| Today, we are responding
to the horrific terrorist attack in London.
We are developing plans and protocol for addressing
the wide spectrum of events that can potentially
disable us—including chemical, biological,
radiological and nuclear attack. We are investing
countless hours training and practicing with
elaborate equipment and protective gear. Our
primary goal is the stabilization of injury
and the preservation of life.
In the event of a terrorist
attack, our physical and safety needs must be
the priority. As we have learned, physical trauma
can destroy many lives. However, we have also
learned that a hidden trauma, traumatic stress,
can ultimately destroy many more. Traumatic
stress refers to the emotional, cognitive, behavioral
and physiological experience of individuals
who are exposed to, or who witness, events that
overwhelm their ability to cope.
A terrorist attack will have
many direct and indirect victims. Certainly,
individuals who are at the scene of a horrific
event may experience traumatic stress. However,
we must recognize the impact on so many others
including, but not limited to, family and friends
of victims, emergency responders, and health
care providers. We must also recognize the power
of the media in affecting people across our
nation. For example, we know that individuals
who witness traumatic events on television experience
very real traumatic stress reactions.
Traumatic stress, resulting
from a terrorist attack, will disable people,
cause disease, precipitate mental disorders,
lead to substance abuse, and destroy relationships
and families. In organizations, traumatic stress
will lead to communication breakdowns, a decrease
in morale and group cohesiveness, workplace
tension and conflict, excessive absenteeism,
employee sabotage, an increase in workers’
compensation and disability claims, employee
litigation, an inability to retain effective
personnel, and ultimately, a decrease in productivity.
Historically, efforts to address
psychological needs arrive in the weeks, months
and years after a traumatic event—after
emotional scars have formed and after people
are labeled with a traumatic stress disorder.
In recent years, techniques have been developed
to demobilize, defuse and debrief people after
disengagement from a crisis—following
a traumatic event.
Notwithstanding, there is little
information offering practical strategies to
help individuals during a traumatic experience...a
time when people are highly suggestible, impressionable
and vulnerable.
How can we keep people
functioning and mitigate long-term emotional
suffering during, and in the wake of, a terrorist
attack?
As caregivers, we must expand
our repertoire of helping skills—beyond
the physical and safety needs of people, and
raise our level of care.
During traumatic events, horrible
sights, sounds, smells, tastes and physical
touch are indelibly etched in our minds. They
repeat over and over again, they “play
back” in our experience as disturbing
“movies,” and they lead to uncomfortable
and overwhelming thoughts, feelings, actions
and physical reactions. These stimuli, the imprint
of horror, are the precipitators of debilitating
traumatic stress disorders.
The fact of the matter is that
whatever we are exposed to, whatever we focus
on during peak emotional experiences in our
lives, will stay with us forever. Knowing this,
we understand how adversity can disable us.
However, in the same way that
negative stimuli are etched in our minds during
a traumatic experience, so too can a positive,
adaptive force. Knowing this, we understand
how adversity can propel us to achieve.
Look around you. People who
have achieved the most in life are often people
who have not had the easiest lives. Crises bring
opportunities. A positive force, early on, can
keep people functioning and lessen the likelihood
of long-term emotional suffering.
What is this positive,
adaptive force?
Several years ago, I had the
opportunity to ride the night tour in police
ambulances, EMS “fly cars,” patrol
cars and with police supervisors for a year.
I left my cozy office to understand what really
happens to people during traumatic experiences.
I wanted to learn, first-hand what could be
done, beyond addressing physical and safety
needs, to address emergent psychological needs.
I wanted to understand how we could keep acute
problems from becoming chronic stress disorders.
My experience led to the development of the
Acute Traumatic Stress Management™ (ATSM)
model—a traumatic stress response protocol
for all emergency responders (Lerner and Shelton,
2001, 2005).
Today, ATSM is being utilized
by first responders around the world (see www.atsm.org)
and it is finding its way into other venues
such as schools, universities, the military,
healthcare organizations and corporations. ATSM
is a positive, adaptive force. The implementation
of ATSM, along with traditional emergency medical
intervention, offers a comprehensive response
strategy to meet the needs of the “whole
person.” ATSM offers practical tools for
addressing the wide spectrum of traumatic experiences—from
mild to the most severe. It is a goal-directed
process delivered within the framework of a
facilitative or helping attitudinal climate.
ATSM aims to “jump start” an individual’s
coping and problem-solving abilities. It seeks
to stabilize acute symptoms of traumatic stress
and stimulate healthy, adaptive functioning.
In the months and years following
a terrorist attack, we know that many people
see their doctors. Many turn to their spiritual
leaders. Others present at a therapist’s
office. At that time, a supportive, educational
process begins. People tell their stories, expose
themselves to painful feelings and learn all
about traumatic stress.
Why do we wait for people to
experience months, and sometimes years, of pain
and dysfunction? If what we focus on during
a peak emotional experience stays with us forever,
we must seize this opportunity!
In the face of a terrorist
attack, one does not need an advanced degree
in mental health in order to provide highly
effective intervention. In fact, the best help
is often rendered by people on the front lines.
People who take the time to listen and say the
“right things” at the “right
time.” However, one must know what to
say and do before a traumatic event. Traumatic
experiences, by their very nature, compromise
our ability to think clearly and often leave
us feeling out-of-control. By having a plan
in place, a traumatic stress response protocol,
we will be in control and we will know what
we need to do. We will be prepared.
How can we prepare
to address the emergent psychological needs
of others?
In the same way that a high
school biology teacher must be knowledgeable
about human anatomy, botany and zoology, those
who strive to help others exposed to a terrorist
attack must be knowledgeable about how people
typically react in the face of a tragedy. They
must understand what traumatic stress is, who
it affects, and how it affects themselves and
others.
Caregivers must learn to recognize
the emotional, cognitive, behavioral and physiological
reactions that people experience during traumatic
exposure. And, they must understand that these
reactions are normal reactions in the face of
an abnormal event. This awareness must come
from training prior to a crisis. (Common Reactions
Experienced in the Face of Traumatic Exposure
are listed in Table 1.)
Beyond understanding traumatic
stress and knowing how it affects ourselves
and others, caregivers must be equipped with
practical tools that they can use to help others
during a traumatic event. This is the primary
goal of ATSM.
ATSM was developed as a 10
stage model in order to provide structure during
an unstructured period of time—and, to
enable caregivers to “read off the same
page.” For example, if I was helping an
individual to remain in a functional state,
by focusing on the facts of a given situation,
it would be unfortunate and potentially problematic
for another caregiver to walk over and ask,
“How ya feeling?” In fact, this
situation was described to me by a police officer
in the wake of September 11th. He reported that
he was talking with a colleague about extricating
bodies when, “...some nut in a red jacket
came over and asked me how I was feeling....
I told him to get the ____ out of here. I wanted
to kill the bastard!” There is a “right
thing” to say, and a “right time”
to say it.
Following is a brief overview
of the 10 Stages of ATSM. The first 4 stages
are of primary importance to EMS personnel and
have to do with considerations surrounding situation
management and emergency medical care. The latter
stages can be implemented by all caregivers.
It is important to recognize
that the nature of the event, time constraints
and the intensity of individuals’ reactions,
will vary during traumatic exposure. Consequently,
appropriate intervention may not fall neatly
into a linear progression of stages. You will
need to be flexible given the presenting circumstances.
1. Assess for Danger/Safety for Self
and Others
Upon arriving at the scene
of a terrorist attack, assess the situation
in order to determine whether there are factors
that can compromise your safety or the safety
of others. You will be of little help to someone
else if you are injured. For example, do not
enter an environment that may be compromised
by dangerous gasses without the appropriate
gear. If possible, remove people from the location
in order to risk further traumatic exposure.
2. Consider the Mechanism
of Injury
Form an initial impression
of those impacted by the event. In order to
understand the nature of an individual’s
exposure, it is important to assess how the
event may have physically impacted the individual—that
is, how environmental factors transferred to
the person. For example, if people are unconscious,
it is important to know what factor, or factors
led to their loss of consciousness. It is also
important to consider the perceptual experiences
of victims. For example, directly observing
people mutilated after a suicide bomber attacks
a crowded bus will have a powerful impact on
those who observe the incident. Similarly, the
sounds of people screaming, in the wake of such
an attack, will etch a lasting impression in
the minds of all who arrive at the scene to
help. Ask yourself whether it is necessary for
you to expose yourself to the inner perimeter.
Direct exposure to a gruesome scene can compromise
your ability to help others.
3. Evaluate the Level
of Responsiveness
It is important to determine
if an individual is alert and responsive to
verbal stimuli. Does he feel pain? Is he aware
of what has occurred, or what is presently occurring?
Is he being influenced by a substance? During
a traumatic event, it is quite possible that
the individual is experiencing “emotional”
shock. Therefore, symptomatology may mimic acute
medical conditions (i.e., rapid changes in respiration,
pulse, blood pressure, etc.). Recognize that
a psychological state of shock may be adaptive
in preventing the individual from experiencing
the full impact of the event too quickly. For
example, in the case of a terrorist attack in
a subway, many people will emerge on the street
from stairways and stare blankly while first
responders attempt to engage them in conversation.
This lack of responsiveness may not be the effect
of a physical agent, but the effect of acute
traumatic stress. This reaction is not unusual.
During traumatic events, people can experience
a wide range of emotional reactivity.
4. Address Medical
Needs
Emergency responders are trained
to assess the ABCs (i.e., airway, breathing
and circulation). They understand that if a
man is not breathing, there will be little else
that can be done to help him. Emergency responders
also understand the importance of addressing
significant symptomatology (e.g., severe chest
pains) as well as the importance of knowing
about existing medical conditions (e.g., diabetes).
They have also been trained to know the kinds
of injuries that may present a threat to life
(e.g., internal bleeding). It is critical that
medical intervention be provided by trained
emergency medical personnel. Consider the potential
danger of moving a young woman who is found
outside of derailed train. Despite the best
intentions of good Samaritans, the woman may
have suffered a back injury and movement could
cause permanent injury to her spinal cord. It
is imperative that life-threatening illness
and injury are addressed prior to psychological
needs.
5. Observe and Identify
Observe and identify those
who have been exposed to the attack. Very often,
these individuals will not be the direct victims.
They may be secondary or hidden victims. Witnessing,
or even being exposed to another individual
who has faced traumatic exposure, can cause
traumatic stress. As you observe and identify
who has been exposed to the event (i.e., directly
and/or indirectly), begin to observe and identify
who is evidencing signs of traumatic stress.
An awareness of the emotional, cognitive, behavioral
and physiological reactions suggestive of traumatic
stress is important. Carefully look around you.
Anyone, including you, may be a direct or hidden
victim. This observation and identification
stage of ATSM may be viewed as the first traumatic
stress specific stage.
6. Connect with the
Individual
During a crisis situation,
introduce yourself and let people know your
role (e.g., “My name is Ron, I’m
a paramedic and firefighter with the Melton
Fire Department.”). If the individual
is not physically injured and has been cleared
by emergency medical personnel, move him away
to prevent further traumatic exposure. Begin
to develop rapport by making an effort to understand
and appreciate his situation. A simple question
such as, “How are you doing?” may
be used to engage the individual. Use appropriate
non-verbal communication (e.g., eye contact,
body turned toward him, a gentle touch, etc.).
Recognize that during a traumatic event, individual
reactions may present on a continuum from a
totally detached, withdrawn reaction to the
most intense displays of emotion (e.g., uncontrollable
crying, screaming, panic, anger, fear, etc.).
During a terrorist attack, you may find yourself
working to connect with small groups of individuals.
7. Ground the Individual
When you have established a
connection with someone (or people) who has
been exposed to a terrorist attack (e.g., eye
contact, body turned toward you, dialogue directed
at you, etc.), you can initiate this grounding
stage. Begin by acknowledging the traumatic
event at a factual level. Here, you attempt
to orient the person by discussing the facts
surrounding the event. Address the circumstances
of the event at a cognitive, or thinking level.
While we do not discourage the expression of
emotion, attempt to focus on the facts in the
here-and-now, and help the individual to know
the reality of the situation. Oftentimes, his
“reality” may be seriously clouded
due to the nature of the event. Remember, traumatic
events overwhelm an individual’s coping
and problem-solving abilities. Assure the individual
that he is now safe, if he is. He may still
be “playing the tape” of the event
over and over in his mind. By reviewing facts,
you may disrupt “negative cognitive rehearsal”
(i.e., repetitive, potentially destructive thinking),
help the individual to function, and help him
to deal with the circumstances at hand.
It is important to “place
the individual in the situation.” Encourage
him to “tell his story” and describe
where he was, what he saw, what it sounded like,
what it smelled like, what he did, and how his
body responded. Encourage the individual to
discuss his behavioral and physiological response
to the event — rather than “how
it felt.”
8. Provide Support
Factual discussion and the
realization of a terrorist attack, particularly
when the event is unfolding, may likely stimulate
thoughts and feelings. This is often the time
when individuals who are exposed to trauma need
the most support. However, in reality, it is
also the time when many people look the other
way. Many individuals feel terribly unprepared
to handle others’ painful thoughts and
feelings. Oftentimes, they fear that they will
“open a can of worms” or “say
the wrong thing.” Generally, a reasonable
attempt to help others is preferable to avoidance.
It is important to establish
and maintain a facilitative or helping attitudinal
climate. Here, you attempt to understand and
respect the uniqueness of the individual—the
thoughts and feelings that he is experiencing.
You strive to “give back” a sense
of control that has been “taken from”
him by virtue of his exposure to the event.
You support him, and you allow him to think
and feel. In the face of a terrorist attack,
many people will experience an overwhelming
sense of aloneness and withdraw into their own
world. You should make a respectful effort to
“enter that world,” and to help
the individual to know that he is not alone
and that his unique perception of his experience
is important. Do not attempt to talk a person
out of a feeling (e.g., “Don’t be
scared, you’re fine.”). Communicate
an appreciation of the other person’s
experience. Attempt to understand the feelings
that lie behind his words (or perhaps actions)
and convey that understanding to him. Developing
these empathic listening skills is an area that
should be addressed prior to a crisis.
9. Normalize the Response
While you are attempting to
support an individual by giving him the opportunity
to express his thoughts and feelings, begin
to normalize his reaction to the attack. This
is an important component when intervening with
people who have been exposed to trauma and who
may be feeling very alone. Experiencing a cascade
of emotions, or perhaps a lack of emotional
reactivity, may cause him to feel as if he is
“losing it” and perhaps, “going
crazy.” Normalizing and validating an
individual’s experience will help him
to know that he is a normal person trying to
deal with an abnormal event.
It is important that you do
not become sympathetic and over identify with
the situation with statements such as, “I
know what it feels like.... When I was....”
Rather, you should attempt to normalize and
validate the individual’s experience with
statements like, “I see this is overwhelming
for you right now... seeing a friend badly injured
would be hard for anyone to handle.”
An important component of the
normalization process is to begin to educate
the individual by helping him to know how people
typically respond to traumatic events. Discuss
the emotional, cognitive, behavioral and physiological
reactions that people frequently experience.
Remember, these reactions do not necessarily
represent an unhealthy or maladaptive response.
Rather, they may be viewed as normal responses
to an abnormal event.
10. Prepare for the
Future
The final phase of the ATSM
process is aimed at preparing the individual
for what lies on the road ahead. It is helpful
to 1) review the nature of the traumatic event,
2) bring the person to the present, and 3) describe
likely events in the future. The educational
process initiated during the previous Normalization
Stage should continue during this final stage
of ATSM.
Be careful not to tell someone
as you near the end of your intervention that
“everything is going to be okay,”
or that “everything is going to work out.”
These kinds of “band-aid” statements
may only serve to minimize an individual’s
feelings and cause him to feel misunderstood.
Instead, focus on the facilitative attitudinal
climate that you have established—“I’m
glad that I had the opportunity to be here with
you during such a difficult time.”
ATSM should not be viewed as
counseling or psychotherapy and, in and of itself,
ATSM is not a comprehensive crisis response
plan. Rather, ATSM provides a road map that
can guide individuals through times of crisis,
keep people functioning and mitigate long-term
emotional suffering.
The possibility of a terrorist
attack is on our minds. In an effort to gain
a sense of control, we are taking important
steps to prepare and equip emergency responders
to address the physical and safety needs of
survivors. While the stabilization of injury
and the preservation of life must always be
the priority, we must not overlook the hidden
trauma—traumatic stress. By preparing
to address emergent psychological needs during,
and in the wake of, a terrorist attack we can
keep people functioning and potentially prevent
acute traumatic stress reactions from becoming
chronic stress disorders.
To learn more
about Acute Traumatic Stress Management, visit
www.ATSM.org.
Table 1. Common
Reactions Experienced in the Face of Traumatic
Exposure
Emotional
Responses during a traumatic
event may include shock, in which
the individual may present a highly
anxious, active response or perhaps
a seemingly stunned, emotionally-numb
response. He may describe feeling
as though he is “in a fog.”
He may exhibit denial, in which there
is an inability to acknowledge the
impact of the situation or perhaps,
that the situation has occurred. He
may evidence dissociation, in which
he may seem dazed and apathetic, and
he may express feelings of unreality.
Other frequently observed acute emotional
responses may include panic, fear,
intense feelings of aloneness, hopelessness,
helplessness, emptiness, uncertainty,
horror, terror, anger, hostility,
irritability, depression, grief and
feelings of guilt.
Cognitive
Responses to traumatic exposure
are often reflected in impaired concentration,
confusion, disorientation, difficulty
in making a decision, a short attention
span, suggestibility, vulnerability,
forgetfulness, self-blame, blaming
others, lowered self-efficacy, thoughts
of losing control, hypervigilance,
and perseverative thoughts of the
traumatic event. For example, upon
extrication of a survivor from an
automobile accident, he may cognitively
still “be in” the automobile
“playing the tape” of
the accident over and over in his
mind.
Behavioral
Responses in the face of
a traumatic event may include withdrawal,
“spacing-out,” non-communication,
changes in speech patterns, regressive
behaviors, erratic movements, impulsivity,
a reluctance to abandon property,
seemingly aimless walking, pacing,
an inability to sit still, an exaggerated
startle response and antisocial behaviors.
Physiological
Responses may include rapid
heart beat, elevated blood pressure,
difficulty breathing*, shock symptoms*,
chest pains*, cardiac palpitations*,
muscle tension and pains, fatigue,
fainting, flushed face, pale appearance,
chills, cold clammy skin, increased
sweating, thirst, dizziness, vertigo,
hyperventilation, headaches, grinding
of teeth, twitches and gastrointestinal
upset.
|
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 has conducted
numerous interviews, including CNN Headline
News, the Los Angeles Times, the Palm Beach
Post, Newsweek, Self Magazine, Stars &
Stripes, Reuters, the Associated Press and
U.S. News & World Report. Most recently,
he appeared on Your Morning on CN8, CNN
and Dateline NBC. Dr. Lerner lives in New
York with his wife and three children.
Go to www.DrMarkLerner.com
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