Monday Morning Crisis Quarterback

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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