Monday, August 31, 2009

The Station Fire

More than 105,000 acres are on fire in Southern California.  For those of us from relatively wet regions of the country, this seems unbelievable.  For those of us with children with a particular fear of fire, it's horrifying.  For a firefighter and their family, it's a source of some ambivalence.

Firefighters become firefighters because they want to fight fire.  It sounds silly when you put it that way, but often we forget.  No one trains for this who doesn't get something out of it.  Jeff Mitchell (whose brother, Doug, is a fire fighter) says you have to be crazy to do it.  The natural reflex of any sane person is to run out of a burning building -- these guys run in.  So many firefighters across the country are looking at the Station Fire and wishing they were there.  Some of them are getting their chance, as firefighters from neighboring states are being called in.

On the other hand, firefighting is only enjoyable when everything comes out right.  Nothing beats the rush these guys can have when they beat back the flames and save a house or a life and no one gets hurt.  But when one of our nation's bravest dies fighting a fire, every firefighter in America feels the loss, and every family member of a firefighter takes a blow to the gut.  Two firefighters out of Los Angeles have died in the Station Fire already.  When this is over -- which isn't predicted to be for one or two more weeks -- that's going to be a hard truth to cope with for the others in their own company, the other fighting this fire, and those who just know it could have been them. 

Reading the coverage of the fire, the inklings of what the themes of an intervention on this event might be are starting to emerge.  Right now there are five people trapped by the fire because they did not comply with mandatory evacuation orders.  Not only did they put their own lives at risk when they made that choice, but they also put the lives of the firefighters who now must try to get to them on the line.  I can't imagine there isn't going to be anger about that, particularly if someone gets hurt or, God forbid, dies trying to get them out.

CISM teams most often help with incidents that happen very close to home.  Right now, CISM teams all over the west are getting ready to intervene with firefighters caught in a critical incident in another state -- some of them may be deploying there right now.  And CISM teams may be hearing about the Station Fire all over this country, as fire departments everywhere watch, wait, and mourn two of their own.

Sunday, August 30, 2009

Ask the Question: Suicide in the Workplace

This week's edition of Business Insurance notes that last year there was a 28% increase in the number of suicides completed in the workplace in the United States.  While the numbers are still relatively small -- 251 last year -- the rapid increase is really alarming.  Can you imagine if I told you that cancer rates had gone up by 28% last year?  We'd all be terrified.

However, as you know, I'm a stickler for putting these things in context and so I did some digging to see what other workplace causes of deaths look like in general and looked like last year.  On the one hand, the number of workplace suicides is miniscule compared to the number of deaths from all causes in the workplace in 2008.  Last year, 5,071 people died at work.  You were far more likely to die in a fall at work or by something falling on you than you were to complete a suicide at work.  You were even more likely to be killed during an assault (keeping in mind that this also includes police officers on the job).  Suicides accounted for just about 5% of workplace deaths.  It's also important to note that in 2006 (the most recent year for which statistics are available) there were more than 33,000 suicides in the United States, so workplace suicide is still a tiny fraction of suicides overall.

On the other hand, the year before, suicides accounted for just 3.5% of workplace deaths.  In fact, while suicides went up by more than a quarter, workplace deaths on the whole declined by more than 10%.  So I do think this is worth paying attention to.  Look at it this way.  At your job, which do you think your employer has paid more attention to preventing, employee death in a fire, or employee suicide?  I'll bet you anything it's fire.  But there were more than 30% fewer workplace deaths by fire last year than there were completed workplace suicides.  In fact, there were probably fewer deaths by fire because employers and governments spend so much energy trying to prevent them.

When people complete suicides at work, they usually are sending a message about work.  People who don't have particular issues with their jobs or workplaces do not generally kill themselves there.  So if the suicide rate is going up at work, that tells you that people's stress level around work is also going up.  In other words, as I've said before, it's the economy.  You are more likely to complete a suicide at work if you are about to be laid off, are afraid you are going to be laid off, are mad because others have been laid off, or are stressed by having to do more with a smaller staff.

Unless your occupation has a particularly high rate of suicide (e.g. law enforcement or military), and sometimes even if it does, chances are that your employer does not have any systematic suicide prevention programming for employees.  You may have an Employee Assistance Program (EAP), and if your supervisor is worth her salt she refers people to it from time to time.  The problem is, referring people to EAP is a far cry from actually getting them to get help.  If the workplace is where the issue is noticed, then there needs to be some way for the workplace to do something.

In the absence of some more formal system to prevent suicide among the workforce, here's something you can do at work tomorrow if the need arises.  Ask the question.  If you have a coworker who seems down or depressed, ask them if they are considering killing themselves.  People are afraid to do this because they are afraid it will give the person ideas, but no one has ever gotten the idea to kill themselves solely from someone asking them.  You aren't going to cause any harm.  And if they say yes, they need to be seen at a psychiatric ER right away.

Anecdotally, it appears that the suicide rate overall rose last year.  Statistics are spotty, but they exist for certain locations and segments of society.  Suicides are up in the military, among veterans and  in national parks, and there is speculation that the suicide rate was up among the middle aged.  We are at war, we are in financial straits, and things aren't looking very far up.  Now would be a good time to start taking care of each other a little better.

Big thanks to Nick Arnett over at Bay Area CISM ( for the lead on this story.  Big ups to Business Insurance for pointing out that worker suicides must be followed up by CISM services.

Saturday, August 29, 2009

H1N1: When the News Isn't Scary, They Just Make it Up

The World Health Organization came out with its latest overview of H1N1 on Friday. Unlike many previous reports, this one didn't take the American media by storm. I suspect that has a lot more to do with the news cycle and funeral coverage for Senator Kennedy than anything else. The report is interesting to read, because, as one would expect, it takes a global perspective. It starts with an overview of recommendations for heightened surveillance and preparedness by regions of the world, and our region is about what we've heard before.
WHO is advising countries in the northern hemisphere to prepare for a second wave of pandemic spread.

OK, so we're preparing. But what else is in this report?

Mostly, this report is an overview of where we are and what countries in the southern hemisphere have experienced during their flu season. So you might think that American blogs and news organizations, if they covered it at all, would have headlines like WHO Shares Lessons Learned on H1N1. OK, you probably don't think that, but only because you know that American writers do not cover at all what they cannot sensationalize.

From a document of 1,087 words, writers have almost unanimously seized upon the following 134:

Severe respiratory failure

Perhaps most significantly, clinicians from around the world are reporting a very severe form of disease, also in young and otherwise healthy people, which is rarely seen during seasonal influenza infections. In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays.

During the winter season in the southern hemisphere, several countries have viewed the need for intensive care as the greatest burden on health services. Some cities in these countries report that nearly 15 percent of hospitalized cases have required intensive care.

Preparedness measures need to anticipate this increased demand on intensive care units, which could be overwhelmed by a sudden surge in the number of severe cases.

OK, so reasonably one could expect from this a headline that says something like WHO Urges ICU Preparedness for H1N1. After all, that is what this section of the report is about, and it is very much not about people dying from severe H1N1.

But of course not. A sampling of headlines from around the net includes:
I think it's important to reiterate here what the WHO warned about. They didn't warn about the severe form of the disease itself. They warned about the burden on the medical system. I particularly like this headline: Doctors Question WHO's Severe Swine Flu Warning: Some say while severe flu exists, warnings may be overblown. I have to ask whether it's the warnings that are overblown or the coverage of them.

In related news, a new poll shows that the public's fear about H1N1 is growing. I hardly think this is a surprise. Perhaps if the media was not so hell bent on scaring us and actually shared the facts and the correct interpretation of those facts, we might have a fighting chance of reacting rationally. Yes, we're scared. And we're still going to be scared, even without sensationalism. But if it's all the same to you bloggers and journalists out there, we really don't need their help getting more scared than we already are.

Friday, August 28, 2009

Hurricane Katrina and the Help That Never Came

Where were you four years ago? This is an easy one for me, since I was home with a three month-old baby watching "overblown" news coverage about this hurricane that was heading straight for New Orleans. The predictions seemed outlandish. Flooding of an entire city? Don't be silly. In the days that came, my son and I continued to watch as the Convention Center in New Orleans where I had given a talk just a year before filled with people and the spokespeople in Washington incredibly said they were unaware that anyone was there, because they had been told not to go there.

The delay in rescuing the people of New Orleans was a national shame. The delay in restoring essential services got less attention, but was no less appalling and no less a failure of our society to care for those in need. There was another delay, though, that is more understandable. That is the delay -- or absence -- of mental health assistance for those whose lives were demolished by the storm and by the lack of help that followed.

In the days directly after the storm, people's basic physiological needs were not being met. It would have been totally inappropriate to go talk to people who are crammed into the Superdome or the Convention Center without basic food and sanitation about how they are feeling. Anyone who had the time and ability to do that should have been, and mostly was, getting people to safety, feeding them, and finding them someplace to stay.

The rule of thumb is to provide early crisis intervention services when the situation is stable and the incident itself is over, as close as possible in time and location to where it happened. But because of the way this disaster played out and the delays in assistance for physical needs, there was never an obvious opportunity to do that. It took many months, if not years, for many who had weathered the storm to be in a physically stable situation. By the time they were, they were literally scattered all over the country. CISM is designed for people who have been through hell and are now returning to a world that is basically still normal, but they don't feel normal. The world was never "still normal" for many Katrina survivors.

That is not to say that no one ever got help. Those with the most extreme manifestations of Post-Traumatic Stress Disorder are still being served by the mental health system. CISM is not designed to prevent PTSD, so I won't argue that earlier intervention would have made a difference. However, studies of PTSD in Katrina victims show that increased watching of news coverage following the storm was associated with risk of PTSD symptoms, and between 38% and 50% of people who lived in New Orleans when Katrina hit have or had symptoms of PTSD. The only thing I can imagine might have been done early is to advise people not to watch TV. That probably wouldn't have worked.

By the way, it's not that no one got CISM services after Katrina. Teams from around the country were mobilized to work with rescue workers following the storm. They had the possibility of coping with this as a discrete incident. Most of the residents never did.

Thursday, August 27, 2009

Waking Up From a Nightmare You've Gotten Used To

It is hard for most people to even imagine, but let's try.  Your daughter is 11 (this part is easy for me, since my daughter actually is 11).  She leaves the house to walk to school, and you stand on your driveway, watching her as she goes.  When she's about a quarter of a mile away, you see a car pull up next to her and someone pulls her inside.  The car drives away before you can get there.  No trace of her is ever found.

This is a nightmare for any parent.  It would take a tremendous amount of assistance and intervention to return you to any kind of functioning.  You do not "get over" something like this. 
The fact that your daughter was never found means that accepting that she isn't coming back is going to be that much harder and take that much longer. Eventually, you find a space for this reality in your mind, and you reach a "new normal."

Then one day, 18 years later (it happens to be the day before what would have been her 29th birthday), the phone rings and you hear something you can't believe.  A woman has walked into a police department and told them she is your daughter.  Two people are under arrest for kidnapping.  You have woken up from the nightmare.

Obviously there is much to celebrate in the reappearance of Jaycee Dugard in California on Wednesday, 18 years after her abduction.  It certainly is preferable to the more common alternative, where what is finally found is only remains.  At the same time, I strongly suspect her parents and she are going to experience some mixed emotions in the days, weeks and months ahead.

Jaycee's parents somehow came to grips with her being gone and built their lives on the notion that she wasn't coming home.  It was imperative for them to do this, because it was the only way they could reclaim their lives.  Now, they're going to have to readjust back.  One presumes that will be easier, but that doesn't make it trivial.  They have missed 18 years of their little girls' life.  They can't pick up where they left off with her.  Whatever guilt they had about not being able to save her in 1991 is going to come back, compounded by whatever residual anger Jaycee brings with her as an adult.

I am thrilled for the Dugard family, and I know they are truly thankful for this miracle.  I just hope that everyone gives them -- and they give themselves -- the space to have some mixed feelings moving forward, and the time to resolve them as best they can.

Wednesday, August 26, 2009

When Your Hero Dies

At the end
of June, I blogged about the death of Michael Jackson and how it wasn't a crisis. About three seconds after I posted it, I got my first inkling that I had perhaps not taken the correct tone in my post. It's not that Jackson's death, for most of us, was truly traumatic, but my tone trivialized what he meant to so many people. Over the summer that point has been driven home to me over and over.

What I now understand is that, as a white woman with no particular love of pop music, I had no particular attachment to Michael Jackson, and I failed to realize that trivializing his death wasn't just trivializing people's grief, it was trivializing the racial and cultural experience in this country. I want to truly apologize for that. A death that is not traumatic is nonetheless a death, and grief is grief. I have been struggling for several weeks to figure out how best to bring this up, and today seems like the right day.

I say that because I was born and raised in a staunch liberal household in Massachusetts. Senator Edward Kennedy was an icon of my childhood. In 1980, I was old enough to be active in politics, and I supported Kennedy. My older brother worked in his Boston office one summer. He was what I understood a great politician was supposed to be. I was absolutely stunned, when I went away to college, to learn that Kennedy was not as revered elsewhere and that people used him as the joking example of liberalism gone too far. I never did.

Senator Kennedy wasn't perfect, by any means. I also grew up in a milieu where "Chappaquiddick" held the same sort of ominous tone as "Watergate." I was very confused when we spent summers on Martha's Vineyard and a youth swim meet was held in Chappaquiddick -- why would you hold it someplace bad? I knew that Kennedy was a drinker and that he had been kicked out of Harvard for cheating. Later on, I was appalled by his architecture of the No Child Left Behind Act, which in my mind was the worst law ever to come out of pure intentions.

Ted Kennedy also exemplified being able to go on with life despite traumatic loss, which he certainly suffered all too often, and despite the guilt of having caused traumatic death. Some would say that he never felt appropriately guilty about the death of Mary Jo Kopechne. That isn't for me to judge. But he certainly showed that that awful night was not the sum total of who he was, and he did not let it end his hopes for doing good in his life.

Anais Nin once said, "We don't see things as they are, we see them as we are." As a white liberal from Massachusetts, I cried when I heard that Kennedy had died. As African-American males growing up in the 80's, several of my friends cried for Michael Jackson. Neither are traumatic, both are sad. I should know better than to judge others' outpouring of emotion just because I don't see things the same way. I am imperfect, just like Kennedy and Jackson were. I hope that I can show that isn't the full measure of who I am, either.

The work goes on.
The cause endures.
The Hope still lives,
and the dream will never die.

Tuesday, August 25, 2009

Is 90,000 a Lot?

The President's Council of Advisors on Science and Technology came out with a new report on H1N1 yesterday. If you only read the headlines, what you will learn is that 90,000 people could die and 2 million be hospitalized this fall in the United States. I hope by now you know better than to only read the headlines. What the report actually does is posit a "plausible scenario" in which 30-50% of the population becomes infected, 20-40% of the population has symptoms and 10-20% of the population seeks medical care. This could lead to 1.8 million hospital admissions, 300,000 ICU beds used (which could be 50-100% of ICU beds at any one time), and 30,000-90,000 deaths.

The point of the report was to make some particular recommendations to the President about preparedness, and they all sound pretty good to me. I also appreciate the level of context they placed around the numbers they quote, something the press seems to be completely omitting in their coverage. This is in clear violation of Qarterback H1N1 Crisis Communication Commandment #5, "Thou shalt put thy information in appropriate context ." Obviously I lack the level of clout of some other commandment issuers.

The thing that I find most troubling about even the low end of the mortality estimate is the fact that the majority of those deaths will be in people under 50 years old. Children are going to die. And while we may be accepting of deaths among the elderly from influenza, we really aren't accepting of deaths among children from any cause, let alone from the flu. And, of course, the 90,000 number seems really high. But is it? Here are some things to compare it to:
  • 30,000-40,000 people die every year from seasonal flu. The predicted number for H1N1 in this scenario is higher almost entirely because a greater percentage of the population is expected to get sick. That's because few if anyone currently has immunity, and the vaccine isn't ready yet.
  • Over 121,000 people die in various kinds of accidents every year in this country (car accidents, falls, construction accidents, etc.)
  • The top number of deaths in this scenario represents 3 out of every 100,000 people in the United States.
  • If the current ratios of different age groups hold up, about 18% of these deaths will be people under 24, or 14,400 at most. That would represent 1.3 children and young adults out of every 100,000. There would still be more people under 24 killed by accidental injury than by H1N1.
The problem is not that 90,000 is a lot. The problem is that 90,000 is more than we're used to, and certainly more than we're used to for young people. It's as though we suddenly discovered that thousands of children were going to die of Alzheimer's Disease. We know that people die of Alzheimer's, but it shoudln't be these people.

I again find myself imploring the press not to pick naked numbers out of thin air and publish them as headlines. Unfortunately, few in the press corps appear to be listening to their Quarterback.

Monday, August 24, 2009

What If It Is Your Fault?

You may have missed it in all the static that sometimes passes for news, but as Hurricane Bill passed off the Maine coast yesterday, a large group of people watching the resulting surf were hit by a gigantic wave. Three were swept out to sea, including 7 year-old Clio Dahyun Axilrod and her father. Clio died, her father was rescued by the Coast Guard, and her mother was seriously injured. 16 people were admitted to the hospital.

Now, let me ask you to imagine a conversation with Clio's parents. They were with her when the wave hit, and in fact were moving away from the shore because of the danger. There had been warnings issued about the surf. What do you want to say to them? What is your gut instinct?

Generally speaking, people give one of two types of answer. The first is, "What were you thinking, that was an incredibly stupid place to be." The second is, "It wasn't your fault, you couldn't have known." We are very black and white about this sort of thing. I'm reminded of a line the Wizard sings in the musical Wicked:
There are precious few at ease
With moral ambiguities
So we act as though they don't exist

You're either right or wrong, at fault or innocent.

The fact is, the truth in this situation is somewhere in between. Yes, there were warnings about the waves and they should not have allowed their daughter to be where she was. And yes, they could not possibly have known that that wave was coming at that moment, and they were trying to move away.

The fact is also that neither of our natural reactions to this family are likely to be at all helpful to them. "It's all your fault" is hardly the support they need. They can beat themselves up, thank you, without our help. At the same time, "It's not your fault" denies reality, and actually takes away their permission to talk about how they are feeling. If you tell them it's not their fault when they think it is, you're telling them they're wrong. They're not going to want to talk to you after that.

So how do people learn to live with situations like this? How do you go on, knowing that you are at least partially responsible for the death of your own child? All I know is that people do. They make their peace. They come to forgive themselves for their human failings. They try to prevent similar things from happening to others. They turn to their spiritual beliefs about forgiveness and the afterlife. It isn't easy.

We can't tell people how to feel, and trying only makes things harder. The best we can do is affirm that what they are feeling makes a lot of sense, and help them explore what those thoughts and emotions mean to them. As judgmental as we like to be, it's not about our judgment.

Sunday, August 23, 2009

Getting Back on the Horse

The L.A. Fitness in Bridgeville, Pennsylvania reopened yesterday, 18 days after a gunman opened fire on a fitness class, killing 3 and injuring 9 more, and then killed himself. Reports say that the room where the shooting occurred is already being used for classes. The floors and mirrors have been completely redone. Apparently it looks pretty nice.

Upon reading about this, I tried to put myself in the shoes of a member of that club. I tried to imagine going back into that club, into that room, knowing what had happened there. And honestly, I'm not sure I could, not after just 18 days. But at the same time, I know that I go into rooms where tragedy has occurred all the time. As tourists, we often go to see the place where someone famous was assassinated or something terrible happened. My own daughter, who was visiting relatives in Washington, D.C. this week, took a tour of the Ford Theater, where Lincoln was shot.

How can we reconcile the idea that it would be hard to return to a space where someone was killed with the fact that we seek them out without a second thought? Two factors come into play: time and emotional distance. There is no doubt in my mind that it would be easier for me to go to that L.A. Fitness than it would for someone who was injured in the shooting. It's probably easier for me than for someone who is a member but wasn't there that night. I have a cognitive association, but I don't have any sensory connection to that space. When I open up the file drawer on that space in my memory, I have newspaper stories and web photos, but I don't have any visceral associations. What's more, I have no doubt that as time passes that space will become less "loaded" for those who were there.

That having been said, there are probably victims who will never set foot in that building again. When the shooting started, their brains flooded with chemicals that heightened their senses and their memory, a throwback to our days in the wild when it was very important to be able to remember everything that was associated with a danger so you could avoid another one. The sight of that space may well be a trigger for them or, alternately, they may find it distressing that the room doesn't look the same. Over time they may feel better about going there, but maybe not.

The earliest studies on post traumatic stress (which is not necessarily post traumatic stress disorder, remember) were done on soldiers in World War I. They found that if soldiers were removed from the front lines and sent to a hospital for treatment, they were much less likely to return to the line than those who had intervention off the front line but still in the field. Once you leave the place where a trauma occurred, it is that much harder to go back.

That's why, to the maximum extent possible, we always tell people not to send their staff home after a trauma until there has been some opportunity to give them information about critical incident stress and self-care. When they leave when things are still in a state of chaos, that is what they viscerally believe will be there to greet them when they return. When they leave after help has arrived -- help for them-- it's easier to believe that things may be manageable if they come back.

The space where a tragedy occurred holds power, sometimes forever. There was a car accident that killed both parents and a son half a mile from my house four years ago, and I think about it every single time I drive through that intersection. But holding power doesn't mean that power has to be absolute. Healing holds power, too.

Saturday, August 22, 2009

Harrison High School's Football Plane Crash

From time to time I am interviewed for some newspaper or magazine story about school safety. The reporter always asks something like, "What is something schools might not think of to do?" and I always say, "Prepare for the fact that bad things are going to happen no matter what you do, and figure out how they're going to respond." Thus far, no reporter has printed that, because it is not what people want to hear. People in the school safety business, and parents who want their kids to be safe, want to hear about metal detectors and buzzer system and closed circuit TV. They don't want to hear that all of that can't prevent traumatic events from happening at a school.

I bring this up, because last night just after 8 PM, a bi-plane crashed right next to the football field at Harrison High School in Harrison, OH during half-time of a scrimmage, killing two people. Witnesses report that the plane appeared to be heading directly for the field before it did an abrupt nosedive. There is some speculation that the pilot may have intentionally gone straight down when he realized he was going to crash into the crowd of between 1,000 and 1,200 people.

There is no possible way that the school could have prevented this from happening. All the metal detectors in the world cannot keep a small plane from crashing, and they certainly cannot heal the trauma experienced by a high school kid looking up in the sky and realizing there is a very good possibility that he or she is going to die. You can have closed circuit cameras, but they won't obliterate the memory of seeing someone on the verge of death die right in front of you after the crash.

Still, many school districts do not have a plan in place for dealing with trauma on their campus. Most don't even have a plan for the more likely eventuality that someone in the community will die suddenly in a car accident or the like. And after the fact is really not the time to be trying to make good decisions with no guidance and no training. You may be thinking that most schools have counselors or social workers, and that is true. Very few school counseling or social work educator programs have any coursework, and certainly not required coursework, on trauma. And I hope we can all agree that helping kids make a college or career plan is a different skill than talking to them about being terrified they were going to die.

If this happened in my district, we have Critical Incident Stress Management teams to assist. If it happened in my county, and the district knew to make the call, they could call in our community-based team. In my opinion, this is a second choice in this instance for two reasons. First, the community team is going to have it's hands full with people from the families of those who died, the people at the airport, and possibly the spectators who were not associated with the school. Second, on our county team there is exactly one educator (me). Many community teams only have mental health professionals. And really, you want someone who knows schools from the inside to help you figure this out. Peer response isn't just for first responders.

I don't know what the folks in Harrison have done or will do to support their community. I do know that they circled school buses around the scene to limit what could be seen from the field. I also note with interest that they quickly made the decision to continue with the football game despite the fact that the rescue and recovery operation was going on less than a quarter mile away. This probably surprises most people, but it actually was a good idea. As it turns out, because it was halftime the players were busy meeting with their coaches and probably saw the least and hence were the least traumatized. If they can manage to play, continuing with the game is a strong counteraction of the natural feeling of traumatized people that the whole world has just come to an end. It gives people some anchoring in normal life. And, frankly, that soon after the crash no one who was really affected was really ready to talk about it anyway. If they could have managed to get a little crisis management briefing at the end of the game, that would have been ideal, but it may not have been possible.

I greatly feel for my administrator colleagues down in Harrison. Monday is going to be an interesting day at Harrison High School. I hope they're ready.

Friday, August 21, 2009

Why the Press Doesn't Get It

My Sister-in-law, who lives in my old hometown of Concord, Massachusetts, wrote today about the evacuation of the Prudential Center in Boston:
As I sit in the waiting room hearing the reports on the Pru Tower water main break, I'm thinking of the "proper" way to keep people updated. Are there newscaster conferences? Can groups like yours do classes specifically for newscasters to be part of the solution instead of a big problem? Or do they already, and the news people don't listen or show up?

SIL is making an assumption here, which is that newscasters, all things considered, want to do this the "proper" way.  I don't want to say that isn't true, but I will submit to you that that is not their primary goal.

To bring you up to speed, a pipe for the air conditioning system, which runs from water tanks on the 52nd floor all the way down, cracked on the second floor of the Prudential Center, which is the second tallest building in Boston.  Water flooded the mall below, knocked out much of the power and disabled the elevators.  About 2,000 people were evacuated from the building using the stairs, and firefighters had to go fetch some folks who couldn't come down the stairs.  There is water damage on multiple floors (including above the crack) but no one knows how much yet.

There, are you all worried?  Traumatized?  Concerned for the safety of your loved ones who work there?  Probably not.  The fact is that this is a "big" story in that it affects a lot of people in a very well-known building.  But it's actually not a big story in terms of danger or trauma.  It's a big nuisance more than anything else for most people.

So why are the newscasts so breathless? (I encourage you to watch one if you haven't seen them to get a sense of the tone.)  Because the press' number one priority is not to keep people calm.  It is to keep people informed while still keeping them watching.  So they break into the regularly scheduled programming to tell us that this big story has happened, but it's hard to report that something is both important and not a scary situation.  They really only have one model of reporting breaking news, and that is based on situations that are more dangerous, or at least more dramatic, than this one.  And on some level, they are also anticipating that this could become dramatic, or might already be dramatic and they don't know it yet, and if that is true they want to be ready.

As a big story unfolds, the press is trying to report what happened, who it affects, and what will happen next.  The result is that they report the absence of news as news.  They say, "there are no reports of injuries thus far," for example, because people watching want to know if there are any injuries.  But the result of a statement like that is to imply that there could be injuries at any moment.  The elevators are out, so it's going to be a little harder to get those in wheelchairs out, and they report that there are "concerns about the evacuation."  What they mean is that it's not completely straightforward, but what they imply is that it's dangerous.

To answer SIL's question, yes, there are classes that reporters take about disseminating public information.  Some of them are much better at it than others.  But fundamentally, they know you are not going to keep watching the broadcast if they say, "There's some excitement at the Pru, but really it's more of a mess than anything else."

N.B. If you want to ask me a question or suggest a topic for the Quarterback, feel free to leave a comment in the box in the righthand column, or email me at

Thursday, August 20, 2009

The Ghosts of Virginia Tech

On April 16, 2007, a student at Virginia Tech University went on a shooting rampage and killed 32 people before completing his own suicide. Today, the records on the shooter from the Cook Counseling Center at Virginia Tech were released, with permission from his family. These records were apparently illegally removed from the center and only recently discovered at an employee's home.

What the school records show is that this student made some suicidal comments and gestures in 2005 and was hospitalized. They also indicate that he was not homicidal to the best of the Center's knowledge and that they did not believe him to be a current threat to himself or others, although he was depressed and having difficulty with the stress of college life.

I have every respect for the families and memories of those who died at Virginia Tech and for those who were traumatized by living through that experience. I also believe that lessons can and have been learned about campus safety and crisis communication at colleges. But I also have to question what end is now served by rehashing this man's psychiatric history.

As you frequent Quarterbackers all know, our minds go to blame very quickly when we are traumatized. We want someone to be at fault and we want them to have consequences. We want trauma to be preventable so we don't have to feel scared. And make no mistake about it, this shooting scared anyone who lives, works or knows anyone on a college campus.

At the same time, the person truly at fault here was the shooter. We can file lawsuits, change policies and stage inquiries, but human beings fundamentally have free will. Stopping someone who is hell bent on killing and who does not care if he dies too is always going to be devilishly hard. And what's more, no matter where we pin the blame, we will never know if someone doing things differently would have made any difference.

Let me say that again. We will never know if this shooter could have been stopped. In our quest for a feeling of safety and security and to place blame, we cannot achieve what we really want, which is to know this will never happen to anyone ever again. We are, again, reminded that there is no such thing as closure.

What I worry is that people looking back at records like these, knowing how the story ends, will want colleges and counselors and hospitals to clamp down on people who seem to be "like" this shooter. In the case of these particular records, that would probably mean mandatory counseling, hospitalization and/or expulsion for depressed college students who express suicidal ideation and seem to be having difficulty adjusting to college life. That's an awful lot of people, most of whom never go on shooting rampages or even have a psychiatric diagnosis. I count myself among them.

Something happened to this shooter between December of 2005 and April of 2007. We don't know what that was, really, and we can't ever know for sure. It may be that the system failed in this case, and it may be that this could have been prevented. But let's make sure, in our efforts to be more vigilant, that we don't wind up pegging everyone with a bad day as a killer.

Wednesday, August 19, 2009

Tom Barrett's Recovery

Milwaukee Mayor Tom Barrett held his first news conference since being beaten after attempting to get emergency help for a woman and baby near the Wisconsin State Fair over the weekend. I blogged a few days ago about this incident, and about the complicated nature of psychological healing after a traumatic incident in which you are being hailed as the hero. I neglected, however, to talk about the added complexity of things when you are a politician, and everything you say or do is already incredibly complex.

Barrett does some interesting things in this news conference. After he introduces the various members of his family who are there and thanks his wife for being by his side, he introduces his niece, Molly, again and points out how terrific she was in the emergency. Then he goes on to explain why his security detail was not with him. Next, he characterizes the situation as one which any citizen of his city would have responded to in the same way, and then he starts to describe what happened, again pointing out that his niece did just what he did.

I think there are a number of things going on here. One is that this is a politician, and politicians always need to worry about how they come across. He can't be the only hero in Milwaukee -- this has to be something anyone would do -- because that makes citizens feel good about themselves and they associate that food feeling with him and vote for him. Imagine how obnoxious he would seem if he came out and said, "I know I was really brave and heroic, and few would do what I did." That would be the end of his career right then and there.

Another thing you see is Barrett explaining away some criticism -- that he didn't have his security detail -- up front. Part of this, too, is simply that he is a public figure. But part, also, may represent him thinking through what could have happened differently. Just about anyone who has ever been assaulted has questioned if they could have prevented it. I'm sure he has, too.

You also see Barrett talking repeatedly about his niece. This is, in part, because he is a nice person and a good uncle and he wants her to get some credit for what she did, as well she should. Realizing that she acted just as he did also helps all of us, and Barrett himself, focus again on the fact that this was random and that he wasn't doing anything wrong. Again, he has thought through whether he could have or should have prevented what happened. If Molly called 911, and if any citizen would have called 911, then calling 911 was not the wrong thing to do. And yes, I have heard criticism in the last few days suggesting he shouldn't have.

During the Q&A, someone asked what he was thinking during the attack. He replies, "This is really bad, this is really bad." Then a reporter mentions that her viewers are calling Barrett their hero, and asks for a reaction. He says that Molly's his hero. At this point, I have to say I don't think this is posturing or politics at all. This is a man who knows he could have been killed and knows who he has to thank for that not happening. A pure politician would have stuck with "I did what anyone would have done" and maybe claimed that during the attack he was concerned for the safety of his family or the baby and grandmother. This is an honest person who has experienced trauma speaking. It rings true.

But perhaps the part of the press conference that touched me the most was at the very end. In talking about the support he has received from others -- including a phone call from President Obama -- he said it meant a great deal to him because, "This is tough." I don't think he only meant physically.

Below is a link to the full video of the news conference, although you will have to go to Youtube to watch it.

Tuesday, August 18, 2009

The Trouble With "Closure"

The District Attorney in Westchester County has concluded the investigation into the crash that killed 8 people on the Taconic State Parkway in July. The crash was caused when a woman who was reportedly drunk and under the influence of marijuana drove her van with five children in the wrong direction on the Parkway and hit an SUV, killing three people in the SUV, four of the children and herself. The D.A. has announced that there will be no criminal prosecution in this case.

There has been a lot of backlash surrounding the lab reports that say the driver had a blood alcohol level of 0.19 (legally drunk is 0.08) and had chemicals from marijuana in her system. Her husband has said:
She did not drink. She was not an alcoholic. Something medical had to have happened. I never saw her drunk since the day I met her.

He insists that he does not believe alcohol caused the crash that killed his wife and one of his two children, despite both the toxicology reports and the fact that a vodka bottle was found in the van.

Michael Bastardi, Jr., the son and brother of two of the men killed in the SUV, on the other hand, has this to say about the husband and his family:
I am appalled that they won’t face the facts that she was drunk and killed seven innocent lives and ruined the lives of so many people.

The Bastardi family is planning a lawsuit.

So what is going on here? Is the husband in denial? Is Bastardi taking this tragedy out on the husband? Yes, and yes. Occam's Razor tells us that when you have two competing theories that have the same results, the less complicated one is true. In that case, the driver was almost certainly drunk. The husband is in denial.

So technically Bastardi is right, the husband "won't face the facts." But the word "won't" tends to imply "could if he really wanted to," and my guess is that he actually really can't right now. The facts are not just that his wife and daughter are dead. The facts are not just that his wife is at fault, or that 6 other people died too, or that everyone is angry at his wife, including him. Throw in there that his wife drank incredibly heavily and he didn't know it. I don't know if she did this a lot or this was a rarity, but it seems clear that her husband was clueless.

On the other side, the Bastardis are angry at the husband. They look at this situation and say that it is perfectly obvious that the wife was to blame, and since she's dead and her husband is defending her, he is a very convenient and obvious target for their natural rage. In tragedy, our minds go to blame. In this one, it doesn't have far to go.

The fact is also that both of these families are traumatized. They are trying to process a traumatic event of monstrous proportions. They won't be successful at doing that until all the investigating and suing and everything else is done, because all of that is retraumatizing. I'm not saying the Bastardis shouldn't sue -- I have no idea. I'm just saying that lawsuits tend to prolong the healing process.

At the same time, I cringe when I hear people say that families in a traumatic situation need to find "closure." That word implies that when all of this is over, this tragedy will be in a box and they can close the lid and move on. The fact is, while they are doing the hard work of processing what has happened, that box doesn't get closed and left behind. The work they are doing now is building a box into which this will fit, and then finding a space for it in their minds. That means moving some other stuff around, and their minds will never be quite the same. They may be healthy. They may be happy. But this will always be a part of them.

At some point, the husband is going to find a place for his wife's substance use/abuse in that box. At some point, Michael Bastardi, Jr. will find a place for anger and blame. Maybe they will "get over" their denial and anger. Maybe today's decision not to charge anyone will help, maybe a lawsuit will, maybe both will hurt. But there will be no closure. The only way to close the box is to bring the dead back to life and make this never have happened. Short of that, for both families, the lid will stay open.

Monday, August 17, 2009

"You Didn't Do the Best You Could"

I don't know about you, but I don't find John Yettaw to be a particularly sympathetic figure.  Yettaw is the American who swam, uninvited, across a lake in Burma (Myanmar) to the compound of opposition leader and Nobel Peace Prize winner Aung San Suu Kyi last May.  Both of them were placed on trial by the military government, along with two of Suu Kyi's employees.  All were convicted, and Suu Kyi was sentenced to an additional 18 months of house arrest.  Yettaw was sentenced to a total of seven years detention, including four hard labor.  This weekend, Virginia Senator Jim Webb went to Burma and negotiated his release

I say that I don't find Yettaw sympathetic because he single-handedly managed to get a world heroine put in even longer detention -- she's been under some form of arrest for 14 of the last 20 years.  There are those who say he is part of a plot and that the timing was no accident.  Under this theory, he did what he did when he did it specifically to get Suu Kyi into more trouble.  There are those who think he is crazy.  One thing that may point to this is that he testified at his trial that God wanted him to go to Burma because he had a dream that terrorists were going to attack Suu Kyi.  Whether you think he's crazy, stupid or evil, I think we can all agree that he did something that caused a big problem.

On the other hand, one can imagine that being arrested and detained in a country known for human rights abuses and then sentenced to hard labor there could be traumatic.  As such, Yettaw, depending on how he is feeling about the whole thing and what he experienced in prison, is a prime candidate for some crisis intervention.  Would you want to be working with him?  Few would.

But the fact is, we deal with less dramatic situations like this every day.  Sometimes, something goes horribly wrong and it really is somebody's fault, even though they didn't mean to cause damage.  Perhaps the most common instance is traffic accidents -- a driver runs a red light or a stop sign or is speeding, an accident occurs and someone dies.  This is traumatic for the driver, but the blame falls squarely on him or her as well.

Folks just starting out in crisis intervention are very inclined to try to "rescue" the people they work with from their feelings.  When someone says, "it's my fault this happened" or "I could have stopped it" we want to run in and say, "You did the best you could."  This is almost always a huge mistake.  We can rarely know whether someone truly did the best they could, and sometimes, as in Yettaw's case, we truly know they messed up.

The point of crisis intervention isn't to rescue people.  People do not get over the guilt of what they have done by someone telling them not to feel guilty, any more than people stop panicking when we tell them not to panic.  People who have made a mistake with horrible consequences do not need to be told they didn't make a mistake, they need to be helped to live with what happened.  Somehow, some way, they need to make it a part of their "new normal."  I don't know how John Yettaw will frame this experience for himself and learn to live with the havoc he has caused for himself, for Suu Kyi and for Burma, but I do know that under no circumstances should anyone say, "You did the best you could."

Sunday, August 16, 2009

The Trauma of Being a Hero

The mayor of Milwaukee, Tom Barrett, was attacked by a man with a pipe last night at the Wisconsin State Fair. That's the headline, at least. What it turns out is that the man was not after Barrett at all, but rather was attacking a woman when Barrett heard her calling for help and started to dial 911. The man then turned on him. He is in stable condition at a hospital in Milwaukee.

This is a good place for a reminder that one never, ever, ever tries to do early crisis intervention work with primary victims who are still hospitalized. If we keep Maslow's Hierarchy of Needs in mind, physical needs come first, and right now Barrett needs to worry about getting well (some of the worst research used to try to debunk CISM, by the way, has been done on victims still in the hospital). So I'm actually not going to talk about how one works with someone like Barrett.

What I would like to talk about, though, is what happens when someone is hailed as a hero. It's not uncommon at all for someone who acted heroically during a critical incident, no matter how successful they were, to be particularly badly impacted by the incident. The two things we hear most often from the "heroes" are, "If people knew how scared I was they wouldn't be calling me a hero" and "If I were a hero, everyone would have been OK." In this instance, it wouldn't be surprising if Barrett is feeling ashamed of his fear and ashamed of having been beaten up. I think that shame is misplaced, and you probably do too, but this is not an issue of reason, it's one of gut emotion.

What even further complicates processing an incident in which you are the hero is that, well, everyone says you're a hero. If you are walking down the street and someone attacks you, people understand that you are impacted. They offer support and cut you some slack. If you are walking down the street and see someone else being attacked and intervene, and in the process get attacked, people call you a hero and talk about how great you are, but often they forget that you are still impacted. You still need that support and that slack, but you are less likely to get it.

This can easily become a vicious cycle. You feel ashamed of how you felt or of not having been completely successful. Everyone treats you like you're fine, because after all, heroes are strong. Now you feel ashamed of feeling ashamed, because the world is telling you you're not "supposed" to be. And on it goes.

So, Tom Barrett, you are a hero. You may well have saved that woman's life. And you probably were scared out of your mind. As it turns out, being scared was a good instinct, because that guy was dangerous. I'm glad you're going to be OK physically, and I hope you give yourself some time to heal emotionally, too.

As an aside, I really couldn't let go by the quotation in the article from Patrice Harris, the spokesperson for the State Fair. She said,
it's our understanding it was just a domestic disturbance and he had replied to someone's cries for help when he was attacked.

This is a wildly unfortunate choice of words. There is no such thing as "just a domestic disturbance," and someone who would attack someone with a pipe for calling 911 could easily have seriously injured or killed the woman involved. I don't care if you are married, or if it's your girlfriend or your child or whomever. When you get violent, it's violence, and there's nothing "just" about it.

Saturday, August 15, 2009

CISM (Or Lack Thereof) at the Lockheed Wildfire

Over 2,400 people in Santa Cruz County, California, have now been evacuated due to the Lockheed Wildfire which began burning earlier this week. With all these people in crisis, you might wonder what the CISM response looks like right now. And if you think of CISM as mostly being one-to-one and small group work, then the answer is: not much.

But that's not completely accurate. CISM includes a large number of components, but I would predict that right now there are only two that are generally and widely appropriate: the Crisis Management Briefing (CMB) and the Demobilization. Both of these, however, are large group interventions.

Demobilization is a strategy used mostly for first responders in large scale operations, which this certainly is. In a demobilization in this instance, as firefighters come off the line following their first shift, they come to some predetermined location where there is food and drink, possibly shower facilities and/or cots. A member of the CISM team spends maybe 10 minutes with them while they eat. They share any new information about the fire and give them some self-care tips and information about what they can expect emotionally in the days ahead, gives them a handout about common stress reactions and about self-care, and then sends them off either to rest or to go home, depending on how the rotation is working.

CMBs may be being used for evacuated residents and/or first responders prior to subsequent shifts. In this intervention, some person in authority (a representative from the fire department or the governor's office, for example) gives the latest information about the fire, what is currently being done, and what the plans are moving forward, and a member of the CISM team does some education about critical incident stress and how to take care of yourself.

What you'll notice in both instances that all the CISM team is doing is "information push." Disaster victims and responders are not really being given an opportunity to process their thoughts and feelings with the team. The reason for this is simple -- the incident isn't over. To draw an analogy, it would be like trying to stitch up a dog bite in someone who is still being chased by a dog. They can't possibly hold still and cooperate in their care because their mind is on outrunning the dog, and they're going to be pretty mad at you if you try to stitch them up instead of at least cheering them on in the outrunning of the dog.

I can't say categorically that nowhere in any shelter is anybody getting any individual or small group help. Folks who had to be rescued from a burning building, for example, may need some support for that portion of the incident and they may be ready to talk about it. But maybe not. Most folks are still worried about whether their home will be there when they get back, whether their pets made it, trying to find loved ones and a more permanent place to stay, etc. And crisis responders ought to be helping them with those things.

Sometimes after mass disasters and major incidents people don't ever get the help they need because it takes so long for an incident to end or the ending is not very clear. For example, many rescue and recovery workers at Ground Zero got some support at the scene but never did a Critical Incident Stress Debriefing (CISD) because there was no agreed upon time when they were done. The CISM teams that supported them on site also didn't always get Post Action Staff Support (PASS) because it never felt like they were done. After Katrina, by the time New Orleans residents were settled enough to get CISM help, they were scattered all over the country. Planning to support victims of long-lasting disasters is a great challenge for crisis responders. I know my colleagues in Santa Cruz are up to the job.

Why I Don't Usually Update Stories

Some of my readers have asked why I often don't post ongoing information about investigations into the critical incidents I blog about.  First of all, it's not true that I never update stories.  I posted additional information about the Steve McNair murder/suicide and the Ed Thomas murder, for example.  However, I have not posted available information uncovered by the investigations into the Disney monorail crash or the plane/helicopter crash over the Hudson, as counterexamples.

My rule of thumb is to write an additional post if the new information will fundamentally change or add to the discussion from a crisis response point of view.  In the case of Steve McNair, for example, the information that his death was, indeed, a murder/suicide gave the opportunity to talk about suicide, suicide prevention, and crisis intervention following suicide.

Often, the new information gained in the investigation of an incident tells us who investigators believe is to blame for the incident.  Sometimes the nature of the event is fundamentally changed by this, as it was when we learned that Ed Thomas' alleged murderer was a former student and that he had apparently been prematurely released from psychiatric care.  More often, however, knowing who may be at fault doesn't really change anything except possibly where the blame is being pointed -- and there is always blame.

While this blog is a current events blog, it is a crisis response blog as well.  Feeding blame is not something I, as a crisis responder, believe is particularly useful unless it serves some other purpose, so I choose not to do it.  There are certainly cases where I make the wrong call -- where a piece of information actually really does change the perspective on the event or where I say it does when it doesn't.  We're all human, even us Quarterbacks.

Friday, August 14, 2009

The Quarterback's 10 Commandments of H1N1 Crisis Communication

I've been blogging a lot recently about H1N1 and how various agencies and the media communicate about it. Most of my posts have been on the critical side, picking apart an incident or document or briefing and saying what is wrong with it and, usually, unless I'm in an especially bad mood, making suggestions for improvement. But, as an educator, I firmly believe that in order for students to have a fair shot at success you have to make your expectations clear ahead of time, and so I offer here something of a rubric for communication about H1N1.

The Quarterback's 10 Commandments of H1N1 Crisis Communication
  1. Thou shalt communicate in multiple media at once, for thy public gets their information from various sources and is confused by thy out-of-date or inconsistent messages.
  2. Thou shalt share all the information thou hast, for failure to be thorough and attempts to cover things up maketh thou seem unreliable, and thy public will not believeth thy word.
  3. Thou shalt empower thy underlings to share thy information, for attempting to centralize thy message maketh thy people not trust thee. Thou shalt make sure thy underlings haveth the most up-to-date information at all times so they may shareth it.
  4. Thou shalt explain thy reasoning in all directives, for "I saidest so" is insufficient for most people.
  5. Thou shalt put thy information in appropriate context so that thy public may understand the dangers they face with relation to other dangers, and not overreact to thy numbers.
  6. Thou shalt recognize the fear of thy public and acknowledge it as a natural response, for thy public will otherwise believe that thou do not gettest it, and ignore you.
  7. Thou shalt not say "don't panic" without explaining why not.
  8. Thou shalt debunk all rumors with relevant facts. "That's not true" doth not, by itself, constitute a relevant fact.
  9. Thou shalt plan for the contingency that thy public will not follow thy directions, for they act out of fear and thou art not as convincing as thou thinkest.
  10. Thou shalt not separate thy discussion of the current status of the pandemic from thy discussion of the emotional reaction to it. So mayest thy people know that thou understandeth them, and trusteth thee. So, too , may thou be constantly reminded that thy words have impact, and consider them, and not be led astray like Joe Biden of old.
Now, if only I could get this into as wide circulation as those original commandments . . .
Thursday, August 13, 2009

Friendly Fire

It reads like the "before the opening credits" section of a Law & Order episode. On May 28, New York City Police Officer Omar Edwards finished his shift and came out to find someone breaking into his car. He wrestled with the suspect, who got away, and then chased him with his gun in hand. Officer Andrew Dunton, who was working in plain clothes, drove by with two other officers and saw an armed man chasing another man down the street. He got out of the car, crouched down behind the door and told Edwards to stop and drop his weapon. Edwards turned towards Dunton with his gun still in his hand and Dunton opened fire, killing Edwards. When responding officers removed Edwards shirt, they found a Police Academy t-shirt, and then found his badge in his pocket. Roll opening credits.

The thing is, this story is true, and today a grand jury in New York declined to indict Officer Dunton, who has been on administrative leave since the shooting. You probably didn't even need to look at the picture with this post to predict that Edwards is African-American and Dunton is White. I don't know what happened that night, and I didn't hear what the grand jury heard, but I have to imagine this outcome will not be without controversy.

Death of a police officer in the line of duty is a "big one" in Critical Incident Stress Management, as are most officer-involved shootings. While Edwards wasn't technically killed in the line of duty, I think for CISM purposes that is a distinction without a difference. The fact that he was killed by "friendly fire" is not going to make this situation any smaller.

One of the reasons CISM works is that groups that work together in the same job with the same experience support each other really well. But it is extremely important that groups for CISM interventions be homogeneous in terms not only of their exposure to the event but their cohesion before the event. You absolutely cannot intervene with a group if there are factions within it or blame and anger at each other. The CISM response to this incident would have to very carefully sort through who goes with whom, looking not only at who was where when it happened and who works with whom, but who is blaming whom.

In the CISM Planning 5 T's of target, timing, trauma, theme and team (or more rightly the 6 T's, including technique), sorting out the targets will in some sense be by theme, and you're going to need a big and trusted team to intervene appropriately. What a mess.

Wednesday, August 12, 2009

The Latest from the Government on H1N1

My sister-in-law wrote this morning to ask for my thoughts about the latest post in the White House Blog about H1N1 preparedness.  This post is an abbreviated form of a longer op-ed piece by Secretaries Kathleen Sebelius (Health and Human Services), Janet Napolitano (Homeland Security) and Arne Duncan (Education) that ran in a number of newspapers in the last couple of days.

The basic message of the communication is fairly simple:  We're preparing for the flu, you should take it seriously, and we need you to prepare too.  In my sister-in-law's e-mail, she points out that the blog post does not address the rumors or panic about H1N1.  That is true, but there is some good stuff in the full article:

This new H1N1 is not the flu we’re used to. It was just getting started when our flu season should have been ending. While anyone can get sick, the pattern of infection is unusual. It hasn’t yet affected many seniors, but it spreads rapidly among otherwise healthy kids up to college age. Scientists at the Centers for Disease Control and Prevention continue to observe higher levels of flu-like illness than normal for this time of year.  
But there’s one way in which the 2009 H1N1 flu isn’t different: it can still send you to the hospital with fever, cough, sore throat, headache, chills and fatigue, and sometimes, diarrhea and vomiting. For the worst cases, it’s still deadly. And it’s especially dangerous for people with chronic illnesses such as asthma, heart disease, or diabetes, and women who are pregnant.  

I will admit to being somewhat surprised at the tone of this, and I'm wondering about the choices they made.  This is written as though they do not believe we (and by "we" I mean the general public) are taking this disease seriously enough.  In my experience, that hasn't been the problem at all.  On the other hand, maybe folks have become complacent since the fall, I don't know.  In my opinion, what is missing from this section is a third paragraph, pointing out that in many ways H1N1 is the same as seasonal flu in the number of people it doesn't kill or send to the hospital.  At the very least, some clear statement about the relative danger from H1N1 as compared to seasonal flu would be helpful.  And talking about the flu sending people to the hospital without putting it into some context can only add to the overwhelming of our ERs of which I've written before.

I think the government is getting better at communicating with us about H1N1 and sharing information.  I think what they still need to work on is nuance.  They seem really unwilling to convey that the situation is in shades of gray, not black and white.  They can't seem to manage the message that we should take this seriously and prepare, as well as recognize that for most of us this isn't a very serious danger.  There is something to be said for, when you want people to behave a certain way (e.g. wash their hands) being very directive and giving them reasons to do it.  But don't forget, people don't only do what you say, they interpret and extend it.  And if getting us all to plan and being very directive in one direction also makes us all panic, freak out and go to the Emergency Room, that's not actually a good thing.

Tuesday, August 11, 2009

Grief, Trauma and Traumatic Grief

I was recently asked to assist at a school where a student had died after a lengthy illness. The usual characters had assembled -- the Principal, the counselors, the social worker, the district communications person, and me on behalf of the crisis team. As we started to think about what needed to be done, one of the others at the table said,
Let's not have a secular response to a spiritual event.

What a great way to put it. This child's death was very sad. Staff and students were grieving, and grieving hard. But they were, indeed, grieving. They were not traumatized. They didn't need intervention, they needed support. My colleague wasn't advocating prayer in public schools, he was advocating recognition that this event was fundamentally different than death from a car accident or a suicide.

I often run into trouble explaining this difference to people. Saying that a death isn't a critical incident, isn't a crisis or isn't a traumatic event is sometimes heard as saying that the event isn't hard or horrible, and that's not what I mean at all. It's just that grief and trauma are different.

If you look up the two words in the New Oxford American Dictionary, you find the following:

Grief: Deep sorrow, especially that caused by someone's death.

Trauma: Emotional shock following a stressful event or a physical injury, which may be associated with physical shock and sometimes leads to long-term neurosis.

The difference between trauma and grief does not have to do with how serious a situation it is, or even with how upset you are. Trauma, however, involves shock, and grief does not. You can see this when you talk to people who have experienced the traumatic death of a loved one. While they may feel sad, that sadness is not usually the primary emotion. Instead, they are shocked, angry, scared or in a state of disbelief.

You can see a difference in the signs and signals of distress that people exhibit with grief and with trauma as well. While those who are traumatized may cry, those who are grieving don't usually experience the numbness and physical ailments that come with trauma.

Traumatic incidents do, of course, very often cause grief. The death of a loved one in a car accident is still a death. What we find, however, is that the trauma gets in the way of the grief. Until people have processed the trauma and its effects, they can't really face and process their grief. The biggest mistake people make in dealing with trauma is trying to talk immediately about the loss and grief and skipping over talking about how it happened and all the reactions surrounding that. When someone dies, we think we're supposed to feel sad and talk about the person who died. We don't allow ourselves or others the room and time to deal with our own reactions to how it happened and to the shock.

On the flip side, it's easy for those of us trained in trauma intervention to treat everything like a trauma, even when it's not. Once an organization has a CISM team, they often want to do CISM for everything. But the C and the I in CISM stand for Critical Incident, and while those trained in CISM may have some good people skills, the techniques of CISM are not designed for uncomplicated, non-traumatic grief.

I don't know if I'd say that trauma is secular and grief is spiritual, but I see what my colleague is getting at. And if it helps us remember to use the right tools at the right time, I'm all for saying that we shouldn't use a secular response for a spiritual event.

Monday, August 10, 2009

What Makes an Incident a "Bad One"

I know it when I see it.

Supreme Court Justice Potter Stewart famously used that line to try to define hard-core pornography.  That's how it feels sometimes trying to define a critical incident.  That's particularly true when you're dealing with first responders -- cops, EMS, firefighters -- who see this stuff every day and can't possibly be traumatized by all of it.  What makes one incident particularly bad?

I know it when I see it.

Yesterday, California Highway Patrol attempted to stop a car on a traffic violation in Dinuba, California.  The car wouldn't stop and the police chased it for about four miles.  Then the car ran a stop sign and hit a pickup truck carrying 5 children.  As of this writing, 8 people -- 5 children and all 3 adults from the car -- are dead.  Four of the children, ages 1,3,4 and 7 were ejected from the truck and died at the scene.

I know it when I see it.

There are certain rules of thumb about critical incidents.  There are certain types of things that are likely to impact a first responder -- line-of-duty-death or serious injury, officer-involved shooting, trauma involving children, and multiple casualties all raise red flags.  And yes, this was a multiple casualty incident involving children.  But that's not what makes me, and probably you, say that this is a "bad one." 

You just know it when you see it.

This one would probably be a big one even without the police chase.  An accident involving multiple dead children offends our sense of how the world should be and, if we are parents or have children close to us, makes us feel uneasy about their safety.  I don't know about you, but one of my first reactions was also to question how five children could possibly be riding safely in a pickup truck, and whether the fact that they were ejected means they weren't wearing seat belts or were riding in the back.  Someone has to be to blame.  Then you add in the car running a stop sign, and you have someone else to blame.  It makes me angry -- it probably makes you angry too. 

And then you add the police chase, which means there were officers on the scene who are now asking themselves what they could have done to stop that car or whether they should have given up the chase, and who witnessed the accident and were first on the scene to see the carnage.  The Fresno Bee already indicates some people are blaming them for the crash.  So now there's going to be an investigation, on top of the guilt.  And that's in addition to being mad at the driver and mad that those children weren't safe and afraid for their own children.

I know it when I see it.  It looks like that.

Saturday, August 8, 2009

Aviation Over the Hudson

Writing this blog requires that I scour the news for something awful every day. Some days it isn't hard, some days it is, and some days, like today, make you just go "ugh." Shortly after noon today a private plane collided with a tour helicopter over the Hudson River in New York. There appear to be no survivors.

When I saw the headline, I made a prediction about how the coverage would run before I ever saw it. I predicted that coverage would very quickly include reference to US Airways Flight 1549, the plane that landed on the Hudson in January. And I wasn't disappointed. The New York Times breaking news article at 4:40 Eastern had its mention of the "Miracle on the Hudson" in the 9th paragraph:
The accident, on a sun-drenched weekend that beckoned people out of doors, occurred seven months after a US Airways jetliner with 155 people on board lost power after striking birds on takeoff from La Guardia Airport and ditched in the icy Hudson a half-mile north of Saturday’s crash, with stunningly different results: all on board were quickly rescued by a flotilla of ferries and emergency boats.
Let's think about this for just a moment. The US Airways crash has, objectively, essentially no relationship to this crash. The cause clearly is not the same, the aircraft are not the same, the people involved are not the same. The only thing they share is landing in the same body of water.

So why does the coverage fly immediately to the US Airways crash? And why does that make sense to us? I think it's because of how we naturally store information and memories. I like to compare our minds to a gigantic system of filing cabinets. We file memories and new information in one or more cabinets based on some label. When something else comes along with the same label, we open that drawer again to file it, and in the process review what's already in the drawer. Today we opened the "Hudson River Plane Crash" drawer, and not surprisingly flight 1549 was already in there.

People who have been traumatized are often surprised by the associations that come up for them. They find that their car accident has them thinking about when they broke their arm in the 3rd grade, and they can't imagine why. But that triggering is all the same mechanism. We only have so many labels in our file drawers, and things that don't have much to do with one another wind up getting filed together.

With that in mind, the people I am concerned about (other than the families of the deceased) in this instance are the pilots of water taxis and tour boats on the Hudson. These folks helped heroically in the rescue efforts for flight 1549, and responded again today. Their reactions today will be not just about today, but about January. And I hope they are able to remember that, when there were survivors to rescue, they made a big difference. They probably aren't feeling so effective today.

Friday, August 7, 2009

The New CDC H1N1 Guidance for Schools

I often use this space to lament the inadequate or wrongheaded response of one group or another to a crisis. That is, after all, the essence of Monday Morning quarterbacking. However, I like to think of myself as a fair person, and as such I would like to give three hearty cheers to the CDC for the new guidance they issued today for schools regarding H1N1 "swine" flu.

I am in no position whatsoever to comment on whether these new guidelines are what they should be in terms of scientific content. At some point, we have to have some faith in our scientists that what they tell us is true. I suppose it is possible that these guidelines are absolutely horrific from a scientific standpoint and will get us all killed by this new virus. I doubt it.

From a crisis preparation and crisis communication standpoint, however, the guidance issued today is very, very good. And since I take such joy from tearing this sort of thing apart, I'd like to look in a fairly detailed way at what is right about how this was done:
  • Information was shared in multiple ways. There was a press conference and a press release, and within a relatively short time a detailed guidance document, as well as the press release and the video of the press conference was available on the web. Someone reading about the new guidelines and wanting more information can find it relatively easily. And if they wanted even more information, each section of the guidelines links to a more detailed "Technical Report" intended for public health officials.
  • The guidelines consider multiple contingencies. There are guidelines for what we expect to happen, and then guidelines for the possibility that the problem will be worse than we expect. This lends credibility to the message of the initial guidelines and makes people more likely to trust that things are under control, because they know up front that the authorities have considered the possibility that this could be really bad. Nothing makes people feel worse than hearing the equivalent of "here's the plan for right now, and if things change, well, we have no idea."
  • Directives include information about why they are being issued, and also consider what those questioning might ask. For example, the directive on school cleaning reads: "School staff should routinely clean areas that students and staff touch often with the cleaners they typically use. Special cleaning with bleach and other non-detergent-based cleaners is not necessary." This not only tells us what to do, it tells us what we don't need to bother with. Last spring, many schools found themselves being pressured to do more than what the CDC recommended, particularly with regards to cleaning, and had no response. With a single sentence, the CDC now has provided them with something specific they can say -- "the guidelines indicate that special cleaners are not necessary." Extra points would have been awarded if they had explained why, but still, high marks.
  • They give schools issues to think about that include emotional reactions to the situation. There is a very large amount of space devoted to how to make local decisions about schools, and it's all very good. The last section is entitled "acceptability" and it asks schools to consider how they will deal with people's anxiety about the flu and their possible resistance to whatever decisions are being implemented. Three more cheers just for this -- they recognized that implementing a plan isn't just about the science of the flu, it's about the psychology of those affected by the plan.
I'll be re-opening my building in a couple of weeks, and I know I'll start getting flu questions pretty quickly. My usual mantra is, "I have no doubt that when it's time to panic, the CDC will let us know." I truly appreciate them putting out a document that really helps us understand their thinking and to communicate it effectively to our communities.

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Naomi Zikmund-Fisher
is a clinical social worker, former school Principal and a Crisis Consultant for schools and community organizations. You can learn more about her at
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