BRIEF REPORT. Social Workers Experiences of the World Trade Center Disaster: Stressors and their Relationship to Symptom Types

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1 Community Mental Health Journal, Vol. 41, No. 2, April 2005 (Ó 2005) DOI: /s y BRIEF REPORT Social Workers Experiences of the World Trade Center Disaster: Stressors and their Relationship to Symptom Types Lisa Colarossi, Ph.D. Janna Heyman, Ph.D. Michael Phillips, Ph.D. ABSTRACT: The study describes New York area social workers experiences of nine different stressors on 9/11. It also examines their reports of working with clients within the 6 months after 9/11. These variables are then analyzed for their relationship with symptomology 6 months after 9/11. Proximity to the WTC on 9/11, knowing someone who was a primary victim, and talking with clients about events related to 9/11 were all related to symptom levels; however, these experiences differentially impacted levels of depressive, anxiety, and somatic symptoms. Sex and race differences were found among the variables. KEY WORDS: September 11, 2001; symptoms; stressors; disaster; World Trade Center. The terrorist attacks on September 11th, 2001 shocked the nation. Victims, families, workers and many Americans faced difficult situations and fears (Schlenger, Cadell, & Ebert, 2002). The 9/11 disaster Lisa Colarossi, Janna Heyman and Michael Phillips are affiliated with the Graduate School of Social Service, Fordham University, 113 West 60th Street, New York, NY, An earlier version of this paper was presented at the Society for Social Work and Research annual conference, Washington DC, Address correspondence to Lisa Colarossi, Graduate School of Social Service, Fordham University, 113 West 60th Street, New York, NY 10023; colarossi@fordham.edu. 185 Ó 2005 Springer Science+Business Media, Inc.

2 186 Community Mental Health Journal resulted in New York area social workers being called upon to provide crisis intervention and on-going counseling for trauma-related effects, while simultaneously trying to cope with their own personal loss of friends and loved ones and having witnessed the disaster in close proximity. While there has been extensive research on natural disasters and their impact, less is known about large-scale man-made tragedies in the US. Yet, catastrophic events such as bombings are linked with a variety of emotional and behavioral sequella (Tucker, Pfefferbaum, Nixon, & Dickson, 2000, p. 406). Research has documented the effects of such events on recovery workers, including firefighters, police, and medical personnel; but the phenomenon of providing services to survivors of the same event that the professional has also experienced as a civilian is rare. This research has shown the service providers who have experienced a similar traumatic event have worse outcomes than those who have not (Dane & Chachkes, 2001; Dougall, Herberman, Inslicht, Baum, & Delahanty, 2000; Luce, Firth-Cozen, Midgley, & Burges, 2002). Even more limited is the research on social workers as trauma responders. What we do know about the impact of providing services after a disaster is primarily based on a series of studies showing that listening to the stories of trauma survivors such as war veterans to Holocaust to sexual assault survivors can have negative physiological and psychological effects on psychotherapists and other care providers (Danieli, 1994; Haley, 1974; McCann & Pearlman, 1990; Taylor & Frazer, 1982). The purpose of this study is to: (1) describe New York social workers experiences of different stressors on 9/11 (including their proximity to the WTC site, knowing a primary victim, and being displaced from home or work) and the frequency of their service provision to clients within the 6 months after 9/11; (2) analyze the relationship of these stressors with symptom types 6 months after 9/11 including post-traumatic stress, depression, anxiety, and somatization; and (3) determine whether there are demographic differences, such as race, age, income, and sex, in these data. Participants and procedures METHODS A cross-sectional survey study was conducted with an availability sample of 777 social work students and M.S.W. practitioners in the New York Metropolitan area (including New Jersey, upstate New York, all five boroughs of New York City, and Connecticut)

3 Lisa Colarossi Ph.D. et al months after 9/11/01. The sample has diverse demographic characteristics with 57% Caucasians, 18% African Americans, 15% Hispanics, 5% each Asian and Caribbean Islanders; 56% single and 44% partnered; 85% females; a mean age of (SD ¼ 12.28). Surveys were administered to M.S.W. students during classroom field seminars, with 642 students completing the survey. All of these students participated in regular fieldwork during the prior 6 months. Additional surveys were obtained by US mail from 135 agency-based social worker(s) who were solicited because of their role as field instructors. Measures Independent variables. Stressor variables were measured using single items, which asked about nine different experiences. Proximity stressor questions included, how close do you live in miles to the WTC site? Did you witness in person any part of the disaster on the day of 9/11?; Where you displaced from your home or work after 9/11, and if so, for how long? Did you have trouble getting home after the attack? Known victim questions included, Were you or someone you know injured during the attacks, and if so, what is their relationship to you? Did you know someone who died as a result of the attack, and if so, what is their relationship to you? Do you know a rescue, recovery, or construction worker assigned to the WTC site? Social work service provision was measured with single items that asked, what percentage of your clients have identified symptoms related to the events of 9/11? How frequently (1 ¼ never, 5 ¼ all the time) do your client talk to you about the events of 9/11 or related events (e.g., war, anthrax, terrorism, etc.)? How many hours per week do you spend on clinical practice, case management, administration, supervision, research? How many hours do you spend providing direct services to children under 12, adolescents, adults, seniors? Dependent variables. Symptoms of anxiety, depression, and somatization were measured using the Patient Health Questionnaire (Diez-Quevedo, Rangil, Sanchez- Planell, Kroenke, & Spitzer, 2001), which asked participants to rate, using a 5-point Likert scale (1 ¼ not at all to 5 ¼ all the time), how often they experienced 28 different symptoms at the time of the survey. Three subscales were mean scored: anxiety (8 items, Chronbach a ¼.87), depression (10 items, a ¼.85), and somatization (10 items, a ¼.80). The appendix lists symptoms in each subscale. A post-traumatic stress (PTS) scale was created using the mean score of 16 items that reflect definitional characteristics of post-traumatic stress disorder (American Psychological Association, 2002) and were consistent with other standardized measures of post-traumatic stress. This study did not intend to measure the diagnostic criteria necessary for a disorder; instead levels of post-traumatic symptoms were measured. Items were selected from the Patient Health Questionnaire and from an instrument designed to measure the effects of 9/11 for the National Institute of Mental Health (Norris, 2001). These items were measured on a 5-point Likert scale (1 ¼ not at all, 5 ¼ all the time), which asked how often they experienced symptoms such as: trouble concentrating, nervousness, muscle tension, nightmares about the disaster, intrusive memories, numbness, difficulty concentrating, and fears of the future. This scale had good internal reliability (a ¼.90). Instead of using one aggregated dependent variable such as an overall symptom score, we analyzed the effects of stressors on different symptom types using subscales of depression, anxiety, and somatization, in addition to a post-traumatic stress score. Each stressor variable was analyzed separately for its effects on the four dependent variables simultaneously using MANOVA. MANOVA provides an advantage over

4 188 Community Mental Health Journal separate ANOVA tests because it accounts for the correlations between the dependent variables and allows a comparison of the differential effects of a stressor variable across each symptom type; it is also robust to intercorrelation (Bray & Maxwell, 1985). RESULTS Initial exploratory analyses indicated that stressor variables did not have linear effects on symptoms. No significant correlations were found between symptoms and the number of miles away from the WTC site, the number of victims known, or the amount of time persons were displaced from their home or work. These continuous variables were then recoded into 5 and 3 intervals. These intervals also had no linear effects on symptoms. Finally, after reviewing the distributions, it appeared that there were specific dichotomous threshold scores that differentiated between those with higher and lower symptom levels. For example, those participants living less than 10 miles radius from the WTC site had similar levels of symptoms, which significantly differed from those who lived more than10 miles away from the site. Also, it did not matter how many victims of the disaster participants knew, rather only whether they knew any victims or not. TABLE 1 Frequency of Experiencing Different Types of 9/11 Stressors Stressor Percent of participants who experienced it (n = 777) Worked < 10 miles from WTC site 36% Know a recovery worker 34% Lived < 10 miles from WTC site 27% Trouble getting home after the attack 20% Witnessed the WTC attack 19% Know someone injured 18% Know someone who died 18% Displaced from work after 9/11 10% Displaced from home after 9/11 2%

5 Lisa Colarossi Ph.D. et al. 189 Frequency of stressors Table 1 presents the percent of participants who experienced each of nine stressors related to the WTC attack. Of the nine stressors, 21.2% of participants reported experiencing no stressors, 53.6% reported experiencing between one and three stressors, and the remaining 25.2% reported between four and eight stressors. It should be noted that even though 10% of participants reported being displaced from work after 9/11, none of the participants in this study lost their jobs as a result of the disaster and work displacement was short term (a few days to a few weeks). Twenty percentage of participants reported having trouble getting home on 9/11 (e.g., bridges, tunnels, and subways were closed down for much of the day), but the vast majority of participants were able to return home in less than 12 h. Also, no participants lost a spouse, parent, or child in the disaster and no participants lived or worked less than 1 mile away from the WTC site (making the less than 10 miles indicator actually between 1 and 10 miles). Chi-Square analyses were conducted to test for differences in stressors by demographic category. There were no differences in individual stressor types by sex or age. Racial/ethnic differences were found for (1) knowing a recovery worker (v 2 ¼ 15.60(4), p ¼.004), (2) knowing someone injured on 9/11 (v 2 ¼ 10.13(4), p ¼.04), (3) having trouble getting home (v 2 ¼ 37.96(4), p ¼.000), and (4) being displaced from work (v 2 ¼ 20.24(4), p ¼.000). Post hoc analyses revealed that more Caucasians (non-hispanic) than would be expected by chance had trouble getting home on 9/11 and were displaced from work after 9/11, while fewer Caucasians knew recovery workers and injured people than did the other racial categories, which were similar to each other across stressors. M.S.W. students had more trouble getting home on 9/11 than did post-m.s.w. practitioners (v 2 ¼ 7.11(1), p ¼.01), while more post-msw s reported knowing someone who was injured than did students (v 2 ¼ 3.76(1), p ¼.05). Finally, t-tests revealed that participants who were displaced from work (t ¼ 2.79, p ¼.01), had trouble getting home (t ¼ 3.84, p ¼.000), and were closer to the WTC site on 9/11 (t ¼ 1.97, p ¼.05) all had lower mean incomes than those who did not experience those stressors. Frequency of symptom types The sample, on average, reported rarely experiencing symptom types (Somatic M ¼ 1.78, SD ¼.63; Depressive M ¼ 1.83, SD ¼.64; Anxiety M ¼ 2.22, SD ¼.78; PTS M ¼ 2.08, SD ¼.67). However, further anal-

6 190 Community Mental Health Journal FIGURE 1 Percent of Total Sample Experiencing Symptom Types and Reporting an Increase after 9/ Somatic Depression Anxiety Never Sometimes Increased ysis reveals that a majority of participants reported experiencing some symptoms, with only 18% reporting never experiencing any somatic symptoms, 15% any depressive symptoms, 11% any anxiety symptoms, and 2% any PTS symptoms (see Figure 1). Of those who did report symptoms, 36% said that depressive symptoms increased after 9/11, 21% that somatic symptoms increased, and 64% that anxiety symptoms increased. Additionally, 14% of participants reported 4 or more PTS symptoms. Table 2 displays MANOVA results for differences in average frequencies of symptom types (i.e., anxiety, depression, somatization, and PTS) between participant race, sex, and pre/post-msw status. Racial/ ethnic differences existed in levels of depression, anxiety, and PTS. Post hoc Tukey tests revealed that Caucasians and Asians reported significantly greater frequency of (1) depression than African Americans, Hispanics, and Caribbean Islanders, (2) anxiety than African Americans, and (3) PTS than Caribbean Islanders. Females reported greater frequency of all symptoms types than did males, even though there were no sex differences in reported stressors. Students reported greater frequencies of somatic symptoms than did M.S.W. practitioners, but no differences existed in depression, anxiety, or PTS between these groups. Pearson Product-Moment correlation analyses indicate a negative relationship between age and all symptoms types such that the younger the participant, the greater frequency of somatization (r ¼ ).12**), depression (r ¼ ).11**), anxiety (r ¼ ).10**) and PTS (r ¼ ).09*). No correlation was found between income and frequency of any symptom.

7 Lisa Colarossi Ph.D. et al. 191 TABLE 2 MANOVA Results for Mean Symptom Levels by Demographic Catergories Demographics Somatic M (SD) Anxiety M (SD) Depression M (SD) PTS M (SD) Race African American 1.68 (.62) 2.08 (.83) 1.68 (.59) 2.03 (.77) Hispanic 1.77 (.69) 2.16 (.79) 1.69 (.62) 2.06 (.72) Asian 1.80 (.51) 2.28 (.74) 2.01 (.71) 2.14 (.61) Caribbean Islander 1.56 (.63) 1.85 (.83) 1.51 (.58) 1.75 (.62) Caucasian 1.81 (.61) 2.31 (.74) 1.94 (.64) 2.13 (.62) F (df = 4) n.s. 5.38*** 9.54*** 3.31** Sex Males 1.57 (.54) 1.96 (.71) 1.68 (.60) 1.87 (.58) Females 1.81 (.64) 2.27 (.78) 1.86 (.65) 2.12 (.68) F (df = 1) 13.79*** 15.19*** 8.20** 13.27*** Pre-MSW 1.80 (.65) 2.23 (.80) 1.84 (.66) 2.09 (.68) Post-MSW 1.64 (.52) 2.17 (.66) 1.79 (.56) 1.99 (.60) F (df = 1) 6.56** n.s. n.s. n.s. Note: *p <.05, **p <.01, ***p <.001. Post-traumatic stress (PTS). Not significant (n.s.).

8 192 Community Mental Health Journal TABLE 3 MANOVA Results for Mean Symptom Levels by Stressor Stressor Somatic M (SD) Anxiety M (SD) Depression M (SD) PTS M (SD) Know a recovery worker 1.87 (.62) 2.31 (.76) 1.90 (.65) 2.14 (.64) Did not know a recovery worker 1.71 (.60) 2.18 (.79) 1.79 (.64) 2.02 (.64) F 10.17*** 4.41* 4.14* 6.61** Live < 10 miles from WTC 1.84 (.64) 2.36 (.75) 1.96 (.63) 2.18 (.64) Live > 10 miles from WTC 1.75 (.58) 2.19 (.78) 1.80 (.64) 2.03 (.64) F 3.59* 6.36** 8.09** 7.70** Witnessed the WTC attack 1.89 (.73) 2.33 (.79) 1.94 (.67) 2.18 (.69) Did not witness 1.74 (.58) 2.20 (.78) 1.80 (.64) 2.03 (.63) F 6.96** 3.11 p= * 5.67** Know someone who died 1.85 (.65) 2.31 (.80) 1.87 (.66) 2.15 (.68) Did not know someone who died 1.72 (.59) 2.17 (.77) 1.81 (.63) 2.01 (.62) F 8.31** 5.22* n.s. 7.22**

9 Lisa Colarossi Ph.D. et al. 193 Trouble getting home after the attack 1.86 (.69) 2.3 (.81) 1.84 (.64) 2.16 (.68) No trouble getting home 1.74 (.59) 2.2 (.77) 1.83 (.65) 2.03 (.63) F 4.65* n.s. n.s. 4.34* Know someone injured 1.89 (.69) 2.24 (.83) 1.86 (.66) 2.14 (.70) Did not know someone injured 1.74 (.60) 2.22 (.77) 1.82 (.64) 2.04 (.63) F 5.69** n.s. n.s. n.s. Displaced from work 1.92 (.77) 2.24 (.87) 1.84 (.68) 2.15 (.76) Not displaced from work 1.75 (.59) 2.22 (.77) 1.83 (.64) 2.05 (.63) F 5.62** n.s. n.s. n.s. Work < 10 miles from WTC Work > 10 miles from WTC F n.s. n.s. n.s. n.s. *Note: *p <.05, **p <.01, ***p <.001. Post-traumatic stress (PTS). Not significant (n.s.)

10 194 Community Mental Health Journal Stressors and symptom types Table 3 displays mean symptom levels and MANOVA analyses of the relationships between stress and symptom types. Participants who experienced (1) personally witnessing the WTC attack, (2) living less than 10 miles from the WTC site, (3) knowing someone who died, or (3) knowing a recovery worker reported significantly greater frequencies of anxiety, depression, somatization, and post-traumatic stress symptoms than did those participants who did not experience these stressors. Participants who were displaced from work and who knew someone injured had greater frequencies of somatic symptoms, but not depression, anxiety, or PTS than those who had not experienced these stressors. Finally, those who had trouble getting home reported greater frequencies of somatic and PTS symptoms, than those who did not. No differences in symptom frequencies were found between those who worked more and less than 10 miles away from the WTC. Service provision and symptom types A number of social work roles and tasks were analyzed for their association with symptomology. No relationships were found between any symptoms and the amount of hours spent on direct client contact or administrative tasks (e.g., supervision, agency management, paper work, etc.) or the amount of time spent with any specific client population (e.g., children, adults, elderly). However, among social workers who spent any amount of time with clients (84%), a positive relationship was found between the percentage of clients who identified symptoms directly related to the disaster (M ¼ 15.54, SD ¼ 23.28) and depression (r ¼.10**), anxiety (r ¼.14**), and PTS (r ¼.18***). Additionally, the frequency with which these workers reported that clients talked about the events of 9/11 or related concerns (e.g., anthrax, war, terrorism, etc.) (M ¼ 2.48, SD ¼ 1.38; rarely to sometimes) was positively associated with worker anxiety (r ¼.10**) and PTS (r ¼.12**). Females reported that a larger percentage of their clients identified symptoms related to 9/11 than did men (M females ¼ 16.26%, SD ¼ 23.90; M males ¼ 11.36%, SD ¼ 18.76; t ¼ 2.20, p ¼.03). There was no sex difference in frequency of talking to clients about 9/11. No differences in race, age, income, or student status existed in any of the service provision variables.

11 Lisa Colarossi Ph.D. et al. 195 DISCUSSION Results show that the vast majority (79%) of participants reported experiencing one or more stressors on 9/11. Additionally, although average symptom levels were low, the majority of participants reported experiencing symptoms 6 months after 9/11. Of those reporting symptoms, between 36% and 64% said that these were increases in symptoms post-9/11, with the most participants reporting increases in anxiety symptoms. Stressors predicted symptom types such that: living within 10 miles of the WTC site, knowing a recovery worker, and directly witnessing the disaster were positively related to all symptom types; knowing someone who died was related to somatic, PTS and anxiety symptoms, but not to depressive symptoms; and knowing someone who was injured in the attacks and being displaced from work after the attacks were significantly related to somatic symptoms only. These differences suggest the importance of disaggregating large symptomology scales to obtain more precise estimates different symptom types. This allows for an understanding of differential effects of stressors on symptoms, which can then be targeted for interventions that are efficacious for the particular type and amount of distress experienced. Furthermore, using a single aggregated scale of post-traumatic stress alone does not provide sufficiently detailed information; and many studies have shown that most people do not experience diagnostic levels of post-traumatic stress disorder after stressful events, but rather different levels and types of symptomology and at varying time frames after the event (Epstein, Fullerton, & Ursano, 1998). Findings also show that providing social work services in general (e.g., the amount of time spend on direct client contact vs. administrative work or the type of client population) did not impact symptom types, but providing services specific to 9/11 (e.g., the percent of clients identifying symptoms related to the disaster and the frequency of talking to clients about 9/11) was positively related to depressive, anxious, and PTS symptoms, but with low to moderate magnitudes of association (for similar findings see Boscarino, Adams, & Figley, 2004). Service provision was measured at six months post-9/11, not immediately after 9/11. Therefore, these services were not related to crisis intervention on 9/11, but to on-going (and possibly lower level) client distress associated with 9/11 over time.

12 196 Community Mental Health Journal The nature of services provided after the WTC was unique in that there were no rescued survivors of the WTC. Social workers who volunteered on the day of 9/11 and who were dispatched to hospitals and even to ground zero (as these researchers were), provided almost no crisis intervention on that day, as there were no rescued survivors after the towers collapsed. Therefore, most services were provided in the weeks and months following this disaster to NY area residents, witnesses, those who were able to exit the towers immediately after the airplanes hit them, and to family members of those who died. This may partly account for the low magnitude of correlations (the small variance in participant symptom levels overall also affects small relationship sizes). However, while social workers, disaster workers, and other professionals are trained to handle intervention-related stress, they still experience psychological effects, especially after a shared traumatic event (Dane & Chachkes, 2001; Holaday & Warren-Miller, 1995; Newhill & Sites, 2000). The need for extra support, debriefing, and training for social workers may continue long after the immediate event and increase with the amount of services provided to clients with trauma-related problems. Demographic differences emerged with regard to race and gender. Caucasians and Asians reported the highest levels of depressive, anxious, and PTS symptoms, but there were no racial differences in levels of somatization. This does not appear to be directly related to greater reports of stressors among Caucasians or Asians. Being a female was not associated with experiencing individual stressors, however, females reported higher levels of each symptom type than did males. This may be partly explained by pre-existing levels of symptomology that tend to be higher for females than males in the general population. It may also be that females are more likely to report symptoms and/or are more reactive to stress than males. APPENDIX A: SEPARATE SYMPTOMS THAT MAKE UP THE PATIENT HEALTH QUESTIONNAIRE SUBSCALES Somatic symptoms Stomach pain Backpain Pain or problems with sexual relations Headaches

13 Lisa Colarossi Ph.D. et al. 197 APPENDIX (Continued) Chest pain Dizziness Heart pounding or racing Shortness of breath Constipation or diarrhea Nausea, gas, or indigestion Depressive symptoms Feeling bad about yourself Angry Poor appetite or overeating Use of alcohol or other drugs Thinking of death or dying Blaming yourself for things Little interest or pleasure in doing things Down, blue, hopeless Sleeping too much Numb or distant from your emotions Anxiety symptoms Trouble concentrating Nervous, anxious, on edge, or worrying a lot Muscle tension, aches, soreness Easily annoyed, irritable Trouble falling or staying asleep Feeling as if your future will be cut short Difficulty concentrating Job stress Additionally, female participants reported having more clients who identified symptoms related to 9/11 than did male participants, which was associated with higher levels of some symptoms. REFERENCES American Psychological Association (2002). Diagnostic and statistical manual of mental disorders, fourth edition-tr. Washington, DC: American Psychological Association. Boscarino, J. A., Adams, R. E., & Figley, C. (2004). Compassion fatigue following the September 11 terrorist attacks: A study of secondary trauma among New York City Social Workers. International Journal of Emergency Mental Health, 7(1).

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