ALBERT R. ROBERTS
Mental health professionals woke up on September 12, 2001, to find them- selves, for the most part, ill-equipped to deal with the many thousands of persons encountering psychological trauma and acute crisis episodes as a result of the horrendous murder of 2,973 people on that fateful day of Sep- tember 11. Although those in the health professions were anxious to help the thousands of survivors who were experiencing shock, fear, somatic stress, trauma, anxiety, and grief in varying degrees, few if any comprehen- sive models for assessment, crisis intervention, or trauma treatment were in current practice. Moreover, we have now come to understand that the ongo- ing intense stress and fear of a nation living under the threat of likely addi- tional terrorist attacks makes the need for crisis-oriented intervention plans imperative for all communities across the nation.
This chapter presents a conceptual three-stage framework and interven- tion model that should be useful in helping mental health professionals pro- vide acute crisis and trauma treatment services. The assessment, crisis in- tervention, and trauma treatment model (ACT) may be thought of as a sequential set of assessments and intervention strategies. This model inte- grates various assessment and triage protocols with three primary crisis- oriented intervention strategies: the seven-stage crisis intervention model, critical incident stress management (CISM), and the 10-step acute traumatic stress management protocol. In addition, this chapter introduces and briefly highlights the other six practical and empirically based papers that appear
in this section of the book, whose focus is on how mental health disaster management skills and crisis-oriented intervention strategies were imple- mented in the aftermath of the September 11, 2001, terroristic mass disaster at the World Trade Center and the Pentagon.
OVERVIEW
This section of the third edition of the Crisis Intervention Handbook was prepared to provide administrators, clinicians, crisis counselors, trainers, re- searchers, and mental health consultants with the latest theories and best crisis intervention strategies and trauma treatment practices currently avail- able. To assist all clinicians whose clients may be in a precrisis or crisis state, 10 experts in crisis intervention or trauma treatment were invited to write or cowrite chapters for this section of the Handbook.
As has been widely reported, the horrific events of September 11, 2001, resulted in the loss of approximately 2,973 lives in the World Trade Center; this includes 343 Fire Department of New York fatalities, 37 Port Authority police, 23 members of the New York Police Department, 125 persons in the Pentagon, and over 300 on four hijacked airliners (National Commission on Terrorist Attacks upon the United States, 2004, p. 311). The suddenness and extreme severity of the terrorist attack, combined with the fear of additional terrorist actions that may lie ahead, serves as a wake-up call for all mental health professionals as we expand and coordinate interagency crisis response teams, crisis intervention programs, and trauma treatment resources. This chapter presents an overarching theoretical framework and intervention model that may be useful in helping mental health professionals provide crisis and trauma services.
This overview chapter is built on the premise that it is useful for counse- lors, psychologists, nurses, and social workers to have a conceptual frame- work, also known as a planning and intervention model, to improve the delivery of services for persons in a precrisis or traumatic state. The second premise is that mental health professionals need an organizing framework to determine sequentially which assessment and intervention strategies to use first, second, and third. Thus, I developed a three-part conceptual frame- work as a foundation model to initiate, implement, evaluate, and modify a well-coordinated crisis intervention and trauma treatment program in the aftermath of the September 11 catastrophes.
Terrorist acts of mass destruction are sudden, unexpected, dangerous, and life-threatening, affecting large groups of people and overwhelming to hu- man adaptation and our basic coping skills. Unfortunately, as long as there are terrorists, senseless murders of innocent persons and destruction of prop- erty are likely to continue. Therefore, it is imperative that all emergency services personnel and crisis workers be trained to respond immediately and
appropriately. In the aftermath of catastrophic terrorist tragedies, people experience different symptoms, including surprise, shock, denial, numbness, fear, anger, adrenal surges, caring for others, attachment and bonding, isola- tion, loneliness, arousal, attentiveness, vigilance, irritability, sadness, and ex- haustion. Many individuals, particularly those not living within 50 miles of the disaster sites and not losing a loved one, will generally adapt relatively quickly and return to their regular work schedules and routines of daily living. However, in the deep recesses of their minds is the knowledge that they may be the next victims. But for many of the survivors and those indi- viduals living close to the disaster site and without personal resources and social supports, acute stress, crisis, and trauma reactions could be prevalent. In view of the most horrific and barbaric mass murders in U.S. history it has become critically important for all informed citizens to know the difference between acute stress, normal grief, acute crisis episodes, trauma reactions, and Posttraumatic Stress Disorder (PTSD). This overview chapter and the chapters by George Everly, Jeff Lating, and Jeff Mitchell; Vincent Henry; Joshua Miller; Sophia Dziegielewski and Kristy Sumner; William Reid and Gary Behrmann; and Rachel Kaul and Victor Welzantt examine the different definitions of acute stress, crisis, and psychological trauma as well as disaster mental health, critical incident stress management, and crisis intervention strategies.
Vincent Henry (currently a professor of criminal justice) was a first re- sponder to the World Trade Center attacks and the rescue and recovery activities. In the weeks directly following the September 11 attacks and near the end of his 21-year career as an NYPD police officer and detective, he served as the commanding officer of a sniper unit on top of St. Vincent’s Hospital in lower Manhattan protecting injured survivors and watching for terrorists. His chapter provides an overview of specific types of weapons of mass destruction and the type of response protocols utilized by police, fire, emergency medical services, and disaster mental health coalitions. He exam- ines some of the psychological crises and traumas experienced by first re- sponders to terrorist attacks and describes a successful clinical service con- sisting of more than 300 specially trained clinical volunteers, the New York Disaster Counseling Coalition. This counseling and psychotherapy group provides confidential and free treatment services to all first responders and their family members who request services. The volunteer clinicians have offices throughout the New York Metropolitan area, northern New Jersey, southern Connecticut, and parts of Pennsylvania.
Professors Mitchell and Everly are internationally known as the founders of the group crisis intervention model CISM, which includes the group crisis intervention protocol critical incident stress debriefing (CISD). It was cer- tainly timely for them to update their chapter for this edition and take into account the adverse impact of mass disaster terrorism as the leading cause of posttraumatic distress. George Everly, Jeffrey Mitchell, and Jeffrey Lating
aptly focus on how to implement CISD as a screening, triage, group discus- sion, and psychoeducational method. The goal of this intervention is to re- duce acute distress and acute crisis episodes. The authors then focus on the 10 core elements of CISM as a multicomponent crisis intervention system and its recent applications to mass disasters, military venues, and terrorist- related situations. They also discuss a recent meta-analysis that demon- strated the effectiveness of crisis intervention with medical and surgical patients.
The poignant chapter by Linda Mills depicts the experiences and reactions of her 5-year-old son, through her eyes, when they were uprooted from their apartment and his school, which were in close proximity to the World Trade Center site. Professor Mills’s chapter is compelling and heart-wrenching be- cause she writes about the horror that she and her family experienced and its impact on her young child.
Rachel Kaul, a former emergency room social worker and American Red Cross disaster mental health responder, describes the disaster mental health strategies applied to the various populations affected by the Pentagon attack. Following her work as a disaster mental health responder, she worked as the coordinator of Trauma and Emergency Services at the Pentagon employee assistant program, assisting workers and family members with trauma re- duction and recovery for over two years. Now, as the Maryland coordinator of emergency services, and in collaboration with Dr. Victor Welzant of the International Critical Incident Stress Foundation and Sheppard Pratt Health Services, she underscores the critical need for implementing crisis manage- ment and disaster mental health strategies as well as self-care techniques among all disaster mental health responders and for employing best practice approaches in the process.
Sophia Dziegielewski and Kristy Sumner’s timely chapter focuses on the nature and extent of bioterrorism threats in the United States and an applica- tion of the seven-stage crisis intervention model to reduce fear, stress, crisis, and trauma among the survivors of bioterrorist attacks. Joshua Miller pro- vides a thorough description of the emergency mental health system re- sponses that he witnessed at the World Trade Center and the responses of the survivors of the tragedy. Professor Miller was inspired by the resiliency of the survivors, their capacity to use this tragedy to reevaluate their lives, cherish their relationships, and strengthen their social bonds with family, friends, and colleagues. This section ends with a chapter by Joseph McBride and Eric Johnson that clarifies the differences between grief counseling and crisis intervention and then examines the ways crisis intervention strategies have been effectively applied with survivors of mass terrorist murders.
According to Lenore Terr (1994), a professor of psychiatry, there are two types of trauma among children. Type I refers to child victims who have experienced a single traumatic event, such as the 26 children from Chow-
chilla, California, who were kidnapped in 1976 and buried alive in their school bus for almost 27 hours. Type II trauma refers to child victims who have experienced multiple traumatic events such as ongoing incest or child abuse. Research has demonstrated that most children experiencing a single isolated traumatic event had detailed memories of the event but no dissocia- tion, personality disorders, or memory loss. In sharp contrast, child survivors experiencing multiple or repetitious incest and/or child sexual abuse trauma (Type II trauma) exhibited dissociative disorders (also known as multiple personality disorders) or Borderline Personality Disorder (BPD), recurring trance-like states, depression, suicidal ideation and/or suicide attempts, sleep disturbances, and, to a lesser degree, self-mutilation and PTSD (Terr, 1994; Valentine, 2000). The age of the incest victim frequently mediates the coping strategies of adult survivors who face crisis and trauma. Research has indi- cated that when the childhood incest was prolonged and severe, an adult diagnosis of BPD, Dissociative Disorder, Panic Disorder, alcohol abuse or dependency, and/or PTSD occurs with greater frequency (Valentine, 2000). The exception to the low incidence of long-lasting mental disorders among victims of a Type I trauma is an extremely horrific single traumatic occur- rence which is marked by multiple homicides and includes dehumanizing sights (e.g. dismembered bodies), piercing sounds, and strong odors (fire and smoke). The long-lasting psychological impact of the September 11 mass disasters will not be known for at least another decade, at which time pro- spective and retrospective longitudinal research studies will be completed.
The American Academy of Experts in Traumatic Stress (ATSM) is a mul- tidisciplinary network of professionals dedicated to formulating and extend- ing the use of traumatic stress reduction protocols with emergency respond- ers (e.g., police, fire, EMS, nurses, disaster response personnel, psychologists, social workers, funeral directors, and clergy). Dr. Mark D. Lerner, a clinical psychologist and president of ATSM, and Dr. Raymond D. Shelton, director of Emergency Medical Training at the Nassau County (New Jersey) Police Training Academy and director of professional development for ATSM, pro- vide the following guidance for addressing psychological trauma quickly during traumatic events:
All crisis intervention and trauma treatment specialists are in agreement that before intervening, a full assessment of the situation and the individ- ual must take place. By reaching people early, during traumatic exposure, we may ultimately prevent acute traumatic stress reactions from becoming chronic stress disorders. The first three steps of Acute Traumatic Stress Management (ATSM) are: (1) assess for danger/safety for self and others; (2) consider the type and extent of property damage and/or physical injury and the way the injury was sustained (e.g., a terroristic explosion); and (3) evaluate the level of responsiveness—is the individual alert, in pain, aware
of what has occurred, or in emotional shock or under the influence of drugs? (Lerner & Shelton, 2001, pp. 31–32)
Personal impact in the aftermath of potentially stressful and crisis-produc- ing events can be measured by:
• Spatial dimensions: The closer the person is to the center of the tragedy, the greater the stress. Similarly, the closer the person’s relationship is to the homicide victim, the greater the likelihood of entering into a crisis state.
• Subjective crime clock: The greater the duration (estimated length of time exposed and estimated length of exposure to sensory experiences, e.g., an odor of gasoline combined with the smell of a fire) that an indi- vidual is affected by the community disaster, violent crime, or other tragedy, the greater the stress.
• Reoccurrence (perceived): The greater the perceived likelihood that the tragedy will happen again, the greater the likelihood of intense fears, which contribute to an active crisis state on the part of the survivor (Young, 1995).