(Dr Bill Webster is often asked to provide “grief counseling” when a crisis such as a tragic accident, suicide, or traumatic event occurs. In this extended article he discusses the concept of crisis intervention, suggesting helpful strategies that schools, communities, businesses and organizations can do before, during and after the event when crisis comes.)
The age of mass media has meant that the average citizen is exposed through television to many national and personal tragedies. We were horrified spectators of the terrorist attacks of September 11th as they happened, and have witnessed shootings, bombings, and endless national and personal tragedies from our arm chairs, with the ongoing aftermath of such events through follow up reporting and analysis.
I am not sure if there are more tragedies in our world, or if we are just being made more aware of them.
The one comment that is repeated in almost every situation is “We didn’t think something like this could happen here.” While we are all painfully aware that tragedies occur, we insulate ourselves by assuming that they happen to “other people”, or “over there”.
So when tragedy does strike, there is often a sense of disbelief. Many of the assumptions that we held about “things like this won’t happen to me” can be shattered, causing a sense of insecurity and anxiety that may surprise us. How do we provide effective tools and resources to enable people who find themselves thrust into such situations cope with crisis.
Many events are considered to be a crisis.
Vehicular Accidents: a friend, colleague, teacher or family member is killed in a vehicle on land, sea or air. Often such events are complicated by multiple deaths or injuries, causing a bereavement overload.
Violence: a homicide, a school shooting, beatings, suicide, and others.
Sexual Trauma: rape or abuse
National Events: the death of national figures (Princess Diana, President Kennedy); assassinations; the 9/11 attacks; bombings; mass murders, plane or train crash.
Natural Disasters: tornado, hurricane, flood, earthquake, drought
Personal Disasters: house fire, robbery, bankruptcy, financial reversal, accidents, ill health. But for some, the crisis may not seem so dramatic. Events like children leaving home, retirement, or other stages or challenges of life can create crisis.
Here is a vitally important distinction:
A crisis is not an event; a crisis is a REACTION to any event.
All the above events involve many losses, but they are not crises in themselves. It is an individual’s or community’s reaction to what is lost through these situations that constitute the crisis. This may explain why, in one and the same situation, some people seem to cope well and handle things, while others appear to fall apart.
In other words, it is not the event itself that determines whether this is a crisis. It is the person’s perception that defines an event to be a critical incident. A crisis occurs when a person’s coping mechanisms are overwhelmed. One person may handle a traumatic situation very well, and not be in crisis. Another individual may be in a similar or even lesser situation and not cope, thus going into a full blown crisis. The reaction may be physical and/or it may emotional. It can be immediate or it may be delayed.
The only way we can determine whether the person is coping or is in crisis is to find out from them. They need to tell us. We then need to understand the reasons why this person has been overwhelmed by the event and help to restore and rebuild the coping mechanisms by which the crisis can be resolved.
The most often used technique in crisis situations is Critical Incident Stress Debriefing (CISD) pioneered by Jeffrey T. Mitchell. To be accurate, it offers crisis intervention rather than grief counseling, and this is an important distinction. Crisis intervention involves the undertaking of activities to reduce the anxiety or tension related to the event, assisting the individuals to resolve the immediate crisis and create a safe place for them to begin to explore the deeper issues. It often occurs one on one, but in a true CISD model, is done in a group.
Mitchell has outlined 7 steps or phases to facilitate the debriefing process.
- Introduction: The facilitator establishes ground rules such as confidentiality and outlines the process.
- Fact Phase: Participants are asked to describe the facts about what happened. Open ended questions such as “What did you see?” are asked. The primary objective is to get participants to focus on the facts rather than on their reactions.
- Thought Phase: Explores the thoughts the individuals had during the event.
- Reaction Phase: Since one of the goals is to help participants avoid stress related illnesses or reactions, it is important to talk about emotions. By asking questions like “What was the most difficult part of this for you” the individual has opportunity to express feelings of sadness, helplessness, etc.
- Symptom phase: the group facilitator helps participants discuss the signs and symptoms of stress. The goal of crisis intervention is to provide stabilization for the individuals, not offer counseling. But these symptoms help the facilitator identify those who may need more intensive ongoing counseling later.
- Teaching Phase: A crisis is a normal reaction to an abnormal event. Individuals need to learn that what they are experiencing and feeling is natural, but also temporary. This fact alone reduces anxiety. This is an abnormal situation so people need help to accommodate it, and that needs to be validated.
- Re-entry phase: Here constructive coping mechanisms can be reinforced. What might be expected in days ahead can be outlined, or questions answered. Handouts or booklets can be distributed to give more information or suggestion.
CISD represents one approach to traumatic loss. It is however, not a counseling technique per se, and, indeed, is not without some criticism as to its effectiveness. I have found when using these techniques in specific situations with professionals, they work astonishingly well, but concede that it is not a technique that would necessarily be used in every situation of crisis with everyone.
When people are in crisis, which we have defined as a reaction to any traumatic event, they commonly suffer from a problem called Post Traumatic Stress Disorder (PTSD). Recent studies estimate that 10% of the total population suffers from PTSD, and that 25% of those exposed to a critical or traumatic incident manifest the symptoms. These percentages are particularly high (65–92%) with those who experience violence or assault.
While the title “PTSD” is fairly recent, the symptoms of post traumatic stress are not new. Samuel Pepys wrote in his diary of the panic and distress of those who survived the great fire of London in 1666: “A most horrid, malicious, blood fire. … So great was our fear … it was enough to put us out of our wits.” For weeks after the fire, Pepys, along with many other survivors, suffered from insomnia, anger and depression, all common symptoms of PTSD.
Soldiers came home from World War 2 suffering what was identified then as “shell shock”. Subsequent studies have shown that this was PTSD, which the research indicated was not connected to pre-existing mental health issues or family stability, as had previously been assumed. Rather, the critical variable was the degree of exposure to combat, and the amount of stress to which the soldier had been exposed.
In the “Diagnostic and Statistical Manual of Mental Disorders” (DSM IV), the official handbook of psychiatric problems, the diagnosis of PTSD depends on meeting the following criteria:
A: You have been exposed to a traumatic event involving actual or threatened death or injury, during which you responded with panic, horror, and feelings of helplessness.
B: You re-experience the trauma in the form of dreams, flashbacks intrusive memories, or unrest at being in situations that remind you of the original trauma.
C: You show evidence of avoidance behavior, such as a numbing of the emotions, and reduced interest in others and the outside world.
D: You experience physiological arousal, as evidenced by insomnia, agitation, irritability, or outbursts of anger.
E: The symptoms in B, C, and D persist for at least one month.
F: The symptoms have significantly affected your social or vocational abilities or other important areas of your life.
PTSD can either be acute or delayed-onset. Acute PTSD occurs within 6 months of the traumatic event. Delayed-onset PTSD usually means the symptoms occur more than 6 months after the traumatic event, and can even be many years after the actual incident. This gives further weight to the contention that the crisis is not the event but rather the reaction to the event.
Post traumatic stress is an entirely normal reaction to an abnormal amount of pressure. Many people exposed to traumatic situations try to be strong. Not to cope feels like weakness, which many of us find the most difficult thing of all. Yet, in a brief moment, one’s emotions, identity, and sense of the world as an orderly, secure place can be severely shaken if not shattered. Trauma truly is an affliction of the powerless. So much so that a traumatized person might think, ‘I just can’t get over it.”
The key to critical stress interventions is to try as quickly as possible to re-establish those feelings of safety and security. For it is only in this context that the traumatized individual will be able to explore the cognitive and emotional reactions to what has occurred and be able to rebuild by taking back control over the things that can be managed.
Carl Jung used the metaphor of a growing tree to describe our life journey. We are like a tree, naturally growing taller and fuller as our roots spread deeper and wider into the ground. When these roots hit a rock or some other obstacle, do they push it away, or try to crack it? Or, alternatively, do the roots just stop growing from there? No. The roots simply grow around the obstruction and then keep going. The obstacle may interrupt or slow the tree’s progress for a while, but it will not stop it from growing. In fact, sometimes these very stones can support and strengthen the root structure of a tree.
The application is obvious. Traumatic events can hamper our personal growth, and may never be completely eliminated. But in the same way that roots surround the rock and make it a part of the tree, so we need to find ways to move past the barrier and grow beyond the trauma.
I have found that a Four Stage model for the healing process works well. Like any model, we must be careful not to apply it too literally to every situation, but it provides a useful framework upon which to build:
- Re-establishment of Safety: The Stabilization Stage
- Reconstructing the Trauma: The Cognitive Stage
- Feeling the Feelings associated with the Trauma: The Emotional Stage
- Empowerment: the Mastery Stage, in which the person finds meaning in the trauma and develops a survivor, rather than a victim, mentality.
What are the grief counselors or crisis management people going to do? How can these fore-mentioned stages be integrated practically in a community in crisis.
Two kinds of behavior generally arise in response to the twin factors of loss and loss threat in any crisis or disaster situation. First there is reactive behavior, referring to the way people “automatically respond” immediately following the news, which can occur either from direct verbal communication or personal observation of the circumstances that have caused the loss or the loss threat. Second, there is an adjustive behavior, referring to the way people accommodate a loss or loss threat over the long haul. This is different from reactive behavior inasmuch as it occurs over a protracted period of time. Adjustment refers to coping with the conditions of any given situation, coming to terms with them, and modifying one’s personal behavior to suit the circumstances.
Every circumstance and every reaction is unique. Every individual responds differently to crisis, and indeed it is the reaction rather than the event that provokes the crisis. Thus, there is no set formula, no “10 easy steps to crisis intervention” that anyone can give. Nonetheless, there is a recognized pattern that often occurs, readily identifiable in 4 stages.
- Re-establishment of Safety: The Stabilization Stage
The central task of this first stage is the establishment of safety
Trauma robs its victims of a sense of power and control. A crisis or traumatic event often increases anxiety because of the sense of helplessness and powerlessness they produce. Realizing that one’s control and power are useless, and that one is unable to undo what has happened, or recover what has been lost, often attacks one’s sense of competence. The intensity and experience of that helplessness profoundly affects the person and is a main factor in the traumatic imprinting of the impact. For many, helplessness may be most difficult to integrate and the most distressing aspect of the entire trauma.
Thus, any intervention must begin by reassuring the individual that they will be OK. Establishing safety begins by focusing on control of the body and the self, before moving outward to control of the environment. It is an expression of this need that often motivates people to “want to stay home” and not venture outside. Suddenly their world has become an unsafe place, and this needs to be understood and addressed before anything else can be achieved.
Far too many counselors rush in and get people to express feelings or relive the story before they feel safe enough to do so, resulting in a much deeper crisis and even more trauma. We dare not bypass the requirements of the establishment of safety and rush headlong into exploring the traumatic aspects of what has happened.
2. Reconstructing the Trauma: The Cognitive Stage
The second stage is more cognitive, by which I mean “capable of knowledge”. It is with a sense of safety established that the person feels able to begin to tell the story of what happened. Yet in many cases, this stage is still just a repetition of facts. It may not reveal the storyteller’s feelings or interpretation of events. The traumatic memory is often described as a series of still snapshots, rather than a movie with words and music.
The reconstruction of the trauma story begins with the person’s life before the circumstances that led up to the event. This enables the survivor to create a context within which the meaning of the trauma can be understood. In other words, when confronted by a traumatic incident, someone can tend to see only that one snapshot, and interpret the whole of life according to that event. The cognitive aspect allows the person to discern that there are other images, experiences and events which are not as horrible, and so the process begins of seeing the snapshot of the crisis in the context of the total picture album of life. Yes, this is a horrible thing you have seen and witnessed, but this is not the only picture. There are other images which can help soften the difficult one.
In this stage is also created the opportunity to provide education as to what the person can expect and what the effects of trauma and grief can be. This legitimizes the process that the person is going through and lets them know that their emotions and reactions, while complex and difficult, are in fact natural.
3. Feeling the Feelings associated with the Trauma: The Emotional Stage
The telling of the story inevitably plunges the person into profound grief. Earlier in the series, I described some of the emotions that can be experienced. Frequently, people resist mourning, not only out of fear, but also out of pride. We want people to think we can “handle it” and surrendering to emotions is often difficult.
The purpose of having people repeat the trauma story is that eventually it no longer arouses quite such intense feeling. Retelling the story makes the incident a part of the survivor’s experience, but only one part of it. The story is a memory and like other memories, begins to lose its vividness. It may even occur to the survivor that this crisis is not the most important, or even the most interesting, part of life.
Admittedly, the reconstruction of trauma is never completed. New conflicts or challenges may trigger or reawaken the trauma. The third stage is accomplished when the person reclaims their own history and feels a renewed hope and energy to engage life.
4. Empowerment: the Mastery Stage.
The violation of one’s assumptive world involving the shattering of global or specific assumptions is a major aspect of mourning. The old self has been destroyed, for we are forever changed by such events. Now a new self must be developed. Having come to terms with the traumatic past, the survivor faces creating a new future.
It is here the person finds meaning in the trauma and develops a survivor, rather than a victim, mentality. Coping with victimization is a process that involves rebuilding the assumptive world and incorporating into one’s own identity our experiences as a victim. To the extent that old assumptions have been held with extreme confidences and have not been challenged previously, they are more likely to be shattered with devastating results. The adjustment process often centers on :
a) a search for meaning in the experience.
b) an attempt to gain mastery over the event in particular and over one’s life more generally
c) an effort to restore self-esteem through enhancing evaluations.
Thus a major goal in the treatment of post-traumatic responses will be the empowerment of the survivor after the trauma as well as throughout the remainder of their life. It is the subsequent gaining of some sense of control that will mitigate to some degree the feelings of helplessness.
In conclusion, whether a school, corporation or community, we need to be prepared for any eventuality. The following goes without saying:
The worst time to prepare for a crisis is when one occurs.
When a crisis occurs, we often hear that “grief counselors have been brought in”. Although I am a grief counselor, I am not convinced this is the best method. People in crisis want to talk to someone they know. School children would rather speak to a teacher, or a school secretary, than some highly qualified stranger who has been parachuted in. Could programs of education be offered in schools and communities that would help prepare specific individuals to step in when the crisis occurs.
One other point. Support must go on long after the “crisis” seems to fade. I recall my sense of surprise when one TV announcer, on the first anniversary of September 11th said, ‘In spite of all the grief counseling, people here still seem to be in shock.” Well … duh!!! There is no “quick fix” here, in spite of effective techniques and interventions that can be applied.
If you examine the responses after September 11th, they had monthly memorials and it is my opinion that the full impact of that horrendous day actually finally hit home one year later, as they commemorated the first anniversary of the event. One can only hope that the support of those who were traumatized by that event lasted at least that length of time, and hopefully even beyond.
In a world where we know that tragedies occur, organizations should have policies, procedures and personnel in place to deal with we do when “This couldn’t happen here”, does happen.