Monday Morning Crisis Quarterback

By now you've probably heard about the murder of four uniformed Lakewood, Washington police officers in a coffee shop yesterday morning.  There seems to be no doubt that the victims were targeted because they were police officers.  Police have a suspect and have been trying to find him in a series of very visible but unsuccessful attempts today.

A lot has been, will be, and should be written about these courageous men and women and their surviving families, including nine children.  The spontaneous outpouring of grief and support is amazing.  The owner of the coffee shop chain where the shootings occurred is an ex-cop himself, and he said yesterday that since his employees were unhurt he was mostly concerned for the families.  Who can blame him?

But the fact of the matter is that there were a handful of other people in the coffee shop when the shootings occurred yesterday -- both staff and patrons.  Police have said that it took some time to get full statements from them because it was so hard for them to describe what they saw right away.  Who can blame them, either?

It is not uncommon for survivors of shootings, particularly shootings in which multiple people are killed, to feel survivor's guilt.  They wonder why they lived when others died.  They feel that if only they had done more, they might have saved others.  Most often, they find some solace in the knowledge that everyone there was a target, and had they done anything different they might well be among the dead.

This situation is a little different.  The other patrons were not, in fact, targets themselves.  It seems pretty clear that the gunman was looking to shoot cops.  It is not as simple as realizing that they had to save themselves.  But in fact, they did have to save themselves.  While they may not have been targets to begin with, had they confronted the gunman they undoubtedly would have become targets.

When all is said and done, however, four police officers are dead in a highly publicized and sensational shooting that is making the national news, and the only people in any kind of position to stop it, one might argue, were the staff and other patrons.  While we all know that we don't blame them and we don't think they could have stopped this, that probably isn't how they are feeling.  That kind of guilt can lead to isolating oneself, and that's a very bad thing to do after a traumatic incident.

Add to this the wrinkle that the gunman is still out there.  The survivors have to be concerned, at least on a gut level, for their own safety.  They are witnesses, and he clearly doesn't care much about human life.  It has to be hard to get up and go out in public under these circumstances.

Most police departments have supports in place for families of officers killed in the line of duty and also for other officers and their families who understandably have renewed fears for other officers' safety.  Fewer communities are really set up to support the civilian survivors of an incident like this.  This is a time when a community-based CISM team is critical.  I hope there is one out there, or that someone asks for one on those people's behalf.  They need our support, too.

Update:  The suspect in these murders was shot and killed by police on December 1.  Hopefully, that will alleviate some small amount of the stress the survivors are experiencing.

A man fell more than 200 feet from the south rim of the Grand Canyon on Saturday and died.  His name has not been released pending notification of family members, and it is not clear how this happened.  Some of his family members, however, already know. He was visiting the park with his son and daughter-in-law and "other extended family."

If we assume this man was not pushed, there are two possible scenarios, both truly awful to contemplate.  The first is that the victim was either looking out over the edge or hiking when he fell, in which case he was almost certainly with members of his family who saw him die.  The second is that he spent the holiday weekend with his family at the park, and then went off by himself and jumped.  Obviously this is a tragedy either way, but it seems to be even more of a tragedy because his family was there in the park.  Why is that?  Why is it worse to have a loved one die while you are traveling with him than while he's off with some tour group?

Having someone die before your eyes has a particular impact.  Our naive but deep-seated belief is that we have control over what we are close to, and particularly what we can see.  When we see someone die, it very much shakes up this understanding of how the world works.  Having this particular belief shaken, furthermore, is especially damaging because trauma makes us feel helpless as it is.  It's bad enough having to deal with the notion that trauma happens and we can't control it.  It's more distressing when it happens in a way that, on a visceral level, we feel like we should be able to control.  Feelings of helplessness and loss of control are, as any mental health professional will tell you, warning signs of depression and red flags for suicide risk.  As much as traumatic incidents always put people at risk, this sort of event may be even worse.

If this were a suicide, on the other hand, it might be even messier.  Suicides leave behind a lot of guilt about what survivors could have or should have done to stop it.  They leave that sense of helplessness that can make suicide contagious.  If this man completed his suicide while traveling with family, however, it adds the additional sense that people have that they are responsible for one another when they are traveling together or even just engaged in an activity together.  "I should have known" becomes "it was my personal responsibility to know."

There are two or three deaths by falling every year at the Grand Canyon, and most of them are accidents.  In all of 2006 there were only 11 violent deaths in the entire National Park system, and only one was a suicide.    Two were people being pushed over cliffs, so, at least that year, a fall from a cliff was more likely to be a murder than a suicide.  Anecdotally there are many more suicide attempts by jumpers or people wanting to leap into the geysers at Yellowstone.  When we imagine the final scary moments for a visitor who falls into the Grand Canyon, we tend to imagine the fall itself -- particularly if we're afraid of heights and have peered nervously over that edge.  Sometimes we forget that every visitor has a family, and sometimes they're watching the tragedy first hand.

At about midnight last night, John Jones, 26, died in a tiny crevice in Nutty Putty Cave in Utah.  He had been stuck upside down for more than 24 hours, and rescuers had been working feverishly to get him out.  At one point they did get him free, but after an equipment failure he got stuck again.  After hours and hours of talking to him and reporting that he was in good spirits, rescuers noted that he was not responding.  He left behind his wife, who is pregnant, a young daughter, his parents and six siblings.

Today is Thanksgiving.  I'm sure it feels very different for the Jones family, as well as for the rescue workers.  The obvious impulse, especially for the Jones family, must have been to cancel their Thanksgiving dinner.  How can anyone concentrate on turkey at a time like this?

As much as we all understand that impulse, I'm hoping that isn't what happened.  When a trauma occurs, it feels like nothing is normal in the entire world.  The mundane tasks of life appear to be completely irrelevant.  The world, it seems, ought to stop turning.  But the world doesn't stop turning, and acting like it has actually prolongs that feeling of unreality.  At times of trauma, people need exactly what they don't feel like giving or can't give themselves -- normalcy.

What I hope happened is that the neighbors, the church, or whomever else is in the Jones' lives reached out to them today.  No, they couldn't necessarily face making a turkey and all the trimmings, but they still need to eat.  What's more, Thanksgiving is always going to have a negative association for this family from now on.  Skipping Thanksgiving entirely this year would cement that feeling even more.  And it would be lonely.  At a time when the world seems to be coming to an end, these people need friends to reach out and tell them they're going to be OK.

The rescue workers are going through something else right now.  Not only have they experienced someone dying literally before their eyes, but someone has died while they were a hair's breadth from saving him.  Their deeply held belief that they are good at what they do and that they make a positive difference with their work is shaken.  We on the outside know they did all they can, but it still feels awful.  And so I'm guessing there were some quiet tables this Thanksgiving, as these workers tried to process what happened and weren't quite ready to join in the revelry.

The Jones family issued a very lovely and moving statement this afternoon.  They said, in part,

We would like to express our heartfelt appreciation and gratitude to the brave, dedicated, and selfless men and women – many of whom were volunteers – who we know did all they could to get John out. We are told nearly one hundred personnel – including sheriffs, firemen, paramedics, cavers, and other rescue workers – were involved with the search and rescue operation, and we are deeply thankful for the compassion and care they showed John and our family – even to the point of singing John primary songs to help get him through the night.

Even in their own darkest hour, the family gave the rescuers a little of what they need. 

No trauma is ever "good," but sometimes it teaches an important lesson.  When the world stops turning, everyone involved needs to reach out to and support each other, and hopefully we all remember that we have a reason to give thanks.

If your loved one dies while serving in the United States Military, whether they are killed in action or by accident, you will receive a letter of condolence from the President.  Presidents have been doing this since Abraham Lincoln.  If your loved one serves in the military and kills themselves, however, you will get many of the same things that other families get, but you will not receive a letter from the Commander in Chief.  That has been true at least since the Clinton administration.

There is a push on from some military suicide survivors to change that policy.  They argue that their loved ones died in service of their country, certainly as much as someone who was killed in an accident.  The injuries they suffered were not visible, but they were certainly service related.  Their families deserve the same consideration from the President as anyone else's, and to do so would go a long way towards reducing the shame that has for so long been associated with death by suicide, particularly in the military.

This is one of those issues which, spun the way these families and the press coverage are spinning it, seems pretty clear cut.  Of course being a suicide survivor should not have stigma associated with it.  These families are grieving just as much as any other, and deserve all the support we can give them.

There is a problem, however.  One of the rules of thumb in responding to a suicide and memorializing people who die by suicide is that you in no way want to glorify the act of killing yourself.  When you have grand ceremonies to honor their memory, you run the risk that someone else who is considering suicide will, consciously or unconsciously, view killing themselves as a means to get that kind of attention for themselves and their families.  This is probably more of an issue with teenagers, who aren't fully able to appreciate the consequences of any action because their brains are not yet fully developed, but it remains an issue for others, too.

I don't know that I have a good answer for this.  On the one hand, families who are survivors of military suicides should not be treated with any kind of stigma.  They deserve our honor and support in a very, very difficult and complicated time.  On the other hand, there is an argument to be made that even what is already done for these families --  receiving a folded flag, a 21 gun salute at the funeral -- let alone a letter from the President might look pretty appealing to a soldier considering suicide.  They might think that in death they can bring honor to their family that they feel they could not bring in life. 

Taking away the stigma associated with suicide in the military may well save lives by making soldiers more willing to seek help.  The question is, by honoring grieving families properly, how many lives will we lose?

Back in September, William Sparkman, a part time census worker, was found hanging from a tree in rural Kentucky with the word "FED" written across his chest.  At the time, the question of whether he was killed as part of a vast right-wing reaction against the census was being bandied about in the press.  Today, word has come that Sparkman killed himself.  He apparently intentionally staged the scene to look like a homicide so his son could collect on multiple life insurance policies Sparkman had recently taken out, totaling in excess of $600,000.  Those policies would not pay in the event of a suicide.

The traumatic death of a loved one is incredibly hard.  When that death is a suicide, it is much more complicated.  When CISM teams plan a response to a suicide, we expect to hear a lot of regret and guilt.  In this instance, police report that Sparkman told someone exactly what he was planning to do, and they did not take him seriously.  That person must be feeling the weight of the world on their shoulders, although of course it's impossible to know whether, had they responded differently, it would have made any difference.

In addition, it's not uncommon for those who kill themselves to express that they think their families will be better off without them, and that sentiment complicates the situation for survivors.  Inevitably, they do not feel "better off" and often feel a combination of anger at their loved one for thinking they would be and guilt that somehow this happened because of them.  It's not uncommon to hear families say, "why didn't he care about me enough to not do this?"

Sparkman's death takes this to a whole new level.  In this instance, Sparkman quite clearly was thinking about his family when he killed himself.  He took the time and effort to elaborately stage the scene so his son could get his life insurance money.  He cared enough to make it look like a murder.

Sparkman had a son that he cared about and wanted to help financially.  He wasn't thinking rationally enough to recognize that killing himself would cause much more than monetary damage, however, or he was in too much psychological pain for that to be a deciding factor.  People who attempt suicide are like fish drowning in a bowl of water.  Everything they need is available to them, and they can't seem to see or take advantage of it.  That isn't anyone's fault, but when it happens to you, it's hard not to feel like it is.

In the early 1980's, Rom Houben, a Belgian 20 year-old, was in a horrific car accident.  He was in a coma, and then diagnosed as being in a persistent vegetative state.  For 23 years, his family refused to accept his diagnosis and insisted he was conscious and aware of his surroundings.  Finally, with advances in brain scan technology, doctors were able to more thoroughly examine his brain and determine it was essentially normal.  Over time, they were able to help him communicate using a single finger and a keypad. 

Houben wasn't in a vegetative state at all, but rather suffering from "locked-in syndrome," a state where he was able to hear and feel and understand, but unable to move or speak.  The medical journal article that detailed his story estimates that up to 43% of people diagnosed as being in a vegetative state are actually conscious.

I'm sure this case will be the subject of much political debate.  The news coverage is rife with mentions of Terri Schiavo, the Florida woman whose husband's battle to remove her feeding tube made its way all the way to the United States Congress.  I acknoweldge that this case raises ethical questions, and I also acknowledge that I am completely unqualified to discuss them.

This story also raises questions for the families of those diagnosed as being in persistent vegetative states.  On the one hand, accepting the reality of their loved one's situation is important, regardless of what people decide to do about it.  Holding out unrealistic hope can trap people in the common trauma reaction of feeling like the situation isn't real.  On the other hand, if this study is accurate, about 4 times out of 10, it truly isn't real.

This story is very encouraging to those left behind by traumatic accident victims in vegetative states.  I truly hope that as many of them can be "unlocked" as this story predicts.  I just worry about the 6 out of 10 situations or more where this research will prevent survivors from accepting reality.

There was a tiny radiation leak at the Three Mile Island nuclear power plant near Middletown, Pennsylvania yesterday afternoon.  The worker with the highest radiation exposure from the incident got the equivalent of about two and a quarter chest x-rays' worth.  Nobody else got any.  Workers were sent home until the building where the leak occurred could be cleaned.  No radiation escaped the building.

By any rational standard, this is not a very exciting news story.  I tried to dig up some statistics on minor nuclear accidents and was unsuccessful (mostly because people only write about major accidents).  However, I was able to discover that the Nuclear Regulatory Commission has as many as 6 reports of incidents involving misuse, mishandling or release of radioactive materials on its website every day.  This undoubtedly was on the more serious end of those, but it's not at all unheard of.  And yet, it's all over the news.

The only reason this story is a story at all is because it happened at Three Mile Island.  The name "Three Mile Island" has come to be synonymous with "major nuclear disaster."  In 1979, Unit 2 at Three Mile Island experienced a partial meltdown.  It is still the biggest civil nuclear disaster ever in the United States, and the second biggest one in the world (behind the Chernobyl disaster).  If you  lived in Pennsylvania in 1979, you certainly remember that incident.  I was nine years old at the time, living in Massachusetts, and I have a vivid memory of my parents buying powdered milk in case the dairy cows on the East coast all suffered radiation contamination.

Three Mile Island is so synonymous with nuclear disaster and so ubiquitous in the American consciousness that the coverage of yesterday's leak uniformly adheres to the following pattern:  The leak yesterday is explained.  the issue of whether there was or is danger to the public is explored.  The accident in 1979 is mentioned with absolutely no segue or connection.

Don't get me wrong, I understand that people are drawing a connection, and so it behooves the press to make that connection, too.  What I find astounding is that there is literally no effort to contrast the seriousness of the 1979 incident with the situation this weekend.  All that would be necessary would be a connecting sentence like,

This incident reminded many local residents of the much more serious accident in 1979,

or,

Official desciptions of this event made it clear it was not nearly as serious as the famous 1979 incident at the same facility.

It may make sense for us to have the memories of those scary days 30 years ago triggered by the news today.  It may even make sense for the media to talk about that connection.  Part of dealing with people's stress reactions, however, is to put their fears in some context.  The media is utterly failing to do that.

Oh, and by the way, how many people do you think died during the incident in 1979?  And how many lives do you believe were shortened by the radiation exposure?  The answer may surprise you -- it certainly surprised me.  No one died at Three Mile Island (then or now), and official estimates are that perhaps one single solitary person may live a shorter life because of the accident.  Perspective is an interesting thing.

The U.S. military is undertaking a large research project using its own soldiers to see if there is a way to predict who will suffer from Post Traumatic Stress Disorder.  They are screening hundreds of soldiers before they deploy, including their baseline stress rate, brain scans, family histories and past history of mental illness, and will be looking to see if any factor or combination of factors can predict who is at highest risk.

This is a very new way to look at PTSD, and raises interesting issues for those of us who work in trauma response.  The conventional wisdom which we learn in training is that the factors that affect whether someone will develop PTSD are mostly  things that occur with the trauma.  We are taught that people who are more closely and directly exposed to an incident are more likely to have PTSD.  People who experience dissociation and/or depression immediately surrounding the trauma are at increased risk.  In addition, the more closely held beliefs, expectations and worldviews are violated, the more likely you are to have PTSD down the line. 

This experiment aims to short-circuit most of those factors.  What if we could predict who is most likely to experience those predictors?  What if we knew that this person is at increased risk for dissociation, and that person will react particularly strongly to the violation of their worldview?  What would that mean for trauma responders?  What would that mean for the people themselves?

Let's suppose, for the sake of argument, that we discover that certain people have a particular kind of activity in a particular part of their brain, and that if you have that activity you are more prone to PTSD.  Do we allow those people to serve in the military?  Can they be police officers or firefighters?  What if it turns out that that same anomaly is associated with bravery and calm under pressure, so these people also make especially good soldiers and first responders?  How will we decide?

We also have to think about how we treat those people.  Traumas will always happen, even if we exclude those most at risk for PTSD from serving.  If we come upon someone at increased biological risk who has, say, witnessed a murder, will they immediately be referred for further care, or can early intervention still help?  Will we be doing brain scans at the scene?

I often say that I love crisis work and I hate that I love crisis work.  I feel guilty that I get so much satisfaction out of helping with other people's misery -- shouldn't I be hoping they aren't miserable?  If this research is successful, it's possible that the whole way we proceed with this work will change.  It's hard to imagine, though, that we won't need to do it at all.

This morning, a man walked into Stissing Mountain Middle School in Pine Plains, New York, assembled a gun in the bathroom, and took my colleague, Principal Bob Hess, hostage. The standoff lasted two hours before the suspect surrendered, releasing Mr. Hess. The entire bulding locked down for those two hours, with children hiding in locked classrooms, the school kitchen and even under the desk in the counseling office right next door to where the gunman was.

The fact is, we all know it's a possibility. Any school Principal who has given any detailed thought to an armed intruder coming into the school has already realized that the most likely target is the Principal. An angry parent, a custody dispute that we intervene in, a trespasser we ask to leave, or a disturbed child, if they took out a gun, could all very well be aiming it at us. In places where, as in Michigan, we practice locking down the school, we practice it with the administrator directing the rest of the staff and taking the lead. We try not to think about the possibility that we would be shot or held hostage ourselves.

Counseling will now be offered to the students, staff and families at Stissing Mountain. In the official curriculum I teach on Critical Incident Stress Management, they say that peers may not be necessary in delivering CISM services to schools. If there's anyone from Pine Plains out there listening, I want you to know that I think a peer is absolutely critical in assisting Mr. Hess.

If this were me, I would not want to talk to a counselor or a social worker or a psychologist. I would want to talk to someone else who has lived with the knowledge they walk around with a big target on their head every day. I would want my person to understand that in an emergency I take pride in being able to keep everyone calm and safe, and who can imagine that being the one person least able to do anything in this situation was horrible. I would want someone who has had their own child in the building when something bad happened, and had to worry about the group, not the individual. I would want someone who knew the significance of having something happen "on your watch." I would want to talk to a really well trained Principal.

I hope they have one in Pine Plains. And Principal Hess, I'm glad you're safe.

He had compassion fatigue. He was a Muslim. He had money problems. He was depressed. He was disgruntled. He didn't want to deploy. He was a terrorist. He was harassed. He faced discrimination. He hated his boss. He was turned down for unemployment. He blamed the company. He blamed the army. He should have been stopped.

Today, as America reels from the second mass shooting in as many days, the blogosphere and the traditional media are lighting up with commentary on why the shooters in the Fort Hood and Orlando killings did what they did. If you google the stories, you find headline after headline with various speculation about motive, interspersed with the occasional article referring to the motives in each shooting as a "mystery."

Human beings don't like uncertainty, as I discussed yesterday. And the media doesn't like to report anything nuanced, and certainly not "we don't know." Where's the human interest in that? So we look for answers, and sometimes the answers we come up with sound good . . . until you think about them.

The shooter at Fort Hood is a psychiatrist. He had treated many people who suffer from Post Traumatic Stress Disorder. Now there is speculation that this experience caused him to be traumatized himself, and in turn caused yesterday's shootings. No sooner had that theory hit the airwaves then we had articles arguing the opposite -- that PTSD is not contagious, and we are just making excuses.

The truth is, PTSD is indeed contagious, in a documented phenomenon called "compassion fatigue" or sometimes secondary or vicarious traumatization. People who work with the traumatized are susceptible to symptoms of trauma themselves -- this is a documented phenomenon and there are documented ways to try to prevent it. But as much as compassion fatigue is a real thing, most people who have it don't shoot people. Saying that is the cause is much too simplistic.

The shooter is also Muslim, true. And yet, most people who are Muslim don't shoot people either. And if mass shootings are caused by being Muslim, how do we account for the Orlando shooter, who certainly wasn't, or the perpetrator in the Pittsburgh gym shootings, or at Virginia Tech, or Columbine? Why is the Fort Hood shooting "terrorism" and those are horrible violent crime?

In Orlando, the shooter almost certainly was a disgruntled former employee with money problems. This is all true. But how many thousands of people fit that description, and never hurt a fly? How many hurt themselves but not others? How do you know who is who and which is which. Unfortunately, you don't.

There is a lot of commentary today suggesting that we as a country are hesitant to admit the "truth" about Fort Hood, and I think they are right. But that truth isn't that the shooter was a Muslim terrorist. That truth is that we just don't know. We may someday, or we may not. And if we don't know, we can't know it won't happen again, and that scares us.

We want to think that if we exclude certain ethnicities or nationalities or religions from our lives, we will prevent the next shooting from happening to us. We want to believe that if we know the Fort Hood shooter was a terrorist, we can protect ourselves by staying away from terrorists. But in Orlando, we discovered that that isn't true either. And that scares us more, so we pretend there's no inconsistency there, no nuance. It seems we'd rather live with our bigotry in this country than with our fear of what is random.

Two high profile cases are in the news today. The first is the kidnapping of Jaycee Lee Dugard, the 11 year old who was kidnapped, raped, and held in a California backyard for 18 years. The second is the discovery of at least 11 women's bodies at a house in Cleveland. If I asked you who is to blame for Dugard's kidnapping, you would probably say her kidnappers are. If I asked you who was to blame for the murders in Cleveland, you would probably pin them on the serial killer. Yet today's coverage points the finger squarely at law enforcement in both cases.

A report from the California Inspector General, which was issued today, says that parole officers had numerous opportunities to discover Dugard during the 10 years they were in charge of supervising her alleged captor. They failed to follow their own procedures in some cases, and in others failed to have decent procedures in the first place. In the Cleveland case, neighbors are coming forward to say that they reported assaults by the alleged perpetrator on their street, and the police did not take them seriously. They also say that there was an odor -- presumably of decomposing bodies -- coming from the property, which was reported but never addressed. At least today, it seems like the answer to whose fault these crimes were is not the perpetrators at all, but law enforcement officials.

So what's going on here? Why have we shifted from outrage at the people who did these things to outrage at the people who didn't catch them? I think what we're seeing is the evolution of people's world view as they try to cope with the horrible things that have occurred.

When the Dugard case first broke, for example, comments on blogs and news sites said things like, "I hope you rot in h*** you sick b*****d." This represented people confronting the idea that there are people out there who do evil things, and we don't know who they are. We heard about the case and conceived of the suspect as sick, twisted, mentally ill, or just plain evil. That scared us, because it seemed so random. If this man could be like this, couldn't anyone? If his neighbors didn't know, do we know about our neighbors?

If there are this sort of person, and/or the alleged murderer in Cleveland, in the world, and if we cannot know who they are, then the world is random. We don't like random. So, as we process these traumatic events, we must move on to the question of how this could have been prevented. If we can't know who is evil, we must rely on those whose job it is to know for us -- the police, the corrections department, etc. We may come to accept that evil people exist, but we don't want to accept that the police can't protect us from them. So now it is their fault.

It's not that there is no logic to investigating what went wrong in these cases. Obviously, we would like to prevent these things from happening again. But in our rush to investigate and prevent, we shouldn't take our eye off the fact that the people most to blame for these crimes are the people who commited them. No one else should suffer solely because we can't accept the randomness of what they did.