Secondary Traumatic Stress Symptomatology
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Running Head: POST 9/11 SECONDARY TRAUMA STRESS IN FIRE FIGHTERS.
Secondary Traumatic Stress Response in Fire Fighters in the Aftermath of
9/11/2001
Traumatology, 11, 75-85
Randal D Beaton1, Shirley Murphy2, L. Clark Johnson3, and Marcus Nemuth4
1,2,3
Department of Psychosocial and Community Health
University of Washington, School of Nursing
Seattle, WA 98195
4
Psychiatry Emergency Service
VA Puget Sound Health Care System
Seattle, WA 98101
Correspondence: Randal D. Beaton, Ph.D., E.M.T., c/o the Department of Psychosocial
& Community Health, Box 357263, School of Nursing, University of Washington,
Seattle, WA 98195-7263, Phone: (206) 543 8551; Fax: (206) 685 9551; e-mail address:
randyb@u.washington.edu
Word Count: 2,053
Acknowledgements:
This project was supported by grant R01-OHO3198 and Rl8-OHO3559 from the
National Institute for Occupational Safety and Health of the Centers for Disease Control
and Prevention, awarded to the first and second authors. This publication was also made
possible by grant number 1 TO1HPO1412-01-00 from the Health Resources and Service
Administration, DHHS, Public Health Training Center Program and its contents are
solely the responsibility of the authors and do not necessarily represent the official views
of HRSA. Finally, this project was supported, in part, under a cooperative agreement
from the Centers for Disease control and Prevention (CDC) through the Association of
Schools of Public Health (ASPH). Grant Number U36/CCU300430-21. The contents of
this article are solely the responsibility of the authors and do not necessarily represent the
official views of CDC or ASPH.
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Abstract
On September 11, 2001, 343 fire fighters died in the line of duty responding to the
terrorist attacks, explosions, fires, and collapse of the World Trade Center Towers.
Coincidentally, a convenience sample of professional urban fire fighters in a northwest state was
participating in a leadership intervention demonstration project and completed survey measures
including a measure of posttraumatic stress symptomatology. The purpose of this study was to
assess secondary traumatic stress symptoms in separate cohorts drawn from this convenience
sample of the fire fighters, who completed surveys either prior to, or in the days and weeks
following the events of 9/11/01. The results suggested that elevations in posttraumatic stress
symptoms reported by the fire fighter cohort completing surveys at one-week post-9/11
represented an acute secondary traumatic stress reaction to the events of 9/11/01.
Word count 133
Key words: Secondary traumatic stress; fire fighters; terrorism; acute posttraumatic stress
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Secondary Traumatic Stress Symptomatology in Fire Fighters in the Aftermath of
9/11/2001
Professional fire fighters in the U.S. have a much higher prevalence of posttraumatic
stress disorder (PTSD) than community comparison samples (Corneil, Beaton, Murphy, Johnson
& Pike, 1999). This increased risk of post-traumatic stress symptomatology appears to be related
to several factors. Among these factors is fire fighters’ exposure[s] to a variety of duty-related
incident stressors (Beaton, Murphy, Johnson, Pike & Corneil, 1998). In a previous study of U.S.
urban fire personnel, fire fighter fatalities (witnessed or not witnessed) were rated as the most
stressful of 33 actual and/or potential duty-related incident stressors (Beaton et al, 1998). On
September 11, 2001, the terrorist attacks on the World Trade Center resulted in 343 fire fighter
fatalities – all members of the Fire Department City of New York (FDNY)
(http://femaweb4.fema.gov/cgi-sh1/weh_evaluate.exe).
The stressor “Criterion A” for Posttraumatic stress disorder recognizes that individuals
can be traumatized without actually being harmed or threatened with physical harm (American
Psychiatric Association [APA], 1994). Figley (1993) has argued that a secondary traumatic
stress (STS) reaction can occur, with symptoms identical to PTSD, from merely knowing about a
traumatizing event experienced by a significant other such as work colleagues of the primary
victims (Figley 1995, Figley & Kleber, 1995; Ortlepp & Friedman, 2002). This is important
since such vicarious traumatization has not been the subject of much study in “crisis workers’
such as fire fighters (Beaton & Murphy, 1995).
Another consideration is the extremely close knit fire fighter occupational “culture”,
stemming, in part, from a reliance on teamwork and upon one another in emergency situations
(Beaton & Murphy, 1995). Mutual bonding, personal and professional affiliations may have
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increased other fire fighters’ sense of identification with their fatally wounded and surviving
FDNY fire fighter comrades at the World Trade Center on 9/11/01 and augmented their sense of
co-victimization (Alexander & Wells, 1991). Thus, we hypothesized that it would be possible to
assess STS reactions in fire fighters who worked in another U.S. state in the aftermath of the
events of 9/11/01.
The primary purpose of this report was to examine the pattern of avoidance and intrusive
secondary traumatic stress symptomatology (and STS “caseness”) in separate cohorts drawn
from a convenience sample(s) of U.S. fire fighters in a NW state who completed surveys either
prior to or in the days and weeks following the events of 9/11/2001. A second purpose was to
determine whether the fire fighter participant sample(s)’ secondary traumatic stress
symptomatology showed evidence of partial or complete recovery within the one month postevent timeframe examined.
Method
Sample and Sampling Procedures
Participants were 261 professional fire fighters employed in an urban fire department in
the Pacific Northwest. The samples for the current analyses provided data for the 6th of 8
planned data collections obtained over a 3-year period. (Prior extended baseline observations on
the same measure were also available for sub analyses.) The sample was 89% Caucasian, with a
mean age of 40.38 years (SD = 7.8), range 22 to 59 years. The majority of the participants were
male (91%), married (70%) and reported a mean of 14.1 years (SD = 1.69) of formal schooling.
At the time of the initial data collection, the study participants had been fire fighters for an
average of 13 years (SD = 8.1) and, of these, 65% were considered “line” fire fighters and
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paramedics (as opposed to supervisors or officers). Separate temporal cohorts of fire fighters,
based on shift assignments, consisted of fire fighters who completed surveys on September 10,
2001 (Day Before; n = 24); on September 12th and 13th 2001 (1-2 Days After; n = 52);
approximately one week after 9/11/2001 (1 Week After; n = 93); approximately 2 weeks after
9/11/2001 (2 Weeks After; n = 21); or approximately one month after 9/11/2001 (1 Month After;
n = 54). Recruitment and investigational procedures were in accordance with university and
APA human subjects guidelines.
Instruments
The Impact of Events Scale (IES) was used to measure the presence and self-reported
frequency of secondary traumatic stress symptoms (Horowitz, Wilner, & Alvarez, 1979). The
IES measures both intrusion (7 items) and avoidance (8 items) symptoms of posttraumatic stress.
Respondents were instructed to indicate the frequency with which they may have experienced a
given symptom or item within the past week using a likert-style format: ‘not at all’ = 0, ‘rarely’ =
1, ‘sometimes’ = 3, and ‘often’ = 5. The IES items address Criterion B and C for PTSD
diagnosis as indicated for DSM IV (APA, 1994). The event instructions provided to all fire
fighter participants/cohorts were identical (“Below is a list of comments made by people after
stressful life events.”) and did not change after 9/11/01. A total IES score of 26 was used as the
STS clinical “caseness” criterion paralleling the PTSD-caseness criterion employed in prior
investigations (Corneil et al, 1998; Corneil, 1995). Zilberg, Weiss, & Horowitz (1982) report
adequate internal reliability for the IES (r = .87, test-retest reliability (r = .89 and .79).
Cronbach’s  for the current study was .95.
Data Collection Procedures and Study Design
Officers in the participating Fire Department received the final intervention module
approximately a year prior to the data presented herein. Therefore, all participating fighters in
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this study would have been exposed to either the direct or indirect effects of the proffered
intervention. Hence the data analyzed and presented in this paper was part of a longitudinal field
study and employed nonequivalent convenience temporal cohorts to ascertain the impact, if any,
of a specified historical event (Pre/Post quasi-experimental design [Campbell & Stanley, 1963]).
Results
Temporal Pattern of IES Avoidance and Intrusive Symptoms and STS “Caseness”
Table 1 shows the means and standard deviations on the IES avoidance and intrusive
subscales for each of the temporal samples (based on date of administration relative to 9/11/01)
as well as the results of ANOVA testing for temporal group differences. Table 1 also shows the
proportion of fire fighters in each temporal group who met the STS caseness criterion, associated
standard deviations as well as the results of ANOVA testing for temporal group differences.
Figures 1 and 2 show the September 10, 2001 baseline, 1-2 days post, 1-week post, 2week post and 1-month post means and 95% confidence bars for the IES avoidance intrusive
subscales, respectively. The results of ANOVA testing for temporal cohort group differences
between the September 10 and all post event time periods on the IES avoidance and intrusive
subscales were both statistically significant; F (4,239) = 5.77, p < .001; F (4,239) = 5.59, p <
.001, respectively. Post hoc Tukey comparisons documented statistically significant differences
between the one week post-event means on both the IES avoidance and intrusive subscales
compared with the mean scores obtained on the day before, 1-2 days post event, and 1 month
post-event (all p’s < .05). The two-week post-event means on the IES avoidance and intrusive
subscales did not differ significantly from the group means obtained from the day before
(September 10) cohort or from any other post-event cohort IES mean score (all p’s > .05). That
is, both avoidance and intrusive secondary traumatic stress responses “spiked” significantly in
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the one week post-event sample. The results of ANOVA testing for temporal/group differences
between the September 10 and all post-event temporal cohorts on the secondary traumatic stress
IES caseness criteria (total IES ≥ 26) was also statistically significant. F (4,239) = 3.,89, p < .01.
Post hoc Tukey comparisons on the IES measure of STS caseness documented statistically
significant differences between the one week post-event cohort prevalence compared to the STS
caseness cohort prevalences obtained on the day before, 1-2 weeks post event and one month
post-event (p < .05). The two-week post-event cohort STS caseness prevalence did not differ
significantly from the September 10th baseline cohort prevalence or from any other post-event
cohort prevalence (all p’s > .05). That is, the prevalence of secondary traumatic stress responses
also “spiked” significantly in the one week post-event sample.
Stability of Pre-event IES Avoidance and Intrusive Symptoms and STS “caseness”
Between group ANOVA tests were generated on the IES for each of the five previous
semi-annual survey administrations of the IES for all subjects who participated in the
September/October 2001 survey cycle (n’s ranged from 150 to 196) and the September 10th
baseline (n = 24) sample. The results of these between group ANOVA tests on the IES
avoidance and intrusive subscales as well as the PTSD caseness criterion all failed to reach
statistical significance; F (5,849) = .79; F (5,849) = .90 and F (5,849) = .66, respectively.
Differences Between Temporal Groups on Trauma Risk Factors
Finally, no between temporal cohort group differences could be documented on any of
the previously documented demographic or occupational risk factors for trauma symptoms in fire
fighters (Corneil et al, 1999). Neither the Chi-Square tests for marital status 2 (5, N = 244) =
7.96, p > .05, nor for rank 2 (5, N = 244) = 13.22, p > .05 were statistically significant. The
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ANOVA test for years of services between (temporal) groups was also not significant F (4,242)
= 1.08, p > .05.
Discussion
The results of data analyses showed temporal cohort group differences on the measures
of secondary traumatic stress symptomatology that appeared to be related to the traumatic events
of 9/11/01. No other local, national or international historical factor could readily be identified
that might explain the pattern of avoidance and intrusive trauma stress symptomatology or STS
caseness prevalences in this fire fighter sample. For example, the first cases of anthrax
bioterrorism in the U.S. were not reported in the media until October 4, 2001 and therefore could
only have influenced the replies of the one-month post-event sample (CDC, 2001).
In the absence of any other plausible historical event and a relatively stable pre-event
baseline on the IES measures, it would seem that a “reasonable causal inference” would be that
the significant elevations on the IES avoidance and intrusive subscales and STS “caseness” at
one week post-event in this fire fighter sample represented a symptomatic reaction to the events
of 9/11 (Cook & Campbell, 1979). This is important since such vicarious secondary traumatic
stress reactions have not been the topic of much study and clearly have the potential to affect the
social and occupational functioning of individuals who have merely learned about a traumatizing
event experienced by a significant other such as a work colleague (Figley & Kleber, 1996).
The STS “caseness” prevalence of more than 40% at one week post-event was one of the
highest posttraumatic stress disorder prevalence’s ever reported in the literature for fire personnel
(McFarlane & Yehuda, 1996) and was approximately twice the previously reported rate for US
fire fighters using the same IES caseness criteria (Corneil et al, 1999). However, since these
Secondary Traumatic Stress Symptomatology
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reported traumatic stress symptoms had clearly not persisted for one month, they would not meet
the APA DSM-IV diagnostic criteria for PTSD (APA, 1994).
It is worth noting that the avoidance and intrusive secondary trauma stress reactions as
well as the STS caseness appeared to “spike” at one-week post exposure in our fire fighter
samples. This suggested that immediate post-event coping and/or defenses, lasting for a few
days at least, seemed to effectively suppress and minimize secondary post trauma reactions
similarly, within 10 days – 2 weeks, post-event coping and/or defenses were strong enough to
initiate a recovery from the one-week acute post-trauma secondary trauma “spike”. We have no
way of assessing if and/or the degree to which our leadership intervention may have affected the
self-reported secondary traumatic stress responses in our fire fighter sample(s). This may limit
the generalizability of our findings to other fire fighters and first responder samples.
There were several other methodological limitations to this investigation including the
relatively small n’s of several of the temporal cohort groups, the pre/post design employed, the
lack of specificity and lack of arousal subscale of the IES in measuring trauma symptomatology
(Joseph, 2000) and the inability of the IES to detect exaggeration in situations where there might
be motivation to “fake bad” (Lees-Haley, 1990). It was also possible that the replies of our fire
fighter respondents on the IES may have represented an exacerbation of trauma symptoms
related to a prior exposure. Furthermore, no inquires were made of our subjects’ exposures to
media accounts of the events of 9/11/01 which may have affected their secondary traumatic
responses. Thus the present findings are suggestive, but not conclusive evidence, of acute
secondary traumatization in a significant fraction of a fire fighter sample in a NW state
approximately one week following the events of 9/11/01.
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Limitations not withstanding, this article contributes to the extant literature by
demonstrating the likelihood of secondary trauma stress reactions in high-risk groups. These
findings suggest that first responders such as fire fighters and other high-risk populations may
need and benefit from both pre-disaster and post-disaster mental health interventions. The
former might assist fire fighters to better cope with a potential terrorist attack and the latter might
include reducing exposure and an increased focus on worker safety and well-being during the
two week immediate post-event time period to mitigate possible social, psychological and
occupational impairments. The potential benefits of such pre-event mental health training would
be to reduce secondary traumatic stress, vulnerability and to increase their resiliency.
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Table 1
Means and (standard deviations) for IES measures at baseline, 1-2 days post, one-week
post, two-weeks post and 1 month post 9/11. Also shown are the results of temporal
group ANOVA tests (and associated P values).
Measure
IES
avoidance
subscale
IES
intrusive
subscale
STS
“caseness”
September
10th
Baseline
1-2 days
post
Oneweek
post
Two
weeks
post
2.9 (5.5)
5.3 (8.6)
10.5 (9.0)
6.1 (7.8)
5.8 (8.0)
5.77***
4.5 (8.0)
7.5 (9.4)
12.1
(10.7)
6.0 (6.1)
6.7 (8.4)
5.59***
.08 (.28)
.27 (.06)
.42 (.50)
.14 (.36)
.26 (.44)
3.89*
Note. * p <.05. *** p <.001.
One
month
post
F (3, 219)
values
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Figure 1. IES avoidance scale means (and 95% confidence intervals) for September 10,
2001 baseline and post-event time periods.
Figure 2. IES intrusive scale means (and 95% confidence intervals) for September 10,
2001 baseline and post-event time periods.
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14
12
10
8
6
4
2
0
-2
N=
24
52
Day Before
93
21
1wk After
1-2days After
54
1 mth After
2wk After
Time w/ reference to 9/11/01
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16
14
12
10
8
6
4
2
0
N=
24
52
Day Before
93
21
1wk After
1-2days After
54
1 mth After
2wk After
Time w/ reference to 9/11/01