Kathryn C. Shafer

The United States has sustained the most brutal terrorist attack in history. The ordinary response to horrific events and atrocities is to banish them from consciousness, and to proceed with life �as normal.� Certain violations of the personal schema are considered too terrible or impossible to imagine: this is the meaning of the word unthinkable. Such tragedies are taboo is discuss or to talk about: this is the meaning of unspeakable.

The recent atrocities regarding the attacks of September 11 have raised many questions regarding the appropriate response personally and professionally to the many emotional, social, and community needs that arise in the time of crisis. Traumatology has become a primary focus of interest in mental health. While the psychological problems that arise from extreme trauma have been documented in literature since Homer, our understanding of this field has varied over the years, and has come into the mainstream only in the past decade.

PRACTICE IMPLICATIONS

For the health care professional, there is a cost to caring. As providers of service to the victims and families impacted by these events , clarification and careful consideration need to be given to our knowledge about trauma, our own attitudes and reactions toward the traumatic event, and our beliefs about treatment of and recovery from such disasters.

To study psychological trauma requires a person to come face to face with human vulnerability and the capacity for evil. This literally means bearing witness to horrible events. When the events are natural disasters or �Acts of God�, those who bear witness sympathize readily with the victim. But when traumatic events are of human design and reach global proportions, witnesses are caught in the crossfire between the helper, the perpetrator, and the victim.

Remaining morally neutral becomes quite a challenge. Therapists cannot totally separate personal life and reactions, upbringing, attitudes, feelings, and beliefs from the therapeutic encounter. One becomes pulled to the universal desire to see, hear, and speak no evil, while the victims appeal to the provider to share the burden of pain.

Listening to the client�s stories of fear, pain, and suffering can challenge our sense of self as separate from our own response to the unthinkable. How clinicians choose to understand trauma will determine how they envision the overall treatment of trauma survivors. The personal events in the life of the therapist can affect the quality and characteristics of therapy. What is compelling to note is how clients, not the personal life experiences of the therapist, are stressful and difficult to handle.

DEFINITIONS

Acute Stress Disorder (ASD): The individual has experienced or witnessed an event that has been threatening to himself or another person. The experience produces a response of the person involving intense fear, helplessness, or horror. ASD is distinguished from PTSD is the emphasis on dissociative symptoms such as: numbing or detachment, reduced awareness of surroundings, derealization, depersonalization, and dissociative amnesia. In ASD, the trauma is reexperienced in thoughts, dreams, flashbacks or a sense of reliving the event, or distress on exposure or reminders of the event.

Critical Incident Stress -A traumatic event or a critical incident is one that causes one to experience unusually strong emotional reactions which have the ability to potentially interfere with the individual�s ability to function, either at the scene, or later. It is quite normal for people to experience emotional aftershocks when they have passed through a horrible event or be subject to ongoing stressors.

Post-Traumatic Stress Disorder (PTSD): The person has experienced an event outside the range of usual human experience that would be markedly distressing to almost anyone: a serious threat to his or her life or physical integrity; serious threat or harm to children, spouse or close relatives or friends; sudden destruction of his home or community; or seeing another person seriously injured or killed.

While commonly associated with returning soldiers, it is very common in victims of rape or child abuse, persons who have survived an earthquake, bombing, or a hurricane, victims of a mugging or severe physical assault, and others who have suffered through some physical hardship. This also include those who have been an eye witness to the traumatic event.

Symptoms typically appear anywhere from directly after the event to six months, but may not appear until one or many years later. The impact and duration of symptoms depends on the person�s coping skills, how horrifying the event was, what types of support the person has, and whether the person was injured. The disorder can increase one�s risk of suicide, substance abuse, clinical depression, and anxiety disorders.

Compassion Fatigue - Secondary Traumatic Stress Disorder (STS): The natural consequence, behaviors, and emotions resulting from knowing about a traumatizing event experienced by another-the stress resulting from helping or wanting to help a traumatized or suffering person. This consequence is defined as the caring that occurs in the therapeutic encounter; one of whom has been traumatized, and the other of whom if affected by the person�s recounting of the traumatic experiences.

COMMON SIGNS AND SYMPTOMS

In response to a specific trauma, the appearance of one or more symptoms may appear immediately after the trauma, in a few hours, a few days, and in some cases, weeks or months later. The signs and symptoms may last a few days, a few weeks, or a few months, depending on the severity of the incident.

With understanding and support of loved ones, stress reactions usually pass quickly. Occasionally the traumatic event is so painful professional help is needed, indicating the event was too powerful to manage by themselves.

The common signs of a stress reaction are Physical, Cognitive, Emotional, Behavioral, and Spiritual.

Physical: Fatigue, chills, thirst, headaches, visual difficulties, vomiting, grinding of the teeth, weakness, dizziness, profuse sweating, chills, rapid heart rate, nausea, muscle tremors, chest pain*, difficulty breathing, elevated blood pressure*, fainting (* indicated need for medical evaluation), etc.

Emotional: Intense anger, anxiety, guilt, grief, denial, severe panic, fear, uncertainty, loss of emotional control, feeling overwhelmed, inappropriate emotional response, irritability, etc.

Cognitive (thoughts and beliefs): blaming someone, confusion, poor attention, can�t focus or concentrate, memory disorientation, lack of or increased awareness of surroundings, poor problem solving, loss of time, disturbed or distorted thinking, nightmares, conversations with the self, etc.

Behavioral: Sudden changes in routine, changes in speech patterns, withdrawal, emotional outbursts, loss or increase in appetite, alcohol and drug use, change in sexual functioning, somatic complaints, failure to keep commitments, etc.

Spiritual: Anger at God, questioning of basic beliefs, withdrawal from place of worship, loss of meaning and purpose, faith practices and rituals seem empty, etc.

TREATMENT

Treatment for post-traumatic stress syndrome can involve a combination of medications, psychotherapy, counseling, nutrition, and spiritual journeys. Psychotropic medication, nutritional supplements, vitamins, and homeopathic remedies can be prescribed, helping the client to process and get much needed validation for feelings. It also eases the isolation from others who have not been impacted by the trauma.

Critical Incident Debriefing (CISD): A debriefing is an organized approach to the management of stress responses following a traumatic or critical incident. It is a specific, focused intervention to assist workers in dealing with the intense emotions that are common at such a time. A debriefing teaches about normal stress responses, specific coping skills for coping with stress, and how to provide support for each other .

Mental Imagery: Sometimes called visualization is the language used by the mind to communicate with the body. This technique has been researched and validated as an essential tool for addressing the core issues involved in healing many medical, emotional, and substance abuse problems. This technique is a directed mental activity that can create healing changes in a very short period of time. Unlike hypnosis which puts you in a relaxed state (trance), imagery enlivens the participant, thus giving the immediate sense of control and awareness. Mental imagery explores the client�s image of the event, allowing them to come to some meaning the event is teaching them, and then correct the image and change habits for 21 days. This new habit creates a shift in thinking. Corrections in beliefs and behaviors restores the person�s sense of meaning and purpose. Mental imagery can be used to convert or correct the traumatic images into healing responses of coping and learning.

Eye Movement Desensitization and Reprocessing (EMDR), Yoga, and Meditation are among the techniques and tools that are used for treating the trauma response .

The following is recommended as guide to help clients cope with the trauma stress reaction:

Things to try for 21 days:

1) Begin each day with mental imagery, prayer, or guided meditation�what lessons are you learning today?;

2) Physical exercise (aerobic, yoga, swim, bike, walking);

3) Keep a journal (write down thoughts, feelings);

4) Alter diet (drink more bottled water, eat well);

5) Have FUN- do things that make you feel good (alone and with others);

6) Reach out�people do care�talking is a healing medicine (its OK to be upset and share);

7) Listen to Music, Art, Nature you enjoy�limit TV, internet media surfing;

8) Create a Treasure Map�a collage of images you love;

9) Live in and for the moment: structure your time, keep busy, make a contribution (volunteer);

10) Exhale, rest, enjoy, be grateful for what is in your life.

SUMMARY

Recovery from trauma is based on the empowerment of the survivor and the creation of new images, beliefs, meanings, habits, and connections. No intervention that takes power away from the survivor can foster recovery. The therapist�s role is intellectual, relational, and educational, and fosters insight and empathetic connection. Allowing clients to �be their own authority� promotes the value of self determination, and the value inherit in self help programs �to thine own self be true.�

Integrity is the capacity to affirm the value of life in the face of death. Recovery includes feeling safe, the ability to recall and remember the event and mourn, and then reconnect with ordinary life. The foundation of relationships is trust, integrity is the basis upon which trust can be restored. The social worker that is trained in the proper use of any of these techniques and practices these in their personal lives can make a tremendous contribution to those impacted by the events of September 11.

For further information on traumatology training, mental imagery, bibliography, or questions, please contact Kathryn Shafer, Ph.D. at kshafer@chuma1.cas.usf.edu or at T+1(813)9746418.