A CRASH COURSE IN CRISIS COUNSELING
By Florence Isaacs
After the September 11 terrorist attacks on the World Trade Center and Pentagon turned our world upside down, members of the department of psychiatry at UMDNJ-New Jersey Medical School snapped into action to aid rescue workers and others under extraordinary stress. The goal: to help them cope with the horror psychologically, and try to prevent development of post traumatic stress disorder (PTSD), a medical condition caused by exposure to a traumatic event. The response focused on two fronts: training mental health clinicians in disaster skills, and providing outreach to groups at risk.
In a key effort, Steven Keller, PhD, professor of psychiatry, and Ernesto A. Amaranto, MD, coordinator of the Disaster Mental Health Initiative of the Newark campus, organized a training program in critical incident stress debriefing (CISD), a process which helps people address the aftereffects of a disaster.
"On Wednesday, the day following the attacks, Dr. Amaranto and I were discussing the psychological fallout not only for victims families, but for firemen, police and EMTs. He mentioned there werent enough clinicians on campus familiar with, and capable of conducting, crisis intervention and stress debriefing for the numbers of people who might need help," recalls Keller. "I suggested that we train our clinicians to do crisis debriefing." The idea mobilized both men to make it happen in just three days.
Amaranto, an associate professor of psychiatry at NJMS, has conducted debriefings for the Newark police department for years. He called Jacob Steinberg, PhD, Lead Mental Health Clinician for the Red Cross in New Jersey. Steinberg agreed to co-lead the course with him. Keller emailed Pfizer Inc. and Eli Lilly & Company, receiving immediate pledges to underwrite the program. He also informed the psychiatry faculty about the program via email. By Friday, more than 100 psychologists, psychiatrists, social workers and other mental health professionals from the tri-state area and as far away as Washington, DC, had signed up.
Normally, CISD training involves a two day program for laymen. Because attendees were mental health professionals, however, Steinberg and Amaranto were able to conduct introductory training on debriefing in a few hours. In the debriefing process, people who have had similar experiences meet together with two group leaders: a mental health clinician and a peer of the group being debriefed who is certified in CISD. Participants first share the facts of what happened, followed by their thoughts about the event. They then discuss the feelings and symptoms they are experiencing. In the education phase, they learn that these responses are normal reactions to an abnormal event. They also receive advice on stress management. The debriefing process aims to normalize the response to the traumatic event, and leaders identify those who need psychiatric follow-up and make appropriate referrals.
Although debriefing is controversial, with some questions about its effectiveness, it is an accepted practice used by disaster organizations like the Red Cross and the Federal Emergency Management Agency (FEMA). "I think it does help, but it has to be done properly," says Amaranto. "Thats why the program was restricted to mental health professionals." CISD, also known as psychological debriefing, is a group process. One has to be familiar with the concept of group work to be effective.
At the Front Lines
The psychiatric faculty also provided both formal and informal outreach to those in need. A great deal of help was given informally at the Jersey City waterfront. "When youre involved in a rescue effort, youre not in the mode to want to talk to a mental health professional," says Steven Schleifer, MD, professor and interim chair of the department of psychiatry at NJMS, who organized some of the efforts. "But there may be times when having someone who understands what youre going through may be useful. So we just tried to be there, mix with the crowd, and then without intruding, help people who might be worrying about how theyre feeling, whats normal and what isnt." On Friday, September 14, for example, Keller accompanied Drs. Cheryl Kennedy and Jacqueline Bartlett to the staging area in Jersey City. Every five or ten minutes, fresh firemen, police and EMTs boarded boats leaving for Manhattan and the World Trade Center, and coming off the same boats were exhausted rescuers. Keller says: "Sometimes theyd say, Im fine, but you got to get somebody to talk to John over here. He kept finding bits of human flesh. Groups of these guys would be having coffee. Theyd say the worst was the smell and bagging unidentifiable remains. Emotions just poured out."
The next step involved formalized debriefing sessions. Here, the group leader essentially tells participants, "Youre experiencing what most of this room is experiencing and this is what you can expect to continued happen." For many people, this knowledge is all that is needed to gain a sense of reassurance and control. What makes stress a crisis is the feeling that you can no longer handle what you have been able to handle in the past.
Amaranto conducted several debriefing sessions with EMTs who helped at ground zero, and provided individual sessions to some participants. Open sessions were organized for anyone associated with the hospital, from doctors and nurses to maintenance personnel. Faculty members worked with other groups, including a few unexpected ones. Hospital telephone operators, who had been deluged with calls from people searching for loved ones, experienced their own type of stress. Someone would ask, "Is John Smith, my brother, a patient in your hospital?" But obviously more than an inquiry was involved. Desperate people poured out fears and concerns to someone answering the telephone who had no counseling training. Operators relived the experience every time a frantic relative called.
The response added up to an extraordinary effort in catastrophic times. "Being part of this was one of the most important and moving experiences of my life," says Keller, who along with others, remains involved for the long haul.
WHEN DISASTER STRIKES: COPING TIPS
1. Allow for normal symptoms. Almost everyone will suffer some emotional effects in a catastrophe. Its normal for symptoms to interfere with your life at first. The issue is how severe are the symptoms and how long do they last. In most cases, an extreme stress reaction is not an indication youre going to develop PTSD.
2. Know whos at risk for PTSD. The two most important factors to consider are:
Intensity of exposure. Were you actually there at ground zero? Did you escape, while the person at the next desk did not? Often these become the intrusive thoughts that keep returning.
History of mental health problems. Although those directly affected by the trauma are most likely to exhibit stress symptoms, they are not necessarily the only ones, or the most likely to develop chronic PTSD down the line. People who have suffered from anxiety, depression, or other mental health conditions in the past are vulnerable to PTSD.
3. Dont deny the emotional impact. If symptoms continue to interfere with your life, take advantage of debriefing. Sharing experiences with others who have been through a crisis can help you recognize you are not alone. Fear of symptoms can be problem in itself, especially if youre a "macho" type.
4. Contribute in some way. Give blood; it will always help somebody. Send money. Volunteer for the Red Cross or other local organizations.
5. Reach out to the spiritual. Many people find comfort in religious services.
6. Live a normal life. Go out to dinner or see a movie. Jog; go to aerobics class. Reconnect with friends and family. Continue to work.
7. Reassure children. Dont pretend that nothing has happened. Reassure them at their level of comprehension that life is secure. Say, "Yes, something terrible has occurred, but this is not a routine event. Firemen and policemen are here to protect us." You want to restore their sense of control and let them know that while you may have been distressed as well, youre still there for them.
ALL ABOUT PTSD
PTSD affects individuals who have experienced or observed a traumatic event, causing feelings of intense fear, helplessness and horror that last for at least one month. (When distress resolves sooner, the diagnosis is acute stress disorder.) PTSD can persist for months or years, as still seen in some Vietnam veterans. There are generally three categories of PTSD symptoms:
1. Re-experiencing symptoms. The person experiences recurrent intrusive recollections of the event such as flashbacks and dreams, reliving it in a sense.
2. Avoidant symptoms. One avoids places that remind him of the event and that may trigger feelings of overwhelming threat. If you first heard about the disaster while riding on the subway, for example, you might experience symptoms when on a train and seek other transportation.
3. Increased arousal symptoms. A state of hypervigilance puts the individual constantly on edge, fearful that something terrible is about to happen. There may be an exaggerated startle response, such as when hearing the sound of an airplane overhead or a loud boom at a construction site. Irritability, outbursts of anger, and difficulty concentrating or falling asleep are common, as well. In some cases, known as delayed PTSD, symptoms may not emerge for as long as six months or more after actual exposure. "We may be programmed biologically to prevent onset of symptoms while were mobilized to deal with the crisis itself," says Schleifer. "Or we may not allow ourselves to face these emotional states until some time after weve handled the practicalities of life, like checking on family and handling work details."