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Dr.
John P. Wilson is an internationally recognized
expert in the field of Post-Traumatic Stress
Disorder (PTSD). Dr. Wilson is a founding member
and past president of the International Society
for Traumatic Stress Studies (ISTSS). Dr. Wilson
is the author of eight books and over 20 monographs
on traumatic stress syndromes. His most recent
books include: The International Handbook
of Traumatic Stress Syndromes, (co-edited
with Dr. Beverley Raphael, Chairman, Department
of Psychiatry, Royal Brisbane Hospital, Brisbane,
Australia); Counterttransference in the Treatment
of Post-Traumatic Stress Disorder (Guilford
Press); and Assessing Psychological Trauma
and PTSD: A Practitioner's Handbook with
Dr. Terence Keane of the National Center for
PTSD, Boston, MA (Guilford Press). Research
and clinical work developed by Dr. Wilson have
led to consultations with the U.S. Army and
Navy, Department of Veteran Affairs, The White
House, U.S. House and Senate Committees on Veterans
Affairs, National Institute of Mental Health,
National Science Foundation, Commonwealth of
Australia, American Psychiatric Association,
American Red Cross and The World Health Organization,
where he developed mental health programs during
the war in Bosnia in 1994 and 1995. Dr. Wilson
has lectured in the U.S. and abroad on the effects
of trauma. Included among his numerous awards
and honors are a Presidential Commendation from
President Jimmy Carter for his work with Vietnam
Veterans. Dr. Wilson is a Diplomate of The American
Academy of Experts in Traumatic Stress and the
Academy is privileged to have him serve on the
Board of Scientific & Professional Advisors.
JSV: I know that you maintain
numerous roles as a psychologist, lecturer,
and consultant with many projects underway.
Can you tell me about your current positions?
JPW: I am a Professor of Psychology
at Cleveland State University in Cleveland,
Ohio. I am also an adjunct Professor at the
Union Institute. I serve as a consultant to
the United Nations, where currently I am working
with the newly created Division of Humanitarian
Affairs designing disaster training modules
for all of the third-world hot zone areas, such
as Bosnia, Rwanda, and Angola. This is something
that is very important to me. This grew out
of my experience in Bosnia and will provide
mental health professionals, physicians and
others involved with traumatic stress with training
before they enter these areas in which their
intervention is necessary. The United Nations
(UN) has now mandated this new initiative under
the direction of Jane Mocelin in Geneva. This
disaster training module has been implemented
so that there will be systematic and universal
training for those who intervene and provide
assistance through the auspices of the UN. It's
a very exciting new adventure and I'm happy
that I have been selected to be a part of it.
JSV: On that note, I know
that you were directly involved with the UN
effort to set up all of the mental health programs
between 1994 and 1996 during the war in Bosnia.
I'm wondering what that experience must have
been like since it had to be dangerous.
JPW: Yes, I was involved from
1994 until 1996 under the two auspices of the
World Health Organization (WHO) and the European
Community Task Force (ECTF). That really was
a profound experience for me personally. I think
it's probably the first time that there was
an attempt coordinated systematically by WHO
and ECTF to try to create mental health programs
for the victims of war while the war was still
going on. We created a regional model that was
multi-tiered that started in Sarajevo and then
expanded to Vihatch, Tusla and Belgrade. Those
were the regions where we first created our
out-reach efforts to train professionals including
physicians, psychologists, psychiatrists, social
workers, and refugee workers in posttraumatic
stress disorder interventions so that the model
could proliferate throughout the regions of
Bosnia and Croatia during the war. This was
an extraordinary experience because there were
3 million refugees there at that time. The war
was ongoing and there was constant warfare,
24 hours a day with shelling, bombing, and sniper
attacks. There was no safe place in Bosnia during
this time. The day I arrived in Sarajevo, I
saw 11 people killed right in front of me. We
were traveling through difficult terrain and
we had a radio contact. We were told to be careful
and that there was a lot of sniper activity.
And there, on the main thoroughfare in which
there's a tram that runs through Sarajevo, were
11 bodies of people who had just been killed
by a Serb sniper from a cemetery above the tracks.
It brought the reality of war immediately home
to me in a way that was surreal. How did this
just happen? These were innocent war victims.
But that was Bosnia. Everywhere you would turn,
literally, someone was being killed by a sniper,
a booby trap, or land mines. After 1996 in Sarajevo,
I went to Kuslah to set up a hospital. I was
going to do training and develop programs around
posttraumatic interventions and I was off to
one of the area hospitals (which was the only
remaining hospital in Sarajevo at that point
in time). The hospital had been shelled. The
neuro-psychiatric unit of the hospital was a
five-story wing. Serb rebels had attacked the
unit. There were bullet holes in the fourth
and fifth floor and debris in the hallway. There
were patients who were injured and they were
trying to kill the Chief of Staff who was a
Muslim. The effort to do this was well worth
it just in terms of sheer intensity and importance.
This was now my second tour or third tour in
Bosnia, and I was aware of the situation. I
realized I could be killed. I felt vulnerable.
Fortunately for me, I did have the support of
my family and my wife--I have four children
that I look after! She never said anything to
me about her fears that I would be killed. I
had plenty of colleagues who said, "Why
are you doing this? You're crazy. Why are you
going to Bosnia? You could get killed."
I knew certainly by the second time that I went
back that this was real. I could have been killed.
Traumatic stress and trauma reminds us just
how human we all are.
JSV: John, you are regularly
sought out as a trauma expert. You have spent
a considerable amount of time lecturing around
the world. What is the topic areas that you're
currently presenting?
JPW: Well, it's interesting
that you ask that question. At present, I spend
a considerable amount of time consulting and
lecturing on issues involving stress debriefing
and the exploration of the impact of stress
on traumatic experts. It's interesting because
these things truly go together. I'm also asked
to talk about the psychological assessment of
trauma as well as more technical issues. It
is essential to examine how we respond to situations
like Bosnia or airline crashes, or urban disasters--Oklahoma
City type disasters--and so on. How do we structure
proper intervention? How do we employ? How do
we deploy? Take the war in Bosnia for example.
How do you design interventions while a war
is continuing? It's daily and virtually everybody's
exposed to it. How do you target an intervention
program to meet critical needs defined for that
population. Those are really strategic kinds
of questions and there's a big interest in this
issue in many parts of the world. The other
thing that I find interesting is that there
is a growing awareness, again globally, in the
effects of trauma-related work on the helper.
In our profession over the years, I think it's
been assumed that those trained as surgeons,
paramedics, psychologists, psychiatrists, trauma
experts, emergency workers, are somehow immune
from the effects of their work. And you know
that's just not the case. Everyone is vulnerable,
including well-trained professionals. They're
vulnerable to traumatic stress impact. So, increasingly
I find that I'm asked by international organizations,
national organizations, professional organizations,
governments, to come and help them understand
how they keep their people highly functional
and not adversely impacted by the work. It's
a difficult question because of that assumption
that "professionals are professionals"
and this just isn't always the case. Clinicians,
for example, who were in Rwanda--physicians
who were in Rwanda--saw thousands of bodies
of dead kids every day. And they were profoundly
affected by it. They couldn't just walk away
and say, "Okay, well that's a normal day
in the office." This is traumatic impact
and there's clearly a need to increase awareness
regardless of who is doing the work. Traumatic
events, by definition, are abnormal, and their
effects produce predictable consequences to
the victim. We need to understand this as part
of our effort to assist survivors of traumatic
events. And I think that, as we move toward
the 21st century, we are going to need to recognize
and understand the fact that anyone doing extreme
stress work needs to have a way to process,
ventilate and articulate about the consequences
of that work so that they can remain effective.
This, I believe, is where consulting work is
moving at this time. I think that this is one
of the great things about The American Academy
of Experts in Traumatic Stress. It offers a
multidisciplinary forum for those involved with
survivors to come together and share the universal
and common experiences that cross-cut our disciplines.
I think that great things can emerge from such
higher levels of educational programming, training,
and information dissemination (e.g., through
publications such as Trauma Response®)
.
JSV: Today we know that
there are a growing number of organizations
concerned with traumatic stress. How should
the American Academy work with other agencies
to coordinate new initiatives?
JPW: Well, I think that there
are so many ways for this to take place. The
other area in which I've been doing a lot of
writing is in the area of prevention and intervention
of traumatic stress. There's no question that
the issue of the future in terms of traumatic
stress, as it was with illnesses in medicine
50 years ago, is the question of intervention
and prevention. So, a major way that the Academy
can target objectives in working with other
organizations is to first consider who
should be involved. I think one of the things
that should be considered at this time is the
manner in which the Academy can intervene and
cooperate with agencies like the United Nations,
in all of its auspices. This includes WHO, UNICEF,
the UN Commission on Refugees, and so on. There
are so many different divisions by international
mandate and we now have a global mandate to
try to provide assistance for all kinds of psychological
trauma. Given the fact that The American Academy
of Experts in Traumatic Stress represents over
140 areas of specializations and is the largest
organization of its kind in the world, I think
there are many other agencies that the Academy
should be working with including FEMA, the American
Red Cross, the International Red Cross, and
the European Community Task Force on Psychosocial
Assistance, The International Society for Traumatic
Stress Studies, the European Society for Traumatic
Stress, and many others that share a vision
and mission that is similar to the Academy's
vision. And so it behooves us, I think, to ask
"how do we begin to join networks?"
It is a win-win game; no one will ever lose
by doing this. So, I think it is potentially
possible to give The American Academy of Experts
in Traumatic Stress, given its diversity and
scope, a pivotal role in beginning to make possible
that kind of initial coordination and cooperation
of these various agencies throughout the world.
JSV: I know that you were
a member of the DSM-IIIR Committee for Posttraumatic
Stress Disorder. What are you thoughts about
the current criteria for PTSD in DSM-IV?
JPW: I was a member of the
Committee and it was an interesting process
in many ways. I believe that there are some
problems with the current criteria. First of
all, the A-1 criteria I think is okay, but the
A-2 criteria, which talks about the response
to trauma, is too limited. Right now it addresses
symptoms of fear, helplessness, and horror as
the human reaction to traumatic event. I think
that's too limited. People sometimes don't have
those reactions. Sometimes people dissociate;
sometimes people have blanket denial; sometimes
people go totally numb; sometimes people have
profound dissociative reactions to trauma. In
fact, one of the problems with that criteria
is that it's internally inconsistent with the
following category in the DSM-IV which is Acute
Stress Disorder (ASD). The definition in the
B category of Acute Stress Disorder is that
the person has a dissociative reaction, and
they list five types of dissociative reactions
that occur for Acute Stress Disorder. Well,
if that's the case, why don't those same criteria
appear for PTSD? If one is acutely traumatized
and may experience a range of dissociative reactions,
then why don't those same criteria apply to
posttraumatic stress, which is by definition,
a more chronic response than an acute response?
So, the DSM-IV is internally in contradiction
with itself, and that is very problematic from
my point of view. Another area where I think
the criteria is inadequate (that I've written
about as well as Judith Herman to name a few),
is that the DSM-IV suggests a bare bones number
of symptoms which are necessary to diagnose
the traumatic stress response syndrome. What
I have found over the years in my clinical work
and forensic work, is that the really profound
injuries to persons who are traumatized is to
the self. The real damage is more that the experience
of nightmares, flashbacks, or avoidance. Those
are behavioral reactions, and they are perfectly
understandable as normal responses to abnormal
events. But I think the greatest damage of traumatic
stress, especially from events that are highly
personal such as childhood abuse, torture, or
war victimization is the profound change to
the person's sense of their "inner-self."
Repercussions from this experience may include
the loss of pleasure, the loss of a sense of
coherency, maybe the sense of a loss of continuity
of time and space, maybe the sense that "what
you used to be" is gone. This is a more
profound change. The literature has documentation
forever on this. Hiroshima survivors all were
profoundly transformed by the experience, because
the world as they knew it changed in a matter
of minutes after the atomic bomb. There was
no way to construe reality the same way as before,
because the world literally changed for them,
the city was devastated, everything they knew
had changed, most of the things they understood
and had grown up with some sense of coherency
and continuity of their culture had evaporated
with the atomic bombing of a city. How do you
then be the same after that? This plummets the
depth of humanness and the depth of identity.
And I think one of the real absences in the
diagnostic criteria is in this area of a more
complex posttraumatic stress reaction that involves
components of the self that are damaged by traumatic
experiences. It is understandable that those
who have been devising the criteria have struggled
with this issue of "damage to the self"
because it's not as readily observable than
as someone with a sleep disturbance or startle
response. These are more biologically-based
reactions. But I think that when you cut through
the behavioral and conditioned responses to
trauma, the deeper damage really rests inside
the person, inside the ego to their sense of
identity, to their sense of selfhood, to their
sense of sameness and continuity of living day
in and day out. I don't know any survivor of
trauma that I've talked to who has said, "I'm
the same person I was before this happened."
They always say, "I'm a different person
than I was before this happened." Now,
clearly, there are differences in the severity
of trauma, but in truly profound events, this
impact is long-lasting and I think not well
understood. And on that same note, I think it's
important to recognize that prior to having
PTSD as a diagnosis, so many victims of trauma
were misdiagnosed as having personality disorders.
And one of the things that is very clear to
me is that there are posttraumatic personality
changes that take place. And there could be
a radical restructuring of personality after
trauma that is not predicated by a personality
disorder of the type talked about in the literature.
Trauma can transform human character. It can
transform it in many different directions, some
of them positive, some of them negative. On
the positive side, there's resiliency, there's
greater humanness, there's more self-actualization.
One of the things that's so interesting about
trauma survivors who cope fairly well at some
point in time is that they have a capacity to
separate out what is important in life from
what is not. To live every day with a keen understanding
of what's humanly important for this hour versus
what isn't. To separate the essence from that
which is irrelevant. That's something that most
trauma survivors have. On the other hand, there
are trauma survivors who are so profoundly injured
by their experiences that it warps their character.
That they have shame, they have guilt, they
have anhedonia, they lose pleasure, they lose
the zest for life, they have depression, they
have fears and mistrust that permeate their
consciousness regularly, and the world is no
longer a safe place. They live with vigilance
and watchfulness. And as a consequence of their
experience, their pre-traumatic personality
is transformed. I would like to see more research
on longitudinal personality dimension change
in trauma survivors (i.e., complex PTSD). Moreover,
it is not just about psychological symptoms
but also somatic components as well. And these
need to be better understood. And I think that
for the future, the revisions that come in the
DSM system need to broaden the scope of understanding
that PTSD is not just an anxiety reaction. It's
a complex phenomena at the most profound human
level. It's really a distinct category of human
response to traumatic events. And I believe,
philosophically, that by recognizing that, we
are going to go a lot further in advancing the
scientific understanding of the condition.
JSV: What made you focus
on traumatic stress as speciality?
JPW: I began to focus on traumatic
stress as a specialty when I conducted one of
the first large-scale studies on Vietnam veterans
in the early 1970s. I must tell you that I wasn't
trained as a trauma expert. There were no courses
in traumatic stress when I was in graduate school.
In fact, just to shed a little light on that,
sometimes when I'm lecturing to professional
organizations I'll ask the question, "How
many of you had special training in traumatic
stress in your background?" And when you
ask this question to a group of people in any
profession, whether it's psychology, medicine
or dentistry, very few people raise their hands.
And I didn't either. So, the way I got into
it was a project called "The Forgotten
Warrior Project." It was the first national,
large-scale study of Vietnam veterans, which
I began in Cleveland, Ohio in 1973 and carried
forward until 1980. And that's how I got involved
in understanding traumatic stress and particularly
posttraumatic stress disorder. Through that
process, I began consulting with President Carter
and then became appointed by him to assist Max
Cleland, who was the director of the Veteran's
Administration at the time. Max Cleland was
a combat veteran from Vietnam and Jimmy Carter
was launching an initiative to create a national
effort to assist Vietnam veterans with re-adjustment
counseling. I had the role of being one of the
principal architects of the Vietnam Veterans'
Readjustment Counseling Program in the Carter
administration. By 1979, we had developed the
program for President Carter. So from 1973 through
1980, under the Forgotten Warrior Project and
through in collaboration with the Carter Administration
and the Veterans' Administration, I had the
fortunate opportunity to try to design programmatic
efforts to assist Vietnam veterans suffering
from war trauma with readjustment counseling
efforts. During that period of time, in addition
to the research I did, I began to think about
traumatic stress as a syndrome, and I coined
some terms like "delayed stress" and
"post-Vietnam stress." That's how
I got started. And as they say in the movies,
"The rest is history."
JSV: Well, your work certainly
speaks for itself. I'm glad you carried on that
initial spirit.
JPW: Well, the truth is that
the work changed my life. I was trained as a
traditional psychologist. I had training in
both clinical and experimental psychology. And
I always thought, in the early days, after my
Ph.D., that I would be an academician and just
do research and write. But after I got started
with the work in traumatic stress, all of that
changed for me. Now I work with all different
kinds of traumatic events. But in the initial
days, it was intense involvement with Vietnam
combat veterans and their impact on me was enormous
because it was clear that they were suffering.
The despair and anger and sense of betrayal
by the country was enormous. And it caused me
to reflect and try to empathically understand
what this experience had done to 18 and 19 year
old people including a number of friends who
were profoundly affected by the experience.
Once I got into that phenomenology, it was so
real. It was so profound. It was so authentic,
that I really had a hard time doing "traditional
laboratory studies in psychology." It was
so gratifying to understand how to help someone
who had been traumatized.
JSV: What is the Forensic
Center for Traumatic Stress?
JPW: The Forensic Center for
Traumatic Stress is organization that I had
developed in the last year. It developed in
response to what I believe is a very severe
need that seems to be unmet. In our system of
justice, people who have been traumatized and
injured often seek legal recourse if they've
been wrongfully injured or if there are damages.
Moreover, in the criminal sector when a person
has committed a crime and may be suffering in
a severe manner from PTSD, this diagnosis might
serve as an argument for their defense. So there
is a need to have a coordinated center in which
those involved in the litigation process can
have the opportunity to access experts in the
field who have expertise in the areas of litigation
and maintain knowledge and experience at the
highest scientific levels. Thus, whether it
is in the area of dentistry, medicine, emergency
response, psychiatry, or psychology, that when
there's an issue pertaining to traumatic injury
that enters the arena of our legal system, individuals
can now access experts who can assist them in
the proper litigation. So, what I've done is
developed the Center, created a national advisory
board, and developed an internet of experts
who are qualified as experts in traumatic stress
and in litigation. It's one thing to be an expert;
it's another to be an expert in a court of law.
So, the Forensic Center is moving in the direction
of certification, training, and education in
traumatic stress for those who can testify with
scientific expertise in a courtroom.
JSV: I remember we had
a conversation a while ago and you and I discussed
how retraumatizing the process of being in a
courtroom can be for a trauma survivor. A number
of professionals sometimes don't realize the
impact of their questioning and interrogation
on survivors.
JPW: That's very true. Not
only are the victims sometimes re-traumatized
by the full process of litigation, but I have
to tell you that many professionals are sometimes
traumatized because they don't have experience
in litigation and they don't have experience
in understanding the rules and statutes. I hope
that through the Forensic Center for Traumatic
Stress, many will benefit in the effort to upgrade
and systematize the use of traumatic stress
experts in the litigation process. And in that
sense, what we're going to do is raise the bar
of competence and raise the bar of excellence
in terms of service to those involved in litigation,
whether they are experts testifying, or whether
they are victims of traumatic stress.
JSV: Your book Countertransference
Processes in the Study and Treatment of Posttraumatic
Stress Disorder (with J. Lindy) was one
of the first texts to recognize and define patterns
of therapist reactions that developed while
working with traumatized clients. What are the
risks involved in professional work with trauma
survivors?
JPW: Well, there are numerous
risks. The book that Jack Lindy and I had published
examined these patterns and reactions of therapists.
In the last three years I've conducted a study
with one of my doctoral students, Rhiannon Thomas,
in which we surveyed a thousand practitioners,
randomly selected from the International Society
of Traumatic Stress and the International Society
of Dissociative Disorders. We developed a questionnaire
called the Clinicians' Trauma Reaction Survey.
Through this 100-item questionnaire, we examined
the reaction pattern of these therapists working
with different trauma populations to assess
the impact of their work. We've found that there
are about five distinct reaction patterns to
this work. They range from over identification
and over involvement to phenomena such as vicarious
traumatization--where the therapist is now profoundly
impacted emotionally by the work and may have
developed symptoms of PTSD burnout. At the other
end of the continuum, we found one very distinct
pattern in which clinicians develop disdain
for their clients and for their work. And they
don't disclose it or talk about it and they
don't get peer supervision or other forms of
supervision. They may become actually kind of
hostile toward this population. So, there's
very clearly a limited domain of reactive styles.
Nevertheless, one of the most important things
we found is that over 92% of our sample said
that they were impacted by the work. No one
said that it didn't bother them and that it
didn't have some type of lasting impact. Almost
everyone admitted that doing traumatic stress
work had a profound and lasting impact to them
personally and professionally. So, when we talk
about the risk, it's clear that you can't be
in this business without recognizing that there's
going to be an impact to one's sense of well-being
and one's sense of self.
JSV: John, as you are aware,
The American Academy of Experts in Traumatic
Stress is a multidisciplinary organization with
more than 140 areas of specialization represented.
What do you see as the major advantage of an
organization such as the Academy that is dedicated
to increasing awareness and ultimately, improving
the treatment for survivors of such events across
such a eclectic group?
JPW: First and foremost one
significant advantage is that the Academy is
multidisciplinary. This facilitates different
professions coming together under the umbrella
of the American Academy. I think that's a great
virtue. The cross-pollination that comes from
that kind of interaction can only begin to generate
a deeper understanding of the phenomenon of
traumatic stress as it affects survivors and
victims of trauma from all kinds of experience.
Secondly, it provides the opportunity to bring
together multidisciplinary efforts which allow
us "define a mission that transcends ourselves."
And in that sense, the Academy, with its diverse
and international membership, can provide a
forum for education, training, publication,
and consultation. This not only becomes a national
priority or national opportunity, it becomes
potentially global priority of internetting
experts in traumatic stress. And I can't think
of many things more exciting from my perspective
than trying to actualize those objectives which
are readily achievable given our technological
capacities.
JSV: On a final note, as
a member of the Board of Scientific & Professional
Advisors of The American Academy of Experts
in Traumatic Stress, are there any recommendations
and/or suggestions that you have for those individuals
who regularly work with survivors of traumatic
events?
JPW: Yes, there are a number
of them. Remember that self-care is important.
You need to take care of yourself. You need
to have planned time-out and vacations in which
you take yourself out of the stress of the work.
Secondly, I think it's important for people
who want to be involved in traumatic stress
work to have a sense of humor and to have fun.
When you deal with this depth of stress everyday,
if you don't get a perspective on life, you
can get warped by this. Hygiene is important
as well as exercise, good diet, and good connectedness
to other people. I believe that peer consultation
or talk with trusted friends is also important.
If you keep that stress inside, it affects one's
sense of self. It is important to share the
human experience with someone you trust. In
my case, I have planned systematic vacations
a couple times a year, where I get away from
it, where I go and enjoy life and feel restored
so I can go back to the intensity of the work.
Also, it's important that one is not isolated.
To me it's important that people who do this
work have connections to the American Academy
or other agencies in which they can feel a kindredship.
In a sense, it is like having your family or
network of professionals that you can bond with.
The clinicians who find themself in trouble
(i.e., emotionally) are those who isolate themselves
from having contact and an opportunity to share.
One of the things I've done over the years is
work with Native American groups. In many Native
American cultures, the idea of trauma or the
idea of mental illness is consistent with "a
loss of spirit." What I would say here
is that to maintain our spirit, we must try
to maintain a vitality to do the healing. Many
people who do trauma-related work may become
"wounded healers." The wounded healer,
though, has a gift. The wounded healer maintains
their spirit. They have the capacity to be the
spirit of the shaman who touches the spirit
of the trauma survivor so that they can heal.
If one loses that capacity, they cannot be a
healer.
©1999 by
The American Academy of Experts in Traumatic
Stress, Inc. |
