Journal of Loss and Trauma

ISSN: 1532-5024 (Print) 1532-5032 (Online) Journal homepage: https://www.tandfonline.com/loi/upil20

Professional Posttraumatic Growth After a Shared

Traumatic Experience: Manhattan Clinicians'
Perspectives on Post-9/11 Practice

Jennifer Bauwens & Carol Tosone

To cite this article: Jennifer Bauwens & Carol Tosone (2010) Professional Posttraumatic Growth
After a Shared Traumatic Experience: Manhattan Clinicians' Perspectives on Post-9/11 Practice,
Journal of Loss and Trauma, 15:6, 498-517, DOI: 10.1080/15325024.2010.519267

To link to this article: https://doi.org/10.1080/15325024.2010.519267

Published online: 06 Nov 2010.

Submit your article to this journal

Article views: 720

Citing articles: 19 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=upil20
Journal of Loss and Trauma, 15:498–517, 2010
Copyright # Taylor & Francis Group, LLC
ISSN: 1532-5024 print=1532-5032 online
DOI: 10.1080/15325024.2010.519267

Professional Posttraumatic Growth After

a Shared Traumatic Experience:
Manhattan Clinicians’ Perspectives on
Post-9/11 Practice

JENNIFER BAUWENS and CAROL TOSONE

Silver School of Social Work, New York University, New York, USA

Clinicians who live and work in natural and man-made

disaster-prone areas are often exposed to trauma primarily as
citizens and secondarily as a result of their professional practice.
In an attempt to better understand this increasingly common
experience of collective trauma, this study explored the long-term
impact of September 11 on the professional lives of 201 Manhattan
clinicians. Participants reported that 9=11 was the impetus for
enhancing self-care, changing clinical modality, and forging
new skills. Positive changes were also reported within the thera-
peutic relationship, including increased compassion and connect-
edness with clients. Negative effects included feeling ill-equipped to
work in the gravity of 9=11, an increased sense of vulnerability,
and disappointment with professional organizations.

September 11, 2001, reshaped the collective consciousness of American

society as our sense of security as an impenetrable nation was altered follow-
ing the attacks. Security alerts affirmed that life was no longer lived on green
behind white picket fences but on orange or red in potential enemy territory.
The continued ripple effects and attempts to reorganize post-9=11 were a
result of shattered assumptions (Janoff-Bulman, 1992), demanding a reorga-
nization of the American worldview (Calhoun & Tedeschi, 2006; Pals &

Received 10 November 2009; accepted 8 April 2010.

The authors would like to thank Dr. Trudy Festinger and the late Dr. Robert Moore for
their assistance in the design of the survey.
Address correspondence to Carol Tosone, Silver School of Social Work, New York
University, 1 Washington Square North, Room 202, New York, NY 10003, USA. E-mail:
ct2@nyu.edu

498
 Professional Posttraumatic Growth 499

McAdams, 2004). The events of September 11 also required a new form of

collective coping (Pennebaker & Harber, 1993) extending beyond the
borders of the disaster-affected regions into homes across the country, where
the assault was available for repeated viewing. Despite the far-reaching
impact of this disaster, in some aspects, the events of September 11 were
not dissimilar to other mass disasters that were initially characterized by
tremendous grief and, in some instances, irreparable losses; yet from the
rubble, communal ties were strengthened and new dialogues were formed
(Pennebaker & Harber, 1993). The trauma of September 11 was marked by
both devastation and heroism, loss of life with newfound community, and
animosity with munificent demonstrations of volunteerism.
The clinical setting was not devoid of these paradoxes. Instead, clini-
cians during this time were confronted with rewards of helping juxtaposed
with feelings of towering grief. For the clinician who provided therapy in
the milieu of 9=11, an additional layer of grief and trauma was added to
the events because the clinician had to function in a ‘‘dual capacity’’ (Tosone
& Bialkin, 2004, p. 162), an experience termed ‘‘shared trauma’’ (Altman &
Davies, 2002; Saakvitne, 2002; Tosone & Bialkin, 2004; Tosone et al., 2003).
The layered experience of providing therapy to trauma survivors in a
backdrop of a collective disaster is thought to put the clinician at greater risk
(Saakvitne, 2002). Despite the heightened risk associated with shared trauma,
only a few studies have investigated the effects on clinicians who share a
trauma with clients (Boscarino, Figley, & Adams, 2004; Eidelson, D’Alessio,
& Eidelson, 2003; Racanelli, 2005; Somer, Buchbinder, Peled-Avram, &
Ben-Yizhack, 2004). The dearth of literature available on shared trauma is
informed by research investigating the effects of being indirectly exposed
to a traumatic event.

LITERATURE ON INDIRECT EXPOSURE TO TRAUMA

Until the last few decades, the nocent effects of trauma have been interpreted
within the Diagnostic and Statistical Manual of Mental Disorders (DSM)
definition of posttraumatic stress disorder (PTSD). Although the DSM-III-R
(American Psychiatric Association, 1987) recognized that learning about an
extreme trauma, such as torture, could elicit posttraumatic stress, it wasn’t
until the DSM-IV (American Psychiatric Association, 1994) that the diagnostic
criteria (A1) identified a person with PTSD as one who could have witnessed
or been confronted with a traumatic event. This expanded definition includes
those who may just hear about a traumatic event or watch a traumatic event
on television. In fact, even a clinician empathetically engaged with a client’s
trauma narrative could experience posttraumatic stress, albeit vicariously. In
other words, later conceptualizations of trauma clearly identified PTSD as
pertinent to the person who was also a once-removed observer, including
500 J. Bauwens and C. Tosone

the person watching a traumatic event on television (e.g., Cardeña, Dennis,

Winkel, & Skitka, 2005) and the clinician empathetically engaged with a
client’s trauma narrative (e.g., McCann & Pearlman, 1990; Figley, 1995).
PTSD criteria alone have not been enough, however, to identify the
experiences clinicians face while engaging in trauma work. Several terms,
including compassion fatigue, secondary trauma (Figley, 1995), and vicarious
trauma (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995), have been
used to describe the clinician’s experience of indirect exposure to trauma.
Vicarious trauma, compassion fatigue, and secondary trauma are all
thought to occur as a result of indirect exposure to trauma. Whether reading
client charts or listening to the trauma narratives of clients, clinicians can
experience secondary traumatic reactions (McCann & Pearlman, 1990). Such
responses, regardless if the construct is compassion fatigue or vicarious
trauma, may be inevitable, but they can become dysfunctional when the
clinician’s response mirrors the client’s reactions. One of many noteworthy
differences between these terms is that vicarious trauma emphasizes the
effect indirect trauma has with respect to transforming the clinician’s cogni-
tive schema over time (Pearlman & Mac Ian, 1995), whereas secondary
trauma focuses on symptoms primarily outlined by PTSD that can occur at
any time following a trauma (Figley, 1995).
Regardless of terminology, studies show that clinicians providing mental
health services may be at risk by engaging clients of different ages, back-
grounds, and traumas, including violent crimes (Schauben & Frazier, 1995),
domestic violence (Iliffe & Steed, 2000), trauma related to humanitarian work
(McFarlane, 2004), sex offenses (Kadambi & Truscott, 2003), and torture
(Deighton, Gurris, & Traue, 2007), as well as trauma among returning
soldiers (Tyson, 2007). A few studies have looked at clinicians who live
and work (shared trauma) in disaster-affected regions (Adams, Boscarino,
& Figley, 2006). Clinicians in these studies reported high levels of trauma
symptoms, a finding that is congruent with studies examining the effects of
disasters in the general population (Norris, Byrne, Diaz, & Kaniasty, 2001).

LITERATURE ON POSTTRAUMATIC GROWTH

The negative symptoms typically associated with trauma may only be part of
the story. Collective traumas, such as the natural and man-made disasters
assessed by Norris and colleagues (2001), create a unique opportunity for
reorganizing and rebuilding individual and societal cognitive schemas. Ter-
rorist attacks, such as 9=11, are thought to be the most devastating traumas
(Norris et al., 2001) and create a greater opportunity or need for a new life
perspective, known as posttraumatic growth (PTG).
PTG has been defined as ‘‘positive psychological change experienced
as a result of the struggle with highly challenging circumstances’’
 Professional Posttraumatic Growth 501

(Tedeschi & Calhoun, 2004, p. 1). Tedeschi and Calhoun (1996) identified
five areas that result in growth after a trauma: (a) new possibilities, (b) relat-
ing to others, (c) personal strength, (d) appreciation for life, and (e) spiritual
change.
First, new possibilities might be described as a new interest or a new
career. Second, relating to others is associated with greater intimacy or ‘‘an
increased sense of compassion for other persons who suffer’’ (Calhoun &
Tedeschi, 2006, p. 5). Third, in regard to personal strength, trauma serves
as a mirror that reflects back one’s strength that would otherwise remain
unseen. The fourth area, appreciation for life, is characterized by an
increased gratitude for life and a shift in priorities toward the most meaning-
ful aspects of life. Finally, spiritual change is characterized by a deepening of
spirituality, or a change in philosophical assumptions (Calhoun & Tedeschi,
2006).
The validity of PTG is not without controversy, as some question a sub-
stantial difference between PTG and resilience (e.g., Westphal & Bonanno,
2007). PTG proponents, however, hold that resilience relates to mental flexi-
bility, which in turn enables the traumatized person to return to homeostasis
(Lepore & Revenson, 2006; Tedeschi & Calhoun, 2004). Resilience is charac-
terized by a return to a pretrauma state, whereas PTG is identified by change
and is considered a different construct than resilience.
Exactly how PTG occurs is unknown, but theorists have proposed that
growth may be a function of cognitive processing or rumination (Tedeschi &
Calhoun, 1995, 2004). Some studies have found that participants who are
proactive at making meaning out of their trauma are more likely to have
higher levels of growth (Mann et al., 2004; Tennen & Affleck, 1998). How-
ever, participants who suffer with intrusive cognitions tend to score lower
on growth measures (Calhoun & Tedeschi, 2006). Not only is growth
associated with active attempts at making meaning, but more recently
Hobfall and colleagues (2007) found that proactive attempts at doing some-
thing meaningful are associated with higher levels of growth.
PTG research literature has primarily focused on traumas occurring in
the general population, including accidents (Davis, Wohl, & Verberg, 2007),
natural disasters (Cryder, Kilmer, Tedeschi, & Calhoun, 2006), terrorism
(Fischer & Ai, 2008; Linley, Joseph, Cooper, Harris, & Meyer, 2003), war
(Ai, Tice, Whitsett, Ishisaka, & Chim, 2007), illness (Weiss, 2004), and viol-
ence and abuse (Frazier, Conlon, & Glaser, 2001). A recent meta-analysis
conducted on 87 studies showed that significantly large effect sizes were
present when assessing both positive changes and negative symptoms. That
is, negative symptoms (characteristic of PTSD) are often present and highly
correlated with positive symptoms (characteristic of PTG) (Helgeson,
Reynolds, & Tomich, 2006).
More recently, the PTG literature has extended to indirect exposure to
trauma, including studies of clinicians vicariously exposed to trauma in
502 J. Bauwens and C. Tosone

clinical practice. The few studies available have assessed PTG in the context
of clinical practice (Arnold, Calhoun, Tedeschi, & Cann, 2005; Linley &
Joseph, 2007; Linley, Joseph, & Loumidis, 2005; Tehrani, 2007) and after
repeated viewing of a traumatic event on television (Linley et al., 2003). Part-
icipants in these studies reported growth from engaging in their work as
trauma clinicians (Arnold et al., 2005; Linley & Joseph, 2007; Linley et al.,
2005).
For example, in a qualitative study Arnold and colleagues (2005) found
that all of the clinicians in their sample experienced negative symptoms as
well as positive and mixed outcomes resulting from engagement in trauma
work. Similar findings were reported in a qualitative study of 10 caring pro-
fessions, including social workers, doctors, and teachers; approximately 60%
of these caring professionals reported negative changes as a result of their
work, while 92% reported some positive changes associated with their caring
role (Tehrani, 2007). Linley and Joseph (2007) surveyed 156 clinicians and
found growth to be positively associated with therapists who were female,
were currently in therapy and=or supervision, and reported historical trauma.
Clinicians in this study who spent more time in session per week experi-
enced more growth, and the best predictor of both positive changes and
compassion satisfaction was the therapeutic bond.
While there is a compelling body of literature supporting the adverse
effects of trauma work on the clinician, far less research has examined the
clinician working in the aftermath of disaster, especially when the clinician
lives or works in the affected area. Additionally, there is a substantial amount
of literature to support growth after trauma in the general population but less
addressing clinicians’ growth after engaging in trauma work. The focus of
this study was to examine, 6 years after the event, the impact of September
11 on the professional and personal lives of clinicians, whether positive or
negative.

METHODOLOGY

Procedures
The participants in this study were obtained through INFOCUS, a research
agency that compiles lists of participating mental health organizations,
including the National Association for Social Workers (NASW). The INFOCUS
list was used to mail 1,297 questionnaires over the course of two mailings.
Surveys were first mailed in early July 2007, and the cutoff date for accepting
returned surveys was August 31, 2007, to avoid a potential anniversary
response to the 9=11 disaster. First-class mailing and prepaid addressed
return envelopes were used to increase the response rate and minimize
response bias. First, a postcard was sent to inform potential study participants
that a survey regarding their experience with 9=11 would be following.
 Professional Posttraumatic Growth 503

Within 2 weeks of the postcard mailing, the survey was sent with a letter of
invitation explaining the intent of the study. Participants were encouraged to
be candid and were assured that their responses were anonymous.
Within 4 weeks of the first mailing, a follow-up letter was sent with a
second survey and a stamped, self-addressed return envelope. Since the sur-
vey was completely anonymous, follow-up letters were sent to all potential
respondents. The follow-up letter made reference to the initial mailing and
requested completion of the survey, with a brief description of the study.
All information obtained via the questionnaire has been kept strictly confi-
dential in accordance with the requirements of the University Committee
on Activities Involving Human Subjects at New York University.
After the first two mailings were complete, 25 surveys (1.9%) were
returned by the postal service as undeliverable. There were 507 surveys
returned, representing an overall response rate of 39%; however, 26 were
excluded due to the social workers being retired. A total of 481 (38%) surveys
were available for review. The surveys included in the analysis were from
members of the NASW Manhattan Chapter who currently work in direct
practice and hold a minimum of a master’s degree in social work. From
the original study sample of 481 participants, 201 clinicians chose to answer
the open-ended questions and were included in this study.

Measures
This study, the Post 9=11=01 Quality of Professional Practice Survey (PQPPS),
involved a single-occasion, cross-sectional design. The PQPPS survey con-
sists of several established self-report measures, as well as professional
demographics related to practice, supervision, training, and clinician 9=11-
related experience questions. Personal demographics included gender,
age, ethnicity, marital status, living arrangements, religious affiliation, and
annual income. Several yes or no questions were also asked regarding pro-
fessional experiences after September 11. Two open-ended questions were
also included in the instrument, one of which is the focus of this study. This
question invited participants to ‘‘add any additional comments you choose
related to your personal and professional September 11 experiences.’’

FINDINGS

First, bivariate logistic regressions were performed using SAS 9.2 statistical
software (SAS Institute, 2006) to determine if there were differences between
those who answered the open-ended questions and those who did not. The
results of the logistical regressions at the bivariate level showed no significant
differences in the demographic characteristics of those who chose to answer
the open-ended question and those who left the question blank, with the
504 J. Bauwens and C. Tosone

exception that older clinicians were more likely to answer (odds ratio
[OR] ¼ 1.02 per year, p ¼ .04) in this study’s sample.
These 201 clinicians were mostly White (95%) and female (80%), and
their mean age was 61 (SD ¼ 8.65). Although this sample seems overrepre-
sented by both race and gender, the sample characteristics were consistent
with two other study samples on clinicians in the New York City area who
are members of the NASW Manhattan Chapter (Boscarino et al., 2004; Bride,
Robinson, Yegidis, & Figley, 2004).
The majority of these participants received institute training (82%),
maintained a psychoanalytic theoretical orientation (63%), provided pro-
fessional services during 9=11 (63%), and on average had provided 27 years
of clinical services. Participants spent an average of 30.90 hours (SD ¼ 24.65)
a week treating trauma clients. The participants served diverse client popula-
tions represented by adult survivors of childhood sexual abuse (72%), clients
with multiple traumas (48%), rape survivors (39%), domestic and partner
violence (38%), child sexual abuse (19%), and Holocaust survivors (19%).
Participants also reported providing services for survivors of natural disasters
and mass violence; 54% of the sample worked with September 11 victims,
workers, family members, and=or witnesses to the attack, and 10% of the
sample was treating survivors of natural disaster at the time of the survey.
Although the subsample of clinicians who answered the open-ended
questions were not significantly different demographically than the rest of
the sample, differences were found between participants’ responses to the
narrative and their scores on both trauma and resilience scales and the two
additional questions regarding the effects of September 11, 2001. We ran
multiple logistic regressions on the following variables: compassion satisfac-
tion, ambivalence, avoidance, shared traumatic stress, life events, resiliency,
the likelihood of another terrorist attack on New York City within the next 2
years, how much 9=11 still affects them, if they experienced a life change
after 9=11, if they lived alone, and age.
The data showed four primary contributing variables accounting for the
differences. Participants with more traumatic symptoms were more likely to
answer (OR ¼ 1.04 per point, p ¼ .04), as were those with more resiliency
(OR ¼ 1.04 per point, p ¼ .01). A similar trend was found in responses to
the events of September 11. Participants who reported being currently affec-
ted by the events of September 11 were more likely to answer the
open-ended question (OR ¼ 1.30, p ¼ .01), as were those who experienced
life change due to the events of September 11 (OR ¼ 0.41, p ¼ .004).
Responses to the open-ended question were assessed through qualitat-
ive methods of analysis. This study does not meet the criteria, however, for a
traditional qualitative study as outlined by Creswell (2007). Further, the study
design and method do not allow for data to reach saturation, one of the hall-
marks of qualitative studies. However, this is not an inappropriate design
given the exploratory nature of the study, which may be used to inform
 Professional Posttraumatic Growth 505

future inquiries into this relatively unexplored topic. Padgett (2008) notes
that data with only a few collections will not characterize depth. Data that
include a large sample, as in this case with 201 participants, contain breadth.
Breadth is useful when the study purpose is detecting heterogeneity among
participants. In this exploratory study, heterogeneity was of interest and com-
pulsory to obtain general, but diverse, thematic descriptions of clinicians’
post-9=11 experiences.
Given the nature of the data, a content analysis (Lincoln & Guba, 1985)
was conducted on the open-ended question. A constant comparison method
(Glaser & Strauss, 1967) was used to develop codes by reading and rereading
responses. To ensure trustworthiness (Padgett, 2008) of the data analysis, the
primary coder was blinded to the quantitative results of the study until cod-
ing was complete. Codes and themes were developed independently to
reduce researcher bias by subjecting the data to another coder’s analysis.
Themes were discussed between the primary and secondary coder until
agreement could be reached. Following the line-by-line coding, the data
were chunked into 61 codes, which were later collapsed into 17 themes.
The initial codes were used to develop six primary themes consisting of 11
subthemes (see Table 2).
According to Padgett (2008), triangulating interviews (or, in this case,
written narratives) with the quantitative data from the survey material is a
positive strategy that reduces researcher and respondent bias. In this study,
self-report measures were used to triangulate the accuracy of developed
themes with participants’ answers on quantitative measures, including scales
(as previously mentioned) and dichotomous variables.
Responses to six dichotomized (yes or no) variables were also tabulated
(see Table 1). The first question asked how many people witnessed Septem-
ber 11 firsthand. Roughly 38% of the participants who responded to the
open-ended question reported witnessing the attack on the World Trade
Center. Regarding their clinical and supervisory experience, approximately
79% of the sample reported discussing their reactions to 9=11 with their cli-
ents, and 49% discussed the events with a supervisee. Another 42% stated
they discussed the events with their own supervisor. In answer to questions

TABLE 1 Clinicians’ Practice Experiences With September 11.

Question Percentage

Discussed reaction to 9=11 with clients 79

Discussed 9=11 with supervisee 49
Discussed 9=11 with supervisor 42
Practice approach changed after 9=11 47
Change was directly related to 9=11 78
Other aspects of life changed due to 9=11 75
Witnessed 9=11 firsthand: 38
506 J. Bauwens and C. Tosone

related to personal and professional change post-9=11, 47% of participants

reported their practice changed after September 11, while 78% of these
respondents reported that these practice changes were the direct result of
September 11. Many of the participants (75%) also reported that other
aspects of their lives changed due to September 11.
The themes from the open-ended question, however, were not congru-
ent with answers provided from our dichotomous variables. A chi-square
analysis revealed no significant relationship between the themes and any
of the variables in Table 1. Reflecting both positive and negative post-9=11
changes, some participants reported either personal or professional infor-
mation, while others shared a mixture of both personal and professional
September 11 experiences. The themes were developed based on these three
identified groups. The end result yielded a total of six major themes on the
open-ended question (see Table 2).

Theme 1
The first theme, collective and personal vulnerability, represented a negative
change in clinicians’ experiences after September 11. Some participants
expressed a heightened sense of vulnerability and a loss of innocence, which
cannot be regained.

There is a before 9=11 & after 9=11 outlook from all of us that informs
both positively and negatively everything we think and do.

I think for all of us who live in NYC there are reminders of 9=11. Every
time the subway is shut down as it was two weeks ago, or a steam pipe
explodes, people wonder is there something more going on?

TABLE 2 Themes of Clinicians’ Experiences of September 11.

Themes Subthemes

1. Collective and personal vulnerability Living on alert

Lost innocence
2. Past traumas Preparation
Complicated recovery
3. Trauma responses —
4. Blurred roles Positive change
Neutral to negative effect
5. Professional and clinical growth Boundary changes
Connectedness
Skill development
Self-care
Political activism
6. Professional pain —
 Professional Posttraumatic Growth 507

Theme 2
The second theme was past traumas. For some, the experience of trauma was
a guide through the events of September 11, while for others the events of
September 11 were navigated through reminders of historical traumas. Exam-
ples of past traumas viewed as preparation for dealing September 11 are as
follows.

9=11=01 was 2 years to the day (09=11=99) that my house burned down.
The process of coping with that disaster helped me relate to those suffer-
ing from the 9=11=01 disaster, as well as other disasters.

As a survivor of World War II=Holocaust-related trauma—I found that I

didn’t seem to feel as shocked by an event that challenges a basic sense
of safety, already living with a reality that includes such occurrences.

Former traumas also complicated the traumatic events of September 11.

Some participants reported traumas ranging from the time of the Holocaust
to just before the attack.

I saw everything I knew as a child be destroyed and my city become a

third world country. I got flashbacks of 9=11 after Katrina. But during
and after 9=11 I got flashbacks of a childhood trauma.

My mother—a Holocaust survivor—was severely jolted by [9=11] in a

place which was a ‘‘safe refuge’’ for her.

Theme 3
Theme 3 was trauma responses. Some participants reported current traumatic
symptoms or responses that were trauma based.

In the 9=11 attack I was unable to provide services to others as I was too
distraught to be of help to those who also lost loved ones. I’d still find it
difficult to work with a survivor who lost someone close to them.

I am still traumatized by what I witnessed and when I did CISD [critical

incident stress debriefing] for 9=11 survivors. I am still hypervigilant
and startle easily. I am thankful that being a mother of a joyous child bal-
ances and forces me to manage my anxiety. I am also thankful for Zoloft
and Ativan, which I began to help sleep disturbances following 9=11.

Theme 4
Participants described blurred roles (Theme 4) in their practice that were
forced by 9=11, but did not indicate that these role changes existed in their
508 J. Bauwens and C. Tosone

current work. These participants talked about blurred roles and a sense of
sharing the traumatic experience.

Something odd & unusual things happened—I spent almost a whole ses-
sion reversing roles with a phone patient describing the scene from 5th
Avenue to 12th Street. Right at the time of the event she counseled me
to get off the phone and tend to my child after [the] school called me
in the middle of the session to make arrangements.

In regard to September 11 experiences, there has been no other traumatic

event of such magnitude in my 19 years of work that has so impacted my
practice. By this I mean that my patients and myself were ‘‘in the soup’’
together, so to speak and both my patients and myself talked together
about our experiences, thoughts, and feelings.

Theme 5
The fifth theme was professional and clinical growth. This general theme
represents a rubric of growth in which participants generally experienced
positive change related to, or involvement with, their practice. This theme
is elucidated by five subthemes in which participants experienced change
in their professional practice post-9=11: boundary changes, connectedness,
skill development, self-care, and political activism.
Boundary changes that occurred during September 11 were reported as
desirable changes to practice. Some reported maintaining the boundaries fash-
ioned in the shared traumatic experience as part of their post-9=11 practice.

At the time of [9=11] I was more open to talking about my feelings with
patients. This has continued to this time.

A year after September 11, I received a diagnosis of advanced lung cancer

with a poor prognosis. The two events made me far more value my life
and life in general. I am more open as a therapist—I do not work full
time, and do short-term treatment now. I feel well and have lived far
longer than expected (5 years now). Thus—the value of life and human
connection have been enhanced by these experiences.

For some participants, 9=11 facilitated a deeper sense of connectedness,

compassion, and transparency with their clients.

My work as a therapist has changed in as much as I have deepened my

capacity for appreciating the vulnerability and tenderness of the human
experience and see most people as doing their best to live life. Such
things as greed, small-mindedness, and pettiness seem all the more
irrelevant and unenlightened since 9=11—I feel more mature, more
knowing, more human, and more loving.
 Professional Posttraumatic Growth 509

In the immediate aftermath of 9=11 and the subsequent years, I have

become more aware of mortality issues and more appreciative of
relationships . . . as a result of these experiences and increasing age, I
treasure my relationships with family, friends, colleagues, and patients.
My ability to connect with others and my capacity for compassion and
humility has increased. I am grateful even as I feel anger at events I
observe.

In terms of skill development, participants discussed the limitations of

prescribed therapeutic modalities and the need for continued education.
Others discussed 9=11 as the motivation for seeking better practice skills,
including improving the self as a clinical tool.

It challenged me to grow as a clinician and work through what I needed

to work through to better treat my patients.

9=11 inspired me to educate myself in depth about trauma. This has dee-
pened my work with patients in profound ways!

Throughout the costs of caring literature, self-care has been identified as

a protective factor that can prevent the development of secondary trauma or
compassion fatigue (Bober & Regehr, 2006). In this study, participants
reported prioritizing self-care. This theme was expressed in lifestyle and
health changes, as well as occupational changes that reflect taking care of
the self.

I still look back on September 11 and the weeks after as being a night-
mare. I suppose that there were times around the incident that I was in
a dissociative fugue. However, I have become healthier since September
11. I frequently exercise, I never skimp on my sleep, and I eat very
healthily. I am probably more healthy now than I have ever been. I am
much more clear about my priorities and actively pursue things that
are meaningful to me.

I reduced my work in 2002 and built my practice as I did institute train-

ing. In 2006 I went solo. The attack of 9=11 crystallized for me how to
better care for myself.

Political activism was another theme related to practice. This theme

included educational recommendations for clinical practice to include polit-
ical activism, and a newfound desire to be personally politically active. A simi-
lar theme was also noted in a study of university students responding to the
events of September 11 (Ai, Cascio, Santangelo, & Evans-Campbell, 2005).

[We need] more training around crisis=disaster given terrorism. Also think
social work should include more political activism.
510 J. Bauwens and C. Tosone

September 11 inspired me to become involved in political activism again.

This was a positive thing. Since September 11 I have traveled to a conflict
region and met people who deal with trauma and stress all the time and
this really put things in perspective!

Theme 6
The final theme was professional pain. Some participants expressed mixed
and even painful feelings when thinking back on September 11.

Being traumatized myself while working with patients was a negative

experience for me. At the time I felt I had no choice but to be there
for my patients but did not know how to help myself. I eventually found
my way. Since 9=11 I believe talking treatment has its limitations . . . I’m at
a professional crossroad.

Not enough time or space to process personal reactions to clients’

feelings=experiences. I organized a few peer-supervision groups, but felt
like I didn’t necessarily know where to turn. Who heals the healers when
we ourselves are frightened?

DISCUSSION

The intent of this study was to understand the long-term professional and
personal impact of September 11 on clinicians living and working in the
affected area, and the qualities that enabled them to cope with extreme trau-
matic stressors while assisting others through the same event. Our findings
suggest that some clinicians experienced sustained change 6 years after the
shared traumatic experience of September 11, and that the collective trau-
matic event served as an impetus for making changes in their practices. While
some clinicians reported feeling more vulnerable, having continued hypervi-
gilance and traumatic memories, feeling unsupported by professional organi-
zations, and feeling ill-equipped to provide services post-9=11, others
reported making a conscious decision to improve their work situation after
the shared traumatic experience of September 11.
The themes, however, did not collaborate with our dichotomous vari-
ables. On the surface, it appeared that a large percentage of participants
answering the open-ended question were making changes to their lives
and practices that were affirmed by the narrative accounts. A chi-square
analysis did not support this idea. One reason for this finding may be due
to the fact that our dichotomous variables did not specify the type of changes
clinicians made, nor did it account for how the changes were viewed (i.e.,
helpful or not).
 Professional Posttraumatic Growth 511

The logistic regression revealed that the members of our subsample

were more likely to report life change, but to be more traumatized and still
affected by the events of September 11, 2001, than the rest of the sample.
Considering that the participants were more likely to report still being affec-
ted by 9=11, their decision to respond to the open-ended question may be
reflective of their active attempts to cognitively process and make meaning
out of the trauma. Decisions to answer the question may also be reflective
of participants who were successful at creating a working narrative about
9=11 that could be easily recorded in the survey.
The findings from the logistic regression are congruent with the themes
that suggest that, for some clinicians, the shared trauma of September 11 pro-
duced a paradoxical experience where growth and pain coexist. The the-
matic findings support the research of Linley and colleagues (2003), who
maintain that positive and negative change after trauma should be concep-
tualized as unique but assessed together. Studies looking at clinicians
indirectly exposed to trauma have also found positive change to exist con-
currently with negative change (e.g., Arnold et al., 2005; Linley et al.,
2003). Tehrani (2007) found in her sample of caring professionals that most
participants (92%) who experienced high levels of growth and insight from
their caring professions were also likely to report negative changes.
Our findings are similar to previous studies investigating clinicians’ pro-
fessional experiences without disaster. What is distinct in this study are the
positive changes some clinicians described after living and working through
a shared traumatic event, and the changes that followed in professional prac-
tice. This theme, although considered positive, was sometimes reported with
feelings of being overwhelmed by helping others while modulating personal
feelings in the midst of the traumatic event. We called this theme professional
posttraumatic growth and used it to describe the positive change clinicians
reported as improving their professional lives. This theme included adopting
new theoretical orientations, creating more open and flexible boundaries
(Tosone et al., 2003), deeper connection and compassion for clients, and
developing better self-care habits related to professional practice. Under this
theme, we also found that some clinicians described a newfound desire to be
politically active, a finding consistent with Ai and colleagues’ (2005) results
after September 11.
Another aspect of professional posttraumatic growth pertains to bound-
aries at the time of and following the September 11 disaster. Boundaries
changed for many clinicians, even for some professionals accustomed to
stringent and traditional clinical dyads. Boundaries can serve as a protective
factor against vicarious=secondary trauma (Pearlman, 1999). We classified
boundary changes as occurring when participants expressed that new
boundaries were sustained and desirable in practice.
Boundary changes may be connected to clinicians who reported
increased compassion and connectedness in the therapeutic relationship.
512 J. Bauwens and C. Tosone

The boundary changes may have been instrumental in forging a new

relationship allowing for a greater understanding of the traumas clients faced
pre- and post-9=11. Linley and Joseph (2007) found that the therapeutic bond
was the best predictor of both positive change and compassion satisfaction in
clinicians. Clinicians in our sample who were better able to relate to their cli-
ents may have experienced more growth and satisfaction from clinical work.
Developing connectedness in the therapeutic relationship may be one way to
enhance growth and moderate the effects of vicarious and personal trauma
(Tosone, 2006).
Although this study does not draw any conclusions about who grows
and how after a shared traumatic event, one theme indicated some clinicians’
experiences and=or changes after September 11 may be related to trauma
history as either facilitating or hindering a return to health. Our findings
are consistent with existing literature that supports the idea that trauma
exposure can alter people’s worldview (Janoff-Bulman, 1992) and increase
their risk for a vicarious traumatic response (e.g., Pearlman & Mac Ian,
1995; Quitangon et al., 2002) while also allowing for possible growth
(Tedeschi & Calhoun, 2004).

Limitations
This study, like all qualitative studies, is limited to the confines of the sample
and cannot be generalized to the broader population. Participants in the
study were self-selected and solicited from a professional list. Since clinicians
in this sample were surveyed 6 years after the events of September 11, 2001,
time may be an important consideration in our findings (e.g., Helgeson et al.,
2006; Park & Lechner, 2006). The point at which data are collected after a
traumatic event may be indicative of the types of themes that emerge. Rumi-
nation or cognitive processing could have influenced the amount of growth
reported in this study (e.g., Tedeschi & Calhoun, 1995, 2004).
There may be other variables unaccounted for that contributed to the
changes these clinicians reported. Our sample primarily consisted of sea-
soned trauma clinicians with relatively stable approaches to practice. These
participants were highly experienced and working with large caseloads.
Higher levels of growth have been found with greater involvement in trauma
work (Linley & Joseph, 2007). We were also unable to determine if these clin-
icians were more resilient and therefore more apt to experience growth. Less
experienced clinicians may not experience the same amount of growth.
Despite these limitations, our findings have potential significance for
understanding the long-term impact of trauma on clinicians living and work-
ing in environments characterized by exposure to natural disasters and acts
of terrorism. Beyond potential vicarious trauma exposure in the clinical
setting, the clinicians in our study have also been directly exposed to the
same collective traumas as their clients. Their brief narrative accounts of
 Professional Posttraumatic Growth 513

concomitant primary and secondary exposure to trauma have potential

implications for clinical work and training in disaster-prone areas.

Conclusion
This was a preliminary study investigating clinicians’ responses to providing
trauma therapy after the collective trauma of September 11, 2001. The initial
findings indicate that clinicians experienced both positive and negative
changes 6 years post-9=11. The sheer magnitude of 9=11, according to
respondents, created the need for better trauma techniques and an approach
other than prescriptive practice. Some participants expressed professional
growth related to 9=11 that changed the course of their trauma work. Others
expressed a mixture of both experiences.
As natural and man-made traumas become more frequent, clinicians will
increasingly be called to practice in the aftermath of disasters. Our findings
merit further investigation into both the positive and negative sequelae of
clinicians working in disaster-affected regions. Further research is needed
to develop training and education to prepare for and mitigate the deleterious
effects of shared trauma and to facilitate well-being in the professional men-
tal health community.

REFERENCES

Adams, R. E., Boscarino, J. A., & Figley, C. R. (2006). Compassion fatigue and
psychological stress among social workers. American Journal of Orthopsychia-
try, 76, 103–108.
Ai, A. L., Cascio, T., Santangelo, L. K., & Evans-Campbell, T. (2005). Hope, meaning,
and growth following the September 11, 2001, terrorist attacks. Journal of
Interpersonal Violence, 5, 523–548.
Ai, A. L., Tice, T. N., Whisett, D. D., Ishisaka, T., & Chim, M. (2007). Posttraumatic
symptoms and growth of Kosavar war refugees: The influence of hope and
cognitive coping. Journal of Positive Psychology, 2, 55–65.
Altman, N., & Davies, J. M. (2002). Out of the blue: Reflections on a shared trauma.
Psychoanalytic Dialogues, 12, 359–360.
American Psychiatric Association. (1987). Diagnostic and statistical manual of
mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: Author.
Arnold, D., Calhoun, L. G., Tedeschi, R. G., & Cann, A. (2005). Vicarious post-
traumatic growth in psychotherapy. Journal of Humanistic Psychology, 45,
239–263.
Bober, T., & Regehr, C. (2006). Strategies for reducing secondary or vicarious
trauma: Do they work? Brief Intervention and Crisis Intervention, 6, 1–9.
514 J. Bauwens and C. Tosone

Boscarino, J. A., Figley, C. R., & Adams, R. E. (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, 6, 57–66.
Bride, B. E., Robinson, M. M., Yegidis, B., & Figley, C. R. (2004). Development and
validation of the Secondary Traumatic Stress Scale. Research on Social Work
Practice, 14, 27–35.
Calhoun, L. G., & Tedeschi, R. G. (2006). The foundations of posttraumatic growth:
An expanded framework. In L. G. Calhoun & R. G. Tedeschi (Eds.), Handbook
of posttraumatic growth: Research and practice. New York: Erlbaum.
Cardeña, E., Dennis, J. M., Winkel, M., & Skitka, L. J. (2005). A snapshot of terror:
Acute posttraumatic responses to the September 11 attack. Journal of Trauma
& Dissociation, 6, 69–84.
Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among
five approaches (2nd ed.). Thousand Oaks, CA: Sage.
Cryder, C. H., Kilmer, R. P, Tedeschi, R. G., & Calhoun, L. G. (2006). An exploratory
study of posttraumatic growth in children following a natural disaster. American
Journal of Orthopsychiatry, 76, 65–69.
Davis, C. G., Wohl, M. J. A., & Verberg, N. (2007). Profiles of posttraumatic growth
following an unjust loss. Death Studies, 31, 693–712.
Deighton, R. M., Gurris, N., & Traue, H. (2007). Factors affecting burnout and com-
passion fatigue in psychotherapists treating torture survivors: Is the therapist’s
attitude to working through trauma relevant? Journal of Traumatic Stress, 20,
63–75.
Eidelson, R. J., D’Alessio, G. R., & Eidelson, J. I. (2003). The impact of September 11
on psychologists. Professional Psychology: Research & Practice, 34, 144–150.
Figley, C. R. (1995). Compassion fatigue: Toward a new understanding of the costs
of caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self–care issues for
clinicians researchers, and educators (pp. 3–28). Lutherville, MD: Sidran.
Fischer, P., & Ai, A. (2008). International terrorism and mental health: Recent
research and future directions. Journal of Interpersonal Violence, 23, 339–361.
Frazier, P., Conlon, A., & Glaser, T. (2001). Positive and negative life changes
following sexual assault. Journal of Consulting and Clinical Psychology, 69,
1048–1055.
Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine.
Helgeson, V. S., Reynolds, K. A., & Tomich, P. L. (2006). A meta-analytic review of
benefit finding and growth. Journal of Consulting and Clinical Psychology, 74,
797–816.
Hobfoll, S. E., Hall, B. J., Canetti-Nisim, D., Galea, S., Johnson, R. J., & Palmieri, P. A.
(2007). Refining our understanding of traumatic growth in the face of terrorism:
Moving from meaning cognitions to doing what is meaningful. Applied
Psychology: An International Review, 56, 345–366.
Iliffe, G., & Steed, L. (2000). Exploring counselors’ experience of working with per-
petrators and survivors of domestic violence. Journal of Interpersonal Violence,
15, 423–432.
Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of
trauma. New York: Free Press.
 Professional Posttraumatic Growth 515

Kadambi, M. A., & Truscott, D. (2003). Vicarious traumatization and burnout among
therapists working with sex offenders. Traumatology, 9, 216–230.
Lepore, S., & Revenson, T. (2006). Relationships between posttraumatic growth and
resilience: Recovery, resistance, and reconfiguration. In L. G. Calhoun & R. G.
Tedeschi (Eds.), Handbook of posttraumatic growth: Research and practice.
New York: Erlbaum.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.
Linley, P. A., & Joseph, S. (2007). Therapy work and therapists’ positive and negative
well-being. Journal of Social and Clinical Psychology, 26, 385–403.
Linley, P. A., Joseph, S., Cooper, R., Harris, S., & Meyer, C. (2003). Positive and nega-
tive changes following vicarious exposure to the September 11 terrorist attacks.
Journal of Traumatic Stress, 16, 481–485.
Linley, P. A., Joseph, S., & Loumidis, K. (2005). Trauma work, sense of coherence,
and positive and negative changes in therapists. Psychotherapy & Psychoso-
matics, 74, 185–188.
Mann, S., Ostroff, J., Winkel, G., Goldstein, L., Fox, K., & Grana, G. (2004). Posttrau-
matic growth following breast cancer: Patient, partner and couple perspectives.
Psychosomatic Medicine, 66, 442–454.
McCann, L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for
understanding the psychological effects of working with victims. Journal of
Traumatic Stress, 3, 131–147.
McFarlane, C. A. (2004). Risks associated with the psychological adjustment of
humanitarian aid workers. Australasian Journal of Disaster and Trauma
Studies, 1. Retrieved from http://www.massey.ac.nz/~trauma/issues/2004-1/
mcfarlane.htm
Norris, F. H., Byrne, C. M., Diaz, E., & Kaniasty, K. (2001). 50,000 disaster victims
speak: An empirical review of the empirical literature, 1981–2001. Washington,
DC: National Center for PTSD.
Padgett, D. K. (2008). Qualitative methods in social work research (2nd ed.).
Thousand Oaks, CA: Sage.
Pals, J. L., & McAdams, D. P. (2004). The transformed self: A narrative understanding
of posttraumatic growth. Psychological Inquiry, 15, 65–69.
Park, C. L., & Lechner, S. (2006). Measurement issues in assessing growth fol-
lowing stressful life experiences. In L. G. Calhoun & R. G. Tedeschi
(Eds.), Handbook of posttraumatic growth: Research and practice. New York:
Erlbaum.
Pearlman, L. A. (1999). Self-care for trauma therapists: Ameliorating vicarious trau-
matization. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues
for clinicians, researchers, and educators (2nd ed., pp. 51–63). Lutherville,
MD: Sidran.
Pearlman, L. A., & Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study
of the effects of trauma work on trauma therapists. Professional Psychology:
Research & Practice, 26, 558–565.
Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist: Countertrans-
ference and vicarious traumatization in psychotherapy with incest survivors.
New York: Norton.
516 J. Bauwens and C. Tosone

Pennebaker, J. W., & Harber, K. D. (1993). A social stage model of collective coping:
The Loma Prieta earthquake and the Persian Gulf War. Journal of Social Issues,
49, 125–145.
Quitangon, G., Lascher, S., De Francisci, L., Rovine, D., & Eth, S. (2002). Vicarious
traumatization at a Manhattan hospital one year after the 9=11 tragedy.
Unpublished manuscript.
Racanelli, C. (2005). Attachment and compassion fatigue among American and
Israeli mental health clinicians working with traumatized victims of terrorism.
International Journal of Emergency Mental Health, 7, 115–124.
Saakvitne, K. (2002). Shared trauma: The therapist’s increased vulnerability. Psycho-
analytic Dialogues, 12, 443–450.
SAS Institute. (2006). SAS Version 9.2. Cary, NC: Author.
Schauben, L., & Frazier, P. (1995). Vicarious trauma: The effects on female counse-
lors working with sexual violence survivors. Psychology of Women Quarterly,
19, 49–54.
Somer, E., Buchbinder, E., Peled-Avram, M., & Ben-Yizhack, Y. (2004). The stress
and coping of Israeli emergency workers following terrorist attacks. Qualitative
Health Research, 14, 1077–1093.
Tedeschi, R. G., & Calhoun, L. G. (1995). Trauma and transformation: Growing in
the aftermath of suffering. Thousand Oaks, CA: Sage.
Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory:
Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9,
451–471.
Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual founda-
tions and empirical evidence. Psychological Inquiry, 15, 1–18.
Tehrani, N. (2007). The cost of caring—The impact of secondary trauma on assump-
tions, values and beliefs. Counseling Psychology Quarterly, 20, 325–339.
Tennen, H., & Affleck, G. (1998). Personality and transformation in the face of
adversity. In R. G. Tedeschi, C. L. Park, & L. G. Calhoun (Eds.), Posttraumatic
growth: Positive changes in the aftermath of crisis (pp. 65–98). New York:
Psychological Press.
Tosone, C. (2006). Therapeutic intimacy: A post 9=11 perspective. Smith College Stu-
dies in Social Work, 76, 89–98.
Tosone, C., & Bialkin, L. (2004). Mass violence and secondary trauma in clinical prac-
tice. In S. L. A. Straussner & N. K. Phillips (Eds.), Social work with victims of
mass violence (pp. 157–167). New York: Pearson Allyn & Bacon.
Tosone, C., Bialkin, L., Campbell, M., Charters, M., Gieri, K., Gross, S., et al. (2003).
Shared trauma: Group reflections on the September 11th disaster. Psychoana-
lytic Social Work, 10, 57–77.
Tyson, J. (2007). Compassion fatigue in the treatment of combat-related trauma
during wartime. Clinical Social Work Journal, 35, 183–192.
Weiss, T. (2004). Correlates of posttraumatic growth in husbands of breast cancer
survivors. Psycho-oncology, 13, 260–268.
Westphal, M., & Bonanno, G. A. (2007). Posttraumatic growth and resilience to
trauma: Different sides of the same coin or different coins? Applied Psychology:
An International Review, 56, 417–427.
 Professional Posttraumatic Growth 517

Jennifer Bauwens received her degree from the George Warren Brown School of
Social Work at Washington University in 1998, and is currently a doctoral student in
the Silver School of Social Work at New York University. She is an experienced clinician
working with children and adult abuse survivors. She has also developed violence pre-
vention and intervention programs and has taught both nationally and internationally.

Carol Tosone is an associate professor at the New York University Silver School of
Social Work, a recipient of the NYU Distinguished Teaching Award, and a Distinguished
Scholar in Social Work in the National Academies of Practice in Washington, D.C. She is
editor-in-chief of the Clinical Social Work Journal and serves on the editorial boards of
several other professional journals.