TERRORIST
ATTACK
How
We Can Prepare for the Hidden Trauma
Today,
we are responding to threats of an imminent terrorist
attack in New York City. We are developing plans and protocol
for addressing the wide spectrum of events that can potentially
disable us - including chemical, biological, radiological
and nuclear attack. We are investing countless hours training
and practicing with elaborate equipment and protective
gear. Our primary goal is the stabilization of injury
and the preservation of life.
In the event of a terrorist attack, our physical and safety needs
must be the priority. As we have learned, physical trauma
can destroy many lives. However, we have also learned
that a hidden trauma, traumatic stress, can ultimately
destroy many more. Traumatic stress refers to the emotional,
cognitive, behavioral and physiological experience of
individuals who are exposed to, or who witness, events
that overwhelm their ability to cope.
A
terrorist attack will have many direct and indirect victims.
Certainly, individuals who are at the scene of a horrific
event may experience traumatic stress. However, we must
recognize the impact on so many others including, but
not limited to, family and friends of victims, emergency
responders, and health care providers. We must also recognize
the power of the media in affecting people across our
nation. For example, we know that individuals who witness
traumatic events on television experience very real traumatic
stress reactions.
Traumatic
stress, resulting from a terrorist attack, will disable
people, cause disease, precipitate mental disorders, lead
to substance abuse, and destroy relationships and families.
In organizations, traumatic stress will lead to communication
breakdowns, a decrease in morale and group cohesiveness,
workplace tension and conflict, excessive absenteeism,
employee sabotage, an increase in workers' compensation
and disability claims, employee litigation, an inability
to retain effective personnel, and ultimately, a decrease
in productivity.
Historically, efforts to address
psychological needs arrive in the weeks, months and years
after a traumatic event - after emotional scars have formed
and after people are labeled with a traumatic stress disorder.
In recent years, techniques have been developed to demobilize,
defuse and debrief people after disengagement from
a crisis - following a traumatic event.
Notwithstanding, there is little
information offering practical strategies to help individuals
during a traumatic experience...a time when people are
highly suggestible, impressionable and vulnerable.
How
can we keep people functioning and mitigate long-term
emotional suffering during, and in the wake of, a terrorist
attack?
As
caregivers, we must expand our repertoire of helping skills
- beyond the physical and safety needs of people, and
raise our level of care.
During
traumatic events, horrible sights, sounds, smells, tastes
and physical touch are indelibly etched in our minds.
They repeat over and over again, they "play back" in our
experience as disturbing "movies," and they lead to uncomfortable
and overwhelming thoughts, feelings, actions and physical
reactions. These stimuli, the imprint of horror, are the
precipitators of debilitating traumatic stress disorders.
The
fact of the matter is that whatever we are exposed to,
whatever we focus on during peak emotional experiences
in our lives, will stay with us forever. Knowing this,
we understand how adversity can disable us.
However,
in the same way that negative stimuli are etched in our
minds during a traumatic experience, so too can a positive,
adaptive force. Knowing this, we understand how adversity
can propel us to achieve.
Look
around you. People who have achieved the most in life
are often people who have not had the easiest lives. Crises
bring opportunities. A positive force, early on, can keep
people functioning and lessen the likelihood of long-term
emotional suffering.
What is this positive, adaptive
force?
Several
years ago, I had the opportunity to ride the night tour
in police ambulances, EMS "fly cars," patrol cars and
with police supervisors for a year. I left my cozy office
to understand what really happens to people during traumatic
experiences. I wanted to learn, first-hand what could
be done, beyond addressing physical and safety needs,
to address emergent psychological needs. I wanted to understand
how we could keep acute problems from becoming chronic
stress disorders. My experience led to the development
of the Acute Traumatic Stress Management (ATSM) model
- a traumatic stress response protocol for all emergency
responders (Lerner and Shelton, 2001, 2005).
Today,
ATSM is being utilized by first responders around the
world (see www.atsm.org) and it is finding its way into
other venues such as schools, universities, the military,
healthcare organizations and corporations. ATSM is a positive,
adaptive force. The implementation of ATSM, along with
traditional emergency medical intervention, offers a comprehensive
response strategy to meet the needs of the "whole person."
ATSM offers practical tools for addressing the wide spectrum
of traumatic experiences - from mild to the most severe.
It is a goal-directed process delivered within the framework
of a facilitative or helping attitudinal climate. ATSM
aims to "jump start" an individual's coping and problem-solving
abilities. It seeks to stabilize acute symptoms of traumatic
stress and stimulate healthy, adaptive functioning.
In
the months and years following a terrorist attack, we
know that many people see their doctors. Many turn to
their spiritual leaders. Others present at a therapist's
office. At that time, a supportive, educational process
begins. People tell their stories, expose themselves to
painful feelings and learn all about traumatic stress.
Why
do we wait for people to experience months, and sometimes
years, of pain and dysfunction? If what we focus on during
a peak emotional experience stays with us forever, we
must seize this opportunity!
In
the face of a terrorist attack, one does not need an advanced
degree in mental health in order to provide highly effective
intervention. In fact, the best help is often rendered
by people on the front lines. People who take the time
to listen and say the "right things" at the "right time."
However, one must know what to say and do before a traumatic
event. Traumatic experiences, by their very nature, compromise
our ability to think clearly and often leave us feeling
out-of-control. By having a plan in place, a traumatic
stress response protocol, we will be in control and
we will know what we need to do. We will be prepared.
How
can we prepare to address the emergent psychological needs
of others?
In
the same way that a high school biology teacher must be
knowledgeable about human anatomy, botany and zoology,
those who strive to help others exposed to a terrorist
attack must be knowledgeable about how people typically
react in the face of a tragedy. They must understand what
traumatic stress is, who it affects, and how it affects
themselves and others.
Caregivers
must learn to recognize the emotional, cognitive, behavioral
and physiological reactions that people experience during
traumatic exposure. And, they must understand that these
reactions are normal reactions in the face of an abnormal
event. This awareness must come from training prior to
a crisis. (Common Reactions Experienced in the Face of
Traumatic Exposure are listed in Table 1.)
Beyond
understanding traumatic stress and knowing how it affects
ourselves and others, caregivers must be equipped with
practical tools that they can use to help others during
a traumatic event. This is the primary goal of ATSM.
ATSM
was developed as a 10 stage model in order to provide
structure during an unstructured period of time -and,
to enable caregivers to "read off the same page." For
example, if I was helping an individual to remain in a
functional state, by focusing on the facts of a given
situation, it would be unfortunate and potentially problematic
for another caregiver to walk over and ask, "How ya feeling?"
In fact, this situation was described to me by a police
officer in the wake of September 11th. He reported that
he was talking with a colleague about extricating bodies
when, "...some nut in a red jacket came over and asked
me how I was feeling.... I told him to get the ____ out
of here. I wanted to kill the bastard!" There is a "right
thing" to say, and a "right time" to say it.
Following
is a brief overview of the 10 Stages of ATSM. The first
4 stages are of primary importance to EMS personnel and
have to do with considerations surrounding situation management
and emergency medical care. The latter stages can be implemented
by all caregivers.
It
is important to recognize that the nature of the event,
time constraints and the intensity of individuals' reactions,
will vary during traumatic exposure. Consequently, appropriate
intervention may not fall neatly into a linear progression
of stages. You will need to be flexible given the presenting
circumstances.
1. Assess for Danger/Safety for Self and Others
Upon
arriving at the scene of a terrorist attack, assess the
situation in order to determine whether there are factors
that can compromise your safety or the safety of others.
You will be of little help to someone else if you are
injured. For example, do not enter an environment that
may be compromised by dangerous gasses without the appropriate
gear. If possible, remove people from the location in
order to risk further traumatic exposure.
2.
Consider the Mechanism of Injury
Form
an initial impression of those impacted by the event.
In order to understand the nature of an individual's exposure,
it is important to assess how the event may have physically
impacted the individual - that is, how environmental factors
transferred to the person. For example, if people are
unconscious, it is important to know what factor, or factors
led to their loss of consciousness. It is also important
to consider the perceptual experiences of victims. For
example, directly observing people mutilated after a suicide
bomber attacks a crowded bus will have a powerful impact
on those who observe the incident. Similarly, the sounds
of people screaming, in the wake of such an attack, will
etch a lasting impression in the minds of all who arrive
at the scene to help. Ask yourself whether it is necessary
for you to expose yourself to the inner perimeter. Direct
exposure to a gruesome scene can compromise your ability
to help others.
3.
Evaluate the Level of Responsiveness
It
is important to determine if an individual is alert and
responsive to verbal stimuli. Does he feel pain? Is he
aware of what has occurred, or what is presently occurring?
Is he being influenced by a substance? During a traumatic
event, it is quite possible that the individual is experiencing
"emotional" shock. Therefore, symptomatology may mimic
acute medical conditions (i.e., rapid changes in respiration,
pulse, blood pressure, etc.). Recognize that a psychological
state of shock may be adaptive in preventing the individual
from experiencing the full impact of the event too quickly.
For example, in the case of a terrorist attack in a subway,
many people will emerge on the street from stairways and
stare blankly while first responders attempt to engage
them in conversation. This lack of responsiveness may
not be the effect of a physical agent, but the effect
of acute traumatic stress. This reaction is not unusual.
During traumatic events, people can experience a wide
range of emotional reactivity.
4.
Address Medical Needs
Emergency
responders are trained to assess the ABCs (i.e., airway,
breathing and circulation). They understand that if a
man is not breathing, there will be little else that can
be done to help him. Emergency responders also understand
the importance of addressing significant symptomatology
(e.g., severe chest pains) as well as the importance of
knowing about existing medical conditions (e.g., diabetes).
They have also been trained to know the kinds of injuries
that may present a threat to life (e.g., internal bleeding).
It is critical that medical intervention be provided by
trained emergency medical personnel. Consider the potential
danger of moving a young woman who is found outside of
derailed train. Despite the best intentions of good Samaritans,
the woman may have suffered a back injury and movement
could cause permanent injury to her spinal cord. It is
imperative that life-threatening illness and injury are
addressed prior to psychological needs.
5.
Observe and Identify
Observe
and identify those who have been exposed to the attack.
Very often, these individuals will not be the direct victims.
They may be secondary or hidden victims. Witnessing, or
even being exposed to another individual who has faced
traumatic exposure, can cause traumatic stress. As you
observe and identify who has been exposed to the event
(i.e., directly and/or indirectly), begin to observe and
identify who is evidencing signs of traumatic stress.
An awareness of the emotional, cognitive, behavioral and
physiological reactions suggestive of traumatic stress
is important. Carefully look around you. Anyone, including
you, may be a direct or hidden victim. This observation
and identification stage of ATSM may be viewed as the
first traumatic stress specific stage.
6.
Connect with the Individual
During
a crisis situation, introduce yourself and let people
know your role (e.g., "My name is Ron, I'm a paramedic
and firefighter with the Melton Fire Department."). If
the individual is not physically injured and has been
cleared by emergency medical personnel, move him away
to prevent further traumatic exposure. Begin to develop
rapport by making an effort to understand and appreciate
his situation. A simple question such as, "How are you
doing?" may be used to engage the individual. Use appropriate
non-verbal communication (e.g., eye contact, body turned
toward him, a gentle touch, etc.). Recognize that during
a traumatic event, individual reactions may present on
a continuum from a totally detached, withdrawn reaction
to the most intense displays of emotion (e.g., uncontrollable
crying, screaming, panic, anger, fear, etc.). During a
terrorist attack, you may find yourself working to connect
with small groups of individuals.
7.
Ground the Individual
When
you have established a connection with someone (or people)
who has been exposed to a terrorist attack (e.g., eye
contact, body turned toward you, dialogue directed at
you, etc.), you can initiate this grounding stage. Begin
by acknowledging the traumatic event at a factual level.
Here, you attempt to orient the person by discussing the
facts surrounding the event. Address the circumstances
of the event at a cognitive, or thinking level. While
we do not discourage the expression of emotion, attempt
to focus on the facts in the here-and-now, and help the
individual to know the reality of the situation. Oftentimes,
his "reality" may be seriously clouded due to the nature
of the event. Remember, traumatic events overwhelm an
individual's coping and problem-solving abilities. Assure
the individual that he is now safe, if he is. He may still
be "playing the tape" of the event over and over in his
mind. By reviewing facts, you may disrupt "negative cognitive
rehearsal" (i.e., repetitive, potentially destructive
thinking), help the individual to function, and help him
to deal with the circumstances at hand.
It
is important to "place the individual in the situation."
Encourage him to "tell his story" and describe where he
was, what he saw, what it sounded like, what it smelled
like, what he did, and how his body responded. Encourage
the individual to discuss his behavioral and physiological
response to the event - rather than "how it felt."
8.
Provide Support
Factual
discussion and the realization of a terrorist attack,
particularly when the event is unfolding, may likely stimulate
thoughts and feelings. This is often the time when individuals
who are exposed to trauma need the most support. However,
in reality, it is also the time when many people look
the other way. Many individuals feel terribly unprepared
to handle others' painful thoughts and feelings. Oftentimes,
they fear that they will "open a can of worms" or "say
the wrong thing." Generally, a reasonable attempt to help
others is preferable to avoidance.
It
is important to establish and maintain a facilitative
or helping attitudinal climate. Here, you attempt to understand
and respect the uniqueness of the individual - the thoughts
and feelings that he is experiencing. You strive to "give
back" a sense of control that has been "taken from" him
by virtue of his exposure to the event. You support him,
and you allow him to think and feel. In the face of a
terrorist attack, many people will experience an overwhelming
sense of aloneness and withdraw into their own world.
You should make a respectful effort to "enter that world,"
and to help the individual to know that he is not alone
and that his unique perception of his experience is important.
Do not attempt to talk a person out of a feeling (e.g.,
"Don't be scared, you're fine."). Communicate an appreciation
of the other person's experience. Attempt to understand
the feelings that lie behind his words (or perhaps actions)
and convey that understanding to him. Developing these
empathic listening skills is an area that should be addressed
prior to a crisis.
9.
Normalize the Response
While
you are attempting to support an individual by giving
him the opportunity to express his thoughts and feelings,
begin to normalize his reaction to the attack. This is
an important component when intervening with people who
have been exposed to trauma and who may be feeling very
alone. Experiencing a cascade of emotions, or perhaps
a lack of emotional reactivity, may cause him to feel
as if he is "losing it" and perhaps, "going crazy." Normalizing
and validating an individual's experience will help him
to know that he is a normal person trying to deal with
an abnormal event.
It
is important that you do not become sympathetic and over
identify with the situation with statements such as, "I
know what it feels like.... When I was...." Rather, you
should attempt to normalize and validate the individual's
experience with statements like, "I see this is overwhelming
for you right now... seeing a friend badly injured would
be hard for anyone to handle."
An
important component of the normalization process is to
begin to educate the individual by helping him to know
how people typically respond to traumatic events. Discuss
the emotional, cognitive, behavioral and physiological
reactions that people frequently experience. Remember,
these reactions do not necessarily represent an unhealthy
or maladaptive response. Rather, they may be viewed as
normal responses to an abnormal event.
10.
Prepare for the Future
The
final phase of the ATSM process is aimed at preparing
the individual for what lies on the road ahead. It is
helpful to 1) review the nature of the traumatic event,
2) bring the person to the present, and 3) describe likely
events in the future. The educational process initiated
during the previous Normalization Stage should continue
during this final stage of ATSM.
Be
careful not to tell someone as you near the end of your
intervention that "everything is going to be okay," or
that "everything is going to work out." These kinds of
"band-aid" statements may only serve to minimize an individual's
feelings and cause him to feel misunderstood. Instead,
focus on the facilitative attitudinal climate that you
have established - "I'm glad that I had the opportunity
to be here with you during such a difficult time."
ATSM
should not be viewed as counseling or psychotherapy and,
in and of itself, ATSM is not a comprehensive crisis response
plan. Rather, ATSM provides a road map that can guide
individuals through times of crisis, keep people functioning
and mitigate long-term emotional suffering.
The
possibility of a terrorist attack is on our minds. In
an effort to gain a sense of control, we are taking important
steps to prepare and equip emergency responders to address
the physical and safety needs of survivors. While the
stabilization of injury and the preservation of life must
always be the priority, we must not overlook the hidden
trauma - traumatic stress. By preparing to address emergent
psychological needs during, and in the wake of, a terrorist
attack we can keep people functioning and potentially
prevent acute traumatic stress reactions from becoming
chronic stress disorders.
To learn more about Acute Traumatic Stress
Management, visit www.ATSM.org
Table
1. Common Reactions Experienced in
the Face of Traumatic Exposure
Emotional Responses
during a traumatic event may include shock,
in which the individual may present a highly
anxious, active response or perhaps a seemingly
stunned, emotionally-numb response. He may
describe feeling as though he is "in a fog."
He may exhibit denial, in which there is an
inability to acknowledge the impact of the
situation or perhaps, that the situation has
occurred. He may evidence dissociation, in
which he may seem dazed and apathetic, and
he may express feelings of unreality. Other
frequently observed acute emotional responses
may include panic, fear, intense feelings
of aloneness, hopelessness, helplessness,
emptiness, uncertainty, horror, terror, anger,
hostility, irritability, depression, grief
and feelings of guilt.
Cognitive Responses
to traumatic exposure are often reflected
in impaired concentration, confusion, disorientation,
difficulty in making a decision, a short attention
span, suggestibility, vulnerability, forgetfulness,
self-blame, blaming others, lowered self-efficacy,
thoughts of losing control, hypervigilance,
and perseverative thoughts of the traumatic
event. For example, upon extrication of a
survivor from an automobile accident, he may
cognitively still "be in" the automobile "playing
the tape" of the accident over and over in
his mind.
Behavioral Responses
in the face of a traumatic event may include
withdrawal, "spacing-out," non-communication,
changes in speech patterns, regressive behaviors,
erratic movements, impulsivity, a reluctance
to abandon property, seemingly aimless walking,
pacing, an inability to sit still, an exaggerated
startle response and antisocial behaviors.
Physiological Responses
may include rapid heart beat, elevated blood
pressure, difficulty breathing*, shock symptoms*,
chest pains*, cardiac palpitations*, muscle
tension and pains, fatigue, fainting, flushed
face, pale appearance, chills, cold clammy
skin, increased sweating, thirst, dizziness,
vertigo, hyperventilation, headaches, grinding
of teeth, twitches and gastrointestinal upset.
|
 |
ATSM
offers “practical tools” for addressing the wide
spectrum of traumatic experiences—from mild to the
most severe. It is a goal-directed process delivered
within the framework of a facilitative or helping
attitudinal climate. ATSM aims to “jump-start” an
individual’s coping and problem-solving abilities.
It seeks to stabilize acute symptoms of traumatic
stress and stimulate healthy, adaptive functioning.
Finally, ATSM may increase the likelihood of an
individual pursuing mental health intervention,
if need be, in the future.
www.ATSM.org |
IN
THE AFTERMATH OF HURRICANES RITA AND KATRINA
Addressing
Emergent Psychological Needs
Hurricanes
Rita and Katrina are among our nation's worst natural
disasters. The loss of life and destruction seems immeasurable.
Today, in the aftermath of these hurricanes, the focus
of caregivers must be the stabilization of injury and
illness and, ultimately, the preservation of life. As
our nation rushes to help, by addressing the physical
and safety needs of survivors, we must not overlook the
myriad victims of the hidden trauma - traumatic stress.
Traumatic
stress refers to the feelings, thoughts, actions and physical
reactions of individuals who are exposed to, or who witness,
events that overwhelm their coping and problem-solving
abilities. Traumatic stress disables people, causes disease,
precipitates mental disorders, leads to substance abuse,
and destroys relationships and families.
Beyond
those who have survived Rita and Katrina, many of whom
have faced serious physical injury, are those who have
experienced devastating losses of loved ones. Countless
people have lost their homes, all of their possessions,
and all that was familiar to them.
Today,
our world is witnessing the aftermath of these devastating
hurricanes. We receive daily doses of the "imprint
of horror" - images destruction are being recorded
in our minds. Truly, our nation is experiencing traumatic
stress.
Addressing
the emergent psychological needs of survivors
Reaching
such an inordinate number of people, who have been directly
and indirectly affected by Rita and Katrina, is a formidable
task. Ultimately, a multimodal approach will be most effective.
Beyond individual and group interventions, the media (e.g.,
radio, television and newspapers) can play a tremendous
role in helping people by offering practical, timely information.
In
this column, I'll discuss how significant traumatic events,
such as devastating hurricanes, affect people. Then, I'll
present an overview of a traumatic stress response protocol,
Acute Traumatic Stress Management (ATSM). ATSM is a pragmatic
process that was developed to keep people functioning,
and mitigate ongoing emotional suffering.
Traumatic
Events and Traumatic Stress
Generally,
as traumatic events become more severe, and as people
get physically closer to them, there's a greater likelihood
for traumatic stress. We also know that people have a
particularly difficult time with events that are gruesome
- such as viewing the dead and seeing victimized children.
The
manner in which an individual responds will be based upon
a number of variables including pre-trauma factors (e.g.,
a history of mental illness, prior traumatic exposure,
substance abuse, etc.), characteristics of the traumatic
event (e.g., the severity, proximity, etc.), and post-trauma
factors (e.g., having the opportunity to "tell his
story," level of familial support, etc.). The personal
meaning that an individual ascribes to a hurricane will
also influence his/her response.
Helping
people to understand how traumatic events affect them,
gives back a sense of control that seems to have been
taken away in the face of a traumatic experience. For
instance, helping people to know that certain reactions
are normal, in the wake of an abnormal event, helps to
validate disturbing feelings. Following, is a brief discussion
of how traumatic events affect peoples' feelings, thoughts,
actions and physical reactions.
When
people face a traumatic event, some experience "emotional
shock." They're anxious, nervous and sometimes even
panicky - while others, feel nothing... just a numbness.
Both reactions are very common and both are very normal.
Some people experience denial, where they don't seem to
know that something really bad has happened. Denial is
a mechanism that prevents people from feeling too much,
too quickly. For many people, the painful realization
of the magnitude of Rita and Katrina, and their impact,
will be experienced after initial denial.
Many
survivors will experience "flashbacks." Flashbacks,
or feeling as if a traumatic event is happening over and
over again, is common among people who've experienced
traumatic events - particularly early on. Other common
emotional reactions are feelings of aloneness, emptiness,
sadness, anger, grief and feelings of guilt.
It's
so important that we don't put a bandage on feelings by
advising others that, "with time, you'll feel better."
Instead, we must help others to understand that experiencing
these feelings, as uncomfortable and as painful as they
are, is normal. It's okay, not to be okay, right now.
One
of things that make it so hard for people to function
during, and in the aftermath of a traumatic experience,
is difficulty concentrating. Traumatic events, by their
very nature, interfere with peoples' thinking. As human
beings, we don't focus and think very clearly during a
crisis, because the right half of our brain is activated.
It's in what we call the "fight-or-flight" mode,
working to keep us alive. It's not until later on, when
the left side, the verbal, the "thinking" part
of our brain takes over that we begin to process and label
what's happening. It's hard for us to make decisions,
our attention span is shorter than usual, and we are suggestible
and vulnerable. It's also common for us to "play
the tape" of what's happened, over and over in our
minds - even when we want to turn it off. Many people
recall past traumatic experiences.
People
act differently during traumatic events. Some of us withdraw,
"space-out" and become non-communicative. Others
become impulsive and energetic - walking and pacing aimlessly.
Some people will avoid anything associated with the event
- thoughts, feelings, conversations, activities, people
and places.
One
thing that's particularly important to know is that how
people respond, how they choose to react during a traumatic
experience will stay with them forever. Not only that,
how others act and react will stay with them as well.
Do you remember the televised images of Mayor Rudy Giuliani
walking through the streets of New York City on September
11th? The Mayor didn't "take-cover" during the
tragedy, he decided to "take-action."
Hurricanes
Rita and Katrina remind us that we can't control the events
in our lives, but we can control how we'll to respond
to them - how we choose to act. People can make decisions
to regain control, at a time when it when it feels like
they've lost control. Those who have witnessed the devastation,
and made donations to help survivors, understand this.
There
are so many kinds of traumatic experiences that can affect
people, yet there aren't nearly as many kinds of physical
reactions. In fact, people respond the same way to a car
backfiring as they do to a gunshot - the "fight-or-flight
response." It's not until they begin thinking about
their experience that they become aware of, and, begin
to understand what's happening to them.
It's
not uncommon for survivors to experience physical changes
- headaches, muscle aches and stomach aches. Individuals
who have difficulty breathing, or those who experience
chest pains or palpitations, should be seen by a doctor.
It's also very common for people to experience changes
in their sleep patterns and to have some very disturbing
dreams. Their minds are working overtime to try to make
sense of the senseless. Many people experience changes
in their eating patterns.
One
of the most common reactions in the face of a traumatic
event is hypervigilance. Survivors are excessively watchful
and cautious - they're uncomfortably nervous and wary.
This is a basic survival mechanism that protects us. Hypervigilance
was reflected in a two-page newspaper article that I read
today entitled, "What if a Category 5 hurricane hit
here?" Also, very common is an increased or exaggerated
startle response. People tend to be "jumpy"
- particularly with loud noises.
We
can't prevent or inoculate people from experiencing traumatic
stress, because it's a normal response to an abnormal
event. However, by having an understanding of what's happening,
while it's happening, and by helping people to know that
their reactions are normal, is empowering.
Acute
Traumatic Stress Management
Whatever
happens to us during peak emotional experiences in our
lives, the gifts of life and the losses of life, will
stay with us forever. In the same way that negative experiences
are etched in our minds, so too may the positive force
of Acute Traumatic Stress Management. Having someone say
and do the right thing, at the right time, can dramatically
affect an individual's recovery.
It
is important to realize that addressing emergent psychological
needs in the aftermath of a tragedy does not require an
advanced degree in mental health. In fact, the best help
is often rendered by people on the front lines - people
who take the time to listen, and say the right things
at the right time. However, it's important for caregivers
to know what to say and do before they reach out to help
others. Traumatic experiences, by their very nature, compromise
our ability to think clearly and often leave us feeling
out-of-control. By having a plan, a traumatic stress response
protocol, caregivers will be in control. They will know
what to say and do. They will be prepared.
Beyond
having an understanding of traumatic events and traumatic
stress, caregivers must be equipped with practical tools
that they can use to help others in the face traumatic
exposure. This is the primary goal of Acute Traumatic
Stress Management (ATSM).
ATSM
was developed as a 10 stage model in order to provide
structure during an unstructured period of time - and,
to enable caregivers to "read off the same page."
For example, if I was helping an individual to remain
in a functional state, by focusing on the facts of a given
situation, it would be unfortunate and potentially problematic
for another caregiver to walk over and ask, "How
ya feeling?" In fact, this situation was described
to me by a New York City police officer in the wake of
September 11th. He reported that he was talking with a
colleague about extricating bodies when, "...some
nut in a red jacket came over and asked me how I was feeling....
I told him to get the ____ out of here. I wanted to kill
the bastard!" There is a right thing to say, and
a right time to say it.
Following,
is a brief overview of the 10 Stages of ATSM. For additional
information, caregivers are encouraged to read Comprehensive
Acute Traumatic Stress Management (www.ATSM.org).
Noteworthy, is that ATSM was built on a strong, empirically-based
foundation. The first four stages of this model are of
primary importance to emergency medical personnel, and
have to do with considerations surrounding situation management
and emergency medical care. The latter six stages may
be implemented by all caregivers.
It
is important to recognize that time constraints and the
intensity of individuals' reactions, will vary. Consequently,
appropriate intervention may not fall neatly into a linear
progression of stages. Caregivers will need to be flexible
given the presenting circumstances.
1.
Assess for Danger/Safety for Self and Others
Upon
arriving at the scene, assess the situation in order to
determine whether there are factors that can compromise
your safety or the safety of others. You will be of little
help to someone else if you are injured. For example,
do not enter a building that has obviously sustained structural
damage. If possible, remove people from the location in
order to risk further traumatic exposure.
2.
Consider the Mechanism of Injury
Form
an initial impression of those impacted by the event.
In order to understand the nature of an individual's exposure,
it's important to assess how the event may have physically
impacted the person - that is, how environmental factors
transferred to him. For example, if people are unconscious,
it is important to know what factor, or factors led to
their loss of consciousness. It is also important to consider
the perceptual experiences of victims. For example, directly
observing the bodies of children who have drowned will
have a powerful impact on observers. Similarly, the sounds
of people moaning will etch a lasting impression in the
minds of all who arrive at the scene to help. Ask yourself
whether it is necessary for you to expose yourself to
the inner perimeter. Direct exposure to a gruesome scene
can compromise your ability to address emergent psychological
needs.
3.
Evaluate the Level of Responsiveness
It
is important to determine if an individual is alert and
responsive to verbal stimuli. Does he feel pain? Is he
aware of what has occurred, or what is presently occurring?
Is he being influenced by a substance? In the aftermath
of Rita and Katrina, it is quite possible that people
are experiencing "emotional" shock. Therefore,
symptomatology may mimic acute medical conditions (i.e.,
rapid changes in respiration, pulse, blood pressure, etc.).
Recognize that a psychological state of shock may be adaptive
in preventing the individual from experiencing the full
impact of the event too quickly. Keep in mind that during
traumatic events, people can experience a wide range of
emotional reactivity.
4.
Address Medical Needs
Emergency
responders are trained to assess the ABCs (i.e., airway,
breathing and circulation). They understand that if a
man is not breathing, there will be little else that can
be done to help him. Emergency responders also understand
the importance of addressing significant symptoms (e.g.,
severe chest pains) as well as the importance of knowing
about existing medical conditions (e.g., diabetes). They
have also been trained to know the kinds of injuries that
may present a threat to life (e.g., internal bleeding).
It is critical that medical intervention be provided by
trained emergency medical personnel. Consider the potential
danger of moving a young woman who is found trapped under
rubble. Despite the best intentions of caregivers, the
woman may have suffered a back injury and movement could
cause permanent injury to her spinal cord. It is imperative
that life-threatening illness and injury are addressed
prior to psychological needs.
5.
Observe and Identify
Observe
and identify those who have been exposed to the event.
Very often, these individuals will not be the direct victims.
They may be secondary or hidden victims. As I stated previously,
witnessing, or even being exposed to another individual
who has faced traumatic exposure, can cause traumatic
stress. As you observe and identify who has been exposed
to the event (i.e., directly and/or indirectly), begin
to observe and identify who is evidencing signs of traumatic
stress. An awareness of the emotional, cognitive, behavioral
and physiological reactions suggestive of traumatic stress
is important. Carefully look around you. Anyone, including
yourself, may be a direct or hidden victim. This observation
and identification stage of ATSM may be viewed as the
first traumatic stress-specific stage.
6.
Connect with the Individual
Introduce
yourself and let people know your role (e.g., "My
name is Ron, I'm a social worker"). If the individual
is not physically injured, and he has been cleared by
emergency medical personnel, move him away to prevent
further traumatic exposure. Begin to develop rapport by
making an effort to understand and appreciate his situation.
A simple question such as, "How are you doing?"
may be used to engage the individual. Use appropriate
non-verbal communication (e.g., eye contact, body turned
toward him, a gentle touch, etc.). Recognize that during
a traumatic experience, individual reactions may present
on a continuum from a totally detached, withdrawn reaction
to the most intense displays of emotion (e.g., uncontrollable
crying, screaming, panic, anger, fear, etc.). In view
of the magnitude of these hurricanes, you may likely find
yourself working to connect with small groups of individuals.
7.
Ground the Individual
When
you have established a connection with an individual or
small group of individuals (e.g., eye contact, body turned
toward you, dialogue directed at you, etc.), you can initiate
this grounding stage. Begin by acknowledging the hurricane
at a factual level. Here, you attempt to orient the person
by discussing the facts surrounding the event. Address
the circumstances at a cognitive, or thinking level. While
we do not discourage the expression of emotion, attempt
to focus on the facts in the here-and-now, and help the
individual to know the reality of the situation. His "reality"
may be seriously clouded due to the nature of the event.
Remember, traumatic events overwhelm an individual's coping
and problem-solving abilities. Assure him that he is now
safe, if he is. He may still be "playing the tape"
of the event over and over in his mind. By reviewing facts,
you may disrupt "negative cognitive rehearsal"
(i.e., repetitive, potentially destructive thinking),
help the individual to function, and enable him to deal
with the circumstances at hand.
It
is important to "place the individual in the situation."
Encourage him to "tell his story" and describe
where he was, what he saw, what it sounded like, what
it smelled like, what he did, and how his body responded.
Encourage him to discuss his behavioral and physiological
response - rather than "how it felt."
8.
Provide Support
Factual
discussion, and the realization of a severe hurricane,
may likely stimulate thoughts and feelings. This is often
the time when individuals who are exposed to trauma need
the most support. However, in reality, it is also the
time when many people look the other way. Many individuals
feel terribly unprepared to handle others' painful thoughts
and feelings. Oftentimes, they fear that they will "open
a can of worms" or "say the wrong thing."
Generally, a reasonable attempt to help others is preferable
to avoidance.
It
is important to establish and maintain a facilitative
or helping attitudinal climate. Here, you attempt to understand
and respect the uniqueness of the individual - the thoughts
and feelings that he is experiencing. You strive to "give
back" a sense of control that has been "taken
from" him by virtue of his exposure to the event.
You support him, and you allow him to think and feel.
Due to the magnitude of these storms, many people will
experience an overwhelming sense of aloneness and withdraw
into their own world. You should make a respectful effort
to "enter that world," and to help the individual
to know that he is not alone and that his unique perception
of his experience is important. Do not attempt to talk
a person out of a feeling (e.g., "Don't be scared,
you're fine."). Communicate an appreciation of the
other person's experience. Attempt to understand the feelings
that lie behind his words (or perhaps actions) and convey
that understanding to him.
While
providing support with young children, you may need to
hold and cuddle the child. Reassure him that he is safe,
if he is. Know that children will take cues from adults
around them, particularly those with whom they are close.
It is therefore important to separate children, as quickly
as possible, from all stressors - including emotionally
overwhelmed adults.
Engaging
children must be made consistent with their developmental
level. For example, offering more information than a child
is cognitively able to manage may do more harm than good.
Recognize too that children, particularly young children,
are generally unable to express their feelings verbally.
They may likely convey their feelings through their behaviors/actions.
If you have the time, providing children the opportunity
to draw with crayons may be helpful. For example, you
may encourage them to draw something that they remember
about the event. The drawing may then be used as a vehicle
to understand the thoughts and feeling the child is experiencing.
9.
Normalize the Response
While
you are attempting to support an individual by giving
him the opportunity to express his thoughts and feelings,
begin to normalize his reaction to the tragedy. This is
an important component when intervening with people who
have been exposed to trauma and who may be feeling very
alone. Experiencing a cascade of emotions, or perhaps
a lack of emotional reactivity, may cause him to feel
as if he is "losing it" and perhaps, "going
crazy." Normalizing and validating an individual's
experience will help him to know that he is a normal person
trying to deal with an abnormal event.
It
is important that you do not become sympathetic and over
identify with the situation with statements such as, "I
know what it feels like.... When I was...." Rather,
you should attempt to normalize and validate the individual's
experience with statements like, "I see this is overwhelming
for you right now...seeing so much devastation would be
hard for anyone to handle."
An
important component of the normalization process is to
begin to educate the individual by helping him to know
how people typically respond to traumatic events. Discuss
the emotional, cognitive, behavioral and physiological
reactions that people frequently experience. Remember,
these reactions do not necessarily represent an unhealthy
or maladaptive response. Rather, they may be viewed as
normal responses to an abnormal event.
10.
Prepare for the Future
The
final phase of the ATSM process is aimed at preparing
the individual for what lies on the road ahead. It is
helpful to 1) review what we know about the hurricane,
2) bring the person to the present, and 3) describe likely
events in the future. The educational process initiated
during the previous Normalization Stage should continue
during this final stage of ATSM.
Be
careful not to tell someone as you near the end of your
intervention that "everything is going to be okay,"
or that "everything is going to work out." These
kinds of "band-aid" statements may only serve
to minimize an individual's feelings and cause him to
feel misunderstood. Instead, focus on the facilitative
attitudinal climate that you have established - "I'm
glad that I had the opportunity to be here with you during
such a difficult time."
ATSM
should not be viewed as counseling or psychotherapy. Rather,
ATSM provides a road map that can guide individuals through
this horrific event, keep people functioning and lessen
the likelihood of ongoing emotional suffering.
Conclusion
In
the aftermath of hurricanes Rita and Katrina, our nation
is rushing to address the devastating loss of life and
destruction. Beyond the physical and safety needs of survivors,
we must recognize and address the hidden trauma - traumatic
stress. In this column, I have provided practical information
about traumatic events and traumatic stress that should
be reviewed by caregivers, and shared with survivors.
Consider the potential of radio, television and the printed
news media in helping survivors to understand that their
reactions are normal given such an abnormal circumstance?
By educating people about traumatic stress, we can give
survivors back a sense of control that these hurricanes
seem to have taken away. Knowledge is power!
I
have additionally presented an overview of a traumatic
stress response protocol, Acute Traumatic Stress Management
(see www.ATSM.org).
ATSM aims to keep people functioning and mitigate long-term
emotional suffering. By reaching survivors early, we can
potentially prevent the acute traumatic stress reactions
of today from becoming chronic posttraumatic stress disorders
of tomorrow.
Common
Reactions Experienced in the Face of Traumatic Exposure
Emotional Responses
during a traumatic event may include shock,
in which the individual may present a highly
anxious, active response or perhaps a seemingly
stunned, emotionally-numb response. He may
describe feeling as though he is "in
a fog." He may exhibit denial, in which
there is an inability to acknowledge the
impact of the situation or perhaps, that
the situation has occurred. He may evidence
dissociation, in which he may seem dazed
and apathetic, and he may express feelings
of unreality. Other frequently observed
acute emotional responses may include panic,
fear, intense feelings of aloneness, hopelessness,
helplessness, emptiness, uncertainty, horror,
terror, anger, hostility, irritability,
depression, grief and feelings of guilt.
Cognitive Responses
to traumatic exposure are often reflected
in impaired concentration, confusion, disorientation,
difficulty in making a decision, a short
attention span, suggestibility, vulnerability,
forgetfulness, self-blame, blaming others,
lowered self-efficacy, thoughts of losing
control, hypervigilance, and perseverative
thoughts of the traumatic event. For example,
upon extrication of a survivor from an automobile
accident, he may cognitively still "be
in" the automobile "playing the
tape" of the accident over and over
in his mind.
Behavioral Responses
in the face of a traumatic event may include
withdrawal, "spacing-out," non-communication,
changes in speech patterns, regressive behaviors,
erratic movements, impulsivity, a reluctance
to abandon property, seemingly aimless walking,
pacing, an inability to sit still, an exaggerated
startle response and antisocial behaviors.
Physiological Responses
may include rapid heart beat, elevated blood
pressure, difficulty breathing*, shock symptoms*,
chest pains*, cardiac palpitations*, muscle
tension and pains, fatigue, fainting, flushed
face, pale appearance, chills, cold clammy
skin, increased sweating, thirst, dizziness,
vertigo, hyperventilation, headaches, grinding
of teeth, twitches and gastrointestinal
upset.
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