we are responding to threats of an imminent
terrorist attack. 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.
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.
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
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.
can we keep people functioning and mitigate
long-term emotional suffering during, and
in the wake of, a terrorist attack?
caregivers, we must expand our repertoire
of helping skills - beyond the physical
and safety needs of people, and raise our
level of care.
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
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
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.
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
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).
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.
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.
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!
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.
can we prepare to address the emergent psychological
needs of others?
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
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.)
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.
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.
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
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
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
Consider the Mechanism of Injury
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
Evaluate the Level of Responsiveness
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
Address Medical Needs
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.
Observe and Identify
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.
Connect with the Individual
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
Ground the Individual
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.
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."
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.
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.
Normalize the Response
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
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."
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.
Prepare for the Future
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.
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
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.
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.