Trauma and relationship strain: Oral histories with World Trade Center disaster responders

Abstract

Existing models of couple functioning after trauma are primarily based on the experiences of returning military veterans. In this study, we conducted thematic analysis of a purposive sample of 49 oral histories of responders to the 9/11/2001 terrorist attacks to understand how they navigated life with their spouses after the response experience. Use of multiple coders and analytic matrices increased analytic rigor. In the sample, 34.7% disclosed a PTSD diagnosis and another 22.7% mentioned experiencing at least one trauma symptom. Most responders had not sought mental health intervention, relying instead on their spouses’ caregiving. Responders’ reported limited disclosure to their spouses about the details of their 9/11/01 response work, which may have helped them cope emotionally with repeated 9/11/01 clean-up duties. Shared values regarding the common good and patriotism were important for maintaining an intimate relationship after 9/11/01, helping partners understand and feel understood by each other.

Disaster Response, Trauma, and Spousal Relationships

The 9/11/01 terrorist attack on the World Trade Center (WTC) was the worst human-caused disaster in the history of the United States, causing 2,753 casualties and leaving many others physically and emotionally injured. In the wake of the disaster, professional responders (e.g., paid and volunteer police and firefighters) and non-traditional responders (e.g., construction workers, electricians, transit workers, and other residents) from New York, New Jersey and other locations, came to the site of the attack to aid in rescue and recovery. In doing this work over days, weeks, and months, responders witnessed, smelled, and touched mass carnage. Most spent twelve-hour shifts at a time at the WTC sites, with long commutes back and forth each day. For those ‘on the pile’ at Ground Zero or at the Freshkills Landfill, work tasks included sifting through debris that included bodily remains; work tasks at other WTC response sites included delivering news of DNA evidence to grieving families who were searching for loved ones, security detail at Ground Zero, medical support to survivors and other responders, among others (Bills et al., 2009; Ekenga, Scheu, Cone, Stellman, & Farfel, 2011).

While many of these responders had been trained to work in disaster situations, this event was unconventional in its size and its duration, resulting in significant mental health consequences, including posttraumatic stress disorder (Author Citation) and depression (Wisnivesky et al., 2011). However, little is known about how these changes in mental health affected responders’ familial relationships, including how their family lives were affected. In this paper, we analyze oral histories of responders to the 9/11/01 WTC attacks to understand how responder(s) navigated lives with their intimate partners over time.

Trauma and its Consequences

Trauma is an experience or event that threatens the life or wellbeing of those who are exposed to it. By their very nature, terrorist attacks -- designed to inflict mass destruction without warning -- are traumas. They cause distress, both for responders who have immediate contact with the disaster, and the general public, who are exposed to images and information about the attack via television, social media, and print news.

Posttraumatic Stress Disorder (PTSD) is one possible outcome of exposure to a trauma. To be diagnosed with PTSD, a person must have four concurrent symptoms: intrusive memories, dreams, or flashbacks about the event; avoidance of memories, thoughts, people, places or things that remind the person of the event; negative thoughts and/or mood that begins or worsens after the event; and emotional arousal (e.g., hypervigilance, irritability, sleeplessness, and/or lack of concentration) that begins or worsens after the event (American Psychiatric Association, 2013). Lifetime estimates for PTSD among the general population vary from 6.4% (Pietrzak, Goldstein, Southwick, & Grant, 2011) to 8.0% (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012), with women about twice as likely as men to develop PTSD (Kessler et al., 2012; Pietrzak et al., 2011). PTSD is associated with several adverse physical and mental health outcomes, including substance abuse (Pietrzak et al., 2011), obesity (Kubzansky et al., 2014), and cognitive decline (Author Citation).

Exposure to a trauma can also cause individuals to develop some, but not all, symptoms of PTSD, called subthreshold PTSD (Brancu et al., 2016) or partial PTSD (Pietrzak et al., 2011). Depending on how it is assessed, the average prevalence rate of partial PTSD in the general United States adult population is between 12.6% – 15.6% (Brancu et al., 2016). While the cognitive and psychological effects of partial PTSD tend not to be as severe as full PTSD (Breslau, Lucia, & Davis, 2004), there is evidence to suggest that it is associated with some negative mental and physical health effects, including mood disorders, past suicide attempts, and recent functional impairment (Pietrzak et al., 2011).

In the aftermath of the attacks on the WTC, PTSD among responders was high; estimates are that between 5.4–29.2% of responders experienced PTSD, with differences in rates attributed to occupation of the responder, the length of time in that job, and the length of time conducting WTC disaster response (Liu, Tarigan, Bromet, & Kim, 2014). Over time, while a subset of responders’ PTSD remitted, a substantial proportion of responders continued to have active PTSD or partial PTSD; in one study of 3,231 responders, 9.7% had PTSD ten years past the event, while 5.9% had partial PTSD (Author Citation). Firefighters, police and other professional responders reported fewer posttraumatic stress symptoms than did civilian responders, 5.4 −14.4% (Author Citation; Berninger et al., 2010) compared to 23% (Brackbill et al., 2009). This difference has been attributed to the routine disaster response training that most professional responders receive as part of their job preparation, as well as to the stigma and potential negative job consequences that could arise from reporting (Author Citation).

Trauma and Intimate Relationship Functioning

Partner relationships are often negatively affected when one member of the couple experiences mental health effects from a trauma (Lambert, Engh, Hasbun, & Holzer, 2012; Taft, Watkins, Stafford, Street, & Monson, 2011). Posttraumatic stress is significantly related to intimate relationship discord as well as both physical and psychological aggression perpetration (Taft et al., 2011). In particular, anger and emotional numbing are significantly associated with spousal relationship problems (Campbell & Renshaw, 2013; Roberge, Allen, Taylor, & Bryan, 2016). Angry outbursts of a partner with PTSD can cause the other partner to become withdrawn in an effort to avoid provoking an angry emotional response (Dekel & Monson, 2010; Taft et al., 2011), whereas a partner with PTSD who is experiencing emotional numbing may not communicate clearly or easily with their spouse, leading to confusion and resentment about roles in the relationship (Dekel & Monson, 2010; Lambert et al., 2012). Monk and Nelson Goff (2014) found that many returning military personnel did not share their experiences, desires, or feelings about a trauma with their spouses because they were engaging in “protective buffering:” trying to protect their loved ones from the horrific distress that they themselves had experienced. However, this protective buffering was associated with less perceived marital closeness and less relationship satisfaction (Monk & Nelson Goff, 2014)

While poor communication is associated with low relationship satisfaction for both members of the couple, evidence also suggests that supportive and empathetic communication is associated with better relationship quality in marriages in which one person has posttraumatic stress symptoms (Campbell & Renshaw, 2013; Lambert, Hasbun, Engh, & Holzer, 2015). Henry’s (2015) research with couples in which one partner had experienced a trauma, found that open communication allowed for partners to feel like “insiders” to their partners’ experience of trauma, a feeling which helped them to empathize with their spouses and be able to provide emotional support. In contrast, partners in couples with limited communication felt shut out, like “outsiders” to their loved one’s experience of trauma. Time together has also been found to be a key ingredient to open communication (Lane, Lating, Lowry, & Martino, 2010).

In addition to changes in communication, the caregiving dynamics of a marriage often change when one partner experiences posttraumatic stress symptoms. The symptoms tend to have deleterious effects of a person’s ability to maintain social ties, causing them to become more isolated. In these instances, spouses become instrumental in caring for their partner with PTSD, even as that person might be pushing their family and friends away. (Hayes et al., 2010) found caregivers of service members who had left the military with a mental health diagnosis reported that the service members’ relationships with other family remembers worsened upon their return, leaving both the service member and caregiver without needed support. In a convenience sample of 465 U.S. veterans from various wars, the National Alliance for Caregiving (2010) found that 80% of spouses report managing the PTSD symptoms of their spouse, usually long before the spouse has gone to get professional help.

Perhaps unsurprisingly, then, partners of those with symptoms of posttraumatic stress often experience negative consequences of living with and caring for their loved one. Many report high stress levels as well as depression and other mental health disorders (Dekel, Solomon, & Beleich, 2005). In some cases, spouses may experience secondary traumatic stress (Bride & Figley, 2009), in which the spouse experiences some symptoms similar to those experienced by the person with PTSD, despite having not been directly exposed to the same trauma. All of these consequences can contribute to difficulty in connection, communication and emotion regulation between members of the couple (Waddell, Pulvirenti, & Lawn, 2015).

Conceptual Models of Couple Functioning

Various conceptual models of couple functioning have been proposed to explain couple functioning when one member of the couple of has experienced a trauma. The military-related PTSD dyadic model, developed by Gerlock, Grimesey, and Sayre (2014) describes the functioning of veterans diagnosed with PTSD as occurring through six intersecting relationship axes: responsibility, disability, caregiving, community, communication and trauma. Three relationship qualities--mutuality, locus of control, and tolerance of weakness--predicts how these axes will be navigated by the couple. Couples with high mutuality, balanced locus of control, and similar approach to weakness fare the best post PTSD-diagnosis.

The Couple Adaptation to Traumatic Stress Model (Nelson Goff & Smith, 2005) posits that couple functioning is a dynamic systemic process in which the functioning of the primary trauma survivor affects and is affected by the functioning of the secondary trauma survivor (i.e., the partner), as well as predisposing factors (e.g., age and previous trauma experiences) and resources (e.g., coping and support) available to each member of the couple. The authors suggest various mechanisms through which these systemic effects may occur within couples, including chronic stress, attachment, identification and empathy, projective identification, and conflict and physiological response. When testing the Couple Adaptation to Traumatic Stress model, Oseland, Gallus and Nelson Goff (2016) found that posttraumatic stress symptoms of numbing and avoidance disrupted a person’s ability to connect or form a strong attachment to the partner, pushing the partner further away. They contend that this detachment causes role disruption within the couple, wherein the spouse of the trauma survivor takes on a lot of added responsibilities in order to overcompensate for the trauma survivor’s emotional absence.

It is important to note that these couple trauma models do not only describe attachments as negative when one member of a couple experiences trauma (Fredman et al., 2010); indeed, as Nelson Goff and Smith (2005) point out, it is possible for a strong relational attachment between partners to benefit the survivor in healing from PTSD and reduce symptoms. Indeed, some studies have found that caregivers of spouses with mental illness tend describe a strong love for their spouses and deep commitment to the relationship (Waddell et al., 2015), eschewing words like “carer” and “burden” in preference for words like “husband”/”wife” and “commitment” (Lawn & McMahon, 2014). In fact, many caregivers report that their relationships became stronger over time (Lawn & McMahon, 2014).

Terrorist response as context for relationship strain

To date, most of the research on trauma and relationship functioning has focused on the experience of returning military veterans rather than those who have responded to terrorist attacks (Author Citation). While there are many similarities between the two contexts, several differences merit investigation into the intricacies of terrorist response. One difference is that disaster responders cycle between home and the disaster site regularly; therefore, there is not the same distance between the site of the trauma and the home context as there is with deployed military personnel. A second difference is that a terrorist attack is a trauma for the society as a whole, not just for the responders; this is different from military personnel, who experience trauma when deployed that their family members do not experience. A third difference is that the response corps is not a cohesive group prior to the terrorist attack; it is comprised of responders from a variety of professions as well as civilians who want to help. Thus, the sense of responsibility to a specific unit may be different.

Despite anecdotal evidence that WTC responders’ relationships suffered after 9/11/01, we do not have systematic analysis of how responders navigated family life with their partners. The present study uses a qualitative design to examine the effect of WTC response on relationship quality and functioning.

Method

Recruitment and Consent Procedures

Between 2010–2015, we collected oral histories from WTC responders and their families in order to preserve first-hand accounts of the response and impact of the 9/11/01 attacks. The study was approved by the Institutional Review Board at the lead author’s university. We conducted recruitment through routine medical visits, word of mouth, fliers posted at a health center offering clinical services to WTC responders, and the WTC Health Registry. Each participant provided signed consent to participate. During the consenting process, we explained that the interview would include questions about responders’ experience in the 9/11/01 clean up and their lives since then, including inquiry into their family relationships. We also described that the oral histories were being collected for research and educational purposes, with the ultimate intent of having them publically indexed at the Library of Congress and displayed at the National September 11 Memorial Museum in New York City. The consent process also included detailed instructions for withdrawing from the study. We gave participants a Project Removal Request Form, which they could sign and return at any time order to delete their interview from the database, noting that the interview would be challenging to remove if and when the archive was shared with the Library of Congress and in the public domain.

Data Collection

Videotaped interviews were conducted by one member of a research team from the health clinic. Present at each responder’s interview was a videographer, interviewer, and note taker. The interviewer asked open-ended questions to elicit the respondent’s oral history. We used a semi-structured interview guide to encourage responders to shape their own narratives around various domains of inquiry, including what brought them to the disaster site on 9/11/01, their specific roles in the recovery work, the impact of the recovery work on themselves and their families, and the effects of the 9/1l/01 attacks on their communities and the country.

Directly after each interview, the interviewer and note-taker met to index the interview according to keywords. These keywords were developed inductively from the interviews themselves, succinctly categorizing each interview according to issues that were particularly germane in that interview. Over the course of data collection, the list of keywords grew to 40 words or phrases, including Camaraderie/Unity, Effect on Family and Relationships, Loss of Sense of Self, Patriotism, Physical Health Issue, PTSD, and others. After indexing, the note-taker wrote a summary of the interview and recorded information about the interviewee in a spreadsheet. Categories of information on the spreadsheet included gender, WTC work site, WTC site arrival and departure dates, job duties at WTC work site, and responder’s occupation at the time of attack. Interviews were transcribed, checked for accuracy and edited for clarity.

Sample

For this study, we drew a purposive sample from the original 311 oral histories using a two-step process. First, we gathered all interviews indexed as either Effect on Family and Relationships or PTSD (N=76), as these two keywords were the most closely related to our research topic. Second, given our focus on relationship functioning during and after the WTC response, we selected for further analysis only those only those interviews with respondents who were in a serious, committed relationship at the time of 9/11/01, defined as being married or engaged to a cohabiting partner. This process yielded a final sample of 49 responders.

The sample was 89.8% male (n=44), with an average age of 51 years. The majority (89.8%, n=44) were still married to the same person as on 9/11/01. Occupations of the responders on 9/11/01 were varied: many (42.9%, n=21) were paid responders (police, firefighters or paramedics), 10.2% (n=5) were volunteer responders, 10.2% (n=5) were other New York City workers, 12.2% (n=6) were mental health counselors or therapists, and 20.4% (n=10) had other occupations, such as clergy, construction workers and journalists. Although we did not specifically ask about PTSD in the interviews, 34.7% (n=17) disclosed a PTSD diagnosis and another 22.7% (n=10) described currently experiencing at least one trauma symptom. Of the entire sample, 38.8% (n=19) disclosed having attended mental health counseling.

The demographic profile of this sample was similar to that of the larger cohort of 33,076 responders followed by the World Trade Center Medical Monitoring and Treatment Program (Dasaro et al., 2014), except for the rate of PTSD, which was about double the rate in the overall cohort (Author Citation). Given our criterion sampling approach, which specifically selected interviews indexed as PTSD, this difference in rates was expected. This comparison to the overall cohort suggests that this was a strong maximally varied, criterion sample.

Data Analysis

We loaded transcriptions of the interviews into Atlas.ti 7.5 and analyzed them using the 6-step thematic analysis approach outlined by Braun & Clarke (2006). After reading each transcript several times in its entirety to familiarize ourselves with the data, two team members (RD and MR) independently and inductively initially coded the interviews. They held weekly meetings with the lead author (AH) to review the coding and make decisions about discrepancies. RD, MR, and AH then then grouped these codes into initial themes: Communication with Others vs. Spouse, Feelings of Isolation, Finances, Altered Relationship with Spouse, and Physical Separation. Following Braun and Clarke (2006), we reviewed the themes twice. In the Level 1 review, we examined the themes in relationship to the coded extracts. Through this process, we eliminated or revised several themes to better encapsulate the data. We subdivided the theme Communication with Others vs. Spouse into Connection with Other Responders and Connection with Spouse: Primacy of Response Effort in order to differentiate between the types of relationships and to include relationship dynamics beyond “communication.” The theme Altered Relationship with Spouse was re-labeled Caregiving Relationship to better describe the nature of how the relationship changed. Also, review indicated that finances, while mentioned by several interviewees, were not central to responders’ stories about their relationships; thus, we eliminated the Finances theme.

In the Level 2 review, AH examined the themes in relationship to the entire dataset, by reading all the transcripts, and ensuring that the themes made sense. In collaboration with the other coders, AH developed analytic matrices (Miles, Humberman, & Saldaña, 2013) in order to compare experiences of various groups within the data, for example, (1) professional responders, volunteer responders, and civilian responders, (2) men and women, and (3) self-reported PTSD diagnosis, at least one PTSD symptom, no mention of PTSD or PTSD symptoms. Through this process, AH generated an initial conceptual map of the themes and their interrelationships, which the study team then reviewed and agreed upon (see Figure 1 for the finalized thematic map).

Figure 1:

Thematic map constructed during analysis

The research team used memoing and team discussion throughout the analytic process. RD, MR, and AH wrote analytic memos about initial codes that were applied frequently and/or were particularly interesting/puzzling to them in some way. Many of these memos became the basis for descriptions of the initial Level 1 themes. As Level 1 and Level 2 thematic reviews occurred, we wrote memos to clarify and expand on the meanings and interrelationships among themes. Because each memo was data stamped and attributed to its author, in team meetings we were able to look at an analytic step and identify who made it and when, allowing us to discuss discrepancies in analysis and arrive at a decision, as well as to address a priori assumptions in our interpretation. For example, RD was well-versed in treatments for PTSD, and she wrote a memo in which her interpretation of the data went beyond what was said in the interview to include her own assessment about the interviewee’s clinical needs. When we examined this memo together in a team meeting, we recognized the a priori assumptions embedded in the analysis and revised the analysis accordingly.

Research reflexivity was an ongoing part of our analytic process. We conducted reflexivity in two ways: (1) as we were coding, we wrote memos about how we were affecting and were affected by the research; and (2) we routinely discussed our own reactions to the stories in the data and assessed how our own positions affected our analysis. For example, in several team meetings, we discussed the emotional effects of reading interviewees’ negative comments about Muslims and terrorism; theses reactions differed depending on our own religious and cultural backgrounds (the research team included varied religious faiths, including Christian, Jewish, and Muslim). While such comments were not at the center of our inquiry, they were relevant to some of the themes regarding duty and patriotism; therefore, when we analyzed these comments, we took extra time to consult with each other regarding coding and interpretation to make sure that we were accurately representing the interviewees’ words.

Results

Work with a Purpose

Responders described the rescue and recovery work in weeks and months after 9/11/01 as all-encompassing and exhausting. When talking about their motivation during this time, very few responders described the tasks as being part of a job regardless of whether or not they were professional or volunteer responders; instead, most used words like “purpose,” “important,” or “responsibility” to describe how they felt about the work they did. The responders described this sense of purpose as emerging from two core beliefs. The first was a belief was that helping others in need is always the right thing to do. While many acknowledged that this principle was important for everyone to live by, responders described feeling that they, in particular, felt bound to help others, and that this quality distinguished them from others. Many responders described this identity as an inherent part of themselves—it had always been who they are. In the words of one responder, Patrick¹:

It wasn’t complete. I wanted to follow through. I often feel…that it’s my duty to help people. In fact, my father would often – not chastise me--but kind of joke, “You stop and help people. You’re crazy.” No, it’s not crazy. It’s helping people. It’s like when I was a Boy Scout. The proverbial walking-your-old-lady-across-the-road thing.

Here, Patrick describes his role as a WTC disaster responder as one in a series of ways that he has enacted his identity as a helper throughout his life. His use of generalized language (“I often feel,” “you stop and help people”) constructs his helpfulness as a long-standing, immutable part of who he is. For several of the professional responders, this inherent commitment to “doing the right thing” was an important component of their identities as public servants, police officers or firefighters. They had grown up with relatives (fathers, uncles, grandfathers) who were professional responders, and they described having been immersed in a culture in which doing the right thing was expected and then internalized. John explained:

You just never know what you’re going to come across… I mean, it’s no different than pulling up to a house fire. As you know, firemen, you’re Type A individuals. People do things that most people don’t like to get involved in. So it’s really just the feeling of helping in any way, shape, or form. No matter what it was.

The second core belief was that the United States of America was a wonderful, strong, and resilient country, despite efforts to destroy it. Responders felt anger at the terrorists for upsetting what they considered to be the truth of American exceptionalism. For these responders, participation in the clean-up effort was an effort to reassert America’s position in the world as a free and safe nation. Julia described:

I think that American pride thing they beat in my head from the time I was knee high. I think that was a big part of it ‘cause my genetic makeup was really angry. I kept hearing my grandparents and my parents in my head saying, ‘They’ll never attack America. This country’s too big and too great and too amazing,’ and it’s like you’re not supposed to be able to do this. What the hell?

In many responders’ narratives, both beliefs were present and mutually reinforcing. For example, when asked what drove him to stay at the site for days on end, Chris discussed both patriotism and helping others: “Patriotism. Patriotism and just being human. Just being human. Being there for your fellow man, woman, child. It doesn’t matter what you did in life or who you were in life when it comes down to it you should be there for your fellow man.” Similarly, Ned described how his professional role and patriotism combined, gave him the impetus to respond:

It wasn’t anything I think I had inside of me. I think it was just something that was taught to me…by my dad. A lot of the guys that were there were second generation, third generation cops…. We were just put in a machine; you do what you have to do. You’re doing it for your country; you’re doing it for your city.

Here, unlike Patrick who sees himself as always having been a helper, Ned clearly describes his identity as a helper as learned and then internalized, just like his attachment to his country.

This strong sense of responsibility meant that the responders had a hard time leaving the site, either to go home to sleep for the night, or when it was finally time to stop working at the site for good. When asked how it felt to take a shower after being away for three days with no rest, Patrick said: “I felt like I was shirking my responsibilities. So I had to get back in as quick as possible.” Kyle likened the feeling to an illness:

I think there was a part where it was almost like a sickness not being able to leave. Just having to stay. Because other people could have done it. You know, being relieved and then other people could have done it. But you know, we just couldn’t leave.

The language used by Kyle and Ned is starkly similar to those who describe addiction, being able to recognizing the feeling as an illness, but not being able to stop the behavior.

Home: Place of Refuge and Disconnection

The home stood in stark contrast to the emotional and physical rescue and recovery work. For the most part, responders described ‘home’ in positive terms, calling it a place of security and refuge from the 9/11/01 worksites. However, working at the 9/11/01 site caused short- and long-term upheaval in vast majority of the responders’ marriages. In the words of one responder, 9/11/01 “was definitely a marriage changer.” Despite feeling safer at home, they described feeling disconnected from the people in the home, due to sheer exhaustion and a desire to avoid talking about the disaster. Certain posttraumatic stress symptoms appear in the majority of the accounts of being at home: feeling isolated, decreased interest in activities, avoidance of reminders of the event, and depersonalization.

Ben: It was a sanctuary. That’s all it was honestly. It was, ‘I’m leaving madness, and I’m going home,’ and I was just more than happy to see my wife, my girlfriend at the time.

I: Did you talk about it with her or did you kind of just--

Ben: No. I became a zombie when I got home. Turned on the TV and just decompressed.

Ben’s use of the word zombie connotes a feeling of emptiness and lack of ability to make an interpersonal connection with his now-wife, despite being happy to see her. This feeling of isolation and disconnection was echoed by many responders when they discussed being at home. When asked why they did not communicate openly about their experience with their loved ones, responders gave one of two reasons: (1) a belief that their loved ones did not really want to know what was happening, or (2) a belief that their loved ones would not be able to understand the experience because they had not lived it.

I: Were you talking to your wife about it? To your daughters?

Charlie: It was not something I spoke about. If they asked questions I would answer them….but I think for the most part they were afraid to ask questions.

I: Why do you think that was?

Charlie: I don’t think they wanted to hear the answers.

Julia: They didn’t really wanna know what it was like. They saw it. They saw the pictures. They heard about it. They really didn’t wanna know…. I distinctly had the feeling that something about me was just not me anymore…Whoever I was when I went to Manhattan is not who came home….and I’m not sure they picked it up either. It was just, ‘Don’t really talk about it ‘cause we wanna have fun and you’re a letdown.’

Here, Julia describes having changed profoundly as a result of her response work, yet feeling unseen by her family members who do not want to be let down by the gravity of the terrorist attack. She makes a choice, then, to not be open with them about what is going on with her, because she does not feel that her disclosure would be welcomed. Non-disclosure, then, is a form of self-protection for Julia and other responders, such as Ben; being a “zombie” or not speaking about it was a way of steeling oneself against the emotions of the response effort, perhaps in an effort to be able to continue to go back for other shifts.

Several police and firefighters also described non-disclosure as a form of self-protection, citing professional norms of silence a central reason that they did not talk in depth with their spouses about their experiences. Explicitly and implicitly, the responders indicated that talking with their significant others about work was simply not done in their culture. Josh, a police officer, described this separation between home and work as crucial for keeping himself safe on the job.

She always gets mad at me because I’m a clam when it comes to my job, because I never thought bringing the job home was a smart thing. No matter if it was the first day on the job or my last day on the job, I never really…. There had to be a separation, because if I thought about my wife too much, or my family too much, I would have gotten hurt.

Here, rather than describe non-disclosure as way to protect his family from negative emotional consequences (so called “protective buffering”), Josh cites his own continued safety as the reason for not talking in depth with his wife about this work. He thinks these norms are useful and abides by them. In contrast, Walter described feeling trapped by the norms of nondisclosure, confident that his wife would have been able to handle what he was saying.

One of the problems with PTSD is you stuff it. The Police Department teaches you very unhealthy mental practices. When I was a police officer, I had five kids. I never, ever brought the stuff home that I saw in the city in the street. I never shared it with my wife, and my wife is a trooper. She would have understood, but I played by the rules.

Here, Walter describes norms of non-disclosure as damaging to his mental health, even though he complies with them. He feels like his relationship with his wife and family suffered as a result.

Unlike recent studies of veterans with PTSD, for the most part, respondents did not explain their uncommunicativeness as an attempt to protect their partner from the negative experiences. Only two of our respondents described concern that their communication with their spouse about 9/11/01 would negatively affect their spouse.

Beyond Verbal Communication: Feeling Understood through Shared Values

While almost all responders described uncommunicativeness with their significant others, there were differences in how the responders felt about the health of their marriages depending upon whether or not they felt understood by their partner, regardless of verbal communication. About half the sample of responders (n=27) discussed the importance of shared values in the functioning of their relationship. Most of these responders (n=18) felt that their significant other understood and supported the primacy of their commitment to the 9/11/01 response, which was important in sustaining their dyadic relationship. Conversely, those responders who felt that their spouse did not understand the primacy of the 9/11/01 response (n=7) described more conflict in their marriages. The majority interviewees reporting a shared commitment to the primacy of the 9/11/01 response were professional responders, compared to the majority of those reporting a lack of shared commitment, who were non-traditional responders. Rates of self-reported PTSD differed between the groups as well, with a higher rate of PTSD in the lack of shared commitment group (please see Figure 2).

“It was what was supposed to happen:” Shared understanding of responder’s primary commitment to 9/11/01 site.

Eighteen responders described their marriages as workable because there was a shared understanding between responder and spouse that the responder’s 9/11-related work was very important, and therefore, the spouse would support the responder by picking up the emotional, physical, and logistical slack that resulted from the responder’s attention to the WTC response. For example, Joshua described how his wife’s help was meaningful to him at such a chaotic time.

She put her game face on too. She knew what I do for a living, she knew what all my friends did that I was with. She had a trunk full of stuff that she collected from her friends--water bottles, juice bottles, food, snacks, Nutri-Grain bars…. I went in [to NYC] she said, ‘Look in your trunk.’ I popped the trunk and it was the most helpful thing she could have possibly [done]… because that was one thing we really didn’t have a lot of.

Note that in this story, the verbal communication between Joshua and his wife is sparse, but her instrumental support connotes emotional closeness.

Responders who felt that that their partners shared their primary loyalty to the 9/11/01 response work described a shared feeling with their spouse that they had to get through the experience together because they had made a commitment to each other. Several responders explicitly mentioned that their spouses were also members of groups of professional responders, signaling that the training and/or culture of police and firefighters may be important in learning how to support someone going through a trauma. Ian explained:

My wife at that time was a police officer. She’s now retired. She knew exactly what was going on, so they [my wife and son] actually made it very easy for me. I’d come home, they didn’t ask too many questions. They knew I just wanted to get some sleep and go back.

Many responders in this group acknowledged that they did not have anything emotional to give to their partners, making it a one-way relationship, often for a long period of time.

Isabel: You know, I’m grateful to my husband for having stood by me. Because this was early in our marriage, and he could have said, you know, marriage is a difficult endeavor. And to have been pulled out for so many, you know, most of our first year, I was not there. So I couldn’t be supportive to him. I couldn’t be the wife that I wanted to be.

Ben: It strengthened our relationship because I needed her. I relied on her tremendously. She was there for me every step of the way, but I have to say that I wasn’t there. I think a lot of it was a one way street. I wasn’t producing at the time or being a good mate because I was dealing with what I was dealing with.

Among responders in this group, there was an assumption that this unequal relationship burden was an unavoidable result of the more important focus on 9/11/01 rescue and recovery. As Isabel said later in her narrative, “We [my husband and I] took on different roles. And that’s what was supposed to happen.” From the perspective of most of the responders in this group, they and their partners agreed (explicitly or implicitly) there was no other alternative to making the relationship work in the aftermath of the 9/11/01 response, and it was this shared belief that made their relationships work.

Mismatch of Expectations: Disagreement over responders’ primary commitment to 9/11/01 worksite.

A second relationship dynamic that emerged among a subset of participants was one in which there was a mismatch of expectations between partners about what was “supposed to happen” in the relationship in the face of the responders’ experiences. Several responders reported that their partners did not understand their ongoing need to work at the WTC sites, seeing it as a choice against their relationships and home lives. According to these responders, their spouses did not understand the pull, the sense of purpose, of the 9/11/01 work in the same way that they did, leading to relationship conflict about time spent at the site, especially when it was time over-and-above their work duties. Kenneth explained: “There was resistance at home, you know, in terms of, “Why are you doing that?” Just a—just a different sense of purpose that I had, that I had difficulty communicating at home, I guess.” Caleb described a similar dynamic:

[My wife] kind of broke my chops a little bit. You know, she was raising two young children with no help. So I wasn’t around to be a part of that. So, when I was home, she expected me to help her…I wasn’t too involved with my home -- to keep it going. And so there was a little push, push back and forth with that.

In many ways, these stories are similar to those told by Ben and Isabel earlier: the responders acknowledge that they were not around a lot to offer support to their spouses. The difference, at least according to these responders, is that their spouses did not feel the same sense of urgency or purpose towards the response effort as they did, and therefore were resistant to changing behavioral dynamics at home. Tina poignantly describes that this mismatch in expectations has had long term repercussions on her relationship with her then-fiancé-now-husband:

I had been basically working nonstop...not really speaking or eating or sleeping. So that Saturday or Sunday, we -- together with these friends of his--of ours--went up to some lake somewhere…. They were splashing around in the lake, and I was just sitting on the dock like this, you know? Like with my head in between my knees. Like, ‘I’m not having any fun here.’ And they were just oblivious…. And then, Mike and I got into the car and he started yelling at me about the save-the-date forms or the invitations for the wedding, like--yelling at me about my mother. Something about my mother. And I looked at him and I was like -- excuse me for swearing -- ‘Are you fucking kidding me? Do you know what the fuck is happening in the world and what my role is in it?’ Sorry, that’s a little bit loud. He just didn’t understand then, doesn’t understand now. And it’s been a big issue.

While the incident that Tina describes here happened in the immediate aftermath of 9/11/01, she makes a point to explain that her now-husband’s reactions to her involvement in the WTC response have continued to be unsupportive over the years, and that this lack of empathy is major problem in their marriage. Several responders in this second group described being simply unable to engage emotionally in the ways that their spouses asked of them. These responders described their marriages as “really tough,” “loveless” and “hell.” Each of them placed the blame for the state of the marriage squarely on their own shoulders, explaining that they had not put enough effort into the relationship. Despite the difficulties, however, each remained married to their spouses.

Partner influence on Mental Health Help-Seeking

Despite the trauma symptoms described by many responders in this sample, help-seeking for mental health problems was difficult. Many described refusing mental health treatment, even though it had been recommended by their families and colleagues. Several of the professional responders described their culture as being one in which everyone is expected to be emotionally able to handle trauma; therefore, there was little support from job sites to seek support.

Without formal sources of support, the informal care provided by spouses was crucial. However, the partners themselves were not trained to recognize or help alleviate symptoms of PTSD and other mental health disorders. Thus, it was through insistent prompting from partners that a subset of responders finally sought treatment for PTSD and other trauma-related symptoms, which had worsened over the years, leading to problematic behaviors. Hank explained: “It got to the point where I started drinking really heavily. And I was never a drinker. And my family started to see this. I started fighting with my wife, yelling at my kids. I started punching holes through the walls in my house.” Howard, shared a similar story:

At first I didn’t think it impacted me at all. I thought I was over it, but apparently not…. I became very angry. I didn’t know this. My girlfriend saw it, my kids saw it. I was very angry at home. I couldn’t contain myself. I was going through a lot and I didn’t know it until recently my girlfriend told me, it’s enough and I have to straighten myself out, and I hit rock bottom and it’s because of all this.

Several of the responders credited their spouses with giving them the needed push to seek mental health treatment, resulting in a PTSD diagnosis and counseling, sometimes years after 9/11/01. It may be that responders were more ready to receive this push after time had elapsed, perhaps because they were not as closely tied to their colleagues anymore.

Discussion

These oral histories reveal that responders’ identities as helpers and their beliefs about patriotism and the common good were seminal to their meaning-making about their intimate relationships in the wake of the WTC attacks. Responders reported closing themselves off emotionally from their significant others in the days and weeks after the attacks. While grateful for the safety of home, responders felt guilty for any time spent away from the 9/11/01 clean-up site, hurrying back after brief respites. Those responders who believed that their spouses shared their commitment to the primacy of the WTC response described having a relatively functional relationship dynamic, compared to those responders who believed that their spouses did not share the same commitment. Despite reports of high posttraumatic stress symptomology in this sample, the majority of responders had not sought mental health intervention, relying instead on their spouses’ caregiving. Of those who had sought help, it was usually after the insistence of the spouse.

Responders’ limited verbal communication with their spouses about their involvement in 9/11/0 is concerning, given existing evidence that less disclosure is associated with lower relationship satisfaction in dyads in which one member of the couple has experienced posttraumatic stress symptoms. Similar to results of previous research with trauma survivors, our analysis found that responders described feeling emotionally numb as a reason for their uncommunicativeness. However, in contrast to previous research, the vast majority of responders in this study did not cite protective buffering as a reason for their non-disclosure to spouses; occurred out of a need to protect their spouses from knowing protective buffering as a reason for non-disclosure to spouses regarding the role of emotional numbing in preventing disclosure to spouses; of the entire sample, only two responders mentioned protecting their spouses as reason for not talking to them about what happened.

The permeability between home and the response site may provide some clues as to why protective buffering was not a central theme in the responders’ narratives despite reports of lack of verbal communication with their partners. After this terrorist attack, in contrast to a military deployment, responders knew that their partners had already experienced (at least part of) the trauma via media and other exposure; therefore, they may have felt as though it was less necessary to shield their partners from it. Instead, it may be that lack of communication was a way for responders to emotionally protect themselves, rather than their partners, in order to be able to return to the 9/11/01 clean-up site to do their work day after day. By not communicating with their partners about what they were doing and seeing, they were able to steel themselves against feelings could have made it difficult/impossible to do their work. Instead of simply emotional numbering, this seems to be a more active process of self-protection in service to their identity as helpers. Lane et al. (2010) found something similar in their study of the intimate partner relationships of detectives who investigate cases of child sexual abuse: female detectives who maintained low levels of open communication with their spouses reported higher levels compassion satisfaction at work. This is somewhat of a counterintuitive finding, given other existing research showing that strong emotional support tends to improve work performance and satisfaction (indeed, even the male detectives in Lane et al.’s (2010) study reported less burnout when they were more communicative with their spouses). However, as the experiences of the female detectives and male and female responders in this study suggest, there may be times when non-disclosure is a successful way to cope with the permeable boundaries of home and work, at least in the short-term. However, long-term, this approach may not be sustainable.

Many relationships weathered the emotional and physical intensity of the 9/11/01 clean-up by drawing on a shared understanding of the relative importance of the recovery effort. There appeared to be an agreement between the spouses, at least according to the responders, that the duty to work and country trumped all other responsibilities. Knowing that their partners shared these values helped responders to feel understood. This makes sense, given existing research showing that as a sense of mutual understanding is a crucial aspect of functional relationships after experiencing a trauma. Also wrapped into this concept of shared values was responders’ believing their partners to be ‘helpers’ in the same way that they considered themselves to be helpers: people who ‘pitch in’ when times get tough. Through the 9/11/01 experience, most spouses sprang into action at home, doing more than their share, similar to how the responders were approaching the 9/11/01 clean-up. Thus, the responders could see themselves in their partners and vice versa, which likely helped steady their relationship through hard times.

For the responders describing mismatched values, relationships were more difficult. Perhaps this difficulty grew out of a recognition of significant differences in identity between spouses that were not easily reconciled. Responders’ mental health challenges might also have played a role. More than half the responders who described feeling misunderstood disclosed a PTSD diagnosis. While this is a small, purposive sample and we are unable to generalize from these results, previous literature supports that returning veterans with PTSD have more difficulties in their marriage than those who do not have a PTSD, particularly due to anger and emotional numbing (Creech, Swift, Zlotnick, Taft, & Street, 2016).

These findings complicate existing models of trauma and relationship functioning by suggesting the addition of shared values as a significant component in how couples function after experiencing trauma. The concept of shared values expands the construct of mutuality found in the military-related PTSD dyadic relationship model (Gerlock et al., 2014) and resources found in the CATS model (Nelson Goff & Smith, 2005) to include bidirectional connection to one’s partner through allegiance to larger cultural beliefs that the partner holds dear. While shared values (e.g., to country, to a response effort) may be particularly strongly articulated in the context of a terrorist attack, they are likely also important in any situation in which a couple must marshal emotional resources to deal with a change in the relationship. Thus, it is useful to consider including larger cultural forces in models explaining couple functioning.

Recent studies have documented the delayed onset and seeking of mental health treatment among 9/11/01 responders. These results help to understand the consequences of these delays in their spousal relationships. Partners of these responders were actively managing their partners’ active trauma-related symptomatology without outside intervention or support from clinicians trained in treating such cases. The strain of this continual management became too much to bear for many, causing spouses to push the responder to seek outside help; however, this breaking point often occurred years after symptomatology began.

These stories of help-seeking show the important role of social interaction in recognizing and identifying as someone who has a mental illness. Similar to war veterans in Spoont et al.’s (2009) study about the sensations and symptoms of PTSD, many responders did not recognize the acuity level of their symptoms as problematic until a loved one identified them as abnormal and worsening. Even then, it took insistence from the spouses for the responders to get help. However, social interaction can also serve to dissuade identification as someone with mental illness if a spouse or other sources of social support do not recognize mental illness as a legitimate concern (Shorer, Goldblatt, Caspi, & Azaiza, 2018). For example, the work context(s) of professional responders in this study tended to be places where disclosure of posttraumatic stress symptoms was discouraged, or – in the words of Patrick—”stuffed”—likely reinforcing a culture in which social interaction dissuaded identification as someone with mental illness. Given this situation, the situation at home needs to be different if anyone is going to get help.

There are several limitations of this study. One is that we originally collected this data for purposes of oral history, in order to have a first-hand account of what responders went through in responding to this terrorist attack. Thus, each interview differed in its focus and scope according to what the responder chose to highlight in his or her story. While we asked all responders about the effects of response on their relationships, some interviewees spoke at length about this topic and others provided less information. Also, some interviewers were more skilled than others at facilitating disclosure about relationship details. Retrospective recall of the 9/11/01 event and subsequent activity may also be inaccurate or incomplete. Additionally, we only collected oral histories from responders and not partners, we were not able to know about a partner’s experiences with a responder beyond what the responder reported their experiences were. Additionally, while we were able to make some comparisons according to occupation, lack of more detailed information about responders’ work history--including training in disaster preparedness and time in each job, as well as whether the responder was currently retired--limited our ability to make more fine-grained group comparisons.

Despite these limitations, a significant strength of the use of these oral histories is that they are currently being housed and indexed by the Library of Congress, which will allow for this research to be verified and built upon by later researchers, unlike most qualitative studies in which the data is retained by the researcher and access is limited or nonexistent.

Implications

The language with which responders discussed guilt paired with desire to return to the 9/11/01 clean-up site, is somewhat similar to that used by people with addiction to substances. While none of the responders specifically made a connection between this guilt/compulsion and their functioning at home, it is likely that one affected the other. It may useful to investigate this connection further, particularly as it relates to responders’ ability to successfully move between contexts emotionally.

In addition, the values that both spouses have about each other’s responsibility to home vis-à-vis the terrorist response may be important to relationship functioning. Future research should examine this supposition by analyzing interviews with partners of responders, as well as the testing the independent and interaction effects of expectations and trauma-related symptomatology on relationship outcomes in a larger sample of 9/11/01 responders or responders to another terrorist attack. Cross-cultural comparisons may be particularly fruitful, as the sense of responsibility to country versus family may vary substantially among cultures.

There are several practice implications of this work. The reticence of responders to seek mental health treatment due to workplace norms indicates that more should be done to de-stigmatize mental health treatment among professional responders. The Police Organization Providing Peer Assistance (POPPA) is one example of one such effort in New York City police departments, and could serve as a model for other response efforts. In addition, programs should be developed to provide responders, spouses and significant others with information about the signs of PTSD, so that they are able to recognize as soon as possible when the responder might need mental health services. Given the degree to which the responders seemed to assume, rather than to confirm by active communication, their spouses’ feelings about their involvement in the 9/11, it could also be useful to create structured curricula to help couples communicate more effectively during times of high stress, including during and in the period following terrorist attacks. Finally, it may be prudent to develop methods for responders to broaden their social support networks beyond their spouses in order to relieve caregiving burden.