by Mark D. Lerner, Ph.D.
Originator, Acute Traumatic Stress Management
Chairman, The National Center for Emotional Wellness
Today, we are preparing for a crisis. We are developing plans and protocols for addressing the wide spectrum of events that can potentially disable us. We are investing countless hours in training and practicing with elaborate equipment and protective gear. Our primary goal is the stabilization of injury and the preservation of life.
During a crisis, physical and safety needs must be the priority. As we have learned, physical trauma can destroy many lives. However, we have also learned that a "hidden trauma," traumatic stress, can ultimately destroy many more. Traumatic stress refers to the emotional, cognitive, behavioral, physiological, and spiritual experience of individuals who are exposed to or witness events that overwhelm their ability to cope.
Traumatic events have many direct and indirect victims. Certainly, individuals who are at the scene of a horrific event may experience traumatic stress. However, we must recognize the impact on so many others, including, but not limited to, victims' families and friends, emergency responders, and healthcare providers. We must also recognize the power of the media in affecting people across our nation and worldwide. We know that individuals who witness traumatic events on television, computers, and social media experience very real traumatic stress reactions.
Traumatic stress disables people, causes disease, precipitates mental disorders, leads to substance abuse, and destroys relationships and families. In organizations, traumatic stress will lead to communication breakdowns, a decrease in morale and group cohesiveness, workplace tension and conflict, excessive absenteeism, employee sabotage, an increase in workers’ compensation and disability claims, employee litigation, an inability to retain effective personnel, and ultimately, a decrease in productivity.
Historically, efforts to address psychological needs arrive in the weeks, months, and years after a traumatic event—after emotional scars have formed and after people are labeled with a traumatic stress disorder. Recently, techniques have been developed to demobilize, defuse, and debrief people after disengagement from a crisis—following a traumatic event.
Notwithstanding, there is little information offering practical strategies to help people during a traumatic experience... a time when people are highly suggestible, impressionable, and vulnerable.
During and in the wake of a crisis, traumatic stress will be the norm. People will experience overwhelming thoughts and feelings and a host of behavioral and physical reactions. Furthermore, we know that events of intentional human design will be particularly difficult for us. Survivors will report feeling stigmatized, marked, and different. A deliberately-caused tragedy undermines our basic trust in humanity.
How can we keep people functioning and mitigate long-term emotional suffering during and in the wake of a crisis?
As caregivers, we must expand our repertoire of helping skills—beyond people's physical and safety needs and raise our level of care.
During traumatic events, horrible sights, sounds, smells, tastes, and physical touch are indelibly etched in our minds. They “playback” our experience as disturbing “movies,” leading to uncomfortable and overwhelming thoughts, feelings, actions, and physical reactions. These stimuli, the "imprint of horror," are the precipitators of debilitating trauma and stress-related disorders.
The fact of the matter is that whatever we are exposed to and focus on during peak emotional experiences in our lives will stay with us forever. Knowing this, we understand how adversity can disable us.
However, in the same way that negative stimuli are etched in our minds during a traumatic experience, a positive, adaptive force can also be. Knowing this, we understand how adversity can propel us to achieve.
Look around you. People who have achieved the most in life often have had a challenging life. Crises bring opportunities. A positive force, early on, can keep people functioning and lessen the likelihood of long-term emotional suffering.
What is this positive, adaptive force?
Years ago, I had the opportunity to ride the night tour in police ambulances, EMS “fly cars,” patrol cars, and with police supervisors in Nassau County, New York, for over a year. I left the sanctuary of my office to understand what happens to people during traumatic experiences. I wanted to learn first-hand what could be done beyond addressing physical and safety needs to address emergent psychological needs. I wanted to understand how we could keep acute problems from becoming chronic stress disorders. My experience led to the development of the Acute Traumatic Stress Management (ATSM) model—a traumatic stress response protocol.
Today, ATSM is being utilized by first responders worldwide and has found its way into other venues such as schools, universities, hospitals, airlines, and diverse corporations. I had the privilege of teaching ATSM to mental health providers for the United Nations Department of Safety & Security, with the US Department of Homeland Security, and with numerous other organizations.
ATSM is a positive, adaptive force. Implementing ATSM and traditional emergency medical intervention offers a comprehensive response strategy to meet the needs of the “whole person.” ATSM offers practical tools for addressing the wide spectrum of traumatic experiences—from mild to the most severe. It is a goal-directed process delivered within a facilitative or helping attitudinal climate. ATSM aims to “jump start” an individual’s coping and problem-solving abilities. It seeks to stabilize acute traumatic stress symptoms and stimulate healthy, adaptive functioning.
In the months and years following a crisis, we know that many people see their doctors, turn to their spiritual leaders, and attend a therapist’s office. At that time, a supportive educational process begins. People tell their stories, expose themselves to painful feelings, and learn all about traumatic stress.
Why do we wait for people to experience months, and sometimes years, of pain and dysfunction?
If what we focus on during a peak emotional experience stays with us forever, we must seize this opportunity!
In the face of a crisis, one does not need an advanced degree in mental health to provide highly effective intervention. The best help is often rendered by people on the front lines, such as peers, who take the time to listen and say the “right things” at the “right time.” However, one must know what to say and do before a traumatic event. Traumatic experiences, by their very nature, compromise our ability to think clearly and often leave us feeling out of control. By having a plan in place and a traumatic stress response protocol, we will be in control, and we will know what we need to do. We will be prepared.
How can we prepare to address the emergent psychological needs of others?
In the same way that a high school biology teacher must be knowledgeable about human anatomy, botany, and zoology, those who strive to help others during a crisis must know how people typically react in the face of a tragedy. They must understand what traumatic stress is, who it affects, and how it affects themselves and others.
Caregivers must learn to recognize the emotional, cognitive, behavioral, physiological, and spiritual reactions that people experience during traumatic exposure. They must also understand that these reactions are normal reactions in the face of an abnormal event. This awareness must come from training before a crisis.
Beyond understanding traumatic stress and knowing how it affects ourselves and others, caregivers must be equipped with practical tools that they can use to help others during traumatic exposure. This is the primary goal of ATSM.
ATSM is a 10-stage model that provides structure during an unstructured period of time—and enables caregivers to “read off the same page.” For example, if I was helping an individual to remain functional by focusing on the facts of a given situation, it would be unfortunate and potentially problematic for another caregiver to walk over and ask, “How are ya feeling?” This situation was described to me by an emergency services police officer in the wake of September 11th. He reported talking with a colleague about extricating bodies when “...some nut in a red jacket came over and asked me how I was feeling... I told him to get the ____ out of here. I wanted to kill the bastard!” There is a “right thing” to say and a “right time” to say it.
The Ten Stages of Acute Traumatic Stress Management™
The following is a brief overview of the 10 Stages of ATSM. The first four stages are of primary importance to EMS personnel, situation management, and emergency medical care. All caregivers can implement the latter stages.
It is important to recognize that the nature of the event, time constraints, and the intensity of individuals’ reactions will vary during traumatic exposure. Consequently, appropriate intervention may not fall neatly into a linear progression of stages. Given the presenting circumstances, you will need to be flexible.
1. Assess for Danger/Safety for Self and Others
Upon arriving at the scene, assess the situation to determine whether there are factors that can compromise your safety or the safety of others. You will be of little help to someone else if you are injured. For example, do not enter an environment that may be compromised by dangerous gasses without the appropriate gear. If possible, remove people from the location, the "inner perimeter," to risk further traumatic exposure.
2. Consider the Mechanism of Injury
Form an initial impression of those impacted by the event. To understand the nature of an individual’s exposure, it is important to assess how the event may have physically impacted the individual—how environmental factors transferred to the person. For example, if people are unconscious, it is important to know what factors or factors led to their loss of consciousness. It is also important to consider the perceptual experiences of victims. For example, directly observing people mutilated after a suicide bomber attacks a crowded bus will have a powerful impact on those who observe the incident. Similarly, the sounds of people screaming in the wake of such an attack will etch a lasting impression in the minds of all who arrive at the scene to help. Ask yourself whether it is necessary for you to expose yourself to the inner perimeter. Direct exposure to a gruesome scene can compromise your ability to address emergent psychological needs.
3. Evaluate the Level of Responsiveness
Determining if an individual is alert and responsive to verbal stimuli is important. Does he feel pain? Is he aware of what has occurred or what is presently occurring? Is he being influenced by a substance? During a traumatic event, the individual may be experiencing “emotional” shock. Therefore, symptomatology may mimic acute medical conditions (i.e., rapid changes in respiration, pulse, blood pressure, etc.). Recognize that a psychological state of shock may be adaptive in preventing the individual from experiencing the full impact of the event too quickly. For example, in the case of a terrorist attack in a subway, many people will emerge on the street from the stairways and stare blankly while first responders attempt to engage them in conversation. This lack of responsiveness may not be the effect of a physical agent but the effect of acute traumatic stress. This reaction is not unusual. During traumatic events, people can experience a wide range of emotional reactivity.
4. Address Medical Needs
Emergency responders are trained to assess the ABCs (i.e., airway, breathing, and circulation). They understand that if a man is not breathing, little else can be done to help him. Emergency responders also understand the importance of addressing significant symptomatology (e.g., severe chest pains) and knowing about existing medical conditions (e.g., diabetes). They have also been trained to know the injuries that may threaten life (e.g., internal bleeding). Medical intervention must be provided by trained emergency medical personnel. Consider the potential danger of moving a young woman found outside a derailed train. Despite the best intentions of good Samaritans, the woman may have suffered a back injury, and movement could cause permanent injury to her spinal cord. Life-threatening illness and injury must be addressed before psychological needs.
5. Observe and Identify
Observe and identify those who have been exposed to the event. Very often, these individuals will not be the direct victims. They may be secondary or hidden victims. Witnessing or even being exposed to another individual who has faced traumatic exposure can cause traumatic stress. As you observe and identify who has been exposed to the event (i.e., directly and/or indirectly), begin to observe and identify who is evidencing signs of traumatic stress. An awareness of the emotional, cognitive, behavioral, and physiological reactions suggestive of traumatic stress is important. Carefully look around you. Anyone, including yourself, may be a direct or hidden victim. This observation and identification stage of ATSM may be viewed as the first traumatic stress-specific stage.
6. Connect with the Individual
During a crisis, introduce yourself and let people know your role (e.g., “My name is Ron; I’m a paramedic and firefighter with the Melton Fire Department.”). If the individual is not physically injured and has been cleared by emergency medical personnel, move him away to prevent further traumatic exposure. Begin to develop rapport by trying to understand and appreciate his situation. A simple question such as, “How are you doing?” may be used to engage the individual. Use appropriate non-verbal communication (e.g., eye contact, body turned toward him, a gentle touch, etc.). Recognize that during a traumatic event, individual reactions may range from a detached, withdrawn reaction to the most intense displays of emotion (e.g., uncontrollable crying, screaming, panic, anger, fear, etc.). During a crisis, you may find yourself working to connect with small groups of individuals.
7. Ground the Individual
When you have established a connection with someone (or people) exposed to a traumatic event (e.g., eye contact, body turned toward you, dialogue directed at you, etc.), you can initiate this grounding stage. Begin by acknowledging the traumatic event at a factual level. Attempt to orient the person by discussing the facts surrounding the event. Address the circumstances of the event at a cognitive or thinking level. While we do not discourage the expression of emotion, we attempt to focus on the facts in the here and now and help the individual to know the reality of the situation. His “reality” may often be seriously clouded due to the nature of the event. Remember, traumatic events overwhelm an individual’s coping and problem-solving abilities. Assure the individual that he is now safe if he is. He may still be “playing the recording” of the event repeatedly in his mind. By reviewing facts, you may disrupt “negative cognitive rehearsal” (i.e., repetitive, potentially destructive thinking), help the individual to function, and help him to deal with the circumstances at hand.
It is important to “place the individual in the situation.” Encourage him to “tell his story” and describe where he was, what he saw, what it sounded like, what it smelled like, what he did, and how his body responded. Encourage the individual to discuss his behavioral and physiological response to the event —rather than “how it felt.”
8. Provide Support
Factual discussion and the realization of a traumatic event, particularly when the event is unfolding, may likely stimulate thoughts and feelings. This is often the time when individuals who are exposed to trauma need the most support. However, it is also when many people look the other way. Many individuals feel unprepared to handle others’ painful thoughts and feelings. Oftentimes, they fear that they will “open a can of worms” or “say the wrong thing.” Generally, a reasonable attempt to help others is preferable to avoidance.
It is important to establish and maintain a facilitative or helping attitudinal climate. Here, you attempt to understand and respect the uniqueness of the individual—the thoughts and feelings he is experiencing. You strive to “give back” a sense of control that has been “taken from” him by his exposure to the event. Support him and allow him to think and feel. Many people will experience an overwhelming sense of aloneness and withdraw into their world in the face of a traumatic event. You should make a respectful effort to “enter that world” and help the individual know that he is not alone and that his unique perception of his experience is important. Do not attempt to talk a person out of a feeling (e.g., “Don’t be scared, everything is fine.”). Communicate an appreciation of the other person’s experience. Attempt to understand the feelings behind his words (or perhaps actions) and convey that understanding to him. Developing these empathic listening skills is an area that should be addressed before a crisis.
9. Normalize the Response
While you are attempting to support an individual by allowing him to express his thoughts and feelings, begin to normalize his reactions. This is an important component when intervening with people who have been exposed to trauma and who may be feeling very alone. Experiencing a cascade of emotions, or perhaps a lack of emotional reactivity, may cause him to feel as if he is “losing it” and, perhaps, “going crazy.” Normalizing and validating an individual’s experience will help him to know that he is a normal person trying to deal with an abnormal event.
You must not become sympathetic and overidentify with the situation with statements such as, “I know what it feels like... When I was....” Rather, you should attempt to normalize and validate the individual’s experience with statements like, “I see this is overwhelming for you right now... seeing a friend badly injured would be very hard for anyone to handle.”
An important component of the normalization process is to begin educating the individual by helping him understand how people typically respond to traumatic events. Discuss the emotional, cognitive, behavioral, physiological, and spiritual reactions people frequently experience. Remember, these reactions do not necessarily represent an unhealthy or maladaptive response. Rather, they may be viewed as normal responses to an abnormal event.
10. Prepare for the Future
The final phase of the ATSM process aims to prepare the individual for what lies ahead. It is helpful to 1) review the nature of the traumatic event, 2) bring the person to the present, and 3) describe likely events in the future. The educational process initiated during the previous Normalization Stage should continue during this final stage of ATSM.
Be careful not to tell someone as you near the end of your intervention that “everything is going to be okay” or that “everything is going to work out.” These “band-aid” statements may only minimize an individual’s feelings and cause him to feel misunderstood. Instead, focus on the facilitative attitudinal climate that you have established—“I’m glad that I had the opportunity to be here with you during such a difficult time.”
ATSM should not be viewed as counseling or psychotherapy, and it is not a "crisis response plan." Rather, it provides a road map that can guide individuals through times of crisis, keep people functioning, and mitigate long-term emotional suffering.
The potential for a crisis is on all of our minds. To gain a sense of control, we are taking important steps to prepare and equip emergency responders to address survivors' physical and safety needs. While the stabilization of injury and the preservation of life must always be the priority, we must not overlook the hidden trauma—traumatic stress. By preparing to address emergent psychological needs during, and in the wake of, a traumatic experience, we can keep people functioning and potentially prevent acute traumatic stress reactions from becoming chronic and debilitating stress disorders.