Dr. Mark Lerner's Column In the Aftermath of the Tsunami Addressing Emergent Psychological Needs The recent tsunami is one of the world’s worst disasters. The loss of life and destruction seems immeasurable. Today, in the aftermath of the tsunami, the focus of caregivers must be the stabilization of injury and illness and, ultimately, the preservation of life. As the world rushes to help, by addressing the physical and safety needs of survivors, we must not overlook the myriad victims of the hidden trauma—traumatic stress. Traumatic stress refers to the feelings, thoughts, actions and physical reactions of individuals who are exposed to, or who witness, events that overwhelm their coping and problem-solving abilities. Traumatic stress disables people, causes disease, precipitates mental disorders, leads to substance abuse, and destroys relationships and families. Beyond those who have survived the treacherous waters of the tsunami, many of whom have faced serious physical injury, are those who have experienced devastating losses of loved ones. Countless people have lost their homes, all of their possessions, and all that was familiar to them. Today, our world is witnessing the aftermath of the tsunami. We receive daily doses of the “imprint of horror”—images of death and destruction are being recorded in our minds. Truly, the world is experiencing traumatic stress. Addressing the emergent psychological needs of survivors Reaching such an inordinate number of people, who have been directly and indirectly affected by the tsunami, is a formidable task. Ultimately, a multimodal approach will be most effective. Beyond individual and group interventions, the media (e.g., radio, television and newspapers) can play a tremendous role in helping people by offering practical, timely information. In this column, I’ll discuss how significant traumatic events, such as the tsunami, affect people. Then, I’ll present an overview of a traumatic stress response protocol, Acute Traumatic Stress Management (ATSM). ATSM is a pragmatic process that was developed to keep people functioning, and mitigate long-term emotional suffering. Traumatic Events and Traumatic Stress Generally, as traumatic events become more severe, and as people get physically closer to them, there’s a greater likelihood for traumatic stress. We also know that people have a particularly difficult time with events that are gruesome—such as viewing the dead and seeing victimized children. These are painful realities of the tsunami. The manner in which an individual responds will be based upon a number of variables including pre-trauma factors (e.g., a history of mental illness, prior traumatic exposure, substance abuse, etc.), characteristics of the traumatic event (e.g., the severity, proximity, etc.), and post-trauma factors (e.g., having the opportunity to “tell his story,” level of familial support, etc.). The personal meaning that an individual ascribes to the tsunami will also influence his/her response. Helping people to understand how traumatic events affect them, gives back a sense of control that seems to have been taken away in the face of a traumatic experience. For instance, helping people to know that certain reactions are normal, in the wake of an abnormal event, helps to validate disturbing feelings. Following, is a brief discussion of how traumatic events affect peoples’ feelings, thoughts, actions and physical reactions. When people face a traumatic event, some experience “emotional shock.” They’re anxious, nervous and sometimes even panicky—while others, feel nothing… just a numbness. Both reactions are very common, and both are very normal. Some people experience denial, where they don’t seem to know that something really bad has happened. Denial is a mechanism that prevents people from feeling too much, too quickly. For many people, the painful realization of the tsunami, and its impact, will be experienced after initial denial. Many survivors will experience “flashbacks.” Flashbacks, or feeling as if a traumatic event is happening over and over again, is common among people who’ve experienced traumatic events—particularly early on. Other common emotional reactions are feelings of aloneness, emptiness, sadness, anger, grief and feelings of guilt. It’s so important that we don’t put a band-aid on feelings by advising others that, “with time, you’ll feel better.” Instead we must help others to understand that experiencing these feelings, as uncomfortable and as painful as they are, is normal. It’s okay, not to be okay, right now. One of things that make it so hard for people to function during, and in the aftermath of a traumatic experience, is difficulty concentrating. Traumatic events, by their very nature, interfere with peoples’ thinking. As human beings, we don’t focus and think very clearly during a crisis, because the right half of our brain is activated. It’s in what we call, the “fight-or-flight” mode, working to keep us alive. It’s not until later on, when the left side, the verbal, the “thinking” part of our brain takes over that we begin to process and label what’s happening. It’s hard for us to make decisions, our attention span is shorter than usual, and we are suggestible and vulnerable. It’s also common for us to “play the tape” of what’s happened, over and over in our minds—even when we want to turn it off. Many people recall past traumatic experiences. People act differently during traumatic events. Some of us withdraw, “space-out” and become non-communicative. Others become impulsive and energetic—walking and pacing aimlessly. Some people will avoid anything associated with the event—thoughts, feelings, conversations, activities, people and places. One thing that’s particularly important to know is that how people respond, how they choose to react during a traumatic experience will stay with them forever. Not only that, how others act and react will stay with them as well. Do you remember the televised images of, Mayor Rudy Giuliani, walking through the streets of New York City on September 11th? The Mayor didn’t “take-cover” during the tragedy, he decided to “take-action.” The tsunami reminds us that we can’t control the events in our lives, but we can control how we’ll to respond to them—how we choose to act. People can make decisions to regain control, at a time when it when it feels like they’ve lost control. Those who have witnessed the devastation and made donations to help survivors of the tsunami understand this. There are so many kinds of traumatic experiences that can affect people, yet there aren’t nearly as many kinds of physical reactions. In fact, people respond the same way to a car backfiring as they do to a gunshot—the “fight-or-flight response.” It’s not until they begin thinking about their experience that they become aware of, and, begin to understand what’s happening to them. It’s not uncommon for survivors to experience physical changes—headaches, muscle aches and stomach aches. Individuals who have difficulty breathing, or those who experience chest pains or palpitations, should be seen by a doctor. It’s also very common for people to experience changes in their sleep patterns and to have some very disturbing dreams. Their minds are working overtime to try to make sense of the senseless. Many people experience changes in their eating patterns. One of the most common reactions, in the face of a traumatic event, is hypervigilance. Survivors are excessively watchful and cautious, they’re uncomfortably nervous and wary. This is a basic survival mechanism that protects us. Hypervigilance was reflected in a two-page newspaper article that I read today entitled, “What if the tsunami hit here?” Also, very common is an increased or exaggerated startle response. People tend to be “jumpy”—particularly with loud noises. We can’t prevent or inoculate people from experiencing traumatic stress, because it’s a normal response to an abnormal event. However, by having an understanding of what’s happening, while it’s happening, and by helping people to know that their reactions are normal, is empowering. Acute Traumatic Stress Management Whatever happens to us during peak emotional experiences in our lives, the gifts of life and the losses of life, will stay with us forever. In the same way that negative experiences are etched in our minds, so too may the positive force of Acute Traumatic Stress Management. Having someone say and do the right thing, at the right time, can affect an individual’s recovery. It is important to realize that addressing emergent psychological needs in the aftermath of a tragedy does not require an advanced degree in mental health. In fact, the best help is often rendered by people on the front lines—people who take the time to listen, and say the right things at the right time. However, it’s important for caregivers to know what to say and do before they reach out to help others. Traumatic experiences, by their very nature, compromise our ability to think clearly and often leave us feeling out-of-control. By having a plan, a traumatic stress response protocol, caregivers will be in control. They will know what to say and do. They will be prepared. Beyond having an understanding of traumatic events and traumatic stress, caregivers must be equipped with practical tools that they can use to help others in the face traumatic exposure. This is the primary goal of Acute Traumatic Stress Management (ATSM). ATSM was developed as a 10 stage model in order to provide structure during an unstructured period of time—and, to enable caregivers to “read off the same page.” For example, if I was helping an individual to remain in a functional state, by focusing on the facts of a given situation, it would be unfortunate and potentially problematic for another caregiver to walk over and ask, “How ya feeling?” In fact, this situation was described to me by a New York City police officer in the wake of September 11th. He reported that he was talking with a colleague about extricating bodies when, “...some nut in a red jacket came over and asked me how I was feeling.... I told him to get the ____ out of here. I wanted to kill the bastard!” There is a right thing to say, and a right time to say it. Following, is a brief overview of the 10 Stages of ATSM. For additional information, caregivers are encouraged to read Comprehensive Acute Traumatic Stress Management (www.ATSM.org). Noteworthy, is that ATSM was built on a strong, empirically-based foundation. The first four stages of this model are of primary importance to emergency medical personnel, and have to do with considerations surrounding situation management and emergency medical care. The latter six stages may be implemented by all caregivers. It is important to recognize that time constraints and the intensity of individuals’ reactions, will vary. Consequently, appropriate intervention may not fall neatly into a linear progression of stages. Caregivers will need to be flexible given the presenting circumstances. 1. Assess for Danger/Safety for Self and Others Upon arriving at the scene, assess the situation in order to determine whether there are factors that can compromise your safety or the safety of others. You will be of little help to someone else if you are injured. For example, do not enter a building that has obviously sustained structural damage. If possible, remove people from the location in order to risk further traumatic exposure. 2. Consider the Mechanism of Injury Form an initial impression of those impacted by the event. In order to understand the nature of an individual’s exposure, it’s important to assess how the event may have physically impacted the person—that is, how environmental factors transferred to him. For example, if people are unconscious, it is important to know what factor, or factors led to their loss of consciousness. It is also important to consider the perceptual experiences of victims. For example, directly observing the bodies of children who have drowned will have a powerful impact on observers. Similarly, the sounds of people moaning will etch a lasting impression in the minds of all who arrive at the scene to help. Ask yourself whether it is necessary for you to expose yourself to the inner perimeter. Direct exposure to a gruesome scene can compromise your ability to address emergent psychological needs. 3. Evaluate the Level of Responsiveness It is important to determine if an individual is alert and responsive to verbal stimuli. Does he feel pain? Is he aware of what has occurred, or what is presently occurring? Is he being influenced by a substance? In the aftermath of the tsunami, it is quite possible that people are experiencing “emotional” shock. Therefore, symptomatology may mimic acute medical conditions (i.e., rapid changes in respiration, pulse, blood pressure, etc.). Recognize that a psychological state of shock may be adaptive in preventing the individual from experiencing the full impact of the event too quickly. Keep in mind that during traumatic events, people can experience a wide range of emotional reactivity. 4. Address Medical Needs Emergency responders are trained to assess the ABCs (i.e., airway, breathing and circulation). They understand that if a man is not breathing, there will be little else that can be done to help him. Emergency responders also understand the importance of addressing significant symptoms (e.g., severe chest pains) as well as the importance of knowing about existing medical conditions (e.g., diabetes). They have also been trained to know the kinds of injuries that may present a threat to life (e.g., internal bleeding). It is critical that medical intervention be provided by trained emergency medical personnel. Consider the potential danger of moving a young woman who is found trapped under rubble. Despite the best intentions of caregivers, the woman may have suffered a back injury and movement could cause permanent injury to her spinal cord. It is imperative that life-threatening illness and injury are addressed prior to psychological needs. 5. Observe and Identify Observe and identify those who have been exposed to the event. Very often, these individuals will not be the direct victims. They may be secondary or hidden victims. As I stated previously, witnessing, or even being exposed to another individual who has faced traumatic exposure, can cause traumatic stress. As you observe and identify who has been exposed to the event (i.e., directly and/or indirectly), begin to observe and identify who is evidencing signs of traumatic stress. An awareness of the emotional, cognitive, behavioral and physiological reactions suggestive of traumatic stress is important. Carefully look around you. Anyone, including yourself, may be a direct or hidden victim. This observation and identification stage of ATSM may be viewed as the first traumatic stress specific stage. 6. Connect with the Individual Introduce yourself and let people know your role (e.g., “My name is Ron, I’m a social worker”). If the individual is not physically injured, and he has been cleared by emergency medical personnel, move him away to prevent further traumatic exposure. Begin to develop rapport by making an effort to understand and appreciate his situation. A simple question such as, “How are you doing?” may be used to engage the individual. Use appropriate non-verbal communication (e.g., eye contact, body turned toward him, a gentle touch, etc.). Recognize that during a traumatic experience, individual reactions may present on a continuum from a totally detached, withdrawn reaction to the most intense displays of emotion (e.g., uncontrollable crying, screaming, panic, anger, fear, etc.). In view of the magnitude of the tsunami, you may likely find yourself working to connect with small groups of individuals. 7. Ground the Individual When you have established a connection with an individual or small group of individuals (e.g., eye contact, body turned toward you, dialogue directed at you, etc.), you can initiate this grounding stage. Begin by acknowledging the tsunami at a factual level. Here, you attempt to orient the person by discussing the facts surrounding the event. Address the circumstances at a cognitive, or thinking level. While we do not discourage the expression of emotion, attempt to focus on the facts in the here-and-now, and help the individual to know the reality of the situation. His “reality” may be seriously clouded due to the nature of the event. Remember, traumatic events overwhelm an individual’s coping and problem-solving abilities. Assure him that he is now safe, if he is. He may still be “playing the tape” of the event over and over in his mind. By reviewing facts, you may disrupt “negative cognitive rehearsal” (i.e., repetitive, potentially destructive thinking), help the individual to function, and enable him to deal with the circumstances at hand. It is important to “place the individual in the situation.” Encourage him to “tell his story” and describe where he was, what he saw, what it sounded like, what it smelled like, what he did, and how his body responded. Encourage him to discuss his behavioral and physiological response—rather than “how it felt.” 8. Provide Support Factual discussion, and the realization of the tsunami, may likely stimulate thoughts and feelings. This is often the time when individuals who are exposed to trauma need the most support. However, in reality, it is also the time when many people look the other way. Many individuals feel terribly unprepared to handle others’ painful thoughts and feelings. Oftentimes, they fear that they will “open a can of worms” or “say the wrong thing.” Generally, a reasonable attempt to help others is preferable to avoidance. It is important to establish and maintain a facilitative or helping attitudinal climate. Here, you attempt to understand and respect the uniqueness of the individual—the thoughts and feelings that he is experiencing. You strive to “give back” a sense of control that has been “taken from” him by virtue of his exposure to the event. You support him, and you allow him to think and feel. Due to the magnitude of the tsunami, many people will experience an overwhelming sense of aloneness and withdraw into their own world. You should make a respectful effort to “enter that world,” and to help the individual to know that he is not alone and that his unique perception of his experience is important. Do not attempt to talk a person out of a feeling (e.g., “Don’t be scared, you’re fine.”). Communicate an appreciation of the other person’s experience. Attempt to understand the feelings that lie behind his words (or perhaps actions) and convey that understanding to him. While providing support with young children who have survived the tsunami, you may need to hold and cuddle the child. Reassure him that he is safe, if he is. Know that children will take cues from adults around them, particularly those with whom they are close. It is therefore important to separate children, as quickly as possible, from all stressors—including emotionally overwhelmed adults. Engaging children must be made consistent with their developmental level. For example, offering more information than a child is cognitively able to manage may do more harm than good. Recognize too that children, particularly young children, are generally unable to express their feelings verbally. They may likely convey their feelings through their behaviors/actions. If you have the time, providing children the opportunity to draw with crayons may be helpful. For example, you may encourage them to draw something that they remember about the event. The drawing may then be used as a vehicle to understand the thoughts and feeling the child is experiencing. 9. Normalize the Response While you are attempting to support an individual by giving him the opportunity to express his thoughts and feelings, begin to normalize his reaction to the tragedy. This is an important component when intervening with people who have been exposed to trauma and who may be feeling very alone. Experiencing a cascade of emotions, or perhaps a lack of emotional reactivity, may cause him to feel as if he is “losing it” and perhaps, “going crazy.” Normalizing and validating an individual’s experience will help him to know that he is a normal person trying to deal with an abnormal event. It is important that you do not become sympathetic and over identify with the situation with statements such as, “I know what it feels like.... When I was....” Rather, you should attempt to normalize and validate the individual’s experience with statements like, “I see this is overwhelming for you right now... seeing so many bodies would be hard for anyone to handle.” An important component of the normalization process is to begin to educate the individual by helping him to know how people typically respond to traumatic events. Discuss the emotional, cognitive, behavioral and physiological reactions that people frequently experience. Remember, these reactions do not necessarily represent an unhealthy or maladaptive response. Rather, they may be viewed as normal responses to an abnormal event. 10. Prepare for the Future The final phase of the ATSM process is aimed at preparing the individual for what lies on the road ahead. It is helpful to 1) review what we know about the tsunami, 2) bring the person to the present, and 3) describe likely events in the future. The educational process initiated during the previous Normalization Stage should continue during this final stage of ATSM. Be careful not to tell someone as you near the end of your intervention that “everything is going to be okay,” or that “everything is going to work out.” These kinds of “band-aid” statements may only serve to minimize an individual’s feelings and cause him to feel misunderstood. Instead, focus on the facilitative attitudinal climate that you have established—“I’m glad that I had the opportunity to be here with you during such a difficult time.” ATSM should not be viewed as counseling or psychotherapy. Rather, ATSM provides a road map that can guide individuals through this horrific event, keep people functioning and lessen the likelihood of long-term emotional suffering. Conclusion In the aftermath of the tsunami, the world is rushing to address the devastating loss of life and destruction. Beyond the physical and safety needs of survivors, we must recognize and address the hidden trauma—traumatic stress. In this column, I have provided practical information about traumatic events and traumatic stress that should be reviewed by caregivers, and shared with survivors. Consider the potential of radio, television and the printed news media in helping survivors of the tsunami to understand that their reactions are normal given such an abnormal circumstance? By educating people about traumatic stress, we can give survivors back a sense of control that the tsunami seems to have taken away. Knowledge is power! I have additionally presented an overview of a traumatic stress response protocol, Acute Traumatic Stress Management (see www.ATSM.org). ATSM aims to keep people functioning and mitigate long-term emotional suffering. By reaching survivors of the tsunami early, we can potentially prevent the acute traumatic stress reactions of today from becoming chronic posttraumatic stress disorders of tomorrow. www.DrMarkLerner.com Dr. Mark Lerner is a clinical psychologist and traumatic stress consultant who focuses on helping people during and in the aftermath of traumatic events. He is the President of the American Academy of Experts in Traumatic Stress (www.AAETS.org) and the originator of the Acute Traumatic Stress Management intervention model (www.ATSM.org). Dr. Lerner wrote and produced the newly released audio book, Surviving and Thriving: Living Through a Traumatic Experience (www.DrMarkLerner.com). He is the Editor and Publisher of Trauma Response®, the Academy’s official publication, and the author of five books. Dr. Lerner consults regularly with individuals and organizations—where he specializes in the education, training and implementation of Acute Traumatic Stress Management and the development of organizational crisis management teams. Dr. Lerner lives in New York with his wife and three children. Download Comprehensive Acute Traumatic Stress Management Documents