For the survivors of deadly disasters and accidents, the psychological aftermath can often last longer than the physical injuries.
That's the case not just for victims but also their rescuers, a fact that has earned growing recognition since the terrorist attacks of Sept. 11, 2001.
"I didn't know that what I was feeling was normal, and I sucked it up because that's what you do as a firefighter," says Monica Escamilla, a veteran firefighter paramedic for the Los Angeles Fire Department who suffers from post-traumatic stress disorder (PTSD). "But I learned that it had a name, and that there's help for it." The attacks of 9/11 may also have been a turning point in attitudes toward the disorder, especially among first responders - the police officers, firefighters, paramedics and other personnel who are first on the scene at emergencies.
After a dramatic initial surge in mental health cases treated by New York City's Fire Department after Sept. 11, the number has stabilized, but is at a significantly higher figure than previously - roughly 2,000 annually, more than triple the caseload of 650 before the attacks.
However, the size of the force has remained roughly the same.
Before 9/11, "Going to the counselor's unit was a stigmatizing event, and the numbers tell you it's now more acceptable," says Malachy Corrigan, a 31-year member of the FDNY and director of its counseling service unit.
"In any type of rescue work, there's a high premium on being stronger than those around you, on being a rescuer in all situations," Corrigan adds. "You don't want to show a chink in the emotional armor." That mentality had begun to change before the World Trade Center attacks, which claimed the lives of 404 FDNY, NYPD and Port Authority rescue workers just on the day of the collapse. Since then, estimates have put the toll among first responders at nearly 1,000, factoring in medical ailments that developed later, such as respiratory diseases.
For the first responders left behind, the experience has often been deeply scarring, with many afflicted by PTSD symptoms including depression, nightmares, flashbacks, bursts of anger and other emotions. PTSD can exert a profound effect on both professional performance and relationships, with some sufferers turning to drugs and alcohol, according to the National Institute of Mental Health.
Formally recognized by the American Psychiatric Association in 1980, post-traumatic stress disorder has more usually been associated with soldiers; the term was coined in reference to U.S. veterans of the Vietnam War, but was acknowledged less directly beforehand, having been referred to as soldier's heart after the American Civil War and shellshock following World War I, says Corrigan.
PTSD is now the third most common cause of treatment sought from the FDNY's counseling service unit.
of the approximately 2,000 clients who used the unit's services in 2012, 525 sought support for PTSD, placing it behind only anxiety disorders and depression. As per Corrigan, the ailments often have overlapping characteristics, but are classified according to the "dominant" symptoms.
The number of professional staff available to address PTSD has also increased, rising from nine before 9/11 to 28. Beyond access to FDNY counselors, department staff participate in educational seminars about PTSD.
The FDNY's first responders can also meet with 55 active trained peer counselors, whose work includes presentations addressing PTSD.
For Corrigan, FDNY rescuers' openness to counseling post-9/11 forced a reappraisal of firefighting.
"So many people were obviously hurting that it became more acceptable to seek support," Corrigan says.
"As people step forward and talk about it, it changes," adds Escamilla, president of Love a Hero, a volunteer run charity that provides support for first responders. "Firefighters are stoic but as more people acknowledge their symptoms, the more other people are talking about it. You have to start the dialogue."
WHERE TO TURN
1-800-LifeNet (1-800-5433638) is a free, multilingual, 24/7 service for those searching for help related to a broad swath of mental health and substance abuse issues.
Columbia University's Trauma and PTSD Program conducts studies and provides information about PTSD: columbiatrauma.org; 212-543-6514
New York State Psychiatric Institute compiles research and provides a variety of services: nyspi.org; 212543-5000
New York Disaster Interfaith Services aids recovery through faithbased initiatives: nydis.org; 212-669-6100
Voices of September 11th, an advocacy organization, offers information and other services: voicesofseptember11.org; 866-505-3911