Monday Morning Crisis Quarterback

Yesterday on NPR, Fresh Air had on Chris Cramer. He was a reporter for the BBC in 1980 when he was applying for a visa at the Iranian embassy in London. You may recall that there was a hostage siege at the Iranian embassy in London that year, and lucky Mr. Cramer happened to be there when the terrorists showed up. He was held captive for a day and a half.

Following that experience, he decided that perhaps he did not want to be covering war and conflict and went into management. He was an executive at the BBC, president of CNN International, and is now Global Editor for Multimedia at Reuters. More interestingly, at least for the Quarterback's purposes, Cramer is President of the International News Safety Institute.

I, for one, had never heard of INSI, but they look pretty cool. They are committed to having safety standards for journalists. Very controversially, Cramer was among the first to say that, "no story is worth a life." INSI also trains journalists who are going into conflict areas on things like battle first aid, how to survive a kidnapping, and other light topics.

From a CISM point of view, all that training not only gives journalists the skills that they need if they're going to be in the middle of a war zone, but it also serves to inoculate them against the stress of the experience, at least to some degree. You may recall the Quarterback's recent speculations about New York Times columnist David Rohde and how he might be doing following his recent escape from the Taliban. It might be interesting to know if he had gone through INSI training.

Cramer talked a lot about how journalists know when to take a break, and about the need for managers to tell them when it's time to come home because they don't always see the situation clearly up close. He also talked about how some journalists immediately go see a counselor when they come back from an assignment, and others have trusted friends they talk to.

This is a poster child advertisement for Critical Incident Stress Management. The original idea behind CISM is that first responders would be more comfortable talking to another first responder -- a peer -- than to a counselor, so it was important to train the peers in early crisis intervention and train the mental health professionals both in early crisis intervention and in working with peers. Seems like the same principle might apply to journalists: If folks are going to talk to their peers about traumatic experiences, let's train the peers.

The Quarterback has no idea whether there are journalists out there -- a few or a lot -- who are trained in CISM. It sure sounds like there should be. And if they need a Quarterback to train them, I know just the person!

This morning, one of the Quarterback's friends posted as the status on his Facebook profile that he

hopes no more random media icons die today. But would someone please keep an eye on Robert Loggia?

(If you're like the Quarterback, you may want to click on the link to refresh your memory as to who that is, and then say, "Oh, him!").

My friend is suffering from a new disorder I am calling Multiple Celebrity Death Syndrome, or MCDS. And while my tongue is firmly in my cheek in creating a name for it, there is a phenomenon that is being caused by the death of so many celebrities in a relatively short amount of time, most recently Billy Mays.

As human beings, we are programmed to see patterns. Most of the time, this is useful. For example, if we notice that every time we see a tiger, a member of our group dies, it helps us learn to run away from tigers. On a more refined level, if we notice that members of our group are dying, it causes us to look and find out what the cause is so we can avoid it, whatever it may be. From an evolutionary standpoint, that's all good.

The problem is, we're actually pretty bad at figuring out when patterns aren't really patterns. We don't tend to assume that something can happen a bunch of times in a row by chance. For example, if you flip a coin three times and it comes up heads all three times, you are likely to have at least some suspicion that the coin isn't fair. But the chances of that happening at random are 1 in 8. The chances of it coming up the same all three times (without paying attention to heads specifically) are 1 in 4. We just think of that as being somehow "less random" than, say, heads-tails-tails (which also has a 1 in 8 chance).

So Ed McMahon, Farrah Fawcett, Michael Jackson and Billy Mays all died in the last 5 days, and we see a pattern. Celebrities seem to be dropping like flies. But in fact, people die every day, and some number of them are celebrities. I doubt we've come close to a number of celebrities dying in a short period to make it actually statistically unlikely to be random.

We see this a lot in crisis response, too. Groups of people start to feel "cursed." As my regular readers know, my own district crisis team got battered this past school year. And yes, I did see a pattern, but not one specific to my district or team. I saw a general uptick in critical incidents in the world. I don't even know if that is true.

I suppose it is possible that there is a general uptick in the death rate in the United States right now, and that the celebrities are caught in that wave. I doubt it, mostly because we're not also seeing news stories from coroners nationwide who suddenly are inundated with deaths from the general public. We want to see patterns, and the patterns we see scare us. But really, the recent celebrity deaths are just random, and noticeable because they're well publicized. On the one hand, it's worrying. On the other, we all just have MCDS.

N.B. There definitely has been an uptick in hoaxes reporting the death of various celebrities, including Jeff Goldblum and Miley Cyrus, both of whom are alive and well. It's possible that there aren't any more of those hoaxes than usual, we're just noticing them more because of our MCDS, or it's possible that hoaxters are taking advantage of the situation. At any rate, it's a good time to not believe everything you read!

One of the things you can expect about traumatic incidents is that they very frequently are covered in the media. The very things that make them traumatic -- the unexpectedness, the fear they cause, etc. -- are the things that sell newspapers (or, in this day and age, online advertising).

The Quarterback was thinking about this while reading a story on the local newspaper's website about a local man who was shot by police after allegedly killing his mother and setting fire to the house. If you read the story, there are very few details, including any information at all about who the man was, what if anything led up to the incident, and what he was doing when the police shot him. If you read the comments below the story, you start to see the holes get filled in, some with speculation, some with apparently relevant information, and some where you can't really tell. Here are some examples:

Simple enough, the guy ran and they shot him down like a dog.

Well by the end of this year, Washtenaw County will pay out another $4 Million for a civil case settlement. Before this Deputy involved is righfully cleared of his actions.

Who shooting who.. Yesterday, story was pepole shooting at cops today they shoot back,with good aim..Deadly Aim.Who cares other then thoses involved. Gun owners should be striped of all guns. NO GUNS NO PROLBEMS!!!!

This is such a sad case of Mental Illiness and not reciving the help he should of received. I will keep I.B in my prayers and also his loved ones. I have known him for many years and cannot express my feelings for the family enough to say may you find peace in the creator to find comfort in each other and for the many friends that stay behind you in this awful tradgy [sic].

This last one gave the Quarterback pause. It's easy to forget, when you read these things and particularly when you get sucked into the trollish world of blog posting on news sites, that just because the facts aren't in the article doesn't mean there aren't any to be had. Folks (including the Quarterback) who write about public events and include a lot of speculation can easily start to believe their speculation is fact.

Somewhere, there are relatives and friends of this mother and this son. They know far more about the situation than we do. And they are trying to process what happened. Undoubtedly there is blame being thrown around, there always is. But what there isn't, most likely, is a discussion of county budgets or gun control. What there is is context. Never a bad idea to remember that every new story has it, and few accurately report it.

An update to a story the Quarterback first took a look at a couple of weeks ago. Officials have called off the operation to recover the remains of people who were aboard Air France Flight 447 when it went down off the coast of Brazil on June 1st. In the two weeks since we first looked at this search, only 7 additional bodies have been found, including the pilot and a flight attendant, bringing the total to just 51 of the 228 people aboard. Officials say it is unlikely that any more would be discovered.

As the Quarterback discussed in the June 14 post, it's hard to process trauma until it's over. For the families of those on this flight, this journey started out on June 1 with notice that the plane was missing and feared down and the beginning of a search and rescue operation, to the beginning of the recovery effort, to now the notification that for most of them, there will be no recovery of their loved one's body.

It's easy for us to say that everyone knows no one survived that crash. And yes, the thinking part of these families' minds knows their loved ones are dead. But the feeling part, the part that isn't rational, can hold out hope. And as long as it does, it's hard to process what has happened and find a place for it in the "new normal" of life.

In just the two weeks since I first blogged about this, the Quarterback has noticed a lot of media attention given to situations where people fake their deaths. Just last night I watched a re-run of a CSI Miami from 2005 in which Raymond Caine turns up after having supposedly been dead and then fakes his death again. This phenomenon can't be that common in real life. But when someone you love dies and their body never comes home, it has to cross your mind, and that can't be easy.

The Quarterback is somewhat at a loss for a topic for today because apparently the only thing that happened yesterday is that Michael Jackson died. And while I certainly was sorry to hear that, the death of Michael Jackson is not, in point of fact, a "Critical Incident." This might be a good time to talk about what makes a critical incident, and what doesn't.

A critical incident is an event that overwhelms one's usual coping mechanisms. All of us have a set of skills that help us to deal with stressful situations. And all of us have some point past which we can't deal anymore. That point is when incidents become critical, and it is different for everyone.

Certainly there are some things that we can safely presume will constitute critical incidents for most people. Watching your spouse be murdered, for example, would overwhelm most people's ability to grieve and move on. And certainly there are some things that are generally not critical incidents for most people. For example, the death of an elderly grandparent after a long but not particularly painful illness is sad, but not usually overwhelming.

There are a lot of incidents that lie in the middle. What is intolerable for one person is within the realm of tolerable for another. One person may be seriously traumatized by a shooting in the neighborhood, while another is not, perhaps because it happens more frequently for them. As my frequent readers know, there are some predictors of traumatic stress: believing that you are going to die, sensory exposure to the event, triggering of past events, violation of your worldview and the involvement of children in the event are all predictive, but there are others that can cause trauma and these can all be there and a person still not be traumatized.

The death of Michael Jackson is not, for most people, a critical incident. It is sudden and perhaps shocking, and you may feel that it is sad. But it is within the realm of what most of us can cope with. It won't cause most of us nightmares or loss of appetite or drinking or depression. There may be exceptions, either for his family and close friends, those who were there when he died, or for people who have recent similar losses in their own lives. And if you are traumatized by it, that doesn't make you "wrong" or "crazy," just unusual.

Arguably, the death of Michael Jackson is more likely to be traumatizing than the death, also yesterday, of Farrah Fawcett. Hers was a long time coming, she was older, and she was ill, so it was not as sudden and perhaps not as shocking. But neither are likely to traumatize the general public.

Meanwhile, every family who did experience trauma this week now has an added wrinkle. The families of Neda Soltan and Ed Thomas will now add to their story, "and then Michael Jackson died, and everyone stopped looking at us very suddenly." This may be good and it may be bad. Most likely it will be some of each. But let's not lose sight of what a real critical incident really looks like.

Yesterday, the Quarterback shared an overview of how the CISM response to Iowa football coach Ed Thomas's murder might be handled. I also promised to update, and an update is warranted. A 24 year-old former player has been charged with first degree murder in this case. The suspect has a very lengthy criminal record dating back to a drug charge when he was on the team. He was a known methamphetamine user. Most recently, he was arrested on Saturday night following a high speed police chase, and committed to a local psychiatric ward. Reports differ, but it seems that the hospital was to notify the police before he was released. They didn't, he was released Tuesday evening, and on Wednesday morning he allegedly killed Coach Thomas.

If you read the comments on any story about this posted around Internet, you can see certain themes start to emerge:

• It's the hospital's fault for not keeping him and/or alerting police to his discharge.
• The police shouldn't have taken him to the hospital.
• Back in my day, kids got punished for doing wrong. If that had happened to this guy, he wouldn't be like this.
• This is what happens when parents don't hold kids accountable.

In short, people are going quickly to blame. Blame is perhaps the most common reaction to a tragedy, whether or not there is anyone to blame at all. In this instance, while there are a few comments blaming the suspect, there are many more blaming various authorities and the family for not preventing the suspect from doing what he did.

Why do people move towards blame so quickly? It's a defense mechanism. Critical incidents are terrifying. They violate your worldview, and make you feel unsafe. The mind immediately starts looking for reassurances that the world is, indeed, safe. To do that, something must have gone wrong in this case, and it must be preventable. The world would have been safe but for the failing of some person or group, and therefore the world is safe as long as everyone does their job.

We most commonly see this reaction to suicides. It is too much to bear that someone would kill themselves of their own free will, or even from a state of mental illness. It must have been preventable. It must be someone's fault, and to blame the person who is dead interferes with the grief one naturally feels after such a loss. So family and friends begin to blame each other, to blame mental health professionals, and to blame themselves. Which brings us to another sticky issue in this case.

The other theme that the CISM team now has to be aware of is that it is entirely possible that one or more of the team members who witnessed the shooting knew the suspect or were friendly with his family. Certainly school staff knew him. And that will bring up issues of blaming oneself (e.g. I should have seen it coming, I should have stopped him) but also issues of split loyalties (e.g. my friend did something horrible to my coach, but he's still a good guy).

For school personnel there is the added issue that all of us like to believe that we can make our students successful human beings, intervene in bad situations and make them better, and spot kids in trouble and step in to turn them around. Situations like this one violate that belief and shake us to the core. If a student we taught could turn out like this, what good do we do anyway? What's the point?

The Quarterback isn't in a position to judge whether anyone other than the shooter is to blame in this case. People have free will, and it can be used for good or for evil. We as educators do the best we can, and we do make a difference to some kids. No one can make a difference to all kids. We go through life most days oblivious to the amount we rely on others not to act crazy -- we cross in front of a stopped car at an intersection trusting that the driver won't hit the gas, and we don't think about it. Today the people of Iowa are thinking about it. And their crisis responders are adding blame to their list of themes.

Ed Thomas, the football coach of Aplington-Parkersburg High School in Iowa, was shot to death in the school's weight room this morning in front of students. A suspect is in custody, but no one is commenting on who it is (except to say it's an adult) or what happened. "Crisis Counselors" are reported to be at the school working with the witnesses.

Before commenting, a disclaimer: the Quarterback is not there, doesn't know Ed Thomas and doesn't work for the Aplington-Parkersburg schools. I am acquainted with some folks high up in CISM response for the state of Iowa, and know that they have a pretty well organized structure. Also, this story is only about two hours old as I write this, and by the time you read it more facts may be public. If so, I will try to update the Quarterback site so this post remains relevant.

As you may know, responding to just this kind of situation is what the Quarterback does and is passionate about. So I thought it might be instructive to walk through what I would be thinking about and doing if I were in charge.

As my regular readers know, in Critical Incident Stress Management we talk about the 5 T's: Trauma, Target, Timing, Theme and Team. Let's walk those through:

Trauma: This is fairly straightforward -- a beloved coach was shot in sight of students. Whoever is heading up the response is going to want to get as much detail as possible about what happened, and I guarantee that there is more detail to be had than what is in news reports at this point. Some questions to ask: Do we know who the shooter is and/or what the motive might be? Did the witnesses know the shooter? What did he say? Who tried to help the coach? Who called the police? How were parents notified?

Target: First, a reminder -- we're responding to people's reactions to the incident, not to the incident itself. So we can sketch out who may need help and what might be appropriate, but we won't know if we're right until we find out how people are reacting.

• In the center of the circle are the people who were in the room with the coach when he was shot. Most likely, we'll be wanting to do a Defusing (a.k.a. Immediate Small Group Support) for these folks, depending on how many there are. This is a process whereby they get to briefly talk about what happened and the team will give them information on what kind of stress reactions they might experience and how they can best take care of themselves.
• Someone needs to be assigned exclusively to the family and will be doing Defusings and one-to-one intervention.
  
• Next out, we may need to do a Defusing with first responders, depending on how awful the scene was.
• We will probably also want to Defuse the staff who were in the building.
• Now it's time to deal with the rest of the community. It's time for a Crisis Management Briefing. A member of the team will M.C. The Principal will welcome everyone, the police will state the facts and the state of the investigation, and the team will educate folks on traumatic stress reactions, and then hang around afterwards to talk to anyone who needs individual support.
• Throughout this all, we are assessing, assessing, assessing: Who seems to be in the worst shape? What resources do they have for recovery? What more do they need? Based on the answers to that, we will be doing a lot of individual crisis intervention and may well schedule a Critical Incident Stress Debriefing for those towards the center of the circle.

Timing: Nothing should be done until after every kid in that building has talked to a parent. That need for safety trumps everything else. Hopefully the police will cooperate with the team in allowing Defusings to happen as fast as possible, which means they need to get their interviews done ASAP. On the other hand, I would not send the kids home before a Defusing. They need some resources under their belt to deal with the rest of today and the days ahead, and they will not come back later. The Crisis Management Briefing should probably be tonight if they can get the word out. The Critical Incident Stress Debriefing will depend a lot on the schedule of events, e.g. when the funeral and visitation are. It could be as early as tomorrow and should be no later than the day after the funeral.

Theme: Three big things are going to come up, particularly for the kids in the room when it happened. 1) I should have stopped him. 2) I thought he was going to come after me next and I do not feel safe now and 3) This town was devastated by a tornado last year and now this. Trauma always brings up trauma -- it causes you to open up the same file drawer in your mind and out comes everything else. Folks may well still be fragile from the tornado, so reactions are going to come harder and faster for this.

Team: Everyone responding needs to be trained in CISM. School counselors and social workers are often wonderful, talented, fabulous clinicians, but they do not generally have training in early crisis intervention. The tendency if you are in mental health but don't have this training is to start down the road towards therapy, and now is not the time for that. If this were my response, I would want to send in (presuming we have the personnel) CISM trained counselors, social workers and/or psychologists who work in schools, a CISM trained Principal and teacher, and whoever is CISM trained who the kids feel the most comfortable with, if it's not the folks above.

God bless the folks in this town. I hope they get the best CISM response in the history of the world.

Yesterday, two stories hit the news that caught the Quarterback's attention. Unless you live in Southeast Michigan (and for many of you, even if you live in Southeast Michigan) you probably only heard about one.

The first story came in the morning. A worker constructing the new C.S.Mott Children's Hospital at the University of Michigan Medical Center was killed by falling debris. The second story you've undoubtedly heard. Two cars on the Washington, D.C. Metro collided at the Maryland border, killing 9 and injuring many more.

On the face of it, the hospital construction accident is literally much closer to home for the Quarterback, who lives in Ann Arbor, MI. Both of my children have been hospitalized at Mott, my son was born next door, and my husband and a number of friends are medical center employees. And yet, I found myself following the coverage of the D.C. crash much more closely. Why?

In this situation, the way our brains are wired to acquire new information is truly working against us. Whenever we learn something new, we try to fit it into what we already know. If we imagine our brains and our memories as a gigantic collection of file cabinets, it is much more efficient to file new information in an existing drawer than it is to build a whole new cabinet.

When I heard the news about the construction death, I opened the drawer marked "Mott hospital." I felt a connection, but not any fear. Nowhere in that drawer is there anyone who is working on the construction site. My connection did not travel anywhere near the death of the worker, it only went by way of the physical location.

When I heard about the train crash, my brain opened the drawer marked "D.C. Metro rider." And found all the times I myself have ridden the Metro, as well as my in-laws, cousins and friends who live in Washington and ride the Metro every day. Even though I could be 99% certain, based on the location of the crash, that none of them were affected, I was pulling out the file that told me they could have been -- the file that said I could have been, too. So my reaction was stronger. If I or someone in my close circle were a construction worker, the reverse might well have been true.

Being close to an event doesn't mean physical proximity. It means identifying with it. Closeness is relative in more ways than one. Thank goodness, the Quarterback's relatives are safe.

New York Times reporter David Rohde escaped from 7 months of captivity in Afghanistan on Friday night. He had been kidnapped by Taliban and, if you are like most people, you had no idea. The New York Times decided not to publish the story out of fear for Rohde's safety.

Certainly being kidnapped by the Taliban qualifies as a "critical incident," and I think we could all forgive Mr. Rohde if he has some critical stress reactions in the next several months. But his is an interesting case. You see, he'd been abducted before -- several years ago in Bosnia.

The Quarterback certainly has no way of knowing what either experience was like for Mr. Rohde, but the fact that he continued to work as he did in dangerous, kinapping-prone areas after the first time suggests that he was doing OK. How is he doing now?

There are a number of possibilities:

1. For whatever reason, Mr. Rohde is fairly well inoculated against the traumatic stress of being kidnapped. That doesn't mean he likes it, mind you, but that it doesn't give him nightmares and flashbacks and depression. This is the phenomenon that allows most first responders to stay on the job and only be impacted by the most grisly and shocking events -- day-to-day violence and blood become part of the job.
2. The first kidnapping was indeed traumatic for Rohde, but he got good intervention and the experience largely inoculated him against the distress of the second one.
3. Both kidnappings were traumatic, independent of each other.
4. Rohde's reaction to the second kidnapping is big, and as much about the first incident as the second one. He is reliving the previous traumatic stress while trying to process the current.

Of course we hope that the first one is true. Not that being used to being kidnapped is something we would wish on anyone, but it certainly would be useful if you were going to be kidnapped anyway. And, from an interventionist's standpoint, the last one would be the most complex. Traumatic events always trigger, to some extent, past losses and traumas, but this would be huge.

In fact, the Quarterback knows a lot of responders who wouldn't touch Mr. Rohde with a ten foot pole. I participated in a training once where we planned a response to a workplace hostage situation which ended in a fire and the police shooting the perpetrator. The question of what should be done for the person who was taken hostage, who was the estranged wife of the perpetrator, got about 30 seconds of attention, with everyone (except the Quarterback) agreeing "she gets a referral" to psychiatric intervention. We don't like to work with people who are smack dab in the middle of the trauma. The next concentric circle out is more comfortable.

Certainly there are times when working with the most impacted people is not advisable. You should never be doing intervention with people who are still injured in the hospital, because they are still getting their physical needs met and can't yet attend to their safety and security or belonging and love needs. And it is absolutely the mantra of CISM providers to do what you know you can do well and get out of there -- doing nothing is preferable to doing it wrong, and if you really don't think you can handle this, then you shouldn't be doing it at all.

The problem is, the standard of care for the treatment of traumatic stress, as contrasted by the intervention in traumatic stress, is to wait 30-60 days after the event. And if no one intervenes with the primary victim during that time, it can be a truly hellish couple of months. It's the equivalent of breaking your arm and having the ER say, "We can't operate for a week until the swelling goes down, so go home and wait" without putting it in a splint. The splint isn't going to heal it, but it will make the waiting more bearable and hopefully prevent the injury from getting worse.

But before we go rushing in to hypothetically assist Mr. Rohde, one last caution is in order. Critical Incident Stress Management does not respond to the critical incident. It responds to the critical incident stress. So before anyone does anything, they need to assess what exactly is going on for Mr. Rohde, and don't forget his family and colleagues. If everyone's doing OK, we can go find another trauma to intervene with -- there are plenty. And if not, let's do what we know we can do well, and get out of there.

As the protests over the elections in Iran head into their second week, and the conflict turned deadly yesterday, a video surfaced on YouTube of a woman named Neda dying in the streets of Tehran.

Suddenly, Neda is the rallying cry of the Internet. The video has spread like wildfire and clearly made an impact on those who have seen it. Comments on YouTube, Facebook and Twitter generally fall into three categories: 1) Is this real? 2) Neda, you didn't die in vain and 3) I think I'm going to be sick.

Why? Why is this video, unlike the other pictures and videos of the situation in Iran, so compelling? And why is it so upsetting, particularly in a culture where acts of violence are all over our mass media? After all, this video doesn't show Neda being beaten or even being shot. When the video starts, she is already lying bloody on the ground. We certainly already knew there was violence in Iran, and we don't (as the people in comment category #1, above, point out) even know if the video is real.

First of all, it is certainly the case that people are more affected by things they can see, touch, hear, smell or taste themselves than by descriptions. That is why an appeal from Michael J. Fox is more effective than a typical ad for Parkinson's research: We saw him before the disease, we see him now, and we understand the difference on a very different level than when we hear about it. Seeing Neda die is different from hearing that she died -- we understand it and feel a connection on a deeper level.

Another important clue to why this video is so powerful comes in the form of category #1 questions. The question, "Is this real?" clues us in to the fact that something like this happening violates our worldview. On some deep level, we believe in a world that is safe. That feeling of safety is level two of Maslow's Hierarchy of Needs, which the Quarterback discussed yesterday. It is that belief in safety that enables us to function, to move higher on Maslow's pyramid, and to get out of bed in the morning. We live our lives based on what is likely, not what is possible, in terms of danger. This video brings home in a very vivid way what of course we already knew -- that the world is not safe, particularly if you are a protester in Tehran.

This is also why people feel like they're going to throw up when they see this video. It is not just because it is bloody and graphic, although that is part of it. It is because we presume it to be real, and because that reality violates our fundamental beliefs about the world. That is the hallmark of traumatic incidents. They shake our basic understanding of how the world works, and by doing that throw every other understanding we have into doubt.

Many people seeing this video, particularly if it is unlike any real thing they have seen before, feel unsafe on some level. Our appetite vanishes, we have nightmares, we feel sad or anxious or grouchy. We are experiencing secondary trauma. And if we don't, it may be because we did some other time. The Quarterback remembers feeling very shaken by the video of Nicholas Berg being beheaded in Iraq, even though the most graphic portion of the video was edited out.

I do not mean to imply in any way that the death of Neda is unimportant or that people should not be moved by it. But know what you are doing when you watch it, and when you have others watch it. You are traumatizing yourself. You can choose to do that, and maybe you feel you should, but the usual cautions apply -- find someone to talk to about it, not just about the politics of it but about the emotions of it. Take care of yourself. And be prepared to not feel quite right.

And with that caution, if you care to watch the video, here is the link.

On Wednesday evening, a massive bank of thunderstorms rolled through the Quarterback's former stomping grounds in Pittsburgh, PA. Some reports indicate that up to 3 inches of rain fell in an hour. The damage was massive: there were flash floods, downed power lines, uprooted trees and lots and lots of water damage. The roof of my former synagogue partially collapsed.

I bring this up for two reasons. First, because last night in Ann Arbor, MI we had quite the storm system ourselves and the Quarterback's basement is flooded. Second, and hopefully more relevant to what brings all of you here, is that it raises some interesting issues about crisis response.

Natural disasters that affect large numbers of people are one of the "Big 5" in Critical Incident Stress Management (CISM) [the other four are suicide of a colleague, death on the job, multiple incidents in rapid succession and response after a substantial delay]. These are the ones they teach you about in the Advanced Group Crisis Response class. These are the "don't try this at home" responses.

What makes disasters so complicated? There are a number of issues. First, one of the basic principles of CISM is to remember Maslow's Hierarchy of Needs. If you're not familiar, here's the pyramid. Basically, what Maslow said is that everyone strives for self-actualization, but there are layers that support that and you can't deal with a higher level unless you've dealt with the one below it. People who have been through a disaster are very much rooted in the lowest level. Their physiological needs are threatened. They may not have food or clean water and their shelter is unstable or non-existent.

But CISM works fundamentally at the second and somewhat the third level. We are dealing with the fact that people's sense of safety and security has been damaged, and trying to return them to a sense of love and belongingness. We can't do that work until people's physiological needs are taken care of. People are not ready to deal with their critical incident stress until they are sure they and their family are going to live, they've had a good meal, they have a reasonably long-term place to stay and they've gotten a good night's sleep. Only the first two of those can reasonably be accomplished in a Red Cross shelter.

The second problem with disaster response is that chances are good that if a community is heavily impacted by a storm or an earthquake, most of the crisis responders are affected too. And another of the basic principles of CISM is that you don't respond if you yourself are impacted by the event. Sometimes, the helpers need help.

This is where mutual aid agreements are so important. Those agreements are what will enable members of the Pittsburgh-area teams to combine forces to create whole teams from the bits and pieces of each one that are not personally affected. They will also allow Pittsburgh to call for help from other Pennsylvania teams or teams in other states.

This is also where consistent becomes crucial. If you're going to show up in another town or another state to help out, you have to know that everyone, regardless of where they come from, speaks the same language and is using the same techniques. This is exactly when you don't want some well-meaning therapist or counselor self-deploying and trying to help. Unless they've had specialized coursework, most social workers, psychologists, psychiatrists and counselors -- even those who specialize in treating PTSD -- don't have training in early trauma intervention. And doing it wrong is worse than not doing it at all.

The Quarterback recently had dinner with someone involved in Critical Incident Stress Management (CISM) for pilots. We were discussing the crash in Buffalo in February that killed 50 people. I commented that I supposed those who work with pilots are mostly working with colleagues who are upset by a loss of their own in situations like that, because obviously they aren't working with the pilots themselves.

My companion said that some of the most intense work they do isn't with pilots who are in incidents or standard "line of duty death" sorts of intervention. He told me about someone who is often the one most affected by the event, someone I had never thought about -- I bet you haven't either.

As you probably know, when a crash is being investigated, they're always looking for the "black boxes" from the plane. On big planes there are two: a flight data recorder, that records what the plane was doing before it crashed, what the instrument readings were, etc., and a cockpit voice recorder, which records what the cockpit crew was saying. When they listen to the voice recorder, they're not just listening to the words, but also for background noises, inflections, and other subtle cues.

The tricky thing about the voice recorder, however, is that there are usually at least two people in the cockpit. Both of them are very stressed, neither of them are enunciating clearly, and their voices may sound very similar. Whoever is transcribing the voice recording and listening for background sounds, etc., needs to be able to distinguish between the two voices.

So who do you get to do that? You get someone who knows both the pilot and the co-pilot well. You get one of their mutual friends, the closest one they have. That person has to listen to a recording of their buddies dying, over and over and over again. That person, already experiencing the traumatic stress of the death of a colleague on the job, must have the added and repeated sensory exposure of the tapes.

Not surprisingly, whoever that is often gets two CISM team members assigned just to them. God bless whoever that was in Buffalo, whoever it will be in Brazil or France, and everyone who has to go through that. And God bless the CISM teams that help them. They sure need it.


N.B. You may note that in the sidebar there's now a place for you to leave suggestions of current events you'd like the Quarterback to blog about. I'm interested in what you're interested in -- let me know!

Last weekend, a glider crashed on takeoff from an airfield in Unadilla Township, Michigan, which is in Livingston County, or the next county over from Ann Arbor, if that means anything to you. A passenger was killed and the pilot seriously injured.

When something like this (and by this I mean any kind of messy event such as a car crash, a suicide, or an industrial accident) happens, EMS and fire and police descend upon the scene. Physical injuries are given first aid and people taken to the hospital. The authorities conduct their investigation. And then those affected -- the victims themselves, the people nearby, the businesses, the neighbors -- are left to their own devices.

I don't know whether crisis intervention services were given to the employees of that airfield, where they have had five crashes, two of them fatal, in the last three years, or to the people who live near the airfield. I also don't know if they needed them. But they sure might have.

Many communities these days have Critical Incident Stress Management (CISM) teams that work with civilians. CISM got its start with first responders, and that's still the setting where it is implemented the most systematically, but more and more towns, cities, counties and states are recognizing a need for early crisis intervention in the community. The Monday Morning Crisis Quarterback herself serves on the Traumatic Event Response Network (TERN) for Washtenaw County, Michigan.

However, if your community is like my community, the team doesn't get notified of every event, and we don't "chase cases." We respond when we're asked to. Which requires that people know about us. And I'd venture to guess that if you grabbed 100 people off the street in our county and asked them about crisis response teams, at least 95 of them wouldn't have a clue what you were talking about. In practice, this means that we respond to events where someone involved is or is close to a first responder, where first responders are very much affected and their team (which is coordinated out of the same office) contacts ours, when someone on the team is close to the situation, or when someone knows there must be resources out there, and starts asking around.

This is emblematic of how we think about mental health in our society. Mental health care is not seen as a necessity unless the situation is life threatening. Even those with good insurance tend to have lousy mental health insurance. Traumatic stress is seen as an after-effect, not a primary injury, and so early intervention is not the norm -- we wait to see how people are doing.

Can you imagine if we treated blows to the head the way we treat traumatic stress? We would say, "well, it's possible that you'll have some problems if you have a concussion, so go home and if you don't feel right later, go see a specialist. Your insurance probably won't cover it, by the way." Can you imagine the lawsuits when people started to die? We understand that head injuries need to be evaluated immediately because they can lead to life-threatening problems. Why don't we understand the same about traumatic exposure?

Last month I was sitting in an airport waiting for a plane to go to a conference of the International Critical Incident Stress Foundation (ICISF). I was chatting with a man nearby, having the usual, "why are you traveling" discussions. I told him that I am a school administrator and I respond to schools following traumatic events, and he of course made the connection to Columbine. He said, "I don't know what the point of responding is. You just have to say, these kids were crazy, get over it." Then he paused and said, "If you actually saw those shootings, it would mess you up for the rest of your life."

This, too, is the problem with how we look at traumatic stress. We view prevention and/or early intervention as pointless, we tell people to "get over it," and then we accept permanent damage to the psyche as inevitable. Can't we do things a different way?

I envision a world where 911 dispatches CISM the way they dispatch the fire department to a known fire -- if the incident is at all traumatic, someone from the CISM team goes and evaluates the need for a response. Not everything needs it, just like sometimes the fire department shows up and the fire's already out. But couldn't we make it available to everyone, somehow? People like those folks who work at or live near the airfield should not think for a moment they need to go it alone.

I once taught a mini-elective for upper elementary and middle school students on writing opinion pieces. We generated a list of what made a piece effective, and included that the piece should consider the opposing opinion and respond to what someone who disagrees might say. Then the kids went off to start composing. One student was writing about his support for gay marriage. He wrote, "Gay people should be allowed to get married. It's the right thing to do." I reminded him to respond to what someone who disagreed to him might say, so he added, "Anyone who disagrees with me is a moron."

The Monday Morning Crisis Quarterback thought of this yesterday when, after writing my piece about Tess Sosa's fight to get insurance coverage for her therapy following the crash of US Airways Flight 1549 on the Hudson River, when I stumbled upon an entry at Plastic Surgery 101 on the same topic. In a post entitled "Exhibit A in Why We Will Never Be Able to Control Health Care Costs," Dr. Rob Oliver, Jr., a plastic surgeon in Alabama, writes:

You think Mrs. Sosa and other passengers would count their blessing to be alive and be thrilled with the $5000 check US Airways issued each passenger in compensation (which they didn't even an obligation to do). Apparently this was not acceptable to Mrs. Sosa who is demanding the airlines insurer, A.I.G., pay for all costs associated with her psychotherapy for post traumatic stress disorder, the unprovable sinkhole of psychiatric diagnoses.

Now, to be fair, Dr. Oliver and I are both guilty of not responding to the opposing point of view, although we did not go so far as to state the other is a moron (at least not yet!). So I would like to address what he has to say a little more fully.

PTSD is, indeed, unprovable. So is pretty much every psychiatric disorder. There is no blood test for schizophrenia, depression, bipolar disorder or PTSD. That doesn't mean they don't exist. And if I were Ms. Sosa and I was interested in going after AIG to milk whatever I could out of a deep pocket, don't you think I'd be going for cash? I can't imagine someone saying, "Gee, you know what I really want? Not a car, not a house, not financial security, no, what I want is some EMDR."

Dr. Oliver goes on to question why the insurer is liable at all, since this was an "act of God," (presuming, here, that the same supernatural force that produces earthquakes and lightning produces massive flocks of geese, which I think is fair). Without looking at the policy, it's hard to know whether this incident as a whole is covered. The standard, though, should be whether physical injuries to passengers would be covered. As I said yesterday, if a broken leg is covered, then psychotherapy should be covered. If a broken leg isn't covered, however, then of course neither should mental health care be covered. All I'm suggesting is that we have parity. I'm guessing we don't.

Trauma reactions are real, and in some cases they are really serious. Someone with untreated PTSD is a ticking time bomb, whether it's a vet who shoots in a crowd or a plane crash survivor who crashes her car into yours. Presuming it isn't real and that people are faking is a very good way to increase the death toll from traumatic events, via homicide or suicide.

Oh, and I just have to say. A plastic surgeon blaming a PTSD patient seeking treatment for the rise in healthcare costs because that treatment may be unnecessary? People who live in glass houses . . .

Last week, the Monday Morning Crisis Quarterback brought you thoughts on the experiences of the crew of US Airways Flight 1549. Today, we look at the passengers. More specifically, we look at the experience of Tess Sosa, who, according to Keith Olbermann at MSNBC, was on board the flight that landed in the Hudson in January with her husband and two children.

If Olbermann's report is accurate, and frankly it sounds about what you would expect, when Ms. Sosa contacted the insurer for US Airways seeking insurance coverage for mental health therapy for herself and one of her children relating to the trauma of the accident, the person she spoke to hadn't a clue what she was calling about. Then the insurance company told her to use her private insurance. Then they offered to cover three, but only three, mental health visits. And of course, they keep changing who the contact person is. Oh, and for frosting on the cake, the insurer is AIG.

This is one of those stories that could appear on any number of blogs. It takes a critical incident (which is why the Quarterback is interested) and mixes it in with poor customer service, the mess that is dealing with health insurers, the complete failure of the American medical system to deal in any way that makes sense with mental health issues. Then for fun you throw in the financial crisis and government bailouts. This thing ought to be all over the airwaves. But of course, it isn't. I'm not going to go on about why it isn't, but I am going to comment on Ms. Sosa's continued need for mental health care.

As my regular readers know, one of the best predictors of traumatic stress symptoms is believing that you or your loved one is about to die. Ms. Sosa certainly believed, as the plane was going down, that she was going to die. In fact, statistics indicate that she was more likely to be right than wrong on that one. There aren't all that many plane crash survivors walking the earth these days. She had her husband and two children with her, and she also believed they would die.

Once the plane "landed" on the river, water came in through the tail section of the plane. The passengers and crew evacuated onto the wings and into the water, which was cold. As she was pulled out of the water, she looked back and saw her husband holding one of their children above the water line. She had every reason to believe they might not make it.

I have no idea what immediate crisis support was given to the passengers on this flight. I also have no way of knowing whether more or different early intervention would have helped Ms. Sosa (there is lots of evidence to show that CISM reduces alcohol use and depression, but it isn't intended to magically ward off PTSD). Statistically, it's likely that some percentage of the passengers would need to be referred for further care and some of them wouldn't. Ms. Sosa did, and she's trying to get the help she needs. Good for her.

Ms. Sosa was injured in that accident, just as surely as if she had broken her leg or her nose. And she needs treatment, just as surely as if she needed surgery or physical therapy. Even in the arbitrary world of mental health insurance, three sessions is arbitrarily short. Five with the possibility of renewal would be much more the norm (and that's probably not sufficient coverage for a lot of folks, either).

AIG should thank its lucky stars they aren't paying hefty death benefits to the families of those who were on that plane, suck it up, and cover their mental health treatment. It's just plain the right thing to do.

Yesterday, the Monday Morning Crisis Quarterback ranted about how important the recovery of loved ones' remains is in the healing process. This got me thinking about how we as a culture and we as crisis responders think about the bodies of the dead.

When we think about Themes for crisis response, one that sometimes comes up is the issue of whether or not there will be an open casket at the funeral or visitation. Sometimes the death is so grisly that having an open casket is simply not an option. And those in the CISM biz will sometimes say, "Not having an open casket interferes with people's sense of closure."

I always cringe when I hear this, because it is said with such authority and as though any idiot could figure it out, but it isn't universally true. I had never been to a funeral with an open casket until I was an adult. Jewish funerals do not have open caskets. So failing to have an open casket doesn't interfere with anything for me or my family.

The signs and symptoms of distress that are displayed by those exposed to trauma, and the thoughts and feelings they report are so universal that it's easy to forget that this experience, like all experiences, is rooted in culture. Culture is the lens through which we see absolutely everything, and sometimes that changes what we see or how we see it. We tend to assume that the way we see things is the "normal" way, particularly if the culture we come from is dominant in our society. This is where the listening side of crisis intervention is so important.

It is not uncommon at all for me to hear, as I work with traumatized people, some discussion of whether or not there will be an open casket and how important having one is to the person and their sense of this being a "real" funeral. I know my job is to hear that distress, normalize it, and help the person cope with it. I try to say, "It sounds like having an open casket is very important to you. That makes sense, because it is part of how you understand death. Not having one takes this abnormal situation and makes it even more abnormal for you."

It is not my job, nor should it be anyone's job, to say, "You don't really need that. My family never has open caskets." Yet I also know that, during a group intervention, what I say will be heard by everyone in the group, so I also don't say, "Yes, having an open casket is very important for closure." Who knows what the next person in the circle is used to, or how that will or will not alienate them from the intervention and their sense of trust in me. On the other hand, I have been in interventions where my partner said just that, and it makes me cringe -- not for myself, I can handle it -- but for anyone else for whom closed caskets are the norm.

I don't mean to criticize my colleagues -- we all do the best we can. But how many other things come up in interventions that I, or they, treat as "just normal" when they're really cultural? It's something to think about. I guess Quarterbacks are only human, too.

In today's New York Times, Donald G. McNeil, Jr. wrote a piece entitled, "The Sea Still Claims, but Not for Eternity." In it, he notes the huge differences between the disappearance of Amelia Earhart and the disappearance of Air France Flight 447. He begins with this belief-defying statement:

Watching Brazilian divers haul up the gleaming tricolor tail of Air France Flight 447, one can’t help but wonder what happened to the romantic notion that countless guitar-pickers have celebrated in “Amelia Earhart’s Last Flight” since 1939, two years after she went missing somewhere in the South Pacific. Doesn’t anyone just vanish at sea anymore?

The Quarterback had to read Mr. McNeil's column three times before she could fathom that he really is saying what he seems to be saying. He is lamenting the fact that no one disappears without a trace anymore. He is saddened that bodies are being recovered. He writes, "Not to deny the sadness of so many lives lost, but the abyss suddenly seemed more like a subway grating." His only nod to the possibility that finding remains might be a positive thing is in the last paragraph, when he quotes Charles Lindbergh's widow, who said, "There is a huge terrible difference between 'dead' and 'lost.'"

When there is a well-publicized tragedy, such as the crash of Flight 447, we as a society have a morbid fascination. We talk about how horrible it is, how frightening. But we also seem to lose sight, in the statistics and numbers and news coverage, that these are real human beings. Flight 447 carried 228 human beings. Every one of them left behind someone who loved them, and 184 of those families, sweethearts and friends are still waiting for their bodies to be recovered -- only 44 have been.

Watching from the sidelines, it's easy for us to say, "Look, we now know the plane went down. No one could have survived, so why does it matter whether the bodies are found?" Well, it does matter. For families and loved ones, recovering remains is a very important step in accepting the death, processing the trauma and grieving the loss.

Disbelief is an almost universal response to traumatic loss. Sometimes people say, "It can't be true" or get angry at the person who tells them for lying to them. Sometimes it takes the more subtle form of not being able to process the words that are being spoken. People ask the person bringing the news to repeat themselves, sometimes several times.

As long as bodies are not recovered, it gives the brain one more detour to take in accepting what has happened. "Never giving up hope" sounds good in the movies, but in real life, clinging to false hope prevents you from doing the psychological and emotional work you need to recover from the event. You can't recover because as long as your mind holds out a glimmer of hope, the event is never over.

When crisis teams respond to traumatic events, we plan by thinking about the 5 T's: Trauma, Timing, Target, Team and Theme. Trauma is the event -- what happened? Timing is when the response should happen -- is it over, and are people ready for help? Target is which group(s) need the help. Team is who is going to respond. Theme refers to what the team should expect in terms of aspects of the event that are particularly troubling to those impacted.

If the Monday Morning Crisis Quarterback were responding to the families of Flight 447, you'd better believe we'd be talking about missing remains as a Theme. When the team asks, "What is the worst part of this for you?" not knowing exactly what happened or where the bodies are is going to come up.

So the Quarterback is terribly sorry to burst Mr. McNeil's bubble, but trauma trumps romanticism. It may not be the stuff of country songs or romantic novels, but the Quarterback hopes all 228 bodies are found. The families need that a lot more than you need to be able to sigh at the idealistic notion of "lost at sea."

In the medium-large school district where I work, the CISM teams typically do one or two major responses in a year. We do lots of smaller ones -- helping out when a teacher or parent has died after a long illness -- but only the occasional biggy. By biggy, here, I mean the true trauma -- an event that throws a whole school community or a whole district for a loop, scares parents, upsets children, and renders staff unable to work. We are lucky enough to be in an area with a relatively low crime rate, and so major incidents involving our schools are the exception, not the rule.

That continued to be true until this past winter. Things started out slowly enough. A car accident right around Thanksgiving killed an elementary student, and the responsible team was dispatched to help that school and its parents, children and staff, as well as a neighboring elementary school where the student attended. It was tragic and traumatic. And, unfortunately, this sort of thing just happens. Soon, things returned to the new normal.

In January, a student at one of our high schools collapsed in the hallway outside of his gym class and died. This is huge. This is, to a school, what a line of duty death is for first responders, and it hit the school and community hard.

That same week, a student at another high school was found unconscious in a snow bank in the next town over. Her boyfriend had allegedly hit her over the head with a hammer. She died a week later.

Two weeks later, a mom at one school who worked in the lunch program at another failed to pick up her child from after school childcare. She was found dead in her apartment, allegedly strangled by her boyfriend.

The next day, a student jumped off an overpass headfirst onto the highway. By this point, there truly was no team fully available to respond. Despite having 30 trained CISM responders and dividing the responsibility, we were all burnt out. We called for mutual aid from the county, and we asked ourselves what on earth was going on.

Our city has a homicide rate of less than one per year, but there had been two domestic violence homicides in two three weeks. Our schools have two big tragedies a year, and we had had four in less than a month.

And it wasn't just a bad run for our school district. The county team began responding to suicides in the community and trauma in neighboring school districts at an increased clip as well. What could account for the feeling that our county had suddenly stepped into a black hole?

My answer is simple. To quote Bill Clinton, it's the economy, stupid. My district is not only in the middle of a relatively low crime, high income area, it's also in the middle of Michigan. And while our county has about the same unemployment rate as the rest of the country, we are used to having a much lower one, and the state as a whole has the highest unemployment rate in the country. Engineers and pharmacologists have been laid off left and right from the big 3 automakers and from Pfizer, which moved a major plant out of town. Auto suppliers were next to take a hit, along with the support staff -- from custodians to coffee shop owners -- who suppored Pfizer. We went into recession two years before the rest of the country, and the light is not at the end of the tunnel.

The most naively obvious connection between the economy and tragedy is that suicide rates go up when the economy is bad, because people who are in economic straits feel hopeless. This theory is widely accepted but not without controversy. But that hardly explains all that happened in our district or community. It's a little more nuanced than that.

First of all, there is, unfortunately, a baseline rate of tragedy in the world. Our district had a couple of big traumatic events a year before the economy tanked, and a bad economy certainly doesn't make that any better. We are starting from a basic level of trauma that will always happen. Arguably, we then add on a certain number of adult suicides from people who are unemployed.

But the economy has other, more subtle, effects on the rate of traumatic events. People with a propensity to violence, placed under stress, become more violent. Children at risk for suicide attempt it when their parents lose their jobs. People drive instead of flying, which is more dangerous on a per-mile-traveled basis. People neglect their health care. People are more likely to steal, which endangers and potentially traumatizes others. And events that would be awful under normal circumstances take on an added burden when families must struggle to pay for hospital or funeral expenses.

In short, the economy has everyone standing at least a little closer to their personal "edge," so it takes at least a little less to push them over. And of course, in a tight economy, money for crisis intervention is one of the first things to go. The Quarterback hopes what she does will be obscure but well funded again sooner rather than later.

Well, it finally happened. Yesterday, the World Health Organization moved the Pandemic Alert Level to 6 (pandemic underway), in honor of a huge increase in H1N1 cases in Australia, which is in flu season. Perhaps the most remarkable thing about this is that it wasn't anywhere close to the top story in yesterday's news. Think back to the first week of May, and what would have happened if the alert level had gone to 6 then.

In the beginning of May, we were all in a complete panic here in the U.S.. Now we seem to be uttering a collective yawn. What happened? And why couldn't we have been so laid back 6 weeks ago?

The biggest difference for folks in the U.S. between now and 6 weeks ago is that, having lived with H1N1 in our midst for a month and a half, we have realized that we are not all going to die. On May 1, we were not so sure. Between the time that "swine flu" came to the U.S. and yesterday, we learned a lot of information: that the seasonal flu kills 36,000 Americans every year, so a few deaths was not a big deal by comparison (although clearly still a big deal to those patients and their families); that H1N1 in the United States turns out to have a death rate of less than .1% of cases, which is the rate for a typical seasonal flu; and that "pandemic" actually doesn't have anything to do with the severity of the disease.

You might argue that we had to live through the last 6-8 weeks to really believe that this wasn't that big a deal, but I'm not sure that's true. This is a situation where folks in authority managed their message so well that they didn't actually give us what we needed.

If you watched TV, listened to the radio, or read e-mail the last week of April or the first week of May, you heard the lockstep mantra: don't panic but do be concerned, wash your hands often, stay home if you are sick. I got emails from my school district as an employee, and from that same district as a parent. I also heard from the local health department, the state health department, the CDC, the WHO, my congressman and President Obama. And all of that was good, but it wasn't enough, as evidenced by the fact that people were flooding emergency rooms, demanding that neighbors who had been to Mexico be quarantined, and even, in one case, asking why we were still serving tacos in our lunchrooms (really, the Monday Morning Crisis Quarterback never lies!)

The problem was that we didn't really understand what was going on. The data about flu mortality rates and how this compared to the typical flu came out achingly slowly, and was not well publicized. Joe Biden's "off the cuff" statements that we shouldn't even be taking the subway didn't help.

Good information was hard to find. Each health organization was reporting statistics to the next one up the chain once a day, but not every one was reporting at the same time. The result was that the CDC might report at 11 AM EDT on Tuesday, but the data they reported from Michigan might have been reported to them Monday at noon. In turn, the WHO, upon getting the CDC's report, might well wait 12 or more hours to update their data. The result was that the WHO might be reporting cases from Michigan on Tuesday morning, almost 48 hours later than Michigan published them. Speaking of Michigan, in the Quarterback's fair state the Department of Community Health was releasing press releases that did not match what was on their website, so if you heard something on the news and wanted to learn more, you would go to the website and discover that what you heard did not appear to be true. I'm sure other jurisdictions had their own problems.

The result of this was that the most up to date place to get information was Wikipedia, which is probably not where most public health officials want people to be getting their information. And the mantra of "don't panic" lost credibility, because it was so obvious that the factual information was jumbled that it seemed likely the information about the severity of the situation was also jumbled.

Then, of course, there was the issue of what the United States was doing to respond. If you went online looking for information about pandemic influenza preparedness, you might well have found this chart. If you look at it carefully, you will note that "first human case in North America" is U.S. Response stage 4, which maps to WHO alert phase 6, which is a pandemic. But we were only in alert phase 5. Why?? Because the U.S. stages presumed that the disease would emerge in Asia, and were fairly useless for a Mexico/U.S. outbreak.

In the end, though, the most important problem that kept us from hearing "don't panic" was the complete and utter failure on the part of public figures to acknowledge that we were already panicking. There is an idea out there that if we manage the factual message, people will manage their emotions, and that if we acknowledge the emotions we cause people to be emotional. In CISM, however, we find that the opposite is true. Acknowledging the emotional response, normalizing it, and letting people know that it's understandable lends credibility to everything else you say.

In the long run, it may not matter. However, if H1N1 comes back around in a more virulent form next flu season, the Quarterback hopes that the CDC has more credibility in getting us take it seriously than it did in getting us not to panic this spring.

The Quarterback is looking forward to not having anything to write about in terms of crisis in the news. The Quarterback is also not holding her breath.

When Critical Incident Stress Management (CISM) teams respond to a traumatic event, we often visualize the response in terms of a number of concentric circles. At the center of the circle are the people who were most directly impacted by an event -- the ones who saw it and heard it and experienced it. Each successive circle is a group that was impacted by successively smaller degrees. These might be first responders, people who were evacuated, families, friends, etc. Some events have just a few circles, and some have a ton. The CISM team plans different responses for different groups, based on their exposure to the event and how much impact they are feeling.

Today, the Quarterback takes a look at one of the outermost circles of the shooting yesterday at the museum in Washington, D.C. Yesterday, a man walked into the foyer of the United States Holocaust Museum and opened fire. Security Guard Stephen Tyrone Johns is dead, and the alleged shooter is in critical condition. The suspect is an 88 year old man who is a known white supremacist, anti-semite and conspiracy theorist.

It's not hard to identify the innermost circles: the other guards, the first responders, the patrons who witnessed the shooting, the people who were in the museum, the pedestrians on the street, the families of the guards, the families of the patrons, etc. Out towards the edge of the circle, somewhere between all of these ones and the American public as a whole, lies the American Jewish community. In the interest of full disclosure, I am a member of that community.

You might expect those of us who were not anywhere near Washington yesterday and didn't know anyone on the scene to be just plain angry. And certainly a lot of American Jews are angry and/or sad. But I'd venture a guess that I am not the only one experiencing some mild symptoms of what is known in the trade as "secondary trauma."

Secondary trauma is a term most often used to describe the effect on trauma interventionists and counselors of listening to descriptions of other people's trauma. Not surprisingly, if you listen to enough grisly stories and don't or can't unload the properly, it is going to get to you. In this instance, the trauma being suffered by American Jews is a little bit different. In fact, you could probably argue that it isn't secondary at all. It's "it could have been us" or "we could be next" trauma.

You have probably experienced that kind of trauma yourself. Most Americans did after 9-11. It stems from the realization that someone came to kill people just like you simply because they were just like you. I said several times yesterday that I took this attack personally, and that's because it was intended personally. And of course, it was intended to traumatize and to frighten, and in that sense, to whatever degree, it worked.

If you read the Quarterback's post yesterday, you know that trauma that is played out in the media and politicized is that much harder to bounce back from. That is part of the signs of distress the American Jewish community is experiencing now. While we appreciate and support the expressions of sorrow, outrage and support, there is also that feeling, so often expressed by trauma survivors, that others just don't "get" what it's like for us. And, as CISM responders tell survivors all the time, it is true that others don't get it, and that's ok. We all experience life from our own perspective.

So, what is the intervention for the American Jewish community? What should some CISM team be doing for us? The Quarterback recommends some version of a Crisis Management Briefing (CMB). In a classic CMB, a community comes together to hear the facts of the situation and the details of the investigation from the proper authorities and to learn about signs and symptoms of distress that they may experience following the incident. In schools, we use this with staff after an incident at school or in the school community, and sometimes with parents who want reassurance about what is going on for their kids.

There is no reason, however, that a CMB has to be done in person, and so I would suggest that leaders of Jewish institutions (and I know some of them have already done this) reach out to their constituencies via email and/or websites. The message can be fairly straightforward:

As you know, _____ is what happened. The latest information we have from ____ source is _____. We will keep you updated. It is very understandable that many of us, in addition to anger and sadness, are feeling scared or upset on a personal level. This is to be expected when an attack is aimed so squarely at our community. Some of you might be experiencing symptoms such as feeling irritable or having trouble sleeping. Please take care of yourself: find someone to talk to, or call _____ to talk to us. Take time to do something relaxing for yourself. Try to eat well and get some rest. Your symptoms should subside in the next several days. If they don't, please contact us or the mental health professional of your choice for some assistance.

The funny thing is, by far the most powerful statement in this communication is the simple phrase, "This is to be expected." Ninety percent of trauma response is educating people so they know they aren't crazy, or, as we prefer to say, "This is the typical response of normal people to a very abnormal event."

And of course, the Quarterback hopes that this truly continues to be a very abnormal and isolated event.

As you know, unless you've been living in a cave somewhere, Dr. George Tiller was murdered near the entrance of his church two Sundays ago. If that doesn't ring a bell, perhaps I should remind you that he was a doctor who performed late term abortions, and that the man accused of killing him is an anti-abortion activist.

So, here's what I'm not going to do. I am not going to discuss the pros and cons of abortion or wade into the politics or the moral equivalency or any of that. Others have done that much more eloquently than I, and I will leave it to them (for the best thing I've seen commenting on Dr. Tiller and his work, I invite you to read the sermon preached last Sunday at the Cathedral Church of Saint Paul in Boston by the Very Rev. Jep Streit, posted at http://www.poormojo.org/pmjadaily/archives/027002.php). What I am going to do is think about what George Tiller's family must be dealing with right now.

First off, what we have here is a traumatic death. It leaves grief, because a loved one has died, and trauma because it was sudden and scary. I don't know if he had family members in church that day or whether the news came by phone or a knock on the door, but at some moment his wife learned that she was now a widow, and most likely had the sensation that the world had come to a screeching halt.

As I discussed yesterday, one of the predictors of stress reaction is whether the person perceives that he or she is going to die. Certainly if Jeanne Tiller was in the church that would add to the trauma. What she saw and heard will directly impact her experience, because sensory exposure is also a predictor of stress reactions. But regardless of where she was or how she heard the news, what she experienced was much more than a loss, it was a trauma.

One might argue that it wasn't unexpected. After all, Dr. Tiller had been shot once before. He had bodyguards and security systems. He knew there were people who wanted him dead. But knowing it's coming can only inoculate people from the trauma a certain amount. It doesn't make it easy.

What makes this situation even more complicated, however, is the circumstances and motive surrounding it. Unlike most traumatic deaths, this one is actually causing people, sometimes in so many words, to publicly, openly and constantly discuss whether the victim "deserved" it. Now, most people aren't using that word, nor should they. But the constant discussion of the work that Dr. Tiller did and whether or not it was justified in some sense has that effect. Perhaps I could best illustrate this by way of a counter example: if (God forbid) I were to be murdered tomorrow, the news would mention that I am a school Principal. But it probably wouldn't spend a whole lot of time discussing whether my school is a good one. That complicates things.

Then we add on the fact that the alleged perpetrator is doing media interviews. In an interview with CNN yesterday, the accused gunman expressed joy that Dr. Tiller's clinic was going to close, and while he did not confess to the killing he made it clear that he was not sorry Tiller was dead. One of the things that relatives of traumatic death victims tell us is that they experience guilt that it wasn't them who died and anger that it wasn't somebody other than their loved one. In this instance, the interviews have to be compounding that sense of anger -- George Tiller is dead and his alleged Killer is basically dancing on his grave.

Whenever someone is murdered or dies by the act (either commission or omission) of someone else, the investigation and trial prolong the stress reaction. You can't really process a critical incident until it's over, and the investigation means it isn't over. How much worse must it be that this investigation is, in essence, of the victim as well as the crime, where the accused is answering the perennial question "why" with what to him is a justification, and that all this is happening in the national media.

I can only hope that the world lets the Tiller family process this trauma sooner rather than later. Only then can they move on to processing their grief.

As predicted, news gets in the way of my well-crafted plans!

Today, Congress starts hearings on the so-called "Miracle on the Hudson," the landing of US Airways flight 1549 on the Hudson River on January 15, 2008. Congress apparently wants to know what went wrong (e.g. why did geese bring down a plane?) and what went right (e.g. how did the plane manage to land on the river successfully and everyone get off with only one serious injury and no deaths).

This is a great opportunity for the Monday Morning Crisis Quarterback to review this incident from a Critical Incident Stress Management point of view. It's important to note that I have no idea what services were offered to the crew or passengers following this incident. I have to imagine the crew got something from the airline, although I do know that US Airways, because it is not hooked into the Association of Airline Pilots, did not get support through their CISM team.

The thing that might surprise you (or maybe it doesn't) is that, according to news reports, both the crew and the air traffic controller who was responsible for the flight suffered serious traumatic stress symptoms following this incident. The flight attendants reported not being able to even consider putting on their uniforms afterwards. One didn't return to work for a month or more and another, who was the injury on the flight, didn't return at all.

On the face of this you might be surprised that someone could be traumatized in an incident where nobody died. But, in fact, someone actually dying isn't all that great a predictor of traumatic stress. What is a good predictor, however, is the individual believing that he or she was going to die. And certainly the crew had every reason to fear that they were about to die. Water landings are not generally successful. That's why this was the "miracle on the Hudson." And even if the crew had hope they would make it, the notion that someone was going to die had to have been on their minds.

It's entirely possible their stress symptoms would have been worse if someone had died, but not necessarily. One of the key questions we ask in CISM is "what is the worst part of this for you?" and the answers are sometimes surprising. What really sticks with one person is not what sticks with another.

Another interesting case here is the air traffic controller. I heard an interview with him on the radio recently, and he pointed out that while everyone else was celebrating the successful landing, he was off in a corner thinking he had just lost a plane. The last thing he heard was Captain Sullenberger telling him they were going into the Hudson. That's not good. He had responsibility for all of 145 passengers on board and all of the crew, and as far as he knew they were dead. He said he actually didn't believe it when someone told him they had made it. Again, the stressful issue wasn't what happened, it was what he believed was going to happen.

I have to imagine that the recovery of all of these folks was complicated by the fact that they were being celebrated as heroes. On the one hand, they deserved the praise. On the other hand, they probably weren't feeling like heroes, they were feeling like a quivering mess. And no one expected them to be having trouble, which makes it harder to get the support you need. I hope they got it, and I hope they're doing well. They did a great job, but that doesn't make it easy.

As an aside, I note in the CNN story that Congress is having only one passenger testify, and that they found many conflicting accounts from the passengers about what happened. This in itself is a stress symptom. All of these passengers, who also believed they were going to die, focused in a very tunneled way on what was important to them. Time slowed and they lost focus on what they perceived as extraneous events. They aren't dumb, they aren't lying and they don't have bad memories, their brains just did not encode all of what happened properly. That's a defense mechanism -- anything that wasn't important to keeping them alive got pushed aside. I hope these folks got some CISM support as well, if only to let them know they're not crazy.

We've all heard of a Monday Morning Quarterback. They're the folks who stand around the water cooler the day after football Sunday and expound on what the team should have done.

Well, I'm not much of a Monday Morning Quarterback in the traditional sense. I don't watch much football and I don't know whether the team did what they needed to do or not. Any expounding I do on Monday has to do with the ads that ran during the SuperBowl. But that's another blog.

This is not the Monday Morning Quarterback blog, it's the Monday Morning Crisis Quarterback blog. In this blog, I will be expounding on the various critical incidents and traumatic events in the news and how they are being handled from a mental health point of view.

Like most Monday Morning Quarterbacks, it is much easier for me to give advice looking backwards than it is to respond to a crisis as it is unfolding. I have only the utmost respect for those who choose crisis intervention as their life's work, and for those who have crisis intervention thrust upon them without any training or preference on their part at all.

It is the nature of traumatic events that, if we're lucky, any one person will only have to deal with a couple in their lifetime. That makes it hard to learn from our past experiences and use them to do better in the future. And yet, that is the nature of true learning. So what are we to do? Those of us who care about -- or just worry about -- crisis response must learn from other people's experiences, so all of us can stand on each other's shoulders when our own "big one" comes along.

My plan is to write in the next post or two about the global response to H1N1 -- again, looking at it from a critical incident stress point of view. Of course, if something happens in the news that could change my plans. Stay tuned.