| 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. |
