Research articles

By Dr. Daniel Z. Lieberman , Dr. James C. MacIntyre II , Dr. Larry Wissow , Dr. Rebecca A. Powers , Dr. David Pruitt
Corresponding Author Dr. Daniel Z. Lieberman
Psychiatry and Behavioral Sciences, George Washington University, Department of Psychiatry Rm 8-421 2150 Pennsylvania Ave, NW - United States of America 20855
Submitting Author Dr. Daniel Z Lieberman
Other Authors Dr. James C. MacIntyre II
Carolinas Medical Center, Department of Psychiatry, - United States of America

Dr. Larry Wissow
Johns Hopkins University, Department of Health, Behavior and Society, - United States of America

Dr. Rebecca A. Powers
Stanford University School of Medicine, Department of Psychiatry, - United States of America

Dr. David Pruitt
University of Maryland School of Medicine, Department of Psychiatry, - United States of America


Natural helpers, Terrorism, Bartenders, Hairdressers, Trauma

Lieberman D, MacIntyre II J, Wissow L, Powers R, Pruitt D. Natural Helpers After The Terrorist Attacks Of September 11. WebmedCentral PSYCHIATRY 2010;1(11):WMC001181
doi: 10.9754/journal.wmc.2010.001181
Submitted on: 15 Nov 2010 09:45:18 PM GMT
Published on: 16 Nov 2010 06:13:19 PM GMT


Background: Pathological emotional responses to trauma can paradoxically lead to reluctance to engage in treatment. The purpose of this study was to learn more about the role of natural helpers within the community, and their reactions following the attacks of 9/11. Methods: Bartenders and hairdressers were asked how the 9/11 attacks affected their interactions with customers, and whether they suffered adverse reactions to filling the role of a natural helper in a disaster environment. Results: Compared to librarians, used as controls, significantly more hairdressers and bartenders reported that their customers wanted to talk about their emotional reactions, that high levels of exposure to this topic was experienced as difficult, and that they felt the need to avoid this topic in their personal interactions outside of work. Conclusions: Following the terrorist attacks of 9/11, hairdressers and bartenders played the role of natural helpers to residents who wanted to talk about the event. The high frequency of exposure to this topic led to distress and some avoidant behaviors.


Terrorism is a psychological weapon. Terrorists seek to intimidate societies and governments through the use of violence calculated to produce maximal fear and distress. Although any disaster that causes loss of life can be emotionally traumatic, intentional, human-caused disasters appear to lead to a higher incidence of trauma-related mental illness than natural disasters of comparable magnitude [1].
The terrorist attacks on September 11, 2001 constituted the worst peacetime catastrophe in U.S. history. There was unprecedented loss of human life, massive physical destruction, and severe human and economic consequences. Following the attacks, the New York State Office of Mental Health (NYS-OMH) began immediate efforts to ensure that resources would be available to provide mental health services and treatment to those who required them. As part of its initial application to the Federal Emergency Management Agency (FEMA), NYS-OMH estimated that over 520,000 persons in New York City and the surrounding counties would experience posttraumatic stress disorder (PTSD) from exposure to the attacks [2]. Funded by FEMA, “Project Liberty” was initiated as a large-scale public mental health program as part of New York State’s response to this disaster [3].
After six months, however, Project Liberty reported that most affected adults did not see themselves or their family members as having psychiatric or mental health problems, and relatively few sought or used existing traditional mental health services. Surveys that measured utilization of mental health services before and after September 11 found modest increases despite the predictions of widespread morbidity. Boscarino et al. found that 16.9% percent of people surveyed in New York City reported using mental health services 30 days before the attacks, and 19.4% reported using these services 30 days afterwards [4]. A separate survey of 1,009 adults living in New York City at the time of the attacks found that over half of the individuals had some emotional sequelae three to six months after September 11. Only a small portion of those with severe responses, however, were seeking treatment [5].
A study carried out on a national scale found high levels of psychological distress, but no short term change in the use of services [6]. These findings were consistent with observations following other disasters. Mental health professionals responding to the Oklahoma City bombing in 1995 were struck by the fact that victims were not accessing services [1]. Following an explosion in a large paint factory in Norway, Weisaeth found substantial nonacceptance of early intervention among those who had been exposed to the disaster, and suffered early symptoms predictive of later development of PTSD [7].
Patients at risk for the development of PTSD often suffer from acute stress symptoms that include social withdrawal and avoidance of situations that arouse recollections of the trauma, behaviors that may lead to reluctance to engage in treatment. Formal treatment by a mental health professional, however, is not the only option available to individuals struggling to cope with the effects of severe stress. Every local community and neighborhood has individuals, organizations, and institutions where people seek advice, information, and support [8]. For example, individuals such as clergy, bartenders, barbers, and beauticians provide advice and support for people around them – functioning as a natural support system for the community (Allen J, Enhancing outreach efforts through indigenous natural support networks. Unpublished manuscript from "Project Liberty", 2002). These members of the community are sometimes referred to as “natural helpers,” and can serve as de facto care givers [9]. Professional collaboration with natural helpers has been investigated as a way to overcome shortages in professional mental health providers [10], and to provide outreach to specific at-risk populations [11].
This study reports on a survey of bartenders and hairdressers in New York City, exploring their role as natural helpers in the aftermath of September 11. Hairdressers and bartenders were chosen for a number of reasons. Unlike members of the clergy [12], neither bartenders nor hairdressers receive training in counseling techniques as part of their professional education. In many communities hairdressers, in the course of providing personal services to their clients, become confidantes. While hairdressers may serve the role of confidante for women, bartenders are more likely to serve this role for men. The role that bartenders play appears to have the potential to facilitate revelation of sensitive personal information by their customers [13]. These natural community helpers were surveyed in order to determine if they felt that their customers had a desire to discuss their emotional responses to the events of September 11, 2001, and to determine if the natural helpers suffered adverse emotional consequences related to their role as providers of support following a community disaster.


Telephone numbers of bars, hair salons, and libraries were obtained from a geographically-based directory. Listings were obtained for businesses in New York City in the vicinity of 55th Street on both the East side and West side. This area was chosen because it is a central New York City location, but is not in the immediate vicinity of the World Trade Center collapse. Librarians who worked in this area were selected as a control group because they would be exposed to the same general environment, would have significant contact with the public, but traditionally librarians do not serve as confidantes to their patrons.
A brief, two-page questionnaire was developed, and telephone calls were made during June and July of 2002. Subjects were asked how the September 11 attacks affected the volume of their business, whether customers wanted to talk to them about their feelings and emotional reactions to the attacks, and whether the subject found it difficult to talk about this topic with so many people. Subjects were asked if they found it hard to stop thinking about the attacks after they went home, whether the association of their workplace with thoughts of the attacks ever made them want to avoid work, and whether they ever stayed home from work because of a painful association with the attacks. Subjects were asked if they tried to avoid the topic of the attacks with friends and family due to having so much exposure to it at work, whether they would be interested in information on how to provide emotional help for their customers following a disaster, and how long they had been working in their occupation. Only one person was surveyed at each location in order to make sure that a subject’s responses would not be influenced by overhearing how a colleague had responded.
Subjects who reported experiencing emotional distress were offered the telephone number of LifeNet, a 24-hour, 7-day-a-week mental health information and referral hotline for those affected by the disaster and its aftermath [14]. Analyses included descriptive statistics and correlations. Categorical data was analyzed using chi-square, and continuous data was compared using the t-test for equality of means and Pearson correlations. The protocol was reviewed and approved by the George Washington University Institutional Review Board.


Data was collected a few months prior to the one year anniversary of the bombings between 6/10/2002 and 7/20/2002. One hundred sixty-six hair salon telephone numbers were called; no one answered the telephone at 80, and seven numbers represented duplicate listings of the same salon. Of the remaining 79 numbers, 48 (61%) were answered and had a hairdresser present who was willing to answer the survey questions. The remaining 31 numbers were answered but respondents declined to participate, most often because of being too busy.
Two hundred thirty bar and tavern numbers were called; 169 were never answered. Of the remaining 61, 37 establishments (61%) had a bartender available willing to answer the survey; 24 declined.
Of 152 two library listings, no answer was obtained at 78. Of the remaining 74 numbers, 48 (65%) had a librarian who agreed to participate; 26 declined.
Hairdressers and bartenders were more likely than librarians to report that their patrons wanted to talk about September 11. About one half of the librarians surveyed reported that their patrons wanted to talk to them about their reactions and feelings, compared to 71% of the hairdressers (p<.05 compared to librarians), and 100% of bartenders (p<.001 compared to librarians) (Table 1). The hairdressers and bartenders were also more likely to report that it was difficult to talk about September 11 with clients. Only 10% of librarians found it difficult to talk about this subject with so many people at work, while it was difficult for 42% of hairdressers (p<.001) and 43% of bartenders (p=.001). More than half of all three groups found it difficult to stop thinking about the events of September 11 after they went home from work.
A minority of librarians, hairdressers, and bartenders said that after September 11 they did not want to go to work because their work made them think painful thoughts about September 11, and there was no significant difference among the three groups. When asked if they ever actually stayed home from work for this reason, an affirmative response was given by 15% of librarians, 31% of hairdressers, and 6% of bartenders. There was a trend toward more hairdressers reporting missed days of work because of painful associations with September 11 compared to librarians (p=.052), and the average number of days missed by hairdressers for this reason was significantly greater than for librarians (1.62 vs. 0.38, p<.001).
When asked if they tried to avoid the topic of the terrorist attacks with friends or relatives because they heard so much about it at work, only 8% of librarians answered in the affirmative, compared to 25% of hairdressers (p<.05) and 30% of bartenders (p=.01). Finally, subjects were asked if they would be interested in information on how to provide emotional help to their customers after a disaster. 62% of bartenders answered in the affirmative, significantly more than the 23% of librarians who indicated an interest (p<.001). 38% of hairdressers answered affirmatively.
Subjects were asked how long they had worked in their occupation. Librarians reported an average of 14 years of experience, hairdressers 24, and bartenders 12. The more years that bartenders worked in the field, the less likely they were to report experiencing difficulty talking to so many customers about their emotional reactions to the terrorist attacks (Pearson correlation = -0.458, p<.005). Among bartenders, longer work experience was correlated with greater likelihood of reporting interest in information on how to provide emotional help for customers after a disaster (Pearson correlation = 0.324, p=.05).


Little is known regarding the effects that disasters have on natural helpers, who may provide substantial emotional support for their customers. These natural helpers deserve attention because they may provide support to affected individuals who cannot be reached by traditional mental health services. Bartenders have been used to help increase awareness of the risks of unsafe drinking [15], and to reduce the risk of HIV transmission [11]. The mental health role that bartenders play has been analyzed in some detail, and characteristics that tend to increase the effectiveness of bartenders as confidantes have been identified [13]. Hairdressers have been used to help reduce obesity among African American Women [16].
In the current study, the large majority of hairdressers and bartenders reported that their customers wanted to talk about their emotional reactions to the terrorist attacks of September 11, compared to only about half of librarians. Librarians were chosen as a control because of the assumption that people tend not to discuss personal issues with librarians. While fewer librarians than hairdressers or bartenders reported patrons discussing feelings about 9/11 with them, it is notable that nearly one half said that their patrons did want to discuss emotional reactions. This phenomena may be a reflection of the pressure experienced by New Yorkers to seek emotional support from non-traditional sources following the attacks.
A substantial number of hairdressers and bartenders experienced as difficult the high level of exposure to customers wanting to discuss the attacks. Secondary, or vicarious traumatization can occur when a caregiver experiences close and prolonged exposure to victims of trauma or abuse [17]. This phenomena is sometimes referred to as “compassion fatigue” [18], and can be seen among individuals who treat survivors of a disaster due to the large number of individuals affected within a community [19, 20], and because the shared nature of the trauma in a disaster environment can increase the vulnerability of the caregiver [21].
Not all studies have found that caring for victims of trauma following a disaster led to negative emotional reactions. A study of medical students involved in treatment and support of survivors of the September 11 attacks found that involvement in the relief effort had a beneficial emotional influence [22]. Among bartenders in the current study, those who had more years of experience were less likely to find the experience of talking to many people about their emotional reactions difficult. There may have been a protective effect related to skills learned over the course of their experiences as a bartender. More experienced bartenders were also more likely to express interest in obtaining information on how to effectively provide emotional support to their customers. More experience speaking to customers about emotional issues seems to be correlated with valuing the ability to provide emotional support more highly. Project Liberty in New York is exploring targeted outreach strategies, which include specific messages and information useful to each of the indigenous natural support networks (e.g. school teachers, bartenders, barber shops/hair salons, taxi drivers, etc.). This training could become part of future disaster preparedness efforts.

The questionnaire used in the survey was not designed to establish whether respondents might have PTSD. Instead, it was intended to investigate distress experienced by natural helpers as a result of their occupational role as confidante. Respondents may have experienced additional problems that were not reflected in the items included in the questionnaire. Days missed from work may not be an equally sensitive measure of morbidity across the three groups, since the three professionals may not have equal freedom to take time off. It may be, for example, that hairdressers’ higher rates of days lost from work was facilitated by the greater drop in business that they observed following the September 11 attacks (75% reporting a fall off versus only 27% of bartenders, p<.001; Table 1).
Results might have been different had we used a different control group. Librarians who worked in the same community as the bartenders and hairdressers were used as controls because they would be expected to have exposure to the same level of environmental stress in all respects expect for their occupational role. Hair salons and bars are places where people generally want to talk about feelings and emotional reactions, whereas in a library, conversation is discouraged. There may be other differences among clients, however, that we were not able to measure. Individuals who use libraries may have different coping styles than those who frequent bars, for example, and hairdressers’ clients are largely female while bars and libraries are more likely to serve both men and women.
Finally, while our response rate of 61-65% was reasonable for working telephone numbers, the Internet directories we consulted evidently included many inaccurate listings. The advantage of the Internet was its ability to provide listings of three professions within the same, very specific geographic area, something that would be difficult from other sources. Given our hypotheses about trauma exposure possibly causing avoidance, our rates of distress may be underestimates, as non-respondents may have been more, rather than less likely to be avoiding a reminder of September 11.


Close to one half of the hairdressers and bartenders surveyed reported that it was difficult for them to talk about this subject with so many people, significantly more than the librarians. They also reported negative reactions, including avoiding work because of the association with the terrorist attacks, and wanting to avoid the topic of the attacks with friends and relatives as a result of so much exposure to it at work.
Providing assistance to a community following a disaster is challenging because of the large number of people affected, and because many people who are traumatized by a disaster appear to avoid the traditional mental health system. People with severe acute stress reactions and those who go on to develop frank PTSD should have treatment from a mental health professional. However, the informal network of natural helpers may be a valuable resource for victims who have less severe responses, or for those individuals who are unwilling to see a traditional mental health professional. Identifying ways to provide assistance to natural helpers that allow them to increase their effectiveness with their customers, while diminishing any negative reactions that they may experience as a result of their role, may be a useful element in planning for future disasters.


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