Traumatic Stress/Crisis Intervention Techniques and Tips
Mark Gorkin, MSW, LICSW, "The Stress Doc"
This "how to" guide highlights key questions and concepts, illustrative vignettes and intervention strategies for understanding and responding supportively and therapeutically to individuals grappling with post-traumatic effects after Tuesdays "Day of Terror." The five areas outlined are: 1) Current Bio-Psychosocial Assessment, 2) Historical Factors and Underlying Feelings, 3) Encourage Cognitive Clarification of Emotions and Grief Process, 4) Key Crisis Concepts and 5) Post-Traumatic Coping and Problem Solving.
A. Current Bio-Psychosocial Assessment
1. How is the person functioning now in his or her various roles and relationships? How calm, agitated, lethargic, sad or withdrawn does he or she appear? How appropriate is the overall emotional expressiveness?
2. How does it compare with the person's initial reaction on Sep. 11, 2001?
3. Is the individual fixated on a particular image or memory, e.g., people jumping from the WTC, the building crumbling, being trapped in an inferno, airplane passengers becoming part of a guided missile, etc? When the timing is right, explore the personal significance of these images for the individual.
4. What feelings are most uncomfortable for the person to experience and publicly express?
5. If the individual is a parent, close relative or guardian of a child, encourage the person to:
Remember, to some degree, in such a national catastrophe everyone is grappling with post-traumatic effects. Stress symptoms include:
6. How was the person coping with day-to-day responsibilities and stressors in the days, weeks and months before the day of national trauma? Determine if any previous stress or hazardous events are enhancing the post-traumatic reaction.
Many people are undergoing a loss of impregnability and invincibility with the first massive attack by a foreign enemy, mostly upon civilians, in the Continental United States. Physical and psychological boundaries have been invaded. This can have a significantly disruptive effect not only on a sense of security but on a sense of identity as well.
B. Historical Factors and Underlying Feelings
Key Principle: A natural result of trauma and crisis is that past and, even, deep-seated memories or associations of previous threats, losses or abuses may be stirred up.
1. Is the person having any such recollections?
2. If so, how are they coping with these memories and associations? Are these remembrances themselves confusing, anxiety provoking, enraging or shameful? How effectively did the person cope with any past trauma?
3. The disconcerting association may not be to a specific past event but more to a general feeling, such as being trapped, being out of control, etc.
As an example, one middle-aged male shared how he was still feeling a sense of dis-ease since Tuesday that eluded his cognitive grasp. He saw the parallel with his previous combat experience, connecting the devastating rubble and gray ash around the fallen World Trade Center to the bombed out fields in Vietnam. But the disorientation was still perplexing. I asked J. if it was possible that the subconscious memory being stirred was related to the tragic death of his first wife; she had been trapped in a fire in their home. J. was not home at the time. He now acknowledged not having made this association, and then proceeded to connect the fiery ball and flames from the Twin Towers to his past traumatic loss and helplessness.
C. Encourage Cognitive Clarification of Emotions and Grief Process
1. As mentioned, reinforce the universality of post-traumatic effects, the increased sense of vulnerability, identity confusion, invasion of boundaries, etc.
2. Also, explain the grief process the progressive psychological and behavioral effects, or stages, that individuals tend to experience during times of profound loss and change. While there is a rough sequential order, a person may pass over a stage or make two steps forward and, then, inexplicably fall back to a previous emotional state or stage.
3. Here is a succinct listing of the grief stages. (Email me, firstname.lastname@example.org, for further elaboration of the grief stages.)
Remember, there is no absolute or appropriate time frame for evolving through the grief stages. However, being stuck for a prolonged period of time may be a sign of clinical depression, not simply a lingering post-traumatic effect.
D. Key Crisis Concepts
Definition: Crisis is a heightened state of emotional vulnerability that produces an acute need to regain a sense of psychic control and mind-body equilibrium, that is, to reduce the profound tension and return to some pre-crisis level of adaptation. However, in a crisis state, by definition, ones usual coping mechanisms are not proving sufficient. Here lies the double-edged "danger" and "opportunity" nature of crisis. A heightened vulnerability and sense of threat may challenge the person to move beyond habitual ways of responding. With sufficient support and encouragement a person may allow himself to become more appropriately dependent on others, to reach out for resources and to experiment with new or improved methods of problem solving. Conversely, lacking support or ashamed of displaying neediness, an individual in crisis may regressively withdraw or turn to escapist behavior and other dysfunctional adaptations.
1. Explain that crises are time-limited, that is, usually within one to six weeks, a person will regain a state of mind-body equilibrium. Such acute stress cannot go on indefinitely. However, the ongoing war status, the possibility of more terrorist strikes or counterattacks to American reprisals means many individuals will ebb and flow through gnawing uncertainty and heightened tension if not crisis states.
2. Fortunately, there is a learning curve. Effective coping with an initial crisis sequence often helps prepare an individual for positively responding to and for managing subsequent crises or trauma effects.
E. Post Traumatic Coping and Problem Solving
1. Strive for Realistic Control. Discourage the person from trying to achieve an absolute sense of control of his or her external environment, as this will invariably leave one feeling more at risk. Personally, taking the Amtrak train up to NYC three days after the Twin Towers terrorist attack, while initially a bit unsettling was, ultimately, an anxiety-reducing, confidence building step. The Serenity Prayer is also relevant here:
Grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference.
2. Seek Sources of Support. Encourage individuals to find sources of support when feeling the need for nurturance or reassurance. Are there supportive/nurturing resources available at home, at work, through church, with friends in person, over the phone, on the Internet; is there an online or offline support group available?
3. Take Some Concrete Action Steps. Encourage the person to focus on two or three actions steps that would help the individual feel a small but significant degree of enhanced safety and security. For example, one woman stated that getting a gas mask for her and her cat and stocking up on bottled water would help her feel better. (I declined asking what the cat would think of her plan.)
4. Explore the Need for Counseling. Let people know about the counseling option. If in the next few weeks the person feels stuck in one of the grief stages or the post-traumatic symptoms are not subsiding, professional guidance is indicated. One woman approached me after a recent organizational grief session. Some personal "past issues" had surfaced briefly. She shared having recently met a terrific guy and didnt want her baggage to mess things up. After exploring her workplace mental health insurance coverage she will be calling for an appointment; a classic example of a proactive crisis problem solving response.
5.Communicate Optimism. Reaffirm that post-traumatic stress is natural, that crisis can heighten a persons problem solving capacity, enhance a persons communal circle of support and that the grief process may be a catalyst for potent healing and growth producing energy.
As I once penned: Whether the loss is a key person, a desired position or a powerful illusion each deserves the respect of mourning. The pit in the stomach, the clenched fists and quivering jaw, the anguished sobs prove catalytic in time. In mystical fashion, like Spring upon Winter, the seeds of dissolution bear fruitful renewal.
Some questions and answers to help us all in these traumatic times Practice Safe Stress.
Mark Gorkin, LICSW, "The Stress Doc" , is an internationally recognized speaker and syndicated writer on stress, anger management, reorganizational change, team building and HUMOR! The Doc was recently featured on CBS TV's Newspath segment -- Workplace Violence and in Biography Magazine. He is America Online's "Online Psychohumorist" leading a chat group for AOL/Digital City -- http://www.digitalcity.com/washington/stressdr. Check out his USA Today Online "HotSite" - www.stressdoc.com . For more info, email email@example.com or call 202-232-8662.
(c) Mark Gorkin 2001