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TERRORIST ATTACK

How We Can Prepare for the Hidden Trauma

National Center for Crisis Management
American Academy of Experts in Traumatic Stress


 

Today, 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.

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.

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.