IN
THE AFTERMATH OF HURRICANE KATRINA
Addressing Emergent
Psychological Needs
Mark
D. Lerner, Ph.D.
President, American Academy of Experts in
Traumatic Stress
Hurricane
Katrina is one of our nation's worst natural
disasters. The loss of life and destruction
seems immeasurable. Today, in the aftermath
of Katrina, the focus of caregivers must be
the stabilization of injury and illness and,
ultimately, the preservation of life. As our
nation 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 Katrina, 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 this
devastating hurricane. We receive daily doses
of the “imprint of horror”—images
destruction are being recorded in our minds.
Truly, our nation 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 Katrina,
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 a devastating hurricane,
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 ongoing 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.
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 hurricane 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 magnitude of Katrina, 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 bandage
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.”
Hurricane
Katrina 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, 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 Katrina
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 dramatically 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 Katrina, 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 Katrina, 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 hurricane
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 Katrina,
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 Katrina, 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, 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 much devastation 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 hurricane, 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 ongoing emotional suffering.
Conclusion
In
the aftermath of hurricane Katrina, our nation
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 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 Katrina 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 early,
we can potentially prevent the acute traumatic
stress reactions of today from becoming chronic
posttraumatic stress disorders of tomorrow.
www.DrMarkLerner.com
To learn more
about Acute Traumatic Stress Management visit
www.ATSM.org.
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.MarkLernerAssociates.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.
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