cases vs. 2.2% among non-cases, p < 0.001). Cases were more likely to have probable posttraumatic stress disorder (PTSD) and depression than non-cases (18.1% vs. 5.7% for PTSD, p < 0.001; 23.6% vs. 6.0% for depression, p < 0.001). Increased cigarette use since September 11 was associated with probable PTSD among cases (23.4% vs. 6.4%, p = 0.011) and non-cases (15.1% vs. 5.5%, p = 0.034) but was associated with probable depression only among cases of probable cigarette dependence (28.3% vs. 13.3%, p = 0.027). This study showed the co-occurrence of probable cigarette dependence with increased cigarette use and the co-occurrence of probable cigarette dependence with probable PTSD and depression after September 11.     

Posttraumatic stress disorder and terrorism: 5 years after 9/11

PURPOSE OF REVIEW: This article aims to review and summarize the recent literature investigating the relationship between posttraumatic stress disorder and terrorism. A particular focus is given to the studies related to the terrorist attacks on New York City and Washington, DC on 11 September 2001. The review aims to provide an update on an article published in this journal in the year following the September 11 attacks. RECENT FINDINGS: Elevated rates of posttraumatic stress disorder in the general population follow terrorist attacks but soon normalize, whereas directly exposed populations have higher rates and more persistent symptoms. An increased risk of posttraumatic stress disorder is associated with direct exposure, geographical proximity, female sex, low income, poor education, poor social supports and prior psychotropic drug use, and high-level media reporting of events (for vulnerable individuals). SUMMARY: An accumulating body of data exists on the relationship between posttraumatic stress disorder and terrorism in recent years. Caution needs to be exercised in drawing general conclusions as numerous variables need to be taken into account in addition to the socio-political context of the terrorist attacks. Having said this, a number of consistent findings are emphasized, not least the high degree of psychological resilience demonstrated across populations affected by terrorism.     

Behavior problems in New York City's children after the September 11, 2001, terrorist attacks

Children's behavior was assessed with 3 cross-sectional random-digit-dial telephone surveys conducted 11 months before, 4 months after, and 6 months after September 11, 2001. Parents reported fewer behavior problems in children 4 months after the attacks compared with the pre-September 11 baseline. However, 6 months after the attacks, parents' reporting of behavior problems was comparable to pre-September 11 levels. In the 1st few months after a disaster, the identification of children who need mental health treatment may be complicated by a dampened behavioral response or by a decreased sensitivity of parental assessment to behavioral problems.     

Surrogate motherhood: attachment, attitudes and social support

In recent years, there has been a revival of interest in the procedure of using a surrogate mother to help infertile couples have a child. One of the issues brought into public awareness by the Baby M case, where the surrogate mother refused to give up the baby to the biological father, has been the nature of the attachment of the surrogate mother to the fetus. Thus far, research has not addressed this issue of attachment as well as it has considered other variables involved in the process of surrogacy. The current exploratory study focuses on differences between two groups of pregnant women - surrogate mothers and nonsurrogate mothers - in the degree and quality of attachment, attitudes toward pregnancy, and social support. An understanding of what pregnancy signifies for surrogate mothers is developed, based on objective measures and informal interviews with surrogate and nonsurrogate mothers. The implications of the various phenomena associated with surrogate motherhood are also considered.     

Science for the community: assessing mental health after 9/11

Reactions to the September 11 attacks across the United States were pervasive, and persons throughout the country reported experiences akin to posttraumatic stress disorder (PTSD) in the first week following the attacks. In the New York area, 2 major surveys conducted 4 to 8 weeks after the attacks found that approximately 1 in 10 persons probably met full criteria for PTSD related to September 11. Although tobacco, alcohol, and marijuana use did increase, it was largely among persons already using these substances. The greatest increase, not surprisingly, occurred among persons with PTSD and major depressive disorder. Nationwide during the same time period, rates of PTSD related to September 11 were estimated at 2.7% to 4.3%, a striking finding in that the attacks were witnessed primarily on television outside the New York area. In all studies, having anxiety symptoms or meeting criteria for PTSD was strongly associated with number of hours of television watched on September 11 and in the days afterward. A number of explanations for this new finding are possible. These data can inform our understanding of trauma-related diagnoses, further the evolving diagnostic definitions of the Diagnostic and Statistical Manual of Mental Disorders, and contribute to etiologic models of PTSD. Future directions for postdisaster survey research are briefly discussed.     

Utilization of mental health services following the September 11th terrorist attacks in Manhattan,New York City

To assess mental health utilization in Manhattan following the September 11th terrorist attacks, a random-digit-dial telephone survey was conducted 5 to 8 weeks afterwards, among 988 randomly selected adult householders over 17 years old (females = 52%; whites = 72%; mean age = 42). 16.9% (95% confidence interval [CI] = 14.4-19.5) of residents reported using mental health services 30 days before the attacks and 19.4% (95% CI = 16.7-22.2) reported using these services 30 days afterwards (pre/post NcMemar's chi2 = 8.0, df = 1, p = 0.005, odds ratio[OR] = 2.0). 10.0% (95% CI = 7.9-12.0) increased mental health utilization 30 days after the attacks, compared to 30 days before and 5.3% (95% CI = 3.7-6.9) decreased utilization. Risk factors associated with increased mental health utilization in multivariate analyses included: being 45-64 years of age (vs. 65+; OR = 8.3, p = 0.011) female gender (OR = 2.3, p = 0.004), experiencing 4+ lifetime traumatic events (vs. none; OR = 3.5, p = 0.002), experiencing 2+ stressful life events in the past 12 months (vs. none; OR = 3.3, p < 0.001), and experiencing an acute panic attack during the disaster (OR = 3.3, p < 0.001). Neither current post-traumatic stress disorder (PTSD) nor current depression was predictive of increased post-disaster utilization when panic attack was included in the multivariate analysis. While we did find a statistically significant increase in pre- vs. post-disaster utilization among the general population in Manhattan this increase was not substantial, except among specific subgroups, including those who had a perievent panic attack, among those exposed to previous stressors, among women, and among those less than 65 years old.     

Working toward resilience: a retrospective report of actions taken in support of a New York school crisis team following 9/11

A retrospective report details external support rendered to a Lower Manhattan school crisis team following the 9/11/01 terrorist attack on the World Trade Center This analysis occasions an opportunity for consideration of working assumptions, the formative use of data to plan support actions, and the subsequent emergence of a collaborative approach to post-disaster team support in school settings. The nature of assessment and nature of subsequent service delivery illustrates a community resilience-based approach to school crisis management. Recommendations for such work are based upon mixed qualitative and quantitative data gathered from on-scene team members as part of the ongoing support effort.     

Paroxetine, other antidepressants, and youth suicide in New York City: 1993 through 1998

BACKGROUND: Regulatory agencies in the United Kingdom and the United States have recently issued warnings about a possible link between suicidal ideation and attempts and the use of paroxetine in a pediatric patient population. The objective of this study was to determine the proportion of youth suicides that tested positive for paroxetine or other antidepressants in medical examiner toxicologic testing in New York City from 1993 through 1998, the first 6 years that paroxetine was available in the United States. METHOD: Subjects in this medical examiner surveillance study were suicides less than 18 years of age. Serum toxicology was examined for paroxetine and other antidepressants. RESULTS: There were 66 suicides among persons under 18 years of age in the years 1993 through 1998. Toxicology was tested in 58 (87.9%) of the 66 suicides, and 54 (81.8%) had injury-death intervals of 3 days or less. None of the victims had paroxetine detected in their blood obtained at the time of autopsy. Imipramine was detected in 2 victims and fluoxetine in another 2. CONCLUSION: Despite regulatory concerns, none of the autopsies of youth suicides in New York City detected paroxetine in the victims, although other antidepressants were detected in 4 victims. However, in the vast majority of the youth suicides, there was no evidence of anti-depressant use immediately prior to death.     

Relationships between memory inconsistency for traumatic events following 9/11 and PTSD in disaster restoration workers

The present study examined the relationships between memories for a single incident traumatic event – the 9/11 attack on the World Trade Center (WTC) – and posttraumatic stress disorder (PTSD). 2641 disaster restoration workers deployed at the WTC site in the aftermath of the attack were evaluated longitudinally, one year apart, for PTSD, using clinical interviews. Their recollection of the traumatic events was also assessed at these times. The results showed that recall of traumatic events amplified over time and that increased endorsement of traumas at Time 2 was associated with more severe PTSD symptoms. It was also shown that, of all the exposure variables targeted, memory of the perception of life threat and of seeing human remains were differentially associated with PTSD symptoms. Implications of the results are also discussed.     

Antidepressants and youth suicide in New York City, 1999-2002

OBJECTIVE: To determine the proportion of youth suicides in New York City from 1999 to 2002 in which antidepressants were detected at autopsy. METHOD: This is a medical examiner surveillance study of suicides in New York City among those younger than 18 years of age. The outcome measure is serum toxicology for antidepressants. RESULTS: From 1999 through 2002, there were 41 individuals younger than 18 years of age among residents of New York City who committed suicide. Thirty-six (87.8%) had a serum toxicological analysis and an injury death interval of 3 days or less. There was one (2.8%) suicide in which both bupropion and sertraline were detected at the time of autopsy. Antidepressants were not detected in any of the other youth suicides. CONCLUSIONS: The detection of antidepressants at autopsy was quite rare in youth suicides in New York City from 1999 to 2002.