| 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. |
