The Business of Healing: Focus Group Discussions of Readjustment to the Post-9/11 Work Environment Among Employees of Affected Agencies : Journal of Occupational and Environmental Medicine

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The Business of Healing: Focus Group Discussions of Readjustment to the Post-9/11 Work Environment Among Employees of Affected Agencies

North, Carol S. MD, MPE; Pfefferbaum, Betty MD, JD; Hong, Barry A. PhD; Gordon, Mollie R. MD; Kim, You-Seung MSW; Lind, Lisa PhD; Pollio, David E. PhD

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Journal of Occupational and Environmental Medicine: July 2010 - Volume 52 - Issue 7 - p 713-718
doi: 10.1097/JOM.0b013e3181e48b01
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Because people spend much of their waking lives at their places of employment, there is a substantial likelihood of being highly affected if a disaster strikes the workplace.1 The literature on employee outcomes following workplace stressors has generally focused on organizational factors, largely neglecting extra-organizational events that may lead to emotional distress. Beaton and Murphy2 emphasized the importance of preparing the workplace for management of emotional responses of employees in the event of a major disaster or terrorist event. Although a growing literature provides a wealth of information on mental health issues of disaster-exposed survivors and affected communities, little systematic information exists pertinent to emotional recovery in the disaster-exposed workplace.

Extra-organizational stressors and traumatic events originating outside the workplace environment can lead to negative and potentially damaging reactions among workers3 and can have costly implications for organizations.4 Particularly, severe psychological sequelae can be expected when traumatic events create intense horror and terror,5 encompass an immense scope and magnitude,6,7 and originate from human rather than natural causes. It would be expected, therefore, that the massive and devastating terrorist attacks of September 11, 2001, would have profound effects on subsequent employee functioning and the organizational environments of directly exposed workplaces after this disaster.

Tens of thousands of 9/11 survivors who worked in agencies housed in the World Trade Center were directly exposed to the 9/11 terrorist attacks. On returning to work, they were further distressed by the loss of colleagues and displacement from their offices. Returning to work presented unprecedented challenges in recovery from the aftermath of the attacks and adjustment to a new workplace environment in the days, weeks, and months after 9/11. The nation was unprepared to respond effectively to mental health needs in the workplace after such a large-scale disaster created by a terrorist attack on American soil.8

The 9/11 attacks left workplaces with pressing needs for mental health response capability. Savage9(p. 254) described the 9/11 attacks as “a wake-up call to remind businesses of the need for adequate disaster recovery and business continuity planning”. Fortunately, new workplace receptiveness to mental health interventions has emerged in response to employee needs identified after 9/11.10 Employee assistance organizations have begun to address steps to build resilience and demonstrate support for mental health initiatives for recovery from traumatic events. Suggested elements to include in organizational crisis response plans for traumatic events are flexibility in implementing disaster plans, visibility of leaders in a crisis, communicating and disseminating information frequently during and after a crisis, imparting a vision of hope, and providing postcrisis educational and counseling support at critical dates and milestones.11 Uninformed assumptions about the workplace needs of employees after traumatic events may lead to interventions that are unresponsive to actual need, such as reliance on stress debriefing interventions in lieu of more comprehensive mental health responses.12,13

This report presents findings from qualitative data gathered from focus groups conducted in the second year after the 9/11 attacks with employees of directly affected workplaces, to learn from managers and employees about their experiences and perceptions of the attacks and their subsequent return to work. Focus groups provide a means to begin investigation of topics that are poorly understood, and they may also facilitate the emergence of novel concepts and issues.14 Organized yet open-ended discussions elicited in focus groups allowed participants to express their experiences, reactions, attitudes, feelings, and beliefs in ways not always feasible using other methods.15 Rather than following preconceived ideas and directions of the investigators, the emerging material represents expressions of concerns identified by the disaster-exposed workers as described in their own words.


Because of the complexity of the terrorist attacks on September 11, 2001, and the time it took first to obtain funding to conduct this research, second to identify agencies willing to participate, and third to make necessary arrangements for the study with the local institutional review board (IRB) and with all the participating agencies, the focus groups for this study could not begin until 1 year after the disaster, and it took more than a year to complete all of them. Between 13 and 28 months after the attacks, a convenience sample of 85 employees (22 of whom were managers) of five cooperating agencies who were highly affected by the attacks participated in 1 of 12 focus groups. One of the participating agencies lost several employees in the attacks, and the other four agencies were located either in the World Trade Center towers or in the immediate Ground Zero vicinity. All five agencies, approached through personal contacts of the investigative team, gave permission to the researchers to conduct focus groups at the workplace. These agencies informed their employees of the opportunity to consider participating in one of these focus groups. Employees expressing interest were provided information about the research and invited to a meet with a researcher who explained the study to them. Participants provided written informed consent before enrollment in the study, which was approved in advance by the IRB of Washington University.

The purpose of these groups, as explained to participants, was to learn about personal experiences, reactions, thoughts, feelings, and concerns related to the 9/11 terrorist attacks from the workers' own perspectives. Special care was taken to avoid directing the discussions of the focus groups, as described in previous postdisaster focus group studies by this research group.14,16 Participants were asked to start by talking about where they were and what they experienced at the time of the attacks and subsequently, and then to share their thoughts about how they themselves and their workplace responded to the 9/11 incidents.

Audiotaped focus group discussions were transcribed to text. Using NVivo software, trained raters reviewed the text for recurring themes and categorized its passages into one or more of five theme codes (“nodes”) related to pre- and post-9/11 workplace issues. Passages containing multiple themes received more than one code. Item counts for each code were tabulated, allowing comparison of relative frequencies by category. Kappa measures of inter-rater reliability have been established by this team using these text analysis methods, ranging from 0.83 to 0.88 (calculated on non-negatively scored response pairs only),16 statistics all within the excellent range of reliability.17


In the sample of 85 participants, 72% were women. Most (61%) were white; 25% were black, 11% Hispanic, 2% Asian, and 1% Middle Eastern. Ages ranged from 29 to 66 years (median = 46 years). Detailed demographic information was available for two agencies where the majority (48) of the participants in this study were employed. The combined number of employees of these agencies together was 1688. The gender ratio of the 48 participants in the two agencies with demographic data was 56% women, but the gender ratio of the two agencies combined was 58% men, and thus women were over-represented in the focus groups of these agencies. No information was available about the proportion of managers in these agencies, but the proportion of managers (26% in this study's sample) was likely over-represented because managers were specifically invited to participate in groups.

These group discussions generated 159 passages specifically related to post-9/11 workplace issues. Two themes emerging from the focus group discussions, described in another article (North et al; submitted for publication), include return to work and 9/11-related psychological response of the workplace. Discussion on the topic of return to work covered participants' experiences in reconnecting to the workplace and peer support, including managerial efforts to facilitate a timely and healthy return to work among employees. Discussion on the topic of the workplace response to psychological issues covered demands on managers and explored employee expectations and observations on psychological support in the workplace, including effects of communal work spaces, peer support, and agency responses. The current article describes three additional themes in discussion generated by these groups: communication (14 passages, represented in three groups); flexibility, tolerance, and productivity (26 passages in eight groups); and workplace disruption and displacement (six passages in three groups). Actual focus group quotes are provided below to illustrate these categories.


Employees agreed that responsive and timely communication from a trusted authority was essential to instill a sense of security after catastrophic events such as the 9/11 attacks. A senior manager started the communication process by listening to his employees and asking them, “What are your concerns?” His approach demonstrated to his employees that he communicated responsively by listening and making use of the ideas he solicited from them. His employees told him he had “tremendous credibility with people,” which inspired trust that contributed to their feelings of security. This manager commanded “complete control of the communication,” according to his employees, by establishing himself as a central source of reliable information. He also acknowledged, however, the limits of this information by qualifying his statements with “this is to the best of my knowledge.” His company followed a communication protocol through distribution lists developed in advance “to get the information out there [to establish control in the event of a future crisis] so that it'll filter down.” “Getting that information out has an immediate effect….[people] don't get too upset [before] they know what the full story is.”

In environments that did not implement communication protocols, “a lot of rumors [were] going around. Any time a bad piece of information hit the floor, it circulated like wild fire.” To deal with the rumor problem, one manager instituted periodic meetings to provide updates “to dispel as many false rumors as possible and try to keep everybody informed.” In these meetings, he also solicited other concerns needing to be addressed. Another manager confirmed the importance of consistent efforts to dispel rumors:

My staff…get information from their friends in other buildings and other companies. They hear one thing, and someone else hears something else….I just have to be constantly…saying, “No, that's not true; that's not what I've heard”….You just keep on trying to keep on top of the staff, and not have these little games of telephone going around, because when one person gets it, see how quickly it travels to the next person. You have to keep cutting those rumors off.

Even after 9/11, when another crisis threatened, some employees were unsettled that their companies were still not implementing organized communication strategies. “We had a situation here in August….The bomb squad was across the street, and they exploded a bomb….Not everyone in the whole building heard it, but enough heard it. They started to evacuate,” but, they said, the administration had apparently decided it was not necessary to inform the employees what was going on.

Others noted that lack of timeliness in communication, especially regarding the status of missing coworkers, unnecessarily added to employee distress and hindered normal progression through the grieving process. “There are people I found out about…4 or 5 months later….′Oh, they found Don's body back in April,'.…‘Oh, I didn't know that….’ They could have done a better job keeping us posted.” “We never…knew at the outset [that] this person died. The first thing you hear is these people are unaccounted for….”

Tolerance Versus Productivity

In the post-9/11 period, workplaces experienced new tensions between emotional healing and company productivity. Flexibility was ultimately needed to achieve a balance between tolerance of the emotional toll on functioning and productivity demands. Immediately after 9/11, emotional needs dominated at the expense of company productivity. Some people were too frightened or emotional to even try to come to work after 9/11, which persisted for some time. “Employees in the Trade Center that day…are… sensitive to coming into the city on heightened days of concern about terrorism.” Others could barely function, if at all: “I came back to work the next week…and I just had a fit—the shock, the stun of everything, I just had to leave—I just couldn't function.” “The first month or so is a blur. I felt like I was in another world. I felt very detached from the whole situation like I wasn't there, I was just living, walking around like a zombie, trying to work, and I couldn't. I couldn't concentrate….I was in a daze for a very long time.” Another said, “It's very hard—every day…I still have a hard time coping at work.” Even those who appeared to function well were working at a reduced level: “There was definitely an impact on people's work performance…lapses of concentration.…work was slow….People responded and bounced back at different times and intervals.”

Dedication and drive are definitely on the downturn….employees [who used to] be here for hours on end are those [now] doing their 9-to-5 and going home because they want to be with their families…I can't say that I disagree with that, because I feel the same way, and it's been tough keeping people focused.

Every person deals with it in a different manner….some people who were at the Trade Center, right in the thick of the most severe danger, have dealt with it in a very brave and strong manner, and then there are others who weren't really in any danger whatsoever [who aren't coping].

Many employees commented that the managers were sensitive to their mental and emotional states in the immediate aftermath of 9/11.

There was no forcing people to “be back today, or else.”…Other [WTC] companies [without] the losses of human life we had… gave people time off [but said,] “If you don't come back to work [now] you no longer have a job.” [Our company] was extremely understanding…flexible…I think that helped.

Managers' early efforts to encourage their employees to get back to work were viewed as altruistic by employees. One manager instructed his employees: “When you're ready…come back to work.” To those who responded “I'm not sure I'm ready yet,” he replied, “Don't worry about it; you've got a job.” To his satisfaction, “People came back afterward and thanked me for that, and there was some reward in doing it that way.”

Employees preferred to return to work on their own schedules, and some managers said they tried to be understanding of this. One strategy considered successful by some managers to help people readjust was to implement a graduated return to work.

We had to [reacclimate people] in stages….[At first] we just wanted them to know where the building was…come in to work…not even expecting them to work, and then…trying to be here on time….Then, to stay a whole day…then we made them accountable for the work…Every week, it was another step.…and [we] let them know, “We're here for you; the company's here for you.”

That entire 2-week period after 9/11, the firm [allowed] employees…to adjust to coming back…into work on their own….If they came in late, that's fine. If they didn't feel like coming in today, that's fine, too….I didn't feel the pressure of having to be at my desk at 9:30 if I [feared] commuting through the tunnel during rush hour….The attitude of the firm was one of compassion and understanding, and a lot of people really, really did appreciate that.

Once employees were back at work, managers recognized that some people had trouble regaining focus on their work. One manager described handling the lack of focus in his employees through an acceptance approach: “I'm much more tolerant with my staff than I was before 9/11….Things that would really annoy me before don't [anymore].” Another manager who recognized the inevitability of lost focus and workplace functioning also recognized the need to help his employees begin to restore their previous productivity. “Organizations need to understand…this is a normal reaction; it's not abnormal to feel this way…that people are going to lose focus…[and should] know…the signs to look for…pull [them] aside and say, “What can we do to help you focus?”

Not everyone felt reassured that displaying their emotions would be accepted at the workplace. “People don't want to show their emotions or their lack of focus, because [other] people are going to think something's wrong with them. [But], hey, this is normal. I've been through a crisis, I need to deal with it, and then I can move on.”

Management struggled to achieve an acceptable balance between responding to employees' emotional needs and upholding the company's need for productivity. One manager commented that during a period of heightened security alerts, “People called up saying, ‘Do we have to come to work?’….or ‘How do I get home to my family?’ The managers asked themselves, ‘How do managers in the [post-9/11] work environment help make sure that our employees are productive, address their needs or fears, and yet continue to be productive and make a living?'”

In time, management started to realize that continuing lack of productivity could ultimately jeopardize the future prosperity and the viability of the company. This created conflict. One manager attempting to garner more assistance for his staff was told, “That's enough…go back to work and do your job.” Executives of one agency focused on resuming normal operations while trying to minimize disruption of business, despite the emotional distress of their employees. A manager cautioned the executives, “You know what?.…That is a big mistake….Don't try [to resume usual business right now]. It's not going to work.” Another manager disagreed: “There is a point when business has to get on with business….If somebody's performing at 10%, I've lost 90%. I've got a business that I'm accountable for.”

This shift in the balance toward productivity was met with criticism. Some employees felt their companies were being intolerant in expecting them to continue working as if nothing had changed: “The fact that everyone wanted us to go on normally impacted many people, because many people still feel that it was something big, and they couldn't just go on with normal life.”

Shortly after the 11th…some senior management took a very coarse attitude: “Look, it's over. Deal with it.…Don't use it as a crutch. Go see your counselor; get it out of your system. By Monday, I'd like [everyone] to start work”…A lot of people were taken aback.

Performance demands were incompatible with some workers' difficulties in tolerating return to the worksite. “Other people…didn't feel they had the option to go [home]….coworkers sitting there crying …[were] expected to be troopers and stay [at work].”

Some coworkers did not share their colleagues' difficulties transitioning back to work. “A week after I went back to work, I was one of the only people in our unit who was working who was not a manager or supervisor. I totally threw myself into work.”

Workplace Disruption and Displacement

The workers' sense of loss of their former offices in the World Trade Center towers was profound.

Trade Town was so beautiful….We were so proud of it; it was truly magnificent. The art work, staircases, our views….In my mind's eye, it's all there, my rolodex, everything. It was wonderful; we felt very proud of it. And then we were of course displaced into someplace which was not so beautiful….The offices…were dreary.

The loss of World Trade center offices was magnified by problems in establishing new accommodations. Employees endured construction delays while working in temporary spaces that were crowded and uncomfortable. “Space, I gotta tell you, I think they screwed up…. They waited too damn long…to move people to permanent space. It almost resulted in our office in New York being disbanded, which would have been devastating to everybody.” “Getting the company back together in a location faster than they did would have been extremely helpful. It's tough.”

We felt like gypsies…eight months without a home. Doesn't matter if you're crowded….you need a space where people can put their kids' pictures….It was a very transient type of living for most of us, and the attitude became, “Don't expend any effort on the space, because we're not going to be here for that long.”

The temporary offices were sparse and crowded, lacking office amenities necessary for their work. “We brought in close to a thousand people onto…a couple of floors, so it was very tight quarters….It wasn't a very good time.” Whereas many of the workers had been used to having offices with desks and telephones and computers and filing cabinets, the makeshift offices consisted of large rooms without even cubicles to separate work spaces, and groups of employees sat “jammed in together” at long tables. “You had a pen and a phone, and a laptop, and…no files.” “We were working off of cell phones.…I was typing on the keyboard for my palm.” One worker recalled that before 9/11 they would look in the files to find the answer to a question, but now they had to ask everybody what they could remember: “And so we became our own file cabinets.” “We lost [the last 3 months of] e-mail. We lost everything on the LAN, everything that was archived….So it was kind of like a fresh start.”

Even worse than the disorganization of being crowded together was the disruption of being divided and scattered, as employees of one company described. Staff members were temporarily housed in six different offices in a makeshift loft. The manager was sent out of state and had contact with only two or three people from New York. “I communicated via phone almost daily, but…we had no systems; we got whatever mail we could get and worked on that, but…it was pretty difficult to get constructive work done.”

The issue of space created conflict within one company because there was no available space big enough to house the entire New York City division. To relieve the space problem, executives at company headquarters in a distant city wanted to split the New York City division and move part of the staff to its headquarters. Employees countered with the suggestion of leaving them in two separate offices in Manhattan. They felt splitting the New York office would be better than displacing employees from New York where they wanted to be, which they felt was insensitive to their needs. “I'm downtown and I love it downtown. That's where I've always wanted to be.”

Despite these many difficulties, the crowded work conditions had some positive social effects. “This building…had lots of problems, but the openness of it fostered the group to lean on one another. You couldn't walk around here crying, because the people next to you wouldn't let you.” Being forced into cramped work spaces actually “had a very good effect, because we were able to share, we were able to talk to each other.” “We were just hanging off the rafters in an office that had no space for us. And they were making room for us.…Everybody sort of pitched in and it was good.” “We were with everyone, and that was great. For six months.”


These focus group discussions identified concerns related to risk communication, workplace flexibility, and postdisaster work space. Careful management of these issues was described as pivotal to the well-being and emotional recovery of employees. Employees' needs varied considerably in each of these areas, suggesting the importance of individualizing workplace responses for best results.

Experience has shown that effective risk communication can encourage appropriate behaviors, circumvent rumors, and minimize excessive emotional arousal after disasters.18 Identified elements of effective risk communication include 1) listening and responding directly to the public's concerns, 2) providing timely and unambiguous information by trusted authorities, 3) acknowledging the limits of available information and forecasting the dissemination of future information, 4) organizing authorities to present unified and consistent messages, 5) focusing on directed problem-solving rather than unaddressed needs, and 6) promoting a sense of control by allowing public participation in decision-making and directing people in activities to establish protection against further harm. This is best accomplished with advance preparation and planning, preferably with broad participation in this process.19–23

Providing accurate and timely information to allay fears and anxieties clearly is more than just a compassionate gesture, it is a mental health intervention. Dissemination of knowledge relevant to disaster mental health is the basis of relevant mental health education after disasters.8 Effective risk communication can be a powerful mental health intervention. The focus group participants sought organized communication of vital information to help relieve their anxieties. Insufficient information led to proliferation of rumors and diminished the ability to formulate appropriate company responses to employees' concerns. Capitol Hill staff workers exposed to bioterrorism also described authorities' communications as vital for their emotional functioning and recovery, yet far from adequate.14,16

It is well documented that workplace productivity can be negatively affected by workplace trauma after violent incidents.24 The difficult balance between productivity demands and flexibility to accommodate emotional needs was a point of considerable discussion in the 9/11 focus groups. Managers and employees alike observed that the 9/11 attacks affected productivity, although for longer and more severely in some than in others. Managerial tolerance after 9/11 ranged from understanding and flexibility toward employees' emotional needs at the expense of company productivity to focusing on the company's productivity needs at the cost of perceived insensitivity. Flexibility has been identified important in re-engaging users of mental health services transitioning or returning to work.25 In a published account, one manager who allowed people to take time off work after the 9/11 attacks was surprised to find that most employees followed his example, also returning to work.1

Facilitating the emotional healing of individual workers sometimes conflicted with workplace productivity pressures. Kramar26 observed this conflict in general workplace settings; a report by the Institute of Medicine of the National Academy of Sciences described the phenomenon more specifically in the context of disaster.27

Although both Kramar26 and Eaton28 reported that flexibility in the workplace improves organizational productivity, Kramer cautioned that excessive flexibility could also create worker stress, imbalance of work and personal life, and dissatisfaction with workplace communication. Emotional distress is well known to reduce workplace productivity, ultimately costing the company, through the development of a phenomenon called “presenteeism,” in which impaired workers are ineffective at work rather than absent from work. A relatively new literature on presenteeism suggests that efforts to reduce sick leave may paradoxically result in even greater loss of productivity.29 Managers in this study's focus groups encouraged return to work while tolerating low productivity initially to reap the benefit of social support through extended contact with workplace peers. Eventually their focus returned to workplace productivity.

In the context of the post-9/11 workplace, Argenti30 formalized five guidelines for managers of companies facing crises involving employees' functioning and productivity: 1) physical presence and visibility at the crisis site early and throughout the crisis; 2) creative communication strategies when customary means fail; 3) focus on resuming productive business operations while attending to emotional needs of employees; 4) following emergency plans and developing contingency plans before they are needed; and 5) flexibility grounded in the security of the company's strength. Employing these guidelines may help companies “manage through the unimaginable” of crises such as major disasters.31(p. 58) Schouten et al8 discussed the ethical, moral, and legal burdens on workplaces to have disaster contingency plans, specifically including mental health provisions.

Delays in obtaining new workspaces while having to endure temporary spaces that were crowded and uncomfortable, in the context of mourning their former offices, created hardship, suffering, and conflict. This observation is consistent with the well known effects of crowding on humans in classic research paradigms.32–34 Similar reactions were observed in Capitol Hill staff displaced from their offices by the anthrax attacks.14 “Relocation stress” described in families displaced from their homes by disaster may also apply to workers displaced from their offices by disaster.35

Some positive effects of close work quarters were mentioned, however, as helpful in fostering social support and camaraderie by the former World Trade Center workers in these focus groups and also by displaced Capitol Hill workers after the anthrax attacks.14 Systematic study of temporary postdisaster workplaces is needed to identify ways to maximize potential benefit while minimizing the stress of crowding.

An important strength of this study is that the participants were among the most intensely exposed groups of survivors of the 9/11 attacks in New York City. They represented both sexes, a diversity of ethnicity, a range of adult ages, and both managerial staff and other employees. Women were over-represented in numbers of focus group participants, however, and thus concerns of women may be over-represented in the results. Future studies to conduct analysis by sex might help determine which concerns expressed are relatively more important to men or women. The over-representation of managers allowed sufficient material for analysis, and this imbalance in numbers did not bias results because the discussions of concerns of managers and other employees were considered separately. The large number of participants and groups conducted provided many workplace-related passages for qualitative analysis. This qualitative study, while not permitting statistical hypothesis testing, elicited experiences and concerns of those exposed to the attacks from their own perspectives rather than from preconceived notions of researchers, because the specific content of the discussions of these groups was essentially undirected.

A significant limitation to this study was that the participants comprised a volunteer sample that may not be representative of their workplaces, and the workplaces may not represent workplaces in general or other populations affected by this disaster or by other disasters. Another limitation was the period of time that had elapsed from the 9/11 attacks to the time of the groups, approximately 1 to 2 years, reducing clarity of recollection of early postdisaster experiences and allowing contamination of participants' perspectives by external influences on their views over time. Recall bias over time is a well-established phenomenon.36–38 Additionally, even though confidentiality was assured in the research procedures, the group setting may have discouraged personal disclosure.

Despite its limitations, this study identified potential for improving postdisaster workplace response in areas of risk communication, balancing workplace productivity and employees' emotional needs after disaster, and effects of the postdisaster workspace. Although elements of effective risk communication were used by companies affected by 9/11, their application was generally not a result of organized contingency planning before the disaster but rather the application of common sense by managers with good judgment and problem-solving abilities, including efforts by managers to initiate communication. Formal attention to risk communication strategies before a disaster might yield more consistently effective communication in the postdisaster setting.

Another issue arising in these focus groups was management of postdisaster workplace issues related to crowding. Although more research has indicated that crowding can generally be harmful in life and work spaces, these focus group discussions suggested that social support emerging from close physical proximity was immensely helpful and could purposely be used to advantage in the postdisaster setting.

Finally, achieving and maintaining a healthy balance between flexibility to individual needs and workplace productivity demands was a serious challenge for managers. The literature provides little guidance for attaining a productive and healthy balance of these tensions, suggesting important directions for future disaster workplace research.


The authors gratefully acknowledge the assistance of the participants in this study and the agencies involved.

This research was supported by National Institute of Mental Health grants MH40025 and MH68853 (to Dr North); and Award MIPT106-113-2000-020 from the Oklahoma City National Memorial Institute for the Prevention of Terrorism (MIPT) and the Office for Domestic Preparedness, US Department of Homeland Security (to Dr Pfefferbaum); and by the VA North Texas Health Care System.


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