Monday Morning Crisis Quarterback

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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