| George
S. Everly, Jr., Ph.D. and Jeffrey T. Mitchell,
Ph.D. developed the International Critical Incident
Stress Foundation over a decade ago. Today, it
is the largest organization of its kind providing
education, training, and consultation on the topics
of crisis intervention, psychological trauma and
disaster mental health for the emergency services
professions throughout the world. The Foundation
coordinates an international network of disaster
response teams. Dr. Everly is a leading authority
on human stress and psychological trauma. He serves
on the adjunct faculties of Johns Hopkins University
and Loyola College in Maryland. Dr. Everly was
a Harvard Scholar, Harvard University, a Visiting
Lecturer in Medicine, Harvard Medical School and
Chief Psychologist and Director of Behavioral
Medicine for the Johns Hopkins' Homeward Hospital
Center. He is the author, co-author, and editor
of 12 textbooks and over 125 professional papers
with his works translated into Russian, Arabic,
German, Swedish, Polish, Portuguese, Korean, and
Spanish. Dr. Jeff Mitchell is the President of
the International Critical Incident Foundation.
He is the developer of Critical Incident Stress
Management (CISM) and its related programs which
is utilized by over 700 communities throughout
the world and in over 23 nations. Dr. Mitchell
is a Clinical Associate Professor of the Emergency
Health Services Department at the University of
Maryland. He has over 130 publications on critical
incident stress, crisis intervention and the treatment
of stress in emergency personnel. Drs. Everly
and Mitchell both serve on the Board of Scientific
& Professional Advisors of The American Academy
of Experts in Traumatic Stress.
JSV: The two
of you have very different backgrounds. Can you
tell me about your careers and how you came to
collaborate?
GSE: Academically,
I was initially trained in business administration
and was intrigued with the study of human behavior
within business organizations. Subsequent to the
completion of my studies in business I decided
that it might be even more interesting to try
to understand not only how to describe and predict
behavior, but change it. I became interested in
clinical psychology. Somewhere along the way,
I also became very interested in psychophysiology.
My family had a history of high blood pressure
and I was interested in seeing whether some of
these new techniques that had been emerging, at
least in the United States, such as meditation
would be of any value. We started experimenting
with meditation and biofeedback. I was very lucky
to work in a laboratory that was one of the largest
in the country where we studied biofeedback applications,
blood pressure and general stress. From that point,
I specialized in the area of stress. When I graduated
I was really looking for more of an academic orientation
and saw myself as more of a laboratory scientist
and academic. And then a guy by the name of Jeff
Mitchell introduced himself and, Jeff, I'll let
you pick it up from there and we'll go back and
forth.
JTM: I started
off as an elementary school teacher teaching science
to the sixth grade. I got interested in fire service
so I became a volunteer firefighter and eventually
rose to the rank of Lieutenant and worked for
the fire service for 9 ½ years. I wanted
to become a child psychologist and was actually
studying to do that. I got more and more interested
in the stress that was going on with the emergency
services personnel that I was working with. Gradually,
I started to move toward the Ph.D. and then I
found myself in the position of doing my dissertation
on Paramedic Stress. I needed to do some testing
for the dissertation and found that George Everly
had actually developed some tests that were quick
scales that could get a good assessment of an
individual's stress level. I talked to him about
that and read his publications. I was quite impressed
with the work that he had done and he helped me
to organize the statistical design for the testing
on my doctoral dissertation. I began to refer
people to him including individuals who I had
been meeting who had quite a bit of posttraumatic
stress. He actually pulled off some significant
cures of people who, when I first met them, I
thought would never be able to stay in the emergency
services profession. George was able to work with
them - to get them back on track again. And then
we just started to do things together, like education
programs and large conferences. Since my focus
was crisis intervention and his was the treatment
of traumatic stress, it seemed to be a good match.
I was taking care of the prevention end of the
experience and George was taking care of people
when they already had been exposed to significant
trauma and had developed posttraumatic stress,
so it was a good match there. And we both thought
a lot alike in terms of crisis intervention and
traumatic stress and its impact on people. Since
1982, we have been working together to build this
field to assist people who deal with crises.
GSE: Jeff was
kind enough to invite me to speak at a number
of conferences he had held at University of Maryland
- Baltimore County (UMBC) and this was a world
that I was pretty unfamiliar with at that time.
As I was saying, I was pretty much in the niche
of a laboratory scientist and academic, but as
Jeff had mentioned, I had developed a clinical
specialty in treating stress disorders and I had
a behavioral medicine clinic. What intrigued me
about the world that Jeff had introduced me to
was that I saw people such as fire fighters who
were at unusually high risk for developing this
newly recognized diagnosis of posttraumatic stress
disorder. But I think that it was in 1988 when
Jeff invited me to go to Australia with him to
attend a conference on emergency services stress
that I remember having a certain conversation
with him. I said to him "These people are
at such high risk, occupationally, and there doesn't
seem to be anything in place to really assist
them." There wasn't a line of study or support
for them other than the work that Jeff was beginning
to generate out of UMBC. So I looked at him half-jokingly
and half-seriously and said "You know, what
we really need to do is create a foundation that
would focus it's efforts in support of emergency
services personnel from the psychological mental
health point of view." He must have taken
me seriously! At that point, we started really
thinking about how we could do such a thing -
if it was even possible. In 1989, the International
Critical Incident Stress Foundation was formed.
JTM: George had
referred to UMBC several times. I am a member
of the faculty there in the Department of Emergency
Health Services. At the time I met George, I was
an instructor working my way toward the Ph.D.
I am now a Clinical Associate Professor in the
Emergency Health Services Department. I had come
out of the field of firefighting paramedic work
and transferred my knowledge and education into
working with emergency personnel. By 1988, I had
finished my dissertation and Clinical Associate
Professor of Emergency Health Services was my
full-time job when George proposed that we perhaps
could work together to put together an institute
or foundation to assist emergency personnel. I
thought it was time for me to do that. I went
part-time at the University of Maryland and put
the rest of my energy into creating this non-profit
organization. The organization was basically designed
to provide education and assistance to emergency
personnel, and when George and I started, it was
basically two people in the foundation. There
is now over 5,000 people who belong. So in the
last 10 years it has had remarkable growth. We
started off with two education programs and we
now have at least a dozen courses that we offer
in the field of traumatic stress - everything
from dealing with traumatized children to dealing
with disasters and more. We provide innumerable
consultations with people who call in with problems
dealing with traumatic stress and are asking for
assistance. Basically right now we are handling
nearly 20,000 incoming phone calls a year from
all over the world and about 35,000 - 40,000 written
requests for information each year. We provide
quite a bit of information. We also have a 24-hour
hotline in the Foundation that is answered by
police and fire communications personnel who then
either tell folks where the local teams are for
them or they can provide them with one of our
team members for consultation if necessary. The
services are very broad. We also do a lot of disaster
coordination for emergency mental health services
and take care of the high risk key personnel.
JSV: Jeff,
do you want to give that phone number?
JTM: The emergency
24-hour a day phone number is (410) 313-2473.
The routine number for non-emergencies is (410)
750-9600.
GSE: I think that
one thing that Jeff mentioned that is worth reiterating
is that we didn't start out to just do this on
a grandiose scale necessarily. This was very much
a part-time endeavor. I was very fortunate enough
to be trained and have as a mentor, Theodore Millon,
who's area of expertise was personality disorders.
I was very much interested in doing that research.
When I left the University of Miami, I went to
Harvard where I worked directly with David McClellan,
and again his area of interest was behavioral
medicine and stress. But, in a surprising kind
of way, the growth of the Foundation began requiring
more and more and more of my time. I came back
to Baltimore to work in one of the Johns Hopkins
Hospitals as the Chief of Behavioral Medicine
and Chief of Psychology and it got to a point
where the Foundation just required more and more
time. I still teach at a local college called
Loyola College in Maryland and I also teach part-time
at Johns Hopkins. But I think part of what makes
it work - a lot of our success - is that Jeff
and I come at the problems from two very different
point of views. The good news is we think a lot
alike but we come from two very different experiential
backgrounds. I guess I have more of an academic
and scientific background and Jeff has far more
of an applied background and those two backgrounds
seem to work very nicely together.
JSV: What
are your respective roles with the International
Critical Incident Stress Foundation?
JTM: I serve as
the president, so that means I put signatures
on a lot of things that need to be signed. The
Foundation is run by a volunteer board of directors
and I essentially serve as the highest ranking
operations officer in the Foundation (and certainly
have the co-founder position there). We have a
Director of Operations who works immediately in
my jurisdiction in terms of the line and then
we have an Office Manager and somebody who handles
memberships. We have a receptionist and we have
somebody who handles the scheduling of conferences.
We have another person who takes care of the World
Congress process. My job is just to keep all the
things running from the official point of view
for the Foundation. I'll let George talk about
his role.
GSE: I started
out as Chairman of the Board of Directors and
found that that particular position required so
much time and took me away from the training and
day-to-day operations. I guess technically I'm
Chairman of the Board Emeritus at this point.
I am in charge of strategy, planning, policy making
and Jeff is pretty much the person that makes
it happen. So I come up with the ideas and Jeff
makes them happen, all with the oversight of the
Board of Directors. We are a non-profit organization
and in 1997, we received United Nations (UN) recognition.
JTM: In 1997,
the International Critical Incident Stress Foundation
was recognized as a non-governmental organization
in special consultive status to the United Nations.
We assist the UN and countries worldwide where
they have been running into significant stress
problems.
GSE: Another part
of my job, from a policy point of view, is acting
as a liaison, not only with the United Nations,
but also with other groups such as The American
Academy of Experts in Traumatic Stress.
JTM: George and
I are also two of the main faculty for teaching
education classes for the Foundation. We are not
the only two - there are at least ten faculty
members who were brought on by the Foundation
to provide different courses throughout the world,
wherever they're requested. We also coordinate
a cadre of over 300 basic course instructors who
have been trained to educate in courses throughout
the United States and Canada and some of the European
countries.
JSV: As developers
of Critical Incident Stress Management (CISM),
what goes into a successful response to a traumatic
event?
JTM: We have found
that firefighters listen to firefighters more
than they will to mental health professionals
or to clergy. You'll find that police officers
listen to police officers, nurses listen to nurses,
EMT's listen to EMT's, dispatchers listen to dispatchers,
you could go on with a list like that. We have
put a lot of emphasis into training peer support
personnel who become members of Critical Incident
Stress Management teams. They are one very important
piece of the success of Critical Incident Stress
Management. The second piece is to have mental
health professionals oriented to the needs of
these specialized groups such as emergency personnel
or pilots or groups that they don't usually have
coming into their offices very frequently. We've
look at it as a multi-pronged approach and I think
that this is an important aspect. We have peers,
we have mental health providers and we have clergy
who train together. They learn this material together
and then perform different aspects and roles on
the team. So it is this teamwork approach that
makes the response successful.
GSE: I think from
the broad or "big picture" point of
view. The foundation was originally formulated
to provide training, consultation and direct support
to emergency service personnel from a psychological
perspective. We brought something unique to the
mix, however. Historically, what we were doing
is crisis intervention. We were doing training,
consultation and intervention under the overall
heading of crisis intervention. So it's not like
we invented a new field. We applied crisis intervention
principles to a group of professionals who had
been, to some degree, neglected as recipients
of these types of services. Along the way, we
knew we had to make some adjustments to the way
crisis intervention would be practiced when compared
to a civilian population. Techniques such as critical
incident stress debriefing and the whole genre
which we now call Critical Incident Stress Management
(CISM) emerged. In effect, what the foundation
really is, is a crisis intervention foundation.
However, we apply crisis intervention in a way
that, historically, it has never been applied
before. This is in a very comprehensive way. We
have a comprehensive, total, multi-component approach
to crisis intervention and it has proven successful
to the point that the models are now being used
with populations other than emergency service
personnel. It's being used by the airline industry,
by industries, school systems, psychiatric hospitals,
and general medical hospitals. The programs are
very successful and they seem to be generally
applicable. Some of the best work is that of Dr.
Raymond Flannery out of Harvard Medical School,
who has taken the Critical Incident Stress Management
model and adapted it into something he calls the
Assaulted Staff Action Program. Dr. Flannery has
generated a series of studies demonstrating the
efficacy of the Critical Incident Stress Management
approach as it applies to hospitals and community
mental health centers.
JSV: I am
a firm believer in the benefits of utilizing a
multifaceted approach that capitalizes on local
resources and outside resources as needed.
GSE: And that's
important - because the system works best when
you use local resources as well as external resources.
Whether that means peer counselors and mental
health professionals or whether it means bringing
in other experts from other areas. For us, Critical
Incident Stress Management is utilizing the most
appropriate resources in the most appropriate
way. We use the following analogy. No one would
go out and play a round of golf armed with just
one golf club. Well, we submit that no one would
- or really should - do crisis intervention armed
with only one crisis intervention technique or
modality. Critical Incident Stress Management
is an amalgamation of many crisis intervention
techniques that have been integrated in such a
way that you use the best technique for the particular
need at the particular time. And again, the golf
analogy seems to work for some people - you certainly
wouldn't play an entire round of golf with a putter,
nor with a driver, but under the right circumstances,
the putter is the best club for one situation,
the driver is the best for another. And contrary
to what some people misunderstand - the field
is not only about Critical Incident Stress Debriefing
(CISD). This is one powerful technique that has
been developed by Jeff Mitchell. It is a group
crisis intervention technique, but it is only
one of seven or eight basic techniques that we
utilize. So when people are trained in Critical
Incident Stress Management, they go through a
number of our courses so that they can work with
individuals, large groups, small groups, families
and mass disasters. And we, I think, now have
the distinction of coordinating the largest crisis
response network in the world with standardized
training.
JTM: I want to
reiterate something that George said because I
think that the point is extremely important. As
the developer of the CISD model, I think that
it is important to mention that it is and always
has been a group intervention tactic. And I talk
about it as a tactic because in emergency services,
we talk about strategy and tactics. Strategy is
the big picture - what your goals are and what
you're trying to achieve. Tactics are individual
components that assist in carrying out the overall
goals. You don't put out a fire with ventilation
alone just as you don't arrest a subject with
surveillance alone. CISD is one tactic. It is
the group tactic and it's designed for a specific
function. We also emphasize doing many other things
including one-on-one interventions, family support,
etc.
JSV: With
so many exciting changes taking place in the area
of traumatic stress (e.g., neurobiological findings,
etc.), what things to you think are in need of
greater investigation at this time?
GSE: I think we're
just beginning to understand some of the neurobiology
of trauma. There has certainly been some very
good work done up to this point. I think there
needs to be much more work done. I think that
if we look at Kaplan's model of prevention if
you remember back from 1964, he talked about primary,
secondary, and tertiary prevention. Primary prevention
involves removing the stressors or risk factors,
secondary prevention is crisis intervention and
acute symptom mitigation and tertiary prevention
involves treatment and rehabilitation. There will
always be a need for what we do at the Foundation,
which, again, is crisis intervention. There will
always be a need for treatment. But I think the
future lies in the area of how to make people
crisis and trauma resistant and that is where
we are beginning to turn some of our efforts.
I equate it to giving people in high-risk occupational
groups - "psychological body armor."
We provide soldiers and police officers with,
literally, body armor to go out and do combat.
Well, I think we need to get to the point where
(and we are getting to this point), we are capable
of arming people in high-risk occupational groups
and whom are at high risk for things like acute
and posttraumatic stress disorder. We need to
arm them with a sense of "psychological body
armor" so that they actually become more
resilient to trauma and stress factors. And to
me that's the future and that's the very exciting
area that we need to go in. Science for science
sake is fine, but I happen to believe that science
needs to ultimately improve the human condition.
We need to move into the area of primary prevention
when it comes to acute and posttraumatic stress
disorder.
JSV: I certainly
agree that we need to inoculate support personnel
and survivors essentially through education and
early intervention among other things.
GSE: That's just
part of it. There is some very, very exciting
work being done by Peter Jonsson and people in
Sweden. We are collaborating with them on ways
of actually making the human being less vulnerable
to traumatic situations. For law enforcement,
fire suppression, paramedics and military personnel,
it could represent a rather remarkable breakthrough.
JTM: Critical
Incident Stress Management is prevention-oriented.
Some people have mistaken CISM or one of its single
techniques, debriefing, as therapy and CISM is
not therapy. They are prevention-oriented programs.
They're more about trying to prevent the problem
from taking hold than trying to cure the problem
once it's there. I think that another exciting
challenge besides what George had just mentioned
is trying to help people recover who have been
traumatized badly by some of the experiences that
they have had. And what I find very exciting now
is the linking of prevention efforts of CISM with
some of the newer and very dramatic therapies,
such as Eye Movement Desensitization and Reprocessing
(EMDR). For instance, one of the things that we
have experimented with involves conducting EMDR
very shortly after meeting an individual either
on a one-on-one individual consult or picking
an individual out of a debriefing. That individual
may have had a pretty significant reaction to
an event. A trained therapist will work with the
individual very, very soon after they've been
assessed in a debriefing. We have been finding
that when you get to them that quickly, there
is a recovery rate that is really remarkable.
I think nobody should be fooled that it's a finger-waving
technique. There's a lot of work that goes into
it. There is a very heavy cognitive focus when
you're properly doing EMDR. Therapists really
need to know what they're doing and be properly
trained to be able to provide that particular
therapy. But when we joined it together with the
resources of the CISM team, it has had a very
powerful impact.
JSV: The front
cover of your book Human Elements Training
for Emergency Services, Public Safety and Disaster
Personnel, shows a police car in a ball of
flames. It's a very provocative image, one of
the things that in fact drew me, besides your
names to that particular publication. What led
up to the development of this informative instructional
guide?
GSE: Jeff, you
want to tell the story about the picture?
JTM: Yes, I'll
start off with the picture. The picture was a
Maryland State police officer who was the tail
car on the torch run for the Olympics. I believe
it was in 1992. He was the tail car and he was
a distance behind the runners who were holding
the torch and running the torch across the United
States. A truck came down a hill and became out
of control. This trooper saw this image in his
rear view mirror and knew that the runners were
going to be in deep trouble so he sped ahead,
and caught up to where the runners were. He had
his lights and sirens going and this had not happened
in the race up to that point or in this torch
run at that point. When he did this, people did
turn around and then they saw what was coming
and they got out of the way. He then jammed on
the brakes and as he rolled out of the vehicle,
it was hit by the truck. So here's a trooper who
risked his life to save the runners, knowing that
had he not done that, the truck would have plowed
into the tail of the Olympic torch run. So that
was the story behind that and luckily the trooper
was not injured, although it did destroy the vehicle.
That dramatic picture was picked because we need
to get across to people, again, the importance
of education. If we can let them know what traumatic
stress is, what causes it, what its effects are,
and how they can react to it, then we can do a
lot more for prevention. The Human Elements
Training text really was the instructor guide
for teaching a variety of traumatic stress and
crisis intervention courses to emergency personnel.
It tries to give them that one "leg up"
on the situation so that they're less prone to
being traumatized. They need to know (if something
happens) what the symptoms of traumatic stress
are. It' been my experience in this field that
when people recognize the symptoms of stress they
tend to call for help earlier, they tend to get
help earlier, they recover faster, they stay on
the job longer, they stay healthier, and they
go back to work and I think that if there is anything
that I want to contribute to people, it is helping
them stay healthy and happy on the job, and healthy
and happy in their lives. What we're trying to
do is make a difference. It may not make a difference
in 100% of the cases, but if we can make a difference
in a large number of the cases, we'll be satisfied
with the work.
JSV: In your
work with police officers, firefighters, paramedics
and others who are the "first on the scene,"
what are your observations of the responses of
these individuals to such traumatic events such
as motor vehicle accidents, bombings, and other
catastrophic experiences?
JTM: I think that
smaller events, in their minds, such as auto accidents,
are just "one of those things," but
when the incident has children involved, when
there's a direct threat to them, when there's
stress to their family members, or when there's
something particularly gruesome, then I think
that we see vicarious traumatization with these
people. We see people who can develop a wide arrangement
of stress symptoms from anxiety to depression,
depending on how long they've been dealing with
it. We've seen very good people taken out of service.
We've seen people unable to go back to work again.
And sometimes, they have handled thousands of
cases and one case is that last straw that breaks
the camel's back and we've watched people go out.
One of the reasons I got into this work in the
first place has to do with a gentleman in my unit,
when I was a firefighter, who joined the fire
department when I had joined. We took the training
together, we took the early classes together and
three or four weeks after we had come out of the
training to get in the fire service, he encountered
an episode in which there was the death of a child
in a fire. This particular individual was very,
very deeply impacted by that and he left service
two or three days later and never came back to
the fire service again. He seemed to be a very
strong individual all the way along, and one of
the things that I did learn was that his wife
had just given birth to their first child. He
had related to that very strongly and he really
started to see his own son in the image of the
burned child and he was unable to get passed that.
So he left the fire service and I thought, wow,
we really can lose good people. The other thing
that happened to me along those same lines was
when I was Regional Coordinator of Emergency Medical
Services. I had a five-county area of Maryland
that I was responsible for. I found that when
we were training 1,500 EMT's per year and we were
giving them a 3-year certification, our total
numbers never went up. We were always just filling
the positions. And when I did some studies on
why these people were leaving service, essentially
I found that the vast majority left service because
the stresses were building and there was nobody
that they knew who could talk with them about
this. So those are some of the key trigger points
in my life that said "we've got to have a
better way" and there's got to be something
that we can do to keep healthy people healthy
and functional people functional and keep them
back on the job and keep them healthy in their
lives. That is the core of where my work started.
GSE: Posttraumatic
stress disorder, in my opinion, when it's in it's
most severe form, is one of the most difficult
of the psychiatric disorders to treat. I think
it was in 1989 or 1990 when Arthur McNeil Horton
and I published one of the first, if not the first
paper, on the evidence supporting the notion that
in some cases PTSD resulted in a cognitive deficit
that could potentially be biological in nature
and therefore permanent. We need to focus on treatment
- we need to come up with innovative rehabilitation
and treatment modalities. But I also think that
what you see emerging is, quite literally, a standard
of care in high risk industries where there are
people at high risk for psychological trauma.
These people need to have access to Critical Incident
Stress Management and crisis intervention programs.
The Occupational Safety and Health Administration
(OSHA) has pretty much endorsed this notion by
saying that anyone in the health care industry,
social services industry, aviation industry and
late night retail should have access to crisis
response services and capabilities. The problems
we see including violence in schools and in the
workplace indicate a need for such assistance
from a prevention point of view. How do we mitigate
symptoms? How do we ultimately help people become
stress resistant? This is the direction that I
see the Foundation moving. We have been doing
this already and continue to expand into these
new areas.
JSV: As you
are aware, The American Academy of Experts in
Traumatic Stress is a multidisciplinary organization
with more than 140 areas of specialization represented.
The Academy recognizes that traumatic events are
an unfortunate part of the human experience that
professionals and workers from many fields work
with on a regular basis. 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 quality of intervention
with survivors of such events across such an eclectic
group?
GSE: I'll respond
initially, then Jeff, you can follow up. I think
it boils down to something simple, but very powerful.
The first is, The American Academy of Experts
in Traumatic Stress fosters awareness. As
Sir Francis Bacon said, "information is power."
If we are aware that there is a problem, then
there will be people motivated to address the
problem. The second thing I think that The
American Academy does is to foster discovery,
innovation, creativity, and advancement. And I
think that an organization like The American
Academy helps us strive for raising, to some
degree shall I say, the level of quality assurance
in the field while promoting creativity and innovation
- all with the ultimate goal of being able to
better serve people in need.
JTM: I think one
of The Academy's major contributions
has to do with the fact that this field is so
much bigger than any of the individuals in it.
To achieve great things, we need to join resources
together and have a multidisciplinary approach
(as The Academy does). Instead of competing,
we need to cooperate. Working together, I think
we have greater potential to make a larger impact.
No one will listen to a small organization with
a few members, but when you have a large organization
that cuts across the boundaries of many, many
professions, then politicians will listen, governments
will listen, the citizens will listen, perhaps
a serious difference can be made rather than trying
to do this all by one's self. I just don't think
it's a good idea to work alone in this field -
we need to be allied with one another and assist
one another in making progress to do something
to mitigate the impact of traumatic stress in
people's lives.
JSV: Do you
believe that law enforcement agencies and emergency
personnel training programs provide adequate training
to their staff?
JTM: It depends
on where you are. There are a few places that
are in fact providing quite an adequate preparation
for their personnel, but there are many other
places that have not caught on to the fact that
there is a significant need to do something to
assist their personnel to prepare them for their
field work. There are many places that emphasize
a high level of technical training, so they're
doing really well on the technical aspects of
the job, but where we've seen a lot of it fall
down is the human element. People have not been
skilled and trained in doing crisis intervention.
They have not been skilled in stress awareness.
They have not been skilled in stress prevention.
So a large number of groups that I have seen over
the years have not risen to the challenge. We
congratulate those who have seen a challenge and
have done something about it. We encourage those
who have not trained or who are not providing
education, to start moving in that direction because
it is crucial to the survival of the personnel
of the next century.
JSV: George,
do you want to add anything to that?
GSE: I think Jeff
has covered most of the bases, but I think it
may be worth pointing out how some agencies such
as the FBI, the ATF, the Secret Service and the
Marshall Service, were leaders in recognizing
the potentially debilitating nature of law enforcement
work that their agents perform. We certainly take
our hats off to those people who were leaders
in the field in the early days.
JSV: Although
it's taken some time, we're discovering more and
more about the effects of secondary traumatic
stress on caregivers. What advice do you have
for those who treat trauma survivors? Are there
any suggestions that you could offer to help buffer
caregivers from becoming traumatized and/or overwhelmed
through their efforts to assist others?
JTM: I think each
person finds some of their own ways to help manage
the stress on the job. One of the things that
our organization does and that your organization
does, is try to collect the experiences of other
people and try to understand what they have been
able to do and then try to educate others. We
try to mitigate traumatic stress by helping people
(i.e., caregivers) to understand that they did
not cause the incident to occur - whatever that
awful incident may be. They didn't play an active
role in causing the damage. Their role is to do
something to repair the damage or to alter the
course of the damage. One of the things to remember
that is crucial (if I were to take the collective
knowledge that I've picked up from so many others)
is not to accept responsibility for another person's
tragedy. You need to look at it and say "this
is a horrible thing, it's terrible that it happened
to them, but it is not my incident" but don't
accept personal ownership for the situation. I
think that is one of the first things to consider.
Another step that can help emergency personnel,
again, if I were to take the collective knowledge
that people have shared with me over the years,
is to look at the situation and try to make it
an intellectual response rather than an emotional
response. In other words, if a person keeps focusing
on a particular thing - "isn't this horrible...
isn't this awful... I feel so bad for those people,"
they have a better chance of getting caught up
in this. They instead need to look at the situation
and say "yes, it's a very bad event, but
I have to keep my head on my shoulders and I have
to make a decision of what it is that I can do
to make a difference for these people." They
may say "what can I do to help and what steps
do I need to take?" or "what are the
tasks that I can perform that can help people
in this situation to deal with the situation -
to process it and begin to recover from it?"
I think that if people can recognize these aforementioned
things, then they'll be one step closer to maintaining
their own health as they do this work. I think
another thing I'd say is that people need to recognize
that they are vulnerable and if they do get impacted
by an event, they will need the maturity to recognize
that they've been impacted and the maturity to
seek out support from appropriate resources whether
those resources may be with family, clergy or
resources of a Critical Incident Stress Management
team. George?
GSE: My gosh...
you've covered it pretty well. If I'd add anything,
it would be just to reiterate, perhaps in different
terms. Both the people that are affected and the
people who treat victims of trauma and crisis
need to understand that the crisis or traumatic
event is not this person's fault. But, nevertheless,
they do have some ability, not to control the
crisis, necessarily, but to control their response
to the crisis. I happen to think the cognitively-oriented
therapy approach is particularly applicable in
this field. And to some degree, that is also consistent
with the notion of psychological body armor and
immunization by setting appropriate expectations.
Consider the three concepts of crisis intervention
- immediacy, proximity, and expectancy. Expectancy
may be the most powerful variable within that
triad and, again, what we need to do is prepare
people cognitively for crisis and traumas as best
as we can and as best as we can anticipate. For
the ones that we can't prepare for and anticipate,
then I think we need to arm people with a sense
of self-efficacy that they can play a positive
role in their recovery and not just simply be
a passive victim.
JSV: You have
both been instrumental in defining and operationalizing
the term "psychotraumatology" as it
relates to psychological trauma. How did this
term evolve and why do you believe it's a more
precise description of the events associated with
traumatization and it's aftermath?
GSE: I started
using the term "psychotraumatology"
because the term that had previously been used
was something called "traumatology."
If you look up traumatology in most standard medical
textbooks, you'll find that traumatology is about
the study of wounds - physical wounds - and there
seemed to be something missing! Someone had even
told me that there was a traumatology center at
one particular hospital, but again, they dealt
solely with physical wounds. So in an effort to
make the term more technically correct, we had
to bring the concept of "mind" into
it. In fact, if you quite literally look up "traumatology"
in the dictionary, it will say "the science
of wounds resulting from external force or violence."
I think it's easy to confuse physical traumatology
with psychological traumatology. So I simply suggested,
in an article several years ago, using the term
"psychotraumatology" which, literally,
refers to the study of psychological trauma, whether
it is the factors that produce it, the sequelae
itself, or the factors that contribute to treatment
and rehabilitation. It's designed to be a more
technically-specific term.
JTM: I was quite
happy when George started using the term because
I came out of the field of emergency medicine
and there was mass confusion going on regarding
this term. They were just throwing the word "trauma"
about all over the place and many, many folks
were getting it confused with physical injuries.
It helped to more clearly define the field by
having this term "psychotraumatology."
GSE: So, ultimately,
when I (with Dr. Jeff Lating) edited a book on
trauma, of course we called it Psychotraumatology,
as a way of trying to capture the broad scope
of the entire field.
JSV: And,
on that note, in the groundbreaking book, Psychotraumatology,
George, you define the "Two-Factor Model
of Post-Traumatic Stress." Can you describe
this practical and state-of-the-art perspective?
GSE: Well, it
was an interesting challenge because as part of
my career, I was trained as a psychologist and
in another part of my career, I was trained in
the biomedical sciences. The study of stress is
the study of the inextricable intertwining of
mind and body. And that's what stress is. And
psychological trauma is the most extreme variant
of that intertwining. I like the work of Leonardo
DaVinci who said, "first, study the science,
then practice the art." In the early 80's,
it appeared to me that we were running off treating
PTSD without really knowing what it was. So my
colleagues and I decided that we would try to
take a phenomenological approach and say "well,
where is the lesion?," "what is it?"
and "What is it that we're really trying
to do here?" "What part of the brain
or body are we trying to mend?" And what
we discovered was really a two-factor phenomenology
that we had a brain in overarousal. I wrote a
paper called "PTSD as a Disorder of Arousal."
I was fortunate enough to work with Dr. Herbert
Benson at Harvard Medical School. He and I formulated
that concept many years ago - that stress-related
diseases were disorders of overarousal. PTSD fit
this to a tee. But then the questions came up
- "Well, what drives what?," "does
the biology drive the mind or does the mind drive
the biology?" And my opinion is that it is
the psychology that drives the biology, if you
will. The mind drives the biology. So we then
had to understand that psychologically, there
was a "functional lesion" also. We believed
that we discovered that the lesion is some insult
or injury to some basic core and very personal
belief system. And it is that injury to this overarching
belief system which William James and the like
called the Weltanschauung. It's a German
word which means "world-view." A very
important world-view somehow has been threatened,
challenged, or even destroyed by the trauma. This
insult or injury then releases this remarkable
physiologic cascade that has the ability to not
only overstimulate neurons, but to create a toxic
condition. And we wrote some early papers on what
we called "excitatory toxicity," where
the same chemistry that serves the brain in normal
conditions, in trauma can now, quite literally,
destroy the brain.
JSV: And,
specifically, there is data looking at the hippocampus.
And the hippocampus - in terms of it's function
in arousal and memory - it fits so well with some
of the primary symptoms that we see when we assess
and treat traumatic stress and PTSD.
GSE: Well, that's
what we look for. But basically we, as phenomenologists,
say "well, where is the lesion?"and
"Where is PTSD hiding?" And we can explain
all of the symptoms of PTSD by looking at the
functions and dysfunctions of the hippocampus
and the amygdala.
JSV: What
do you perceive as the most important factors
for clinicians and professionals including non-mental
health personnel, to consider when intervening
on behalf of a survivor of a traumatic event (e.g.,
a plane crash)?
JTM: I think there
are several important factors to consider when
assisting people in crisis. First, you do whatever
you can to stabilize and cut down on the amount
of stimuli in the environment. If you can cut
down on auditory, visual and olfactory stimuli,
then right off the bat, you've already taken some
key steps to get the person in the right position
for support messages. For the survivor, I think
containment is important. We must find out what
they perceive are their initial needs. A lot of
times they just need information, so you want
to try to fulfill those things. If it's an Operations
person, they're going to continue to do operations
and they're not going to be paying much attention
to their own needs, so they have to have "mission
completion." Before people can hear psychological
support messages, they have to be finished doing
their job. Or if they're in the situation, they
have to have a sense of security - a sense that
the dangers have been mitigated and taken away
from them or else they will not be able to hear
those messages. So, when we start thinking about
rescuers and victims, you have to start looking
almost at two different tracks - one has different
needs than the other. It boils down to the same
thing - stabilizing the current situation and
making sure the mission is complete for them.
I think another thing that's quite important is
that people should not go beyond their training
levels, no matter what they are doing. Never go
beyond what you really know how to do. Also, never
open up anything in crisis intervention that cannot
be "put back in the box," so to speak,
within the allotted time. So if you only have
10 minutes to work with somebody, you don't want
to get into conversations that are going to take
you 45 minutes. People have to be aware that sometimes
there is "a time and place for all things,"
as the Bible says, and sometimes it's just not
a good opportunity to open people up. I think
that you have to really look at three issues that
I'm always concerned with and I suggest that others
look at as well - the "target" - who
you are trying to help?, "timing" -
is it the right timing to do what you need to
do? and what "type"of help are you going
to offer? And if we're always looking at "target,"
"timing," and "type," then
we're going to make a little bit more sense out
of what we're doing. We will be in a better position
to know who needs the help, when is the best time
to reach them and what type of help they need.
Not every type of help is appropriate under certain
circumstances. For instance, in disaster, you
don't use debriefing until weeks after the disaster
is over. But you would do a lot of one-on-one
support in what we call "on-scene support
services." So you have to choose the right
intervention at the right time and apply it to
the right group.
GSE: I'll take
the risk of just oversimplifying what Jeff has
said. To quote Hippocrates, "First do no
harm." When you are working with rescuers,
what you need to remember is get out of their
way. Don't be part of the problem. Don't be an
intrusion. Be a support. One of the most common
complaints we hear is that sometimes well-meaning
mental health and crisis interventionists will
actually get in the way, especially while doing
on-scene support. So, "do no harm" to
the rescuers by staying out of their way, giving
them some distance, but be there to support them
when they need it. And then "do no harm"
to the civilian population by not using powerful
probing and interpretational techniques that may
take hours, days, or weeks to resolve. Don't open
a door that you can't close. Again, "do no
harm."
JSV: In the
many years that both of you have been involved
in crisis intervention, do any specific events
stand out in your memories that you believe have
influenced you both personally and professionally?
JTM: Well, certainly
from a traumatic point of view, I have been on
events that have left pretty indelible marks with
lots of very strong memories. I think in life
we have a choice of becoming bitter or better
and when I went through some of those events,
I decided rather than let them make me bitter,
that I was going to take those opportunities to
try to do something to make me better and make
other people better over the circumstances. So,
I think that some of the loss of the life and
events that I have encountered - they really stick.
Some of those experiences include baby deaths,
young people killed unnecessarily and terrible
auto accidents and things like that. I've seen
a variety of those things in my life.
GSE: I think there
are three events that have impacted me - Kuwait,
Croatia, and the Oklahoma City bombing. These
things impacted me on an existential level. When
I was responsible for training the Kuwaiti therapists
who were treating epidemic PTSD, I obviously spent
a lot of time in Kuwait. The experience of war
first hand and being responsible for treating
the aftermath of war had a major impact on me
existentially. It changed my life in such a way
that I certainly appreciate life more now. I guess
that I appreciate each day a little bit more than
I might have otherwise.
JSV: As members
of the Board of Scientific & Professional
Advisors of The American Academy of Experts in
Traumatic Stress, are there any suggestions or
concluding comments that you could offer to our
members with regard to assisting survivors of
traumatic stress?
GSE: Get training.
I don't think you could be overtrained in this
particular area. When human lives are at stake,
it is important to continue your training no matter
how well trained you think you are. I think you
have to understand that there are different constituent
groups. There's the general civilian population,
there's the military, there's the emergency service
personnel and there are certain religious communities.
It's very important to understand the sociology
and the culture of the people that you are trying
to intervene with. Most people can go through
an M.D. or Ph.D. program without getting a whole
lot of training in crisis intervention. I think
specific training in crisis intervention is essential
before you go and do this work. Some understanding
about the population that you're trying to help
is also essential.
JTM: It has been
my experience in traumatic work that the more
practical we make the intervention tactics, the
better it is. We just had an episode of that with
our Foundation when people were asking for things
to do to help survivors of the flooding in Mexico.
We had sent them our sheets on what to do in a
crisis event and we sent it to them in English.
They asked permission to translate it into Spanish,
which we gave them, and they ended up giving out
nearly 50,000 of these sheets. So I think that
providing information and making this information
accessible to the citizen population is a great
contribution.
JSV: I'm glad
you brought that up Jeff. A while ago, the Academy
implemented an Automated Fax Back System to facilitate
the dissemination of information worldwide. In
addition, the Academy maintains documents called
Trauma Response® Infosheets. Their
purpose is to provide survivors of traumatic events
with valuable information to assist them in their
recovery and provide professionals, across disciplines,
with practical information to assist them in their
work with survivors.
GSE: I'd add one
last thing, too. I think, Joe, that it is important
for organizations such as The American Academy
of Experts in Traumatic Stress and the International
Critical Incident Stress Foundation to find as
many ways as possible to collaborate and work
together. I think we can, together, be a very
positive force in helping victims of crisis and
disaster. Unfortunately, I see organizations that
are out there competing and it's almost like they
are competing for victims and the like. I think
one thing that I've always been very impressed
with about your organization is your willingness
to collaborate toward a higher goal, if you will.
And that's why I'm very proud to be associated
with The Academy.
JSV: We're
glad to have you both. I think that, in general,
there's just too much work to be done. When we
talk about the nature of trauma, we have to remember
that no one discipline, specialty, or profession
owns it. I would agree that together, we'll be
more effective in our mission to assist survivors.
JTM: I just want
to say that I'm really delighted to be part of
the Board of Scientific & Professional Advisors
of The American Academy of Experts in Traumatic
Stress. I really appreciate the invitation
and I think it's going to be exciting working
together. I look forward to it.
JSV: Well,
we're glad to have you, Jeff.
GSE: Joe, this
has been an honor.
©1999
by The American Academy of Experts in Traumatic
Stress, Inc. |
