| 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,
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