|
George
S. Everly, Jr., Ph.D. and Jeffrey T. Mitchell,
Ph.D. developed the International Critical Incident
Stress Foundation over a decade ago. Today,
it is the largest organization of its kind providing
education, training, and consultation on the
topics of crisis intervention, psychological
trauma and disaster mental health for the emergency
services professions throughout the world. The
Foundation coordinates an international network
of disaster response teams. Dr. Everly is a
leading authority on human stress and psychological
trauma. He serves on the adjunct faculties of
Johns Hopkins University and Loyola College
in Maryland. Dr. Everly was a Harvard Scholar,
Harvard University, a Visiting Lecturer in Medicine,
Harvard Medical School and Chief Psychologist
and Director of Behavioral Medicine for the
Johns Hopkins' Homeward Hospital Center. He
is the author, co-author, and editor of 12 textbooks
and over 125 professional papers with his works
translated into Russian, Arabic, German, Swedish,
Polish, Portuguese, Korean, and Spanish. Dr.
Jeff Mitchell is the President of the International
Critical Incident Foundation. He is the developer
of Critical Incident Stress Management (CISM)
and its related programs which is utilized by
over 700 communities throughout the world and
in over 23 nations. Dr. Mitchell is a Clinical
Associate Professor of the Emergency Health
Services Department at the University of Maryland.
He has over 130 publications on critical incident
stress, crisis intervention and the treatment
of stress in emergency personnel. Drs. Everly
and Mitchell both serve on the Board of Scientific
& Professional Advisors of The American
Academy of Experts in Traumatic Stress.
JSV: The two of you have
very different backgrounds. Can you tell me
about your careers and how you came to collaborate?
GSE: Academically, I was initially
trained in business administration and was intrigued
with the study of human behavior within business
organizations. Subsequent to the completion
of my studies in business I decided that it
might be even more interesting to try to understand
not only how to describe and predict behavior,
but change it. I became interested in clinical
psychology. Somewhere along the way, I also
became very interested in psychophysiology.
My family had a history of high blood pressure
and I was interested in seeing whether some
of these new techniques that had been emerging,
at least in the United States, such as meditation
would be of any value. We started experimenting
with meditation and biofeedback. I was very
lucky to work in a laboratory that was one of
the largest in the country where we studied
biofeedback applications, blood pressure and
general stress. From that point, I specialized
in the area of stress. When I graduated I was
really looking for more of an academic orientation
and saw myself as more of a laboratory scientist
and academic. And then a guy by the name of
Jeff Mitchell introduced himself and, Jeff,
I'll let you pick it up from there and we'll
go back and forth.
JTM: I started off as an elementary
school teacher teaching science to the sixth
grade. I got interested in fire service so I
became a volunteer firefighter and eventually
rose to the rank of Lieutenant and worked for
the fire service for 9 ½ years. I wanted
to become a child psychologist and was actually
studying to do that. I got more and more interested
in the stress that was going on with the emergency
services personnel that I was working with.
Gradually, I started to move toward the Ph.D.
and then I found myself in the position of doing
my dissertation on Paramedic Stress. I needed
to do some testing for the dissertation and
found that George Everly had actually developed
some tests that were quick scales that could
get a good assessment of an individual's stress
level. I talked to him about that and read his
publications. I was quite impressed with the
work that he had done and he helped me to organize
the statistical design for the testing on my
doctoral dissertation. I began to refer people
to him including individuals who I had been
meeting who had quite a bit of posttraumatic
stress. He actually pulled off some significant
cures of people who, when I first met them,
I thought would never be able to stay in the
emergency services profession. George was able
to work with them - to get them back on track
again. And then we just started to do things
together, like education programs and large
conferences. Since my focus was crisis intervention
and his was the treatment of traumatic stress,
it seemed to be a good match. I was taking care
of the prevention end of the experience and
George was taking care of people when they already
had been exposed to significant trauma and had
developed posttraumatic stress, so it was a
good match there. And we both thought a lot
alike in terms of crisis intervention and traumatic
stress and its impact on people. Since 1982,
we have been working together to build this
field to assist people who deal with crises.
GSE: Jeff was kind enough to
invite me to speak at a number of conferences
he had held at University of Maryland - Baltimore
County (UMBC) and this was a world that I was
pretty unfamiliar with at that time. As I was
saying, I was pretty much in the niche of a
laboratory scientist and academic, but as Jeff
had mentioned, I had developed a clinical specialty
in treating stress disorders and I had a behavioral
medicine clinic. What intrigued me about the
world that Jeff had introduced me to was that
I saw people such as fire fighters who were
at unusually high risk for developing this newly
recognized diagnosis of posttraumatic stress
disorder. But I think that it was in 1988 when
Jeff invited me to go to Australia with him
to attend a conference on emergency services
stress that I remember having a certain conversation
with him. I said to him "These people are
at such high risk, occupationally, and there
doesn't seem to be anything in place to really
assist them." There wasn't a line of study
or support for them other than the work that
Jeff was beginning to generate out of UMBC.
So I looked at him half-jokingly and half-seriously
and said "You know, what we really need
to do is create a foundation that would focus
it's efforts in support of emergency services
personnel from the psychological mental health
point of view." He must have taken me seriously!
At that point, we started really thinking about
how we could do such a thing - if it was even
possible. In 1989, the International Critical
Incident Stress Foundation was formed.
JTM: George had referred to
UMBC several times. I am a member of the faculty
there in the Department of Emergency Health
Services. At the time I met George, I was an
instructor working my way toward the Ph.D. I
am now a Clinical Associate Professor in the
Emergency Health Services Department. I had
come out of the field of firefighting paramedic
work and transferred my knowledge and education
into working with emergency personnel. By 1988,
I had finished my dissertation and Clinical
Associate Professor of Emergency Health Services
was my full-time job when George proposed that
we perhaps could work together to put together
an institute or foundation to assist emergency
personnel. I thought it was time for me to do
that. I went part-time at the University of
Maryland and put the rest of my energy into
creating this non-profit organization. The organization
was basically designed to provide education
and assistance to emergency personnel, and when
George and I started, it was basically two people
in the foundation. There is now over 5,000 people
who belong. So in the last 10 years it has had
remarkable growth. We started off with two education
programs and we now have at least a dozen courses
that we offer in the field of traumatic stress
- everything from dealing with traumatized children
to dealing with disasters and more. We provide
innumerable consultations with people who call
in with problems dealing with traumatic stress
and are asking for assistance. Basically right
now we are handling nearly 20,000 incoming phone
calls a year from all over the world and about
35,000 - 40,000 written requests for information
each year. We provide quite a bit of information.
We also have a 24-hour hotline in the Foundation
that is answered by police and fire communications
personnel who then either tell folks where the
local teams are for them or they can provide
them with one of our team members for consultation
if necessary. The services are very broad. We
also do a lot of disaster coordination for emergency
mental health services and take care of the
high risk key personnel.
JSV: Jeff, do you want
to give that phone number?
JTM: The emergency 24-hour
a day phone number is (410) 313-2473. The routine
number for non-emergencies is (410) 750-9600.
GSE: I think that one thing
that Jeff mentioned that is worth reiterating
is that we didn't start out to just do this
on a grandiose scale necessarily. This was very
much a part-time endeavor. I was very fortunate
enough to be trained and have as a mentor, Theodore
Millon, who's area of expertise was personality
disorders. I was very much interested in doing
that research. When I left the University of
Miami, I went to Harvard where I worked directly
with David McClellan, and again his area of
interest was behavioral medicine and stress.
But, in a surprising kind of way, the growth
of the Foundation began requiring more and more
and more of my time. I came back to Baltimore
to work in one of the Johns Hopkins Hospitals
as the Chief of Behavioral Medicine and Chief
of Psychology and it got to a point where the
Foundation just required more and more time.
I still teach at a local college called Loyola
College in Maryland and I also teach part-time
at Johns Hopkins. But I think part of what makes
it work - a lot of our success - is that Jeff
and I come at the problems from two very different
point of views. The good news is we think a
lot alike but we come from two very different
experiential backgrounds. I guess I have more
of an academic and scientific background and
Jeff has far more of an applied background and
those two backgrounds seem to work very nicely
together.
JSV: What are your respective
roles with the International Critical Incident
Stress Foundation?
JTM: I serve as the president,
so that means I put signatures on a lot of things
that need to be signed. The Foundation is run
by a volunteer board of directors and I essentially
serve as the highest ranking operations officer
in the Foundation (and certainly have the co-founder
position there). We have a Director of Operations
who works immediately in my jurisdiction in
terms of the line and then we have an Office
Manager and somebody who handles memberships.
We have a receptionist and we have somebody
who handles the scheduling of conferences. We
have another person who takes care of the World
Congress process. My job is just to keep all
the things running from the official point of
view for the Foundation. I'll let George talk
about his role.
GSE: I started out as Chairman
of the Board of Directors and found that that
particular position required so much time and
took me away from the training and day-to-day
operations. I guess technically I'm Chairman
of the Board Emeritus at this point. I am in
charge of strategy, planning, policy making
and Jeff is pretty much the person that makes
it happen. So I come up with the ideas and Jeff
makes them happen, all with the oversight of
the Board of Directors. We are a non-profit
organization and in 1997, we received United
Nations (UN) recognition.
JTM: In 1997, the International
Critical Incident Stress Foundation was recognized
as a non-governmental organization in special
consultive status to the United Nations. We
assist the UN and countries worldwide where
they have been running into significant stress
problems.
GSE: Another part of my job,
from a policy point of view, is acting as a
liaison, not only with the United Nations, but
also with other groups such as The American
Academy of Experts in Traumatic Stress.
JTM: George and I are also
two of the main faculty for teaching education
classes for the Foundation. We are not the only
two - there are at least ten faculty members
who were brought on by the Foundation to provide
different courses throughout the world, wherever
they're requested. We also coordinate a cadre
of over 300 basic course instructors who have
been trained to educate in courses throughout
the United States and Canada and some of the
European countries.
JSV: As developers of Critical
Incident Stress Management (CISM), what goes
into a successful response to a traumatic event?
JTM: We have found that firefighters
listen to firefighters more than they will to
mental health professionals or to clergy. You'll
find that police officers listen to police officers,
nurses listen to nurses, EMT's listen to EMT's,
dispatchers listen to dispatchers, you could
go on with a list like that. We have put a lot
of emphasis into training peer support personnel
who become members of Critical Incident Stress
Management teams. They are one very important
piece of the success of Critical Incident Stress
Management. The second piece is to have mental
health professionals oriented to the needs of
these specialized groups such as emergency personnel
or pilots or groups that they don't usually
have coming into their offices very frequently.
We've look at it as a multi-pronged approach
and I think that this is an important aspect.
We have peers, we have mental health providers
and we have clergy who train together. They
learn this material together and then perform
different aspects and roles on the team. So
it is this teamwork approach that makes the
response successful.
GSE: I think from the broad
or "big picture" point of view. The
foundation was originally formulated to provide
training, consultation and direct support to
emergency service personnel from a psychological
perspective. We brought something unique to
the mix, however. Historically, what we were
doing is crisis intervention. We were doing
training, consultation and intervention under
the overall heading of crisis intervention.
So it's not like we invented a new field. We
applied crisis intervention principles to a
group of professionals who had been, to some
degree, neglected as recipients of these types
of services. Along the way, we knew we had to
make some adjustments to the way crisis intervention
would be practiced when compared to a civilian
population. Techniques such as critical incident
stress debriefing and the whole genre which
we now call Critical Incident Stress Management
(CISM) emerged. In effect, what the foundation
really is, is a crisis intervention foundation.
However, we apply crisis intervention in a way
that, historically, it has never been applied
before. This is in a very comprehensive way.
We have a comprehensive, total, multi-component
approach to crisis intervention and it has proven
successful to the point that the models are
now being used with populations other than emergency
service personnel. It's being used by the airline
industry, by industries, school systems, psychiatric
hospitals, and general medical hospitals. The
programs are very successful and they seem to
be generally applicable. Some of the best work
is that of Dr. Raymond Flannery out of Harvard
Medical School, who has taken the Critical Incident
Stress Management model and adapted it into
something he calls the Assaulted Staff Action
Program. Dr. Flannery has generated a series
of studies demonstrating the efficacy of the
Critical Incident Stress Management approach
as it applies to hospitals and community mental
health centers.
JSV: I am a firm believer
in the benefits of utilizing a multifaceted
approach that capitalizes on local resources
and outside resources as needed.
GSE: And that's important -
because the system works best when you use local
resources as well as external resources. Whether
that means peer counselors and mental health
professionals or whether it means bringing in
other experts from other areas. For us, Critical
Incident Stress Management is utilizing the
most appropriate resources in the most appropriate
way. We use the following analogy. No one would
go out and play a round of golf armed with just
one golf club. Well, we submit that no one would
- or really should - do crisis intervention
armed with only one crisis intervention technique
or modality. Critical Incident Stress Management
is an amalgamation of many crisis intervention
techniques that have been integrated in such
a way that you use the best technique for the
particular need at the particular time. And
again, the golf analogy seems to work for some
people - you certainly wouldn't play an entire
round of golf with a putter, nor with a driver,
but under the right circumstances, the putter
is the best club for one situation, the driver
is the best for another. And contrary to what
some people misunderstand - the field is not
only about Critical Incident Stress Debriefing
(CISD). This is one powerful technique that
has been developed by Jeff Mitchell. It is a
group crisis intervention technique, but it
is only one of seven or eight basic techniques
that we utilize. So when people are trained
in Critical Incident Stress Management, they
go through a number of our courses so that they
can work with individuals, large groups, small
groups, families and mass disasters. And we,
I think, now have the distinction of coordinating
the largest crisis response network in the world
with standardized training.
JTM: I want to reiterate something
that George said because I think that the point
is extremely important. As the developer of
the CISD model, I think that it is important
to mention that it is and always has been a
group intervention tactic. And I talk about
it as a tactic because in emergency services,
we talk about strategy and tactics. Strategy
is the big picture - what your goals are and
what you're trying to achieve. Tactics are individual
components that assist in carrying out the overall
goals. You don't put out a fire with ventilation
alone just as you don't arrest a subject with
surveillance alone. CISD is one tactic. It is
the group tactic and it's designed for a specific
function. We also emphasize doing many other
things including one-on-one interventions, family
support, etc.
JSV: With so many exciting
changes taking place in the area of traumatic
stress (e.g., neurobiological findings, etc.),
what things to you think are in need of greater
investigation at this time?
GSE: I think we're just beginning
to understand some of the neurobiology of trauma.
There has certainly been some very good work
done up to this point. I think there needs to
be much more work done. I think that if we look
at Kaplan's model of prevention if you remember
back from 1964, he talked about primary, secondary,
and tertiary prevention. Primary prevention
involves removing the stressors or risk factors,
secondary prevention is crisis intervention
and acute symptom mitigation and tertiary prevention
involves treatment and rehabilitation. There
will always be a need for what we do at the
Foundation, which, again, is crisis intervention.
There will always be a need for treatment. But
I think the future lies in the area of how to
make people crisis and trauma resistant and
that is where we are beginning to turn some
of our efforts. I equate it to giving people
in high-risk occupational groups - "psychological
body armor." We provide soldiers and police
officers with, literally, body armor to go out
and do combat. Well, I think we need to get
to the point where (and we are getting to this
point), we are capable of arming people in high-risk
occupational groups and whom are at high risk
for things like acute and posttraumatic stress
disorder. We need to arm them with a sense of
"psychological body armor" so that
they actually become more resilient to trauma
and stress factors. And to me that's the future
and that's the very exciting area that we need
to go in. Science for science sake is fine,
but I happen to believe that science needs to
ultimately improve the human condition. We need
to move into the area of primary prevention
when it comes to acute and posttraumatic stress
disorder.
JSV: I certainly agree
that we need to inoculate support personnel
and survivors essentially through education
and early intervention among other things.
GSE: That's just part of it.
There is some very, very exciting work being
done by Peter Jonsson and people in Sweden.
We are collaborating with them on ways of actually
making the human being less vulnerable to traumatic
situations. For law enforcement, fire suppression,
paramedics and military personnel, it could
represent a rather remarkable breakthrough.
JTM: Critical Incident Stress
Management is prevention-oriented. Some people
have mistaken CISM or one of its single techniques,
debriefing, as therapy and CISM is not therapy.
They are prevention-oriented programs. They're
more about trying to prevent the problem from
taking hold than trying to cure the problem
once it's there. I think that another exciting
challenge besides what George had just mentioned
is trying to help people recover who have been
traumatized badly by some of the experiences
that they have had. And what I find very exciting
now is the linking of prevention efforts of
CISM with some of the newer and very dramatic
therapies, such as Eye Movement Desensitization
and Reprocessing (EMDR). For instance, one of
the things that we have experimented with involves
conducting EMDR very shortly after meeting an
individual either on a one-on-one individual
consult or picking an individual out of a debriefing.
That individual may have had a pretty significant
reaction to an event. A trained therapist will
work with the individual very, very soon after
they've been assessed in a debriefing. We have
been finding that when you get to them that
quickly, there is a recovery rate that is really
remarkable. I think nobody should be fooled
that it's a finger-waving technique. There's
a lot of work that goes into it. There is a
very heavy cognitive focus when you're properly
doing EMDR. Therapists really need to know what
they're doing and be properly trained to be
able to provide that particular therapy. But
when we joined it together with the resources
of the CISM team, it has had a very powerful
impact.
JSV: The front cover of
your book Human Elements Training for Emergency
Services, Public Safety and Disaster Personnel,
shows a police car in a ball of flames. It's
a very provocative image, one of the things
that in fact drew me, besides your names to
that particular publication. What led up to
the development of this informative instructional
guide?
GSE: Jeff, you want to tell
the story about the picture?
JTM: Yes, I'll start off with
the picture. The picture was a Maryland State
police officer who was the tail car on the torch
run for the Olympics. I believe it was in 1992.
He was the tail car and he was a distance behind
the runners who were holding the torch and running
the torch across the United States. A truck
came down a hill and became out of control.
This trooper saw this image in his rear view
mirror and knew that the runners were going
to be in deep trouble so he sped ahead, and
caught up to where the runners were. He had
his lights and sirens going and this had not
happened in the race up to that point or in
this torch run at that point. When he did this,
people did turn around and then they saw what
was coming and they got out of the way. He then
jammed on the brakes and as he rolled out of
the vehicle, it was hit by the truck. So here's
a trooper who risked his life to save the runners,
knowing that had he not done that, the truck
would have plowed into the tail of the Olympic
torch run. So that was the story behind that
and luckily the trooper was not injured, although
it did destroy the vehicle. That dramatic picture
was picked because we need to get across to
people, again, the importance of education.
If we can let them know what traumatic stress
is, what causes it, what its effects are, and
how they can react to it, then we can do a lot
more for prevention. The Human Elements
Training text really was the instructor
guide for teaching a variety of traumatic stress
and crisis intervention courses to emergency
personnel. It tries to give them that one "leg
up" on the situation so that they're less
prone to being traumatized. They need to know
(if something happens) what the symptoms of
traumatic stress are. It' been my experience
in this field that when people recognize the
symptoms of stress they tend to call for help
earlier, they tend to get help earlier, they
recover faster, they stay on the job longer,
they stay healthier, and they go back to work
and I think that if there is anything that I
want to contribute to people, it is helping
them stay healthy and happy on the job, and
healthy and happy in their lives. What we're
trying to do is make a difference. It may not
make a difference in 100% of the cases, but
if we can make a difference in a large number
of the cases, we'll be satisfied with the work.
JSV: In your work with
police officers, firefighters, paramedics and
others who are the "first on the scene,"
what are your observations of the responses
of these individuals to such traumatic events
such as motor vehicle accidents, bombings, and
other catastrophic experiences?
JTM: I think that smaller events,
in their minds, such as auto accidents, are
just "one of those things," but when
the incident has children involved, when there's
a direct threat to them, when there's stress
to their family members, or when there's something
particularly gruesome, then I think that we
see vicarious traumatization with these people.
We see people who can develop a wide arrangement
of stress symptoms from anxiety to depression,
depending on how long they've been dealing with
it. We've seen very good people taken out of
service. We've seen people unable to go back
to work again. And sometimes, they have handled
thousands of cases and one case is that last
straw that breaks the camel's back and we've
watched people go out. One of the reasons I
got into this work in the first place has to
do with a gentleman in my unit, when I was a
firefighter, who joined the fire department
when I had joined. We took the training together,
we took the early classes together and three
or four weeks after we had come out of the training
to get in the fire service, he encountered an
episode in which there was the death of a child
in a fire. This particular individual was very,
very deeply impacted by that and he left service
two or three days later and never came back
to the fire service again. He seemed to be a
very strong individual all the way along, and
one of the things that I did learn was that
his wife had just given birth to their first
child. He had related to that very strongly
and he really started to see his own son in
the image of the burned child and he was unable
to get passed that. So he left the fire service
and I thought, wow, we really can lose good
people. The other thing that happened to me
along those same lines was when I was Regional
Coordinator of Emergency Medical Services. I
had a five-county area of Maryland that I was
responsible for. I found that when we were training
1,500 EMT's per year and we were giving them
a 3-year certification, our total numbers never
went up. We were always just filling the positions.
And when I did some studies on why these people
were leaving service, essentially I found that
the vast majority left service because the stresses
were building and there was nobody that they
knew who could talk with them about this. So
those are some of the key trigger points in
my life that said "we've got to have a
better way" and there's got to be something
that we can do to keep healthy people healthy
and functional people functional and keep them
back on the job and keep them healthy in their
lives. That is the core of where my work started.
GSE: Posttraumatic stress disorder,
in my opinion, when it's in it's most severe
form, is one of the most difficult of the psychiatric
disorders to treat. I think it was in 1989 or
1990 when Arthur McNeil Horton and I published
one of the first, if not the first paper, on
the evidence supporting the notion that in some
cases PTSD resulted in a cognitive deficit that
could potentially be biological in nature and
therefore permanent. We need to focus on treatment
- we need to come up with innovative rehabilitation
and treatment modalities. But I also think that
what you see emerging is, quite literally, a
standard of care in high risk industries where
there are people at high risk for psychological
trauma. These people need to have access to
Critical Incident Stress Management and crisis
intervention programs. The Occupational Safety
and Health Administration (OSHA) has pretty
much endorsed this notion by saying that anyone
in the health care industry, social services
industry, aviation industry and late night retail
should have access to crisis response services
and capabilities. The problems we see including
violence in schools and in the workplace indicate
a need for such assistance from a prevention
point of view. How do we mitigate symptoms?
How do we ultimately help people become stress
resistant? This is the direction that I see
the Foundation moving. We have been doing this
already and continue to expand into these new
areas.
JSV: As you are aware,
The American Academy of Experts in Traumatic
Stress is a multidisciplinary organization with
more than 140 areas of specialization represented.
The Academy recognizes that traumatic events
are an unfortunate part of the human experience
that professionals and workers from many fields
work with on a regular basis. 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 quality
of intervention with survivors of such events
across such an eclectic group?
GSE: I'll respond initially,
then Jeff, you can follow up. I think it boils
down to something simple, but very powerful.
The first is, The American Academy of Experts
in Traumatic Stress fosters awareness.
As Sir Francis Bacon said, "information
is power." If we are aware that there is
a problem, then there will be people motivated
to address the problem. The second thing I think
that The American Academy does is to
foster discovery, innovation, creativity, and
advancement. And I think that an organization
like The American Academy helps us
strive for raising, to some degree shall I say,
the level of quality assurance in the field
while promoting creativity and innovation -
all with the ultimate goal of being able to
better serve people in need.
JTM: I think one of The
Academy's major contributions has to do
with the fact that this field is so much bigger
than any of the individuals in it. To achieve
great things, we need to join resources together
and have a multidisciplinary approach (as The
Academy does). Instead of competing, we
need to cooperate. Working together, I think
we have greater potential to make a larger impact.
No one will listen to a small organization with
a few members, but when you have a large organization
that cuts across the boundaries of many, many
professions, then politicians will listen, governments
will listen, the citizens will listen, perhaps
a serious difference can be made rather than
trying to do this all by one's self. I just
don't think it's a good idea to work alone in
this field - we need to be allied with one another
and assist one another in making progress to
do something to mitigate the impact of traumatic
stress in people's lives.
JSV: Do you believe that
law enforcement agencies and emergency personnel
training programs provide adequate training
to their staff?
JTM: It depends on where you
are. There are a few places that are in fact
providing quite an adequate preparation for
their personnel, but there are many other places
that have not caught on to the fact that there
is a significant need to do something to assist
their personnel to prepare them for their field
work. There are many places that emphasize a
high level of technical training, so they're
doing really well on the technical aspects of
the job, but where we've seen a lot of it fall
down is the human element. People have not been
skilled and trained in doing crisis intervention.
They have not been skilled in stress awareness.
They have not been skilled in stress prevention.
So a large number of groups that I have seen
over the years have not risen to the challenge.
We congratulate those who have seen a challenge
and have done something about it. We encourage
those who have not trained or who are not providing
education, to start moving in that direction
because it is crucial to the survival of the
personnel of the next century.
JSV: George, do you want
to add anything to that?
GSE: I think Jeff has covered
most of the bases, but I think it may be worth
pointing out how some agencies such as the FBI,
the ATF, the Secret Service and the Marshall
Service, were leaders in recognizing the potentially
debilitating nature of law enforcement work
that their agents perform. We certainly take
our hats off to those people who were leaders
in the field in the early days.
JSV: Although it's taken
some time, we're discovering more and more about
the effects of secondary traumatic stress on
caregivers. What advice do you have for those
who treat trauma survivors? Are there any suggestions
that you could offer to help buffer caregivers
from becoming traumatized and/or overwhelmed
through their efforts to assist others?
JTM: I think each person finds
some of their own ways to help manage the stress
on the job. One of the things that our organization
does and that your organization does, is try
to collect the experiences of other people and
try to understand what they have been able to
do and then try to educate others. We try to
mitigate traumatic stress by helping people
(i.e., caregivers) to understand that they did
not cause the incident to occur - whatever that
awful incident may be. They didn't play an active
role in causing the damage. Their role is to
do something to repair the damage or to alter
the course of the damage. One of the things
to remember that is crucial (if I were to take
the collective knowledge that I've picked up
from so many others) is not to accept responsibility
for another person's tragedy. You need to look
at it and say "this is a horrible thing,
it's terrible that it happened to them, but
it is not my incident" but don't accept
personal ownership for the situation. I think
that is one of the first things to consider.
Another step that can help emergency personnel,
again, if I were to take the collective knowledge
that people have shared with me over the years,
is to look at the situation and try to make
it an intellectual response rather than an emotional
response. In other words, if a person keeps
focusing on a particular thing - "isn't
this horrible... isn't this awful... I feel
so bad for those people," they have a better
chance of getting caught up in this. They instead
need to look at the situation and say "yes,
it's a very bad event, but I have to keep my
head on my shoulders and I have to make a decision
of what it is that I can do to make a difference
for these people." They may say "what
can I do to help and what steps do I need to
take?" or "what are the tasks that
I can perform that can help people in this situation
to deal with the situation - to process it and
begin to recover from it?" I think that
if people can recognize these aforementioned
things, then they'll be one step closer to maintaining
their own health as they do this work. I think
another thing I'd say is that people need to
recognize that they are vulnerable and if they
do get impacted by an event, they will need
the maturity to recognize that they've been
impacted and the maturity to seek out support
from appropriate resources whether those resources
may be with family, clergy or resources of a
Critical Incident Stress Management team. George?
GSE: My gosh... you've covered
it pretty well. If I'd add anything, it would
be just to reiterate, perhaps in different terms.
Both the people that are affected and the people
who treat victims of trauma and crisis need
to understand that the crisis or traumatic event
is not this person's fault. But, nevertheless,
they do have some ability, not to control the
crisis, necessarily, but to control their response
to the crisis. I happen to think the cognitively-oriented
therapy approach is particularly applicable
in this field. And to some degree, that is also
consistent with the notion of psychological
body armor and immunization by setting appropriate
expectations. Consider the three concepts of
crisis intervention - immediacy, proximity,
and expectancy. Expectancy may be the most powerful
variable within that triad and, again, what
we need to do is prepare people cognitively
for crisis and traumas as best as we can and
as best as we can anticipate. For the ones that
we can't prepare for and anticipate, then I
think we need to arm people with a sense of
self-efficacy that they can play a positive
role in their recovery and not just simply be
a passive victim.
JSV: You have both been
instrumental in defining and operationalizing
the term "psychotraumatology" as it
relates to psychological trauma. How did this
term evolve and why do you believe it's a more
precise description of the events associated
with traumatization and it's aftermath?
GSE: I started using the term
"psychotraumatology" because the term
that had previously been used was something
called "traumatology." If you look
up traumatology in most standard medical textbooks,
you'll find that traumatology is about the study
of wounds - physical wounds - and there seemed
to be something missing! Someone had even told
me that there was a traumatology center at one
particular hospital, but again, they dealt solely
with physical wounds. So in an effort to make
the term more technically correct, we had to
bring the concept of "mind" into it.
In fact, if you quite literally look up "traumatology"
in the dictionary, it will say "the science
of wounds resulting from external force or violence."
I think it's easy to confuse physical traumatology
with psychological traumatology. So I simply
suggested, in an article several years ago,
using the term "psychotraumatology"
which, literally, refers to the study of psychological
trauma, whether it is the factors that produce
it, the sequelae itself, or the factors that
contribute to treatment and rehabilitation.
It's designed to be a more technically-specific
term.
JTM: I was quite happy when
George started using the term because I came
out of the field of emergency medicine and there
was mass confusion going on regarding this term.
They were just throwing the word "trauma"
about all over the place and many, many folks
were getting it confused with physical injuries.
It helped to more clearly define the field by
having this term "psychotraumatology."
GSE: So, ultimately, when I
(with Dr. Jeff Lating) edited a book on trauma,
of course we called it Psychotraumatology,
as a way of trying to capture the broad scope
of the entire field.
JSV: And, on that note,
in the groundbreaking book, Psychotraumatology,
George, you define the "Two-Factor Model
of Post-Traumatic Stress." Can you describe
this practical and state-of-the-art perspective?
GSE: Well, it was an interesting
challenge because as part of my career, I was
trained as a psychologist and in another part
of my career, I was trained in the biomedical
sciences. The study of stress is the study of
the inextricable intertwining of mind and body.
And that's what stress is. And psychological
trauma is the most extreme variant of that intertwining.
I like the work of Leonardo DaVinci who said,
"first, study the science, then practice
the art." In the early 80's, it appeared
to me that we were running off treating PTSD
without really knowing what it was. So my colleagues
and I decided that we would try to take a phenomenological
approach and say "well, where is the lesion?,"
"what is it?" and "What is it
that we're really trying to do here?" "What
part of the brain or body are we trying to mend?"
And what we discovered was really a two-factor
phenomenology that we had a brain in overarousal.
I wrote a paper called "PTSD as a Disorder
of Arousal." I was fortunate enough to
work with Dr. Herbert Benson at Harvard Medical
School. He and I formulated that concept many
years ago - that stress-related diseases were
disorders of overarousal. PTSD fit this to a
tee. But then the questions came up - "Well,
what drives what?," "does the biology
drive the mind or does the mind drive the biology?"
And my opinion is that it is the psychology
that drives the biology, if you will. The mind
drives the biology. So we then had to understand
that psychologically, there was a "functional
lesion" also. We believed that we discovered
that the lesion is some insult or injury to
some basic core and very personal belief system.
And it is that injury to this overarching belief
system which William James and the like called
the Weltanschauung. It's a German word
which means "world-view." A very important
world-view somehow has been threatened, challenged,
or even destroyed by the trauma. This insult
or injury then releases this remarkable physiologic
cascade that has the ability to not only overstimulate
neurons, but to create a toxic condition. And
we wrote some early papers on what we called
"excitatory toxicity," where the same
chemistry that serves the brain in normal conditions,
in trauma can now, quite literally, destroy
the brain.
JSV: And, specifically,
there is data looking at the hippocampus. And
the hippocampus - in terms of it's function
in arousal and memory - it fits so well with
some of the primary symptoms that we see when
we assess and treat traumatic stress and PTSD.
GSE: Well, that's what we look
for. But basically we, as phenomenologists,
say "well, where is the lesion?"and
"Where is PTSD hiding?" And we can
explain all of the symptoms of PTSD by looking
at the functions and dysfunctions of the hippocampus
and the amygdala.
JSV: What do you perceive
as the most important factors for clinicians
and professionals including non-mental health
personnel, to consider when intervening on behalf
of a survivor of a traumatic event (e.g., a
plane crash)?
JTM: I think there are several
important factors to consider when assisting
people in crisis. First, you do whatever you
can to stabilize and cut down on the amount
of stimuli in the environment. If you can cut
down on auditory, visual and olfactory stimuli,
then right off the bat, you've already taken
some key steps to get the person in the right
position for support messages. For the survivor,
I think containment is important. We must find
out what they perceive are their initial needs.
A lot of times they just need information, so
you want to try to fulfill those things. If
it's an Operations person, they're going to
continue to do operations and they're not going
to be paying much attention to their own needs,
so they have to have "mission completion."
Before people can hear psychological support
messages, they have to be finished doing their
job. Or if they're in the situation, they have
to have a sense of security - a sense that the
dangers have been mitigated and taken away from
them or else they will not be able to hear those
messages. So, when we start thinking about rescuers
and victims, you have to start looking almost
at two different tracks - one has different
needs than the other. It boils down to the same
thing - stabilizing the current situation and
making sure the mission is complete for them.
I think another thing that's quite important
is that people should not go beyond their training
levels, no matter what they are doing. Never
go beyond what you really know how to do. Also,
never open up anything in crisis intervention
that cannot be "put back in the box,"
so to speak, within the allotted time. So if
you only have 10 minutes to work with somebody,
you don't want to get into conversations that
are going to take you 45 minutes. People have
to be aware that sometimes there is "a
time and place for all things," as the
Bible says, and sometimes it's just not a good
opportunity to open people up. I think that
you have to really look at three issues that
I'm always concerned with and I suggest that
others look at as well - the "target"
- who you are trying to help?, "timing"
- is it the right timing to do what you need
to do? and what "type"of help are
you going to offer? And if we're always looking
at "target," "timing," and
"type," then we're going to make a
little bit more sense out of what we're doing.
We will be in a better position to know who
needs the help, when is the best time to reach
them and what type of help they need. Not every
type of help is appropriate under certain circumstances.
For instance, in disaster, you don't use debriefing
until weeks after the disaster is over. But
you would do a lot of one-on-one support in
what we call "on-scene support services."
So you have to choose the right intervention
at the right time and apply it to the right
group.
GSE: I'll take the risk of
just oversimplifying what Jeff has said. To
quote Hippocrates, "First do no harm."
When you are working with rescuers, what you
need to remember is get out of their way. Don't
be part of the problem. Don't be an intrusion.
Be a support. One of the most common complaints
we hear is that sometimes well-meaning mental
health and crisis interventionists will actually
get in the way, especially while doing on-scene
support. So, "do no harm" to the rescuers
by staying out of their way, giving them some
distance, but be there to support them when
they need it. And then "do no harm"
to the civilian population by not using powerful
probing and interpretational techniques that
may take hours, days, or weeks to resolve. Don't
open a door that you can't close. Again, "do
no harm."
JSV: In the many years
that both of you have been involved in crisis
intervention, do any specific events stand out
in your memories that you believe have influenced
you both personally and professionally?
JTM: Well, certainly from a
traumatic point of view, I have been on events
that have left pretty indelible marks with lots
of very strong memories. I think in life we
have a choice of becoming bitter or better and
when I went through some of those events, I
decided rather than let them make me bitter,
that I was going to take those opportunities
to try to do something to make me better and
make other people better over the circumstances.
So, I think that some of the loss of the life
and events that I have encountered - they really
stick. Some of those experiences include baby
deaths, young people killed unnecessarily and
terrible auto accidents and things like that.
I've seen a variety of those things in my life.
GSE: I think there are three
events that have impacted me - Kuwait, Croatia,
and the Oklahoma City bombing. These things
impacted me on an existential level. When I
was responsible for training the Kuwaiti therapists
who were treating epidemic PTSD, I obviously
spent a lot of time in Kuwait. The experience
of war first hand and being responsible for
treating the aftermath of war had a major impact
on me existentially. It changed my life in such
a way that I certainly appreciate life more
now. I guess that I appreciate each day a little
bit more than I might have otherwise.
JSV: As members of the
Board of Scientific & Professional Advisors
of The American Academy of Experts in Traumatic
Stress, are there any suggestions or concluding
comments that you could offer to our members
with regard to assisting survivors of traumatic
stress?
GSE: Get training. I don't
think you could be overtrained in this particular
area. When human lives are at stake, it is important
to continue your training no matter how well
trained you think you are. I think you have
to understand that there are different constituent
groups. There's the general civilian population,
there's the military, there's the emergency
service personnel and there are certain religious
communities. It's very important to understand
the sociology and the culture of the people
that you are trying to intervene with. Most
people can go through an M.D. or Ph.D. program
without getting a whole lot of training in crisis
intervention. I think specific training in crisis
intervention is essential before you go and
do this work. Some understanding about the population
that you're trying to help is also essential.
JTM: It has been my experience
in traumatic work that the more practical we
make the intervention tactics, the better it
is. We just had an episode of that with our
Foundation when people were asking for things
to do to help survivors of the flooding in Mexico.
We had sent them our sheets on what to do in
a crisis event and we sent it to them in English.
They asked permission to translate it into Spanish,
which we gave them, and they ended up giving
out nearly 50,000 of these sheets. So I think
that providing information and making this information
accessible to the citizen population is a great
contribution.
JSV: I'm glad you brought
that up Jeff. A while ago, the Academy implemented
an Automated Fax Back System to facilitate the
dissemination of information worldwide. In addition,
the Academy maintains documents called Trauma
Response® Infosheets. Their purpose
is to provide survivors of traumatic events
with valuable information to assist them in
their recovery and provide professionals, across
disciplines, with practical information to assist
them in their work with survivors.
GSE: I'd add one last thing,
too. I think, Joe, that it is important for
organizations such as The American Academy
of Experts in Traumatic Stress and the
International Critical Incident Stress Foundation
to find as many ways as possible to collaborate
and work together. I think we can, together,
be a very positive force in helping victims
of crisis and disaster. Unfortunately, I see
organizations that are out there competing and
it's almost like they are competing for victims
and the like. I think one thing that I've always
been very impressed with about your organization
is your willingness to collaborate toward a
higher goal, if you will. And that's why I'm
very proud to be associated with The Academy.
JSV: We're glad to have
you both. I think that, in general, there's
just too much work to be done. When we talk
about the nature of trauma, we have to remember
that no one discipline, specialty, or profession
owns it. I would agree that together, we'll
be more effective in our mission to assist survivors.
JTM: I just want to say that
I'm really delighted to be part of the Board
of Scientific & Professional Advisors of
The American Academy of Experts in Traumatic
Stress. I really appreciate the invitation
and I think it's going to be exciting working
together. I look forward to it.
JSV: Well, we're glad to
have you, Jeff.
GSE: Joe, this has been an
honor.
©1999 by
The American Academy of Experts in Traumatic
Stress, Inc. |
