Joel Beam/DVIDS

Trying to grasp everything that is going on around oneself during a traumatic event can take its toll on the soul. Military and civilian first responders responsible for managing chaos on a daily basis can push their team to the limit.

The multitasking you must perform as you make timely decisions, while providing some direction to others, is continuous. Providing for the well-being and care of your subordinates doesn’t stop after an event—it begins.

How many have received the check the box treatment? Responders go to class, read the slides, watch a video and sign here. Sound familiar? Are they OK now? Maybe some responders are, but not everyone deals with the effects a catastrophic event, war or a life-threatening situation the same way. Recovery can be a longer process for some to achieve than others. Not all practitioners require the same amount of care. Given enough trauma, any individual could develop what is called post-traumatic stress disorder (PTSD). Senior managers owe proper care to their subordinates (as well as themselves) in promoting both awareness and obtaining quality and continuous treatment for this affliction.

Whether it’s an ER nurse at the Combat Surgical Hospital (CSH) in downtown Baghdad or at Bellevue Hospital in New York, the demand of one’s expertise is needed at that very second to perform to the best of their ability to save a life. The soldier in the combat zone often states, “That mortar round was kind of close,” but they keep on coming. As the smoke thickens with the threat of being burned by the unbearable heat, the firemen continue to evacuate victims. The police officer, while trying to apprehend a suspect, is wrestled to the edge of an oncoming subway train and manages to make the arrest.

When should one decompress these types of events? For most, it’s either a shrug off the shoulder or run to the local bar. The best piece of advice is to talk about events with a trustful person. Some of them can be co-workers who are experiencing the same situations or others that have gone through similar actions. Sometimes an event can be too much for one’s body and mind to process and comprehend. Then, for some, it takes a lot of time to let out that experienced situation. The worst thing one can do is keep it to themselves.

What is PTSD?

Post-traumatic stress disorder (PTSD) is a disorder that can develop following a traumatic event that threatens safety or makes one feel helpless.

Dr. Frank Ochberg, a psychiatrist who has worked with and studied victims of war, terrorism, domestic violence, rape, incest and natural disaster in many countries, recognizes PTSD as three reactions that happen simultaneously. These reactions, known as the ‘Triad of Disabling Responses,” is all caused by an event that terrifies, horrifies or renders one helpless. The Triad of Disabling Responses is:

1. Recurring intrusive recollections.

2. Emotional numbing and constriction of life activity.

3. A physiological shift in the fear threshold affecting sleep,concentration and sense of security.

Why Should I Get Help?

Symptoms of PTSD may worsen over time. Finding the right treatment can only start by addressing that someone may need help. PTSD symptoms even can cause difficulty in family relationships, and responders might find themselves pulling away from loved ones. PTSD also can worsen physical health, such as heart problems. More here.

In an effort to help individuals exposed to traumatic events, The Klaxon spoke with Dr. Gerald Cohen, director of clinical affairs for the Division of Mental Hygiene at New York City Department of Health and Mental Hygiene, in offering tips for individuals involved in experiencing psychological problems following a disaster or responding to emergency situations. More here.

Sources of Help

Help Guide: Post-traumatic stress disorder symptoms, treatment and self-help

National Center for PTSD

National Institute of Mental Health: PTSD symptoms and mental health location services

MayoClinic: PTSD causes, complications, risk factors, treatment, coping, support and prevention

[Note from the author: Being both a combat veteran and Sept. 11 first responder, I understand the reasons people don't want to recognize PTSD or receive outside assistance. No one wants to be labeled or be known to have some sort mental issue resulting in a catastrophic event. "If everyone else is OK, so am I," is a coping mechanism that many unfortunately buy into. Many times PTSD victims are told by others they have it instead of them recognizing the symptoms themselves.]

The Klaxon: Natural or human-made disasters are, by definition, disturbing and stressful. Most people exposed to traumatic events can show signs of stress in the immediate and short-term aftermath of the event. What are the signs of disaster stress reactions?

Cohen: All of us are affected by disasters and people can experience a wide range of psychological reactions. The way people react varies from to person to person, and it is important to remember that there is no right or wrong way to react. Some people may experience and express very strong reactions. Others may have only very mild reactions. Some experience reactions immediately while others can experience reactions days, weeks or even months later after the event. One’s reactions may change over time.

Emotional reactions are very common and can include feeling numb, sadness, anxiety, anger, grief, irritability, helplessness and guilt. Some people withdraw, feel restless or on edge, have trouble functioning at work or home, or report simply not acting like themselves. Some have increased alcohol or drug use. Confusion and difficulties with concentration, memory and making decisions can occur. Physical reactions are also quite common- these can include fatigue or exhaustion, general aches and pains, headaches and stomach aches. A number of people report flu-like symptoms, trouble with appetite, or trouble sleeping. Some experience nightmares or recurring dreams about the disaster. Some have spiritual reactions where their religious beliefs and convictions are shaken, such as questioning one’s belief in God.

For many people these reactions to disasters are temporary and often resolve over days to weeks. We like to say these are normal reactions to an abnormal situation. Reactions or symptoms that persist or worsen are of increased concern. Mental health consultation should be considered when such reactions persist or worsen over time, or when they interfere with impairment in normal functioning, such as at work or home.

The Klaxon: Helping people affected by traumatic events requires preparation, sensitivity, and common sense. What type of intervention is recommended to help maintain and stabilize the psychological injuries of victims and their families in the immediate aftermath of a traumatic event?

Cohen: We educate disaster responders and care providers about essential elements of psychological first aid as a way to strengthen resiliency and enhance recovery in the immediate aftermath of disasters. These elements include promoting safety, calm, connectedness, hope and self-efficacy. Promoting safety includes helping to ensure people’s basic immediate needs, such as emergency medical care, food and shelter are being met. We can promote calm by compassionately listening to those impacted who wish to share their experiences and feelings, and by providing accurate information. Other important interventions include helping those impacted by the disaster connect with family, making them aware of and helping them utilize available support services, educating those directly and indirectly impacted and their families about common psychological reactions, and also facilitating referrals to mental health professionals when needed.

The Klaxon: Some persons are more vulnerable and may be at potential risk for developing sustained severe and long-lasting reaction to trauma. What are some of the factors that contribute to the rest of long-term psychological impairment?

Cohen: Although most people are resilient and recover relatively quickly, especially with support from their family, friends and community, a minority of people exposed to disasters develop longer term problems and can have persistent anxiety and other symptoms or develop mental health conditions such as post-traumatic stress disorder and major depression. For example, findings from our World Trade Center Registry are that about one-quarter of survey participants directly exposed to the Sept. 11, 2001, terrorist attack report event-related post traumatic stress symptoms at two to three or five to six years after the disaster.

Many factors may affect vulnerability to longer term psychological problems after disasters. These include the proximity, duration and intensity of exposure to life threatening or horrifying events, the nature and scope of a disaster, and the enduring psychosocial stressors on those impacted. People with pre-existing mental health conditions and a history of previous traumatic experiences are at greater risk Those who experienced loss of loved ones or personal property, who sustained serious physical injuries and who lack family or community supports to help them cope effectively are also at greater risk. More research is needed to better understand the influence of these and other factors contributing to psychological impairment following disasters.

The Klaxon: What is the best way to help children during times of trauma?

Cohen: Just as in adults, children can react to disasters in a variety of ways. Here are some tips to help our children cope.

Try to limit the amount of TV our children watch about the disaster. Exposure to too many upsetting images and news can increase their anxiety, worry and confusion.

When they do watch the news watch it with them, and be available to answer their questions and explain facts honestly, and in age appropriate ways they can understand.

Not all children will want to express their feelings and thoughts about the disaster. When they do, acknowledge their feelings and reactions. Help them find ways to express themselves in a way they are comfortable, such as by talking, through play, or through their artwork.

Monitor you own reactions. The way parents react and cope in a disaster can affect our children. If you seem excessively worried, they can become anxious and afraid. You can help your children feel safe if you stay calm and show you can cope with the situation.

Keep to regular and healthy routines as much as possible. Although in some disaster situations keeping our child’s daily routines such as play dates and afterschool activities may not always be possible, keeping to a daily routine will help give them a sense of security. We should try to keep to basic routines such as family meals and bed time stories as much as possible. We should also try to keep them healthy and make sure that they eat well, sleep enough, and get adequate physical exercise.

The Klaxon: Cultural groups have considerable variation regarding views of loss, death, grieving and may present challenges for helpers. What are some of the guiding principles in providing culturally appropriate mental health services for diverse populations affected by traumatic events?

Cohen: It’s important for us always to be sensitive to cultural differences. Culture reflects how we communicate, how we celebrate life, and how we deal with stress. It also influences people’s “help-seeking” behaviors. Whenever we are working with a population affected by disaster, it’s important for us to consider the cultural context, including religious beliefs ,norms, and values that are specific to a particular group. It’s important to understand where people go to seek help and whom they trust.. Many seek help first in their churches or houses of worship, seeking support from their spiritual leaders. Others will seek help initially from primary care physicians, but not from mental health providers. It’s important to involve and coordinate disaster mental health efforts with community and faith leaders who understand or are part of affected cultural groups. Such coordination can help reach and identify those most in need of emotional support and help facilitate referral for those who may need professional mental health services.

The Klaxon: How do you manage a healthy state-of-mind and body and care for yourself and family members after exposure to disasters and other traumatic events?

Cohen: Here are some tips on taking care of yourself after a disaster.

Recognize the stress you are experiencing: People vary in their emotional reactions to disasters; there is no right or wrong way to react. Some react with sadness, guilt, anger or anxiety. Many have trouble sleeping and difficulty concentrating. Others may experience physical reactions such as fatigue or, aches and pains. Still others may feel they are not acting like themselves.

Keep to your daily routine: Give yourself time to mourn your losses, and time to heal. Maintain your daily routine as much as possible, in order to give your life structure.

Stay informed but not preoccupied: Get information from reliable resources but try not to become preoccupied with the news. Watching and listening to too much coverage about the event can be upsetting to you and those around you, especially your children.

Stay connected with family and friends: Share your thoughts and talk about your feelings when you are able. Realizing that the people around you are experiencing similar feelings may provide comfort and support.

Don’t neglect your health: You can better cope with the stress of the situation if you are healthy. Take care of your body by getting enough sleep, eating well and exercising. Do not smoke, drink excessively or use drugs to cope – these will cause only more problems in the long run.

The Klaxon: When should someone seek help to cope with stress?

Cohen: People should consider seeking help whenever they feel the need and especially if their symptoms or reactions to a disaster persist more than a few weeks, are getting worse, or are interfering with their home, work or other areas of functioning.

The Klaxon: Where can the affected person find professional mental health help?

Cohen: Individuals can find help by speaking with their primary care physician about a referral for mental health services or in New York City by calling 1-800-LIFENET, a 24-hour, free and confidential hotline that provides mental health information and referral. LIFENET is multilingual and multicultural.

The “Art of War” by Sun Tzu has been used over the centuries to teach everything from warfare to marketing and selling products. Emergency Management is no different. From fires to terrorism, the “Art of War” contains strategies that emergency managers (EM) can adopt and put into practice.

Response

“Ponder and deliberate before you make a move.”

Whenever disaster strikes, the public expects some sort of response and rescue.

The response can come from the building’s EM, the local police and, in extreme cases, the National Guard. Their job is to protect life, property and maintain order. However, when responding to any emergency, the EM must first evaluate the extent of the incident.

A rash decision to move quickly into an emergency can be deadly. EMs don’t want to have to rescue the rescuers. This is the point that is often most criticized by “Monday Morning Quarterbacks.” Move too soon and the EM risks the entire operation; move too late and the costs can be insurmountable.

“The control of a large force is the same principle as the control of a few men: it is merely a question of dividing up their numbers.”

The response phase often is chaotic and EMs must maintain a disciplined span of control. If the plan was tested during “peaceful” times, then everyone should know his or her roles. This makes the chaos a little more controlled because the EM knows “who is where and doing what.” Therefore, the incident commander must be a strong leader and a good communicator.

“In battle, there are not more than two methods of attack—the direct and the indirect; yet these two in combination give rise to an endless series of maneuvers.”

EMs often are faced with the tough decision on how to approach the response to a disaster. This problem is often associated with what to do first.

The primary response in any disaster is to protect life by rescuing those that can be immediately secured and then attending to the situations that can cause more hazards. Remember: Not everyone can be rescued at the same time.

Recovery

“In respect of military method, we have, firstly, Measurement; secondly, Estimation of quantity; thirdly, Calculation; fourthly, Balancing of chances; fifthly, Victory.”

During recovery, there are two main focuses: to return the community (or business) to normalcy, and to mitigate against future occurrences. Unfortunately, after an incident, the EM has the ability to establish a new focus on mitigation based on how bad the event was or how bad it could have transpired.

The lessons learned, better known as the After Action Report (AAR), can provide the information that is critical to balance the chances of fairing better in the future against the same type of event.

Before an EM can ever think about a “victory” against a particular hazard, he or she must carefully examine how the event unfolded, measuring each step that was taken during the planning and response phases.

Even though the “Art of War” was written centuries ago for generals during wartime, it holds an important significance in the role of the emergency manager. Identifying potential hazards and mitigating against them is a constant battle. EMs prepare for these battles in two ways: experience and education.

Experience is often the best teacher, but also the cruelest. Sometimes EMs don’t get a second chance. Like Sun Tzu, the EM does not know when or if the “enemy” will attack, but the EM will be prepared for him.

Read the mitigation and preparedness section of this article here.