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.
|
How
Can We Help Grieving Individuals in the
Wake of Hurricanes Rita and Katrina?
Our
heartfelt sympathy goes out to the countless survivors
of Hurricanes Rita and Katrina who have lost loved ones,
their homes and possessions, and all that was familiar
to them. This Trauma Response E-News provides practical
information to assist in your work in supporting and counseling
with survivors.
Grief
refers to the feelings that are precipitated by loss.
The early reactions that we see in grieving individuals
occur during a period of "Numbing." Initially,
the individual may present in shock. There may be a highly
anxious, active response with an outburst of extremely
intense distress or perhaps a seemingly stunned, emotionally-numb
response.
During
this early phase, you may likely observe denial - an inability
to acknowledge the impact of the event or perhaps, that
the event has occurred. The individual may evidence dissociation,
in which he may seem dazed and apathetic, and he may express
feelings of unreality. It is not unusual for people to
make statements such as, "I can't believe it,"
"This is not happening," "This has got
to be a bad dream," etc. Finally, there may be periods
of intense emotion (e.g., crying, screaming, rage, anger,
fear, guilt, etc.). Recognize that these kinds of reactions
to a traumatic loss are normal responses.
Within
hours or perhaps days of the loss, "Yearning and
Searching" may be observed. Here, the individual
begins to register the reality of the loss. There may
be a preoccupation with the lost individual. Symptoms
may include, but not be limited to, insomnia, poor appetite,
headaches, anxiety, tension, anger, guilt, etc. Sounds
and signals may be interpreted as the deceased person's
presence.
Within
weeks to months following the loss is a period of "Disorganization."
Here, feelings of anger and depression are exhibited.
The individual may likely pose questions (e.g., "Why
did this have to happen?") and evidence periods of
"bargaining" (e.g., "If only I could see
him just one last time."). Finally, in the months
or even years following the loss is a time of "Reorganization."
Here, the individual begins to accept the loss - often
cultivating new life patterns and goals.
There
are no "cookbook" approaches to helping people
who are struggling with loss. Perhaps the most important
variable is "being there" for the person. Attempt
to connect with him using the Acute Traumatic Stress Management
model (see www.ATSM.org).
Encourage expression of thoughts and feelings without
insistence. Recognize that although relatives and friends
intend to be supportive, they may be inclined to discourage
the expression of feelings - particularly anger and guilt.
Avoidance of such expression may prolong the grieving
process and can be counterproductive. Allow periods of
silence and be careful not to lecture.
When
working with grieving individuals, avoid cliches such
as "Be strong," and "You’re doing
so well." Such statements may only serve to reinforce
an individual’s feelings of aloneness. Again, allow
the bereaved to tell you how they feel and attempt to
"normalize" grief reactions. Finally, don't
be afraid to touch. A squeeze of the hand, a gentle pat
on the back or a warm embrace can show you are there and
that you truly care.
Practical
Guidelines for Assisting the Grieving Individual
•
Provide opportunities for ventilation of emotions.
•
Provide support and availability if/when a funeral
is held.
•
Practice active and empathic listening (e.g., show
acceptance of the feelings and experiences of the
griever).
•
Provide the individual with an opportunity to reminisce
and reflect on their deceased significant other.
•
Keep tissues visible and available.
•
Encourage the individual to maintain proper care and
nurturance for themselves.
•
Educate the individual regarding the reactions that
they may experience over the next few weeks and/or
months (e.g., sleep difficulty, feelings of anger,
guilt, etc.).
•
Refer for medical consultation in the event of severe
insomnia or physical reactions (e.g., chest pains,
palpitations, migraine headaches).
•
Remain mindful for signs that the individual is not
coping well (e.g., suicidal threats) and seek medical
and/or familial involvement.
•
Be aware of your own feelings surrounding death and
know your limitations in your effort to assist the
individual.
www.DrMarkLerner.com
To
learn more about Acute Traumatic Stress Management visit
www.ATSM.org.
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.
|
HURRICANE
KATRINA
IN THE AFTERMATH OF HURRICANE KATRINA
Addressing Emergent Psychological
Needs
Hurricane Katrina is one of our nation's
worst natural disasters. The loss of life and destruction
seems immeasurable. Today, in the aftermath of Katrina,
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 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 this devastating
hurricane. 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 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 a devastating hurricane, 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 the 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 Katrina, and its 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.”
Hurricane
Katrina reminds 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 Katrina
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 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 Katrina, 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 Katrina, 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 Katrina, 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 hurricane 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 Katrina seems 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.
www.DrMarkLerner.com
To learn more about Acute
Traumatic Stress Management visit www.ATSM.org.
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.
|
TERRORIST ATTACK
How We Can Prepare for the
Hidden Trauma
Today, we are responding to the horrific
terrorist attack in London. 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.
|
Adoption
Stress
Unfortunately, far too many
adoptive children have faced traumatic events including,
but not limited to, neglect, physical and sexual abuse
and various degrees of abandonment. In recent months,
I have accompanied Dr. George Rogu on a speaking tour
with AdoptionDoctors.com. As the “Adoption Psychologist,”
I regularly explain to adoptive parents that by having
an understanding of the symptoms suggestive of traumatic
exposure, we can identify children who may be experiencing
traumatic stress reactions. Ultimately, by identifying
symptoms early, we can address emotional, social, behavioral
and educational needs. As I often say to parents, we certainly
don’t wait to address physical trauma. And, in the
same way, we must not wait to address traumatic stress.
How is traumatic stress manifested
in adoptive children?
In the young adopted child, we see immature
and regressive behaviors—behaviors that have been
abandoned in the past are often observed again (e.g.,
thumb sucking, bed wetting, fear of the dark, loss of
bladder control, speech difficulties, decreases in appetite,
clinging and whining, and separation difficulties). Older
children may manifest periods of sadness and crying, poor
concentration, fears of personal harm, aggressive behaviors,
withdrawal/social isolation, attention-seeking behavior,
anxiety and fears, etc.
So, what is “Adoption Stress”?
Does it refer solely to the experience of so many adoptive
children?
The reality is, when we look closely
at adoption, we realize that traumatic stress is pervasive
- often impacting several, if not all, of the parties
involved. Unfortunately, this traumatic stress, “adoption
stress,” is generally not recognized and its impact
is misunderstood. Consider the following….
Birth parents, who surrender a child
for adoption, typically experience a great deal of stress.
Oftentimes, due to their circumstance, they have little
choice or control and must surrender their child for adoption.
Adoptive parents often bring to the table
a history of stress. For example, pre-adoption stressors,
which may include fertility problems, losses and significant
relationship conflicts. There is also stress associated
with the acquisition of an adoptive child. For example,
there may be serious medical concerns, “misunderstandings,”
and heartbreaking disappointments. Finally, post-adoption
stress may center around the realization of a dream, tremendous
life changes with new responsibilities, and a future marked
by uncertainty and fear.
Adoption stress is manifested in the
feelings, thoughts, actions and physical reactions of
all parties associated with the adoption process—by
birth parents, adoptive parents and certainly, adoptive
children. By understanding adoption stress and recognizing
the symptoms, we can intervene early, educate and empower
victims, and prevent acute difficulties from becoming
chronic problems.
A Perspective on Preventing
School Violence
Not long ago the most severe problems
encountered in our schools were students running in the
halls, making excessive noise, cutting a line, talking
out-of-turn, chewing gum or violating a dress code.
Today, we are faced with an increase
in violence including assaults and gang activity. We are
seeing an increase in the frequency of substance abuse,
self-mutilation, suicide, abandonment of newborn babies,
and serious injuries and deaths from automobile accidents.
We are also contending with new types of violence including
terrorist attacks, hostage-taking, snipers, murders, "hit
lists," threatening graffiti, bomb scares and real
bombs.
The tragedy at Red Lake High School in
Minnesota is a painful reminder of what can happen in
a school. Following, is my perspective on how we may prevent
school violence.
What are the causes of school-based violence?
A wide spectrum of traumatic events are
impacting our nation's schools. And, as a consequence,
our school systems are being charged with the responsibility
of responding to school-based crises. In recent years,
school districts have been scrambling to develop comprehensive
crisis response plans. We no longer question
if a school will be faced with a tragedy, but when.
Many factors contribute to the causes
of school violence. Research is helping us to understand
the relationship between violent television programs,
movies, music lyrics and violent behavior. Additionally,
the interactive nature of violent computer and video games
is being investigated.
We hear about the availability of guns
and other weapons and we cannot ignore the data. During
the last decade, nearly 80% of all violent deaths in schools
were caused by guns (The Center for the Study and Prevention
of Violence).
There is a dramatic increase in alcohol
and substance use among our children, peer pressure and
gang involvement. We are learning about children who are
tormented and teased, and then go on to harm themselves
and others. We are seeing the effects of divorce, "latchkey
kids," parents working long hours and an absence
of parental supervision, training and example-setting.
Today, there are relaxed curfews, a lack of respect for
authority and a lack of family involvement with schools.
There is a changing family structure as well - with a
large number of single parent families, grandparents and
extended family living in the home.
Today, there is a growing trend of violence
related to race and/or religion. This is particularly
disturbing in light of the fact that diversity in America
is rapidly increasing. The extent to which these variables
are related to the quantitative and qualitative changes
in violent school-based crises will become more apparent
with time and with further empirical investigation.
The inevitability of illness, accidents
and loss may be accepted and even anticipated by schools
that often view themselves as microcosms of our world.
But why is there such a dramatic increase in deliberately-caused
tragedies - those of intentional human design?
At the very core of our problem is a
fundamental communication breakdown in families -
the result, in large part, of an increasingly digital
and mechanized world. We are spending less time communicating,
teaching and modeling appropriate behavior with our children_we
are losing the battle to the proliferation of electronic
media in a rapidly changing, mechanized world (Lerner,
1999).
At the breakfast table, printed and televised
media offer a daily dose of violence. Today, our children
leave or avoid the dinner table or family room, opting
for the new era in violent television, video and computer
games, and Internet chat rooms. We used to know where
our children went when they left our homes. Today, we
don't know where they are when they are in their bedrooms.
Our children lack interpersonal communication,
coping and problem-solving skills to meet the challenges
of our new world - one reason why an increasing number
of them act-out feelings of anger and frustration in dangerous
attention-seeking ways, "self-medicate" with
alcohol and other substances, and commit suicide at a
higher rate than ever before.
How can we prevent school violence?
Today, our school systems are investing
in expanded security forces, the installation of metal
detectors and surveillance cameras, hand-held communication
devices, "panic buttons," and computer "fire
walls." Safety audits are becoming standard operating
procedure. Although there are certainly benefits gained
from taking these mechanical steps, we must address the
root of the problem.
We need to help our children and adolescents
to develop and enhance their communication and problem-solving
skills. We must teach them how to actively listen and
to empathize when relating with others. We must help our
children to understand the importance of articulating
their feelings about themselves and for others, and to
know that it is okay to err on the side of caution when
expressing concerns about others. We must regularly remind
them that they can turn to their parents and/or school
support personnel who will take the time to listen and
respond to them. We must invest in the development of
people skills (Lerner, 1999).
Far too often our children hear of disturbing
ideation or plans prior to a tragedy and they do not know
how to respond. It is not until the aftermath of a disaster
that we see survivors interviewed and we hear them describe
how the perpetrator had, in some way, suggested impending
doom. In cases of adolescent suicide, more than 80% of
kids who commit suicide tell someone, in some way, that
they are going to end their life. Our children do not
know what to do or where to turn with critical information.
We must work toward improving communication,
through a multimodal approach, in order to prevent violent
school tragedies. We can address emotional, cognitive,
social, behavioral and physiological factors. For instance,
we can help our children and adolescents to identify physiological
changes in their bodies, which may precede or coincide
with feelings of frustration and anger. We can help them
to understand which of their behaviors/actions cause others
to become frustrated and angry. We can teach them to become
aware of and to identify negative self-statements - cognitions
that generate feelings of frustration and anger. And,
we can help our children to learn to replace self-defeating
statements with positive coping statements. Behaviorally,
we can model and espouse appropriate moral behavior, set
limits and be consistent with our behavior. Ultimately,
we can teach our children to show compassion and sincerity
in relating with others.
We must help our children to understand
that conflict is a natural part of interpersonal relationships.
When we handle conflict well, it presents an opportunity
to learn, to better understand ourselves and to generate
creative solutions. When we handle conflict poorly, it
can lead to violence.
We must help our children to make more
adaptive, goal-directed decisions when faced with feelings
of frustration. For example, we can teach them that it
is okay to walk away from altercations or to take a few
moments to "cool down." We can teach our children
to express themselves assertively, to implement relaxation
techniques, and to utilize conflict resolution and peer
mediation skills. Interestingly, when we ask children
and adolescents what they believe may help to reduce the
frequency of school-based tragedies, they indicate that
there needs to be more constructive opportunities for
expression of feelings. On the other hand, we must keep
in mind that conflict resolution techniques and peer mediation
programs presuppose conflict.
How can we prevent school violence? We
must reach our children when they are very young and invest
in developing communication and problem-solving skills.
Today, we must view all members of the
school family as being "at risk" and become
aware of the "early warning signs" to identify
individuals who may be at greater risk for engaging in
violent behavior (see www.schoolcrisisresponse.com/download.htm).
Let us all become hypervigilant, learn to err on the side
of caution, and work toward preventing violent tragedies
in our schools.
In the Aftermath
of the Tsunami
Addressing Emergent Psychological Needs
The recent tsunami is one of the world’s worst disasters.
The loss of life and destruction seems immeasurable. Today,
in the aftermath of the tsunami, the focus of caregivers
must be the stabilization of injury and illness and, ultimately,
the preservation of life. As the world 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 the treacherous waters
of the tsunami, 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 the tsunami.
We receive daily doses of the “imprint of horror”—images
of death and destruction are being recorded in our minds.
Truly, the world 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 the tsunami,
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 the tsunami, 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 long-term 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. These are painful realities of the tsunami.
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 the tsunami 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 tsunami,
and its 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 band-aid 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.”
The tsunami reminds 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 of the tsunami 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 the tsunami 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 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 the tsunami, 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 the tsunami, 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 tsunami 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 the tsunami,
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 the tsunami, 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 who have survived
the tsunami, 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 many bodies 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 tsunami, 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 long-term emotional suffering.
Conclusion
In the aftermath of the tsunami, the world 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 of the tsunami 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 the tsunami seems 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 of the tsunami
early, we can potentially prevent the acute traumatic
stress reactions of today from becoming chronic posttraumatic
stress disorders of tomorrow.
www.DrMarkLerner.com
Dr. Mark Lerner is a clinical psychologist and traumatic
stress consultant who focuses on helping people during
and in the aftermath of traumatic events. He is the President
of the American Academy of Experts in Traumatic Stress
(www.AAETS.org)
and the originator of the Acute Traumatic Stress Management
intervention model (www.ATSM.org).
Dr. Lerner wrote and produced the newly released audio
book, Surviving and Thriving: Living Through a Traumatic
Experience (www.DrMarkLerner.com).
He is the Editor and Publisher of Trauma Response®,
the Academy’s official publication, and the author of
five books. Dr. Lerner consults regularly with individuals
and organizations—where he specializes in the education,
training and implementation of Acute Traumatic Stress
Management and the development of organizational crisis
management teams. Dr. Lerner lives in New York with his
wife and three children.
Download
Comprehensive Acute Traumatic Stress Management Documents
|
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 |
