Trauma Response Profile:

John P. Wilson, Ph.D., B.C.E.T.S.

Joseph S. Volpe, Ph.D., F.A.A.E.T.S.
Director, Professional Development

Dr. John P. Wilson is an internationally recognized expert in the field of Post-Traumatic Stress Disorder (PTSD). Dr. Wilson is a founding member and past president of the International Society for Traumatic Stress Studies (ISTSS). Dr. Wilson is the author of eight books and over 20 monographs on traumatic stress syndromes. His most recent books include: The International Handbook of Traumatic Stress Syndromes, (co-edited with Dr. Beverley Raphael, Chairman, Department of Psychiatry, Royal Brisbane Hospital, Brisbane, Australia); Counterttransference in the Treatment of Post-Traumatic Stress Disorder (Guilford Press); and Assessing Psychological Trauma and PTSD: A Practitioner's Handbook with Dr. Terence Keane of the National Center for PTSD, Boston, MA (Guilford Press). Research and clinical work developed by Dr. Wilson have led to consultations with the U.S. Army and Navy, Department of Veteran Affairs, The White House, U.S. House and Senate Committees on Veterans Affairs, National Institute of Mental Health, National Science Foundation, Commonwealth of Australia, American Psychiatric Association, American Red Cross and The World Health Organization, where he developed mental health programs during the war in Bosnia in 1994 and 1995. Dr. Wilson has lectured in the U.S. and abroad on the effects of trauma. Included among his numerous awards and honors are a Presidential Commendation from President Jimmy Carter for his work with Vietnam Veterans. Dr. Wilson is a Diplomate of The American Academy of Experts in Traumatic Stress and the Academy is privileged to have him serve on the Board of Scientific & Professional Advisors.

JSV: I know that you maintain numerous roles as a psychologist, lecturer, and consultant with many projects underway. Can you tell me about your current positions?

JPW: I am a Professor of Psychology at Cleveland State University in Cleveland, Ohio. I am also an adjunct Professor at the Union Institute. I serve as a consultant to the United Nations, where currently I am working with the newly created Division of Humanitarian Affairs designing disaster training modules for all of the third-world hot zone areas, such as Bosnia, Rwanda, and Angola. This is something that is very important to me. This grew out of my experience in Bosnia and will provide mental health professionals, physicians and others involved with traumatic stress with training before they enter these areas in which their intervention is necessary. The United Nations (UN) has now mandated this new initiative under the direction of Jane Mocelin in Geneva. This disaster training module has been implemented so that there will be systematic and universal training for those who intervene and provide assistance through the auspices of the UN. It's a very exciting new adventure and I'm happy that I have been selected to be a part of it.

JSV: On that note, I know that you were directly involved with the UN effort to set up all of the mental health programs between 1994 and 1996 during the war in Bosnia. I'm wondering what that experience must have been like since it had to be dangerous.

JPW: Yes, I was involved from 1994 until 1996 under the two auspices of the World Health Organization (WHO) and the European Community Task Force (ECTF). That really was a profound experience for me personally. I think it's probably the first time that there was an attempt coordinated systematically by WHO and ECTF to try to create mental health programs for the victims of war while the war was still going on. We created a regional model that was multi-tiered that started in Sarajevo and then expanded to Vihatch, Tusla and Belgrade. Those were the regions where we first created our out-reach efforts to train professionals including physicians, psychologists, psychiatrists, social workers, and refugee workers in posttraumatic stress disorder interventions so that the model could proliferate throughout the regions of Bosnia and Croatia during the war. This was an extraordinary experience because there were 3 million refugees there at that time. The war was ongoing and there was constant warfare, 24 hours a day with shelling, bombing, and sniper attacks. There was no safe place in Bosnia during this time. The day I arrived in Sarajevo, I saw 11 people killed right in front of me. We were traveling through difficult terrain and we had a radio contact. We were told to be careful and that there was a lot of sniper activity. And there, on the main thoroughfare in which there's a tram that runs through Sarajevo, were 11 bodies of people who had just been killed by a Serb sniper from a cemetery above the tracks. It brought the reality of war immediately home to me in a way that was surreal. How did this just happen? These were innocent war victims. But that was Bosnia. Everywhere you would turn, literally, someone was being killed by a sniper, a booby trap, or land mines. After 1996 in Sarajevo, I went to Kuslah to set up a hospital. I was going to do training and develop programs around posttraumatic interventions and I was off to one of the area hospitals (which was the only remaining hospital in Sarajevo at that point in time). The hospital had been shelled. The neuro-psychiatric unit of the hospital was a five-story wing. Serb rebels had attacked the unit. There were bullet holes in the fourth and fifth floor and debris in the hallway. There were patients who were injured and they were trying to kill the Chief of Staff who was a Muslim. The effort to do this was well worth it just in terms of sheer intensity and importance. This was now my second tour or third tour in Bosnia, and I was aware of the situation. I realized I could be killed. I felt vulnerable. Fortunately for me, I did have the support of my family and my wife--I have four children that I look after! She never said anything to me about her fears that I would be killed. I had plenty of colleagues who said, "Why are you doing this? You're crazy. Why are you going to Bosnia? You could get killed." I knew certainly by the second time that I went back that this was real. I could have been killed. Traumatic stress and trauma reminds us just how human we all are.

JSV: John, you are regularly sought out as a trauma expert. You have spent a considerable amount of time lecturing around the world. What is the topic areas that you're currently presenting?

JPW: Well, it's interesting that you ask that question. At present, I spend a considerable amount of time consulting and lecturing on issues involving stress debriefing and the exploration of the impact of stress on traumatic experts. It's interesting because these things truly go together. I'm also asked to talk about the psychological assessment of trauma as well as more technical issues. It is essential to examine how we respond to situations like Bosnia or airline crashes, or urban disasters--Oklahoma City type disasters--and so on. How do we structure proper intervention? How do we employ? How do we deploy? Take the war in Bosnia for example. How do you design interventions while a war is continuing? It's daily and virtually everybody's exposed to it. How do you target an intervention program to meet critical needs defined for that population. Those are really strategic kinds of questions and there's a big interest in this issue in many parts of the world. The other thing that I find interesting is that there is a growing awareness, again globally, in the effects of trauma-related work on the helper. In our profession over the years, I think it's been assumed that those trained as surgeons, paramedics, psychologists, psychiatrists, trauma experts, emergency workers, are somehow immune from the effects of their work. And you know that's just not the case. Everyone is vulnerable, including well-trained professionals. They're vulnerable to traumatic stress impact. So, increasingly I find that I'm asked by international organizations, national organizations, professional organizations, governments, to come and help them understand how they keep their people highly functional and not adversely impacted by the work. It's a difficult question because of that assumption that "professionals are professionals" and this just isn't always the case. Clinicians, for example, who were in Rwanda--physicians who were in Rwanda--saw thousands of bodies of dead kids every day. And they were profoundly affected by it. They couldn't just walk away and say, "Okay, well that's a normal day in the office." This is traumatic impact and there's clearly a need to increase awareness regardless of who is doing the work. Traumatic events, by definition, are abnormal, and their effects produce predictable consequences to the victim. We need to understand this as part of our effort to assist survivors of traumatic events. And I think that, as we move toward the 21st century, we are going to need to recognize and understand the fact that anyone doing extreme stress work needs to have a way to process, ventilate and articulate about the consequences of that work so that they can remain effective. This, I believe, is where consulting work is moving at this time. I think that this is one of the great things about The American Academy of Experts in Traumatic Stress. It offers a multidisciplinary forum for those involved with survivors to come together and share the universal and common experiences that cross-cut our disciplines. I think that great things can emerge from such higher levels of educational programming, training, and information dissemination (e.g., through publications such as Trauma Response®) .

JSV: Today we know that there are a growing number of organizations concerned with traumatic stress. How should the American Academy work with other agencies to coordinate new initiatives?

JPW: Well, I think that there are so many ways for this to take place. The other area in which I've been doing a lot of writing is in the area of prevention and intervention of traumatic stress. There's no question that the issue of the future in terms of traumatic stress, as it was with illnesses in medicine 50 years ago, is the question of intervention and prevention. So, a major way that the Academy can target objectives in working with other organizations is to first consider who should be involved. I think one of the things that should be considered at this time is the manner in which the Academy can intervene and cooperate with agencies like the United Nations, in all of its auspices. This includes WHO, UNICEF, the UN Commission on Refugees, and so on. There are so many different divisions by international mandate and we now have a global mandate to try to provide assistance for all kinds of psychological trauma. Given the fact that The American Academy of Experts in Traumatic Stress represents over 140 areas of specializations and is the largest organization of its kind in the world, I think there are many other agencies that the Academy should be working with including FEMA, the American Red Cross, the International Red Cross, and the European Community Task Force on Psychosocial Assistance, The International Society for Traumatic Stress Studies, the European Society for Traumatic Stress, and many others that share a vision and mission that is similar to the Academy's vision. And so it behooves us, I think, to ask "how do we begin to join networks?" It is a win-win game; no one will ever lose by doing this. So, I think it is potentially possible to give The American Academy of Experts in Traumatic Stress, given its diversity and scope, a pivotal role in beginning to make possible that kind of initial coordination and cooperation of these various agencies throughout the world.

JSV: I know that you were a member of the DSM-IIIR Committee for Posttraumatic Stress Disorder. What are you thoughts about the current criteria for PTSD in DSM-IV?

JPW: I was a member of the Committee and it was an interesting process in many ways. I believe that there are some problems with the current criteria. First of all, the A-1 criteria I think is okay, but the A-2 criteria, which talks about the response to trauma, is too limited. Right now it addresses symptoms of fear, helplessness, and horror as the human reaction to traumatic event. I think that's too limited. People sometimes don't have those reactions. Sometimes people dissociate; sometimes people have blanket denial; sometimes people go totally numb; sometimes people have profound dissociative reactions to trauma. In fact, one of the problems with that criteria is that it's internally inconsistent with the following category in the DSM-IV which is Acute Stress Disorder (ASD). The definition in the B category of Acute Stress Disorder is that the person has a dissociative reaction, and they list five types of dissociative reactions that occur for Acute Stress Disorder. Well, if that's the case, why don't those same criteria appear for PTSD? If one is acutely traumatized and may experience a range of dissociative reactions, then why don't those same criteria apply to posttraumatic stress, which is by definition, a more chronic response than an acute response? So, the DSM-IV is internally in contradiction with itself, and that is very problematic from my point of view. Another area where I think the criteria is inadequate (that I've written about as well as Judith Herman to name a few), is that the DSM-IV suggests a bare bones number of symptoms which are necessary to diagnose the traumatic stress response syndrome. What I have found over the years in my clinical work and forensic work, is that the really profound injuries to persons who are traumatized is to the self. The real damage is more that the experience of nightmares, flashbacks, or avoidance. Those are behavioral reactions, and they are perfectly understandable as normal responses to abnormal events. But I think the greatest damage of traumatic stress, especially from events that are highly personal such as childhood abuse, torture, or war victimization is the profound change to the person's sense of their "inner-self." Repercussions from this experience may include the loss of pleasure, the loss of a sense of coherency, maybe the sense of a loss of continuity of time and space, maybe the sense that "what you used to be" is gone. This is a more profound change. The literature has documentation forever on this. Hiroshima survivors all were profoundly transformed by the experience, because the world as they knew it changed in a matter of minutes after the atomic bomb. There was no way to construe reality the same way as before, because the world literally changed for them, the city was devastated, everything they knew had changed, most of the things they understood and had grown up with some sense of coherency and continuity of their culture had evaporated with the atomic bombing of a city. How do you then be the same after that? This plummets the depth of humanness and the depth of identity. And I think one of the real absences in the diagnostic criteria is in this area of a more complex posttraumatic stress reaction that involves components of the self that are damaged by traumatic experiences. It is understandable that those who have been devising the criteria have struggled with this issue of "damage to the self" because it's not as readily observable than as someone with a sleep disturbance or startle response. These are more biologically-based reactions. But I think that when you cut through the behavioral and conditioned responses to trauma, the deeper damage really rests inside the person, inside the ego to their sense of identity, to their sense of selfhood, to their sense of sameness and continuity of living day in and day out. I don't know any survivor of trauma that I've talked to who has said, "I'm the same person I was before this happened." They always say, "I'm a different person than I was before this happened." Now, clearly, there are differences in the severity of trauma, but in truly profound events, this impact is long-lasting and I think not well understood. And on that same note, I think it's important to recognize that prior to having PTSD as a diagnosis, so many victims of trauma were misdiagnosed as having personality disorders. And one of the things that is very clear to me is that there are posttraumatic personality changes that take place. And there could be a radical restructuring of personality after trauma that is not predicated by a personality disorder of the type talked about in the literature. Trauma can transform human character. It can transform it in many different directions, some of them positive, some of them negative. On the positive side, there's resiliency, there's greater humanness, there's more self-actualization. One of the things that's so interesting about trauma survivors who cope fairly well at some point in time is that they have a capacity to separate out what is important in life from what is not. To live every day with a keen understanding of what's humanly important for this hour versus what isn't. To separate the essence from that which is irrelevant. That's something that most trauma survivors have. On the other hand, there are trauma survivors who are so profoundly injured by their experiences that it warps their character. That they have shame, they have guilt, they have anhedonia, they lose pleasure, they lose the zest for life, they have depression, they have fears and mistrust that permeate their consciousness regularly, and the world is no longer a safe place. They live with vigilance and watchfulness. And as a consequence of their experience, their pre-traumatic personality is transformed. I would like to see more research on longitudinal personality dimension change in trauma survivors (i.e., complex PTSD). Moreover, it is not just about psychological symptoms but also somatic components as well. And these need to be better understood. And I think that for the future, the revisions that come in the DSM system need to broaden the scope of understanding that PTSD is not just an anxiety reaction. It's a complex phenomena at the most profound human level. It's really a distinct category of human response to traumatic events. And I believe, philosophically, that by recognizing that, we are going to go a lot further in advancing the scientific understanding of the condition.

JSV: What made you focus on traumatic stress as speciality?

JPW: I began to focus on traumatic stress as a specialty when I conducted one of the first large-scale studies on Vietnam veterans in the early 1970s. I must tell you that I wasn't trained as a trauma expert. There were no courses in traumatic stress when I was in graduate school. In fact, just to shed a little light on that, sometimes when I'm lecturing to professional organizations I'll ask the question, "How many of you had special training in traumatic stress in your background?" And when you ask this question to a group of people in any profession, whether it's psychology, medicine or dentistry, very few people raise their hands. And I didn't either. So, the way I got into it was a project called "The Forgotten Warrior Project." It was the first national, large-scale study of Vietnam veterans, which I began in Cleveland, Ohio in 1973 and carried forward until 1980. And that's how I got involved in understanding traumatic stress and particularly posttraumatic stress disorder. Through that process, I began consulting with President Carter and then became appointed by him to assist Max Cleland, who was the director of the Veteran's Administration at the time. Max Cleland was a combat veteran from Vietnam and Jimmy Carter was launching an initiative to create a national effort to assist Vietnam veterans with re-adjustment counseling. I had the role of being one of the principal architects of the Vietnam Veterans' Readjustment Counseling Program in the Carter administration. By 1979, we had developed the program for President Carter. So from 1973 through 1980, under the Forgotten Warrior Project and through in collaboration with the Carter Administration and the Veterans' Administration, I had the fortunate opportunity to try to design programmatic efforts to assist Vietnam veterans suffering from war trauma with readjustment counseling efforts. During that period of time, in addition to the research I did, I began to think about traumatic stress as a syndrome, and I coined some terms like "delayed stress" and "post-Vietnam stress." That's how I got started. And as they say in the movies, "The rest is history."

JSV: Well, your work certainly speaks for itself. I'm glad you carried on that initial spirit.

JPW: Well, the truth is that the work changed my life. I was trained as a traditional psychologist. I had training in both clinical and experimental psychology. And I always thought, in the early days, after my Ph.D., that I would be an academician and just do research and write. But after I got started with the work in traumatic stress, all of that changed for me. Now I work with all different kinds of traumatic events. But in the initial days, it was intense involvement with Vietnam combat veterans and their impact on me was enormous because it was clear that they were suffering. The despair and anger and sense of betrayal by the country was enormous. And it caused me to reflect and try to empathically understand what this experience had done to 18 and 19 year old people including a number of friends who were profoundly affected by the experience. Once I got into that phenomenology, it was so real. It was so profound. It was so authentic, that I really had a hard time doing "traditional laboratory studies in psychology." It was so gratifying to understand how to help someone who had been traumatized.

JSV: What is the Forensic Center for Traumatic Stress?

JPW: The Forensic Center for Traumatic Stress is organization that I had developed in the last year. It developed in response to what I believe is a very severe need that seems to be unmet. In our system of justice, people who have been traumatized and injured often seek legal recourse if they've been wrongfully injured or if there are damages. Moreover, in the criminal sector when a person has committed a crime and may be suffering in a severe manner from PTSD, this diagnosis might serve as an argument for their defense. So there is a need to have a coordinated center in which those involved in the litigation process can have the opportunity to access experts in the field who have expertise in the areas of litigation and maintain knowledge and experience at the highest scientific levels. Thus, whether it is in the area of dentistry, medicine, emergency response, psychiatry, or psychology, that when there's an issue pertaining to traumatic injury that enters the arena of our legal system, individuals can now access experts who can assist them in the proper litigation. So, what I've done is developed the Center, created a national advisory board, and developed an internet of experts who are qualified as experts in traumatic stress and in litigation. It's one thing to be an expert; it's another to be an expert in a court of law. So, the Forensic Center is moving in the direction of certification, training, and education in traumatic stress for those who can testify with scientific expertise in a courtroom.

JSV: I remember we had a conversation a while ago and you and I discussed how retraumatizing the process of being in a courtroom can be for a trauma survivor. A number of professionals sometimes don't realize the impact of their questioning and interrogation on survivors.

JPW: That's very true. Not only are the victims sometimes re-traumatized by the full process of litigation, but I have to tell you that many professionals are sometimes traumatized because they don't have experience in litigation and they don't have experience in understanding the rules and statutes. I hope that through the Forensic Center for Traumatic Stress, many will benefit in the effort to upgrade and systematize the use of traumatic stress experts in the litigation process. And in that sense, what we're going to do is raise the bar of competence and raise the bar of excellence in terms of service to those involved in litigation, whether they are experts testifying, or whether they are victims of traumatic stress.

JSV: Your book Countertransference Processes in the Study and Treatment of Posttraumatic Stress Disorder (with J. Lindy) was one of the first texts to recognize and define patterns of therapist reactions that developed while working with traumatized clients. What are the risks involved in professional work with trauma survivors?

JPW: Well, there are numerous risks. The book that Jack Lindy and I had published examined these patterns and reactions of therapists. In the last three years I've conducted a study with one of my doctoral students, Rhiannon Thomas, in which we surveyed a thousand practitioners, randomly selected from the International Society of Traumatic Stress and the International Society of Dissociative Disorders. We developed a questionnaire called the Clinicians' Trauma Reaction Survey. Through this 100-item questionnaire, we examined the reaction pattern of these therapists working with different trauma populations to assess the impact of their work. We've found that there are about five distinct reaction patterns to this work. They range from over identification and over involvement to phenomena such as vicarious traumatization--where the therapist is now profoundly impacted emotionally by the work and may have developed symptoms of PTSD burnout. At the other end of the continuum, we found one very distinct pattern in which clinicians develop disdain for their clients and for their work. And they don't disclose it or talk about it and they don't get peer supervision or other forms of supervision. They may become actually kind of hostile toward this population. So, there's very clearly a limited domain of reactive styles. Nevertheless, one of the most important things we found is that over 92% of our sample said that they were impacted by the work. No one said that it didn't bother them and that it didn't have some type of lasting impact. Almost everyone admitted that doing traumatic stress work had a profound and lasting impact to them personally and professionally. So, when we talk about the risk, it's clear that you can't be in this business without recognizing that there's going to be an impact to one's sense of well-being and one's sense of self.

JSV: John, as you are aware, The American Academy of Experts in Traumatic Stress is a multidisciplinary organization with more than 140 areas of specialization represented. What do you see as the major advantage of an organization such as the Academy that is dedicated to increasing awareness and ultimately, improving the treatment for survivors of such events across such a eclectic group?

JPW: First and foremost one significant advantage is that the Academy is multidisciplinary. This facilitates different professions coming together under the umbrella of the American Academy. I think that's a great virtue. The cross-pollination that comes from that kind of interaction can only begin to generate a deeper understanding of the phenomenon of traumatic stress as it affects survivors and victims of trauma from all kinds of experience. Secondly, it provides the opportunity to bring together multidisciplinary efforts which allow us "define a mission that transcends ourselves." And in that sense, the Academy, with its diverse and international membership, can provide a forum for education, training, publication, and consultation. This not only becomes a national priority or national opportunity, it becomes potentially global priority of internetting experts in traumatic stress. And I can't think of many things more exciting from my perspective than trying to actualize those objectives which are readily achievable given our technological capacities.

JSV: On a final note, as a member of the Board of Scientific & Professional Advisors of The American Academy of Experts in Traumatic Stress, are there any recommendations and/or suggestions that you have for those individuals who regularly work with survivors of traumatic events?

JPW: Yes, there are a number of them. Remember that self-care is important. You need to take care of yourself. You need to have planned time-out and vacations in which you take yourself out of the stress of the work. Secondly, I think it's important for people who want to be involved in traumatic stress work to have a sense of humor and to have fun. When you deal with this depth of stress everyday, if you don't get a perspective on life, you can get warped by this. Hygiene is important as well as exercise, good diet, and good connectedness to other people. I believe that peer consultation or talk with trusted friends is also important. If you keep that stress inside, it affects one's sense of self. It is important to share the human experience with someone you trust. In my case, I have planned systematic vacations a couple times a year, where I get away from it, where I go and enjoy life and feel restored so I can go back to the intensity of the work. Also, it's important that one is not isolated. To me it's important that people who do this work have connections to the American Academy or other agencies in which they can feel a kindredship. In a sense, it is like having your family or network of professionals that you can bond with. The clinicians who find themself in trouble (i.e., emotionally) are those who isolate themselves from having contact and an opportunity to share. One of the things I've done over the years is work with Native American groups. In many Native American cultures, the idea of trauma or the idea of mental illness is consistent with "a loss of spirit." What I would say here is that to maintain our spirit, we must try to maintain a vitality to do the healing. Many people who do trauma-related work may become "wounded healers." The wounded healer, though, has a gift. The wounded healer maintains their spirit. They have the capacity to be the spirit of the shaman who touches the spirit of the trauma survivor so that they can heal. If one loses that capacity, they cannot be a healer.

©1999 by The American Academy of Experts in Traumatic Stress, Inc.