Addressing Emergent Psychological Needs
Mark D. Lerner, Ph.D.
President, American Academy of Experts in Traumatic Stress
Hurricane Katrina is one of our nation's worst natural disasters. The loss of life and destruction seems immeasurable. Today, in the aftermath of Katrina, the focus of caregivers must be the stabilization of injury and illness and, ultimately, the preservation of life. As our nation rushes to help, by addressing the physical and safety needs of survivors, we must not overlook the myriad victims of the hidden trauma - traumatic stress.
Traumatic stress refers to the feelings, thoughts, actions and physical reactions of individuals who are exposed to, or who witness, events that overwhelm their coping and problem-solving abilities. Traumatic stress disables people, causes disease, precipitates mental disorders, leads to substance abuse, and destroys relationships and families.
Beyond those who have survived Katrina, many of whom have faced serious physical injury, are those who have experienced devastating losses of loved ones. Countless people have lost their homes, all of their possessions, and all that was familiar to them.
Today, our world is witnessing the aftermath of this devastating hurricane. We receive daily doses of the "imprint of horror" - images destruction are being recorded in our minds. Truly, our nation is experiencing traumatic stress.
Addressing the emergent psychological needs of survivors
Reaching such an inordinate number of people, who have been directly and indirectly affected by Katrina, is a formidable task. Ultimately, a multimodal approach will be most effective. Beyond individual and group interventions, the media (e.g., radio, television and newspapers) can play a tremendous role in helping people by offering practical, timely information.
In this column, I'll discuss how significant traumatic events, such as a devastating hurricane, affect people. Then, I'll present an overview of a traumatic stress response protocol, Acute Traumatic Stress Management (ATSM). ATSM is a pragmatic process that was developed to keep people functioning, and mitigate ongoing emotional suffering.
Traumatic Events and Traumatic Stress
Generally, as traumatic events become more severe, and as people get physically closer to them, there's a greater likelihood for traumatic stress. We also know that people have a particularly difficult time with events that are gruesome - such as viewing the dead and seeing victimized children.
The manner in which an individual responds will be based upon a number of variables including pre-trauma factors (e.g., a history of mental illness, prior traumatic exposure, substance abuse, etc.), characteristics of the traumatic event (e.g., the severity, proximity, etc.), and post-trauma factors (e.g., having the opportunity to "tell his story," level of familial support, etc.). The personal meaning that an individual ascribes to the hurricane will also influence his/her response.
Helping people to understand how traumatic events affect them, gives back a sense of control that seems to have been taken away in the face of a traumatic experience. For instance, helping people to know that certain reactions are normal, in the wake of an abnormal event, helps to validate disturbing feelings. Following, is a brief discussion of how traumatic events affect peoples' feelings, thoughts, actions and physical reactions.
When people face a traumatic event, some experience "emotional shock." They're anxious, nervous and sometimes even panicky - while others, feel nothing... just a numbness. Both reactions are very common and both are very normal. Some people experience denial, where they don't seem to know that something really bad has happened. Denial is a mechanism that prevents people from feeling too much, too quickly. For many people, the painful realization of the magnitude of Katrina, and its impact, will be experienced after initial denial.
Many survivors will experience "flashbacks." Flashbacks, or feeling as if a traumatic event is happening over and over again, is common among people who've experienced traumatic events - particularly early on. Other common emotional reactions are feelings of aloneness, emptiness, sadness, anger, grief and feelings of guilt.
It's so important that we don't put a bandage on feelings by advising others that, "with time, you'll feel better." Instead, we must help others to understand that experiencing these feelings, as uncomfortable and as painful as they are, is normal. It's okay, not to be okay, right now.
One of things that make it so hard for people to function during, and in the aftermath of a traumatic experience, is difficulty concentrating. Traumatic events, by their very nature, interfere with peoples' thinking. As human beings, we don't focus and think very clearly during a crisis, because the right half of our brain is activated. It's in what we call the "fight-or-flight" mode, working to keep us alive. It's not until later on, when the left side, the verbal, the "thinking" part of our brain takes over that we begin to process and label what's happening. It's hard for us to make decisions, our attention span is shorter than usual, and we are suggestible and vulnerable. It's also common for us to "play the tape" of what's happened, over and over in our minds - even when we want to turn it off. Many people recall past traumatic experiences.
People act differently during traumatic events. Some of us withdraw, "space-out" and become non-communicative. Others become impulsive and energetic - walking and pacing aimlessly. Some people will avoid anything associated with the event - thoughts, feelings, conversations, activities, people and places.
One thing that's particularly important to know is that how people respond, how they choose to react during a traumatic experience will stay with them forever. Not only that, how others act and react will stay with them as well. Do you remember the televised images of Mayor Rudy Giuliani walking through the streets of New York City on September 11th? The Mayor didn't "take-cover" during the tragedy, he decided to "take-action."
Hurricane Katrina reminds us that we can't control the events in our lives, but we can control how we'll to respond to them - how we choose to act. People can make decisions to regain control, at a time when it when it feels like they've lost control. Those who have witnessed the devastation, and made donations to help survivors, understand this.
There are so many kinds of traumatic experiences that can affect people, yet there aren't nearly as many kinds of physical reactions. In fact, people respond the same way to a car backfiring as they do to a gunshot - the "fight-or-flight response." It's not until they begin thinking about their experience that they become aware of, and, begin to understand what's happening to them.
It's not uncommon for survivors to experience physical changes - headaches, muscle aches and stomach aches. Individuals who have difficulty breathing, or those who experience chest pains or palpitations, should be seen by a doctor. It's also very common for people to experience changes in their sleep patterns and to have some very disturbing dreams. Their minds are working overtime to try to make sense of the senseless. Many people experience changes in their eating patterns.
One of the most common reactions in the face of a traumatic event is hypervigilance. Survivors are excessively watchful and cautious - they're uncomfortably nervous and wary. This is a basic survival mechanism that protects us. Hypervigilance was reflected in a two-page newspaper article that I read today entitled, "What if Katrina hit here?" Also, very common is an increased or exaggerated startle response. People tend to be "jumpy" - particularly with loud noises.
We can't prevent or inoculate people from experiencing traumatic stress, because it's a normal response to an abnormal event. However, by having an understanding of what's happening, while it's happening, and by helping people to know that their reactions are normal, is empowering.
Acute Traumatic Stress Management
Whatever happens to us during peak emotional experiences in our lives, the gifts of life and the losses of life, will stay with us forever. In the same way that negative experiences are etched in our minds, so too may the positive force of Acute Traumatic Stress Management. Having someone say and do the right thing, at the right time, can dramatically affect an individual's recovery.
It is important to realize that addressing emergent psychological needs in the aftermath of a tragedy does not require an advanced degree in mental health. In fact, the best help is often rendered by people on the front lines - people who take the time to listen, and say the right things at the right time. However, it's important for caregivers to know what to say and do before they reach out to help others. Traumatic experiences, by their very nature, compromise our ability to think clearly and often leave us feeling out-of-control. By having a plan, a traumatic stress response protocol, caregivers will be in control. They will know what to say and do. They will be prepared.
Beyond having an understanding of traumatic events and traumatic stress, caregivers must be equipped with practical tools that they can use to help others in the face traumatic exposure. This is the primary goal of Acute Traumatic Stress Management (ATSM).
ATSM was developed as a 10 stage model in order to provide structure during an unstructured period of time - and, to enable caregivers to "read off the same page." For example, if I was helping an individual to remain in a functional state, by focusing on the facts of a given situation, it would be unfortunate and potentially problematic for another caregiver to walk over and ask, "How ya feeling?" In fact, this situation was described to me by a New York City police officer in the wake of September 11th. He reported that he was talking with a colleague about extricating bodies when, "... some nut in a red jacket came over and asked me how I was feeling.... I told him to get the ____ out of here. I wanted to kill the bastard!" There is a right thing to say, and a right time to say it.
Following, is a brief overview of the 10 Stages of ATSM. For additional information, caregivers are encouraged to read Comprehensive Acute Traumatic Stress Management (www.ATSM.org). Noteworthy, is that ATSM was built on a strong, empirically-based foundation. The first four stages of this model are of primary importance to emergency medical personnel, and have to do with considerations surrounding situation management and emergency medical care. The latter six stages may be implemented by all caregivers.
It is important to recognize that time constraints and the intensity of individuals' reactions, will vary. Consequently, appropriate intervention may not fall neatly into a linear progression of stages. Caregivers will need to be flexible given the presenting circumstances.
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