This "how to" guide highlights key questions and concepts, illustrative vignettes and intervention strategies for understanding and responding supportively and therapeutically to individuals grappling with post-traumatic effects after Tuesday's "Day of Terror." The five areas outlined are:

• Current Bio-Psychosocial Assessment
• Historical Factors and Underlying Feelings
• Encourage Cognitive Clarification of Emotions and Grief Process
• Key Crisis Concepts
• Post-Traumatic Coping and Problem Solving

A. Current Bio-Psychosocial Assessment

1. How is the person functioning now in his or her various roles and relationships? How calm, agitated, lethargic, sad or withdrawn does he or she appear? How appropriate is the overall emotional expressiveness?

2. How does it compare with the person's initial reaction on Sep. 11, 2001?

3. Is the individual fixated on a particular image or memory, e.g., people jumping from the WTC, the building crumbling, being trapped in an inferno, airplane passengers becoming part of a guided missile, etc? When the timing is right, explore the personal significance of these images for the individual.

4. What feelings are most uncomfortable for the person to experience and publicly express?

a) Some may be afraid of revealing anger as they believe it will lead to out of control rage and a greater sense of helplessness
b) Some may be ashamed of crying in public for others will judge them as weak or needy
c) Some may feel guilty for being survivors or for having escaped the most brutal consequences

5. If the individual is a parent, close relative or guardian of a child, encourage the person to:

1. speak of any anxieties he or she may have for a child's welfare
2. explore how children are reacting to:
   1) the events,
   2) the coping patterns of the significant adults around them and
   3) the coping behavior of peers?
3. Reassure parents that if they overreact emotionally with a child to a mundane event, e.g., yelling loudly when the child leaves the milk out on the kitchen table, there's always opportunity to soothe any wounds. The parent can subsequently explain that the child was not the cause of the hyperreaction; the parent is under more stress than usual in this crisis period

Remember, to some degree, in such a national catastrophe everyone is grappling with post-traumatic effects. Stress symptoms include:

1. generalized anxiety or helplessness, impending doom; preoccupation with what will happen next?
2. loss of concentration; racing thoughts
3. eating or sleeping disturbance; abusing alcohol and drugs
4. feeling numb or unpredictably weepy; sudden crying
5. somatic stress, such as headaches, muscle tension, rise in blood pressure, etc.
6. loss of interest in previously enjoyable activities, roles and relations

6. How was the person coping with day to day responsibilities and stressors in the days, weeks and months before the day of national trauma? Determine if any previous stress or hazardous events are enhancing the post-traumatic reaction.

Many people are undergoing a loss of impregnability and invincibility with the first massive attack by a foreign enemy, mostly upon civilians, in the Continental United States. Physical and psychological boundaries have been invaded. This can have a significantly disruptive effect not only on a sense of security but on a sense of identity as well.

B. Historical Factors and Underlying Feelings

Key Principle: A natural result of trauma and crisis is that past and, even, deep-seated memories or associations of previous threats, losses or abuses may be stirred up.

1. Is the person having any such recollections?
2. If so, how are they coping with these memories and associations? Are these remembrances themselves confusing, anxiety provoking, enraging or shameful? How effectively did the person cope with any past trauma?
3. The disconcerting association may not be to a specific past event but more to a general feeling, such as being trapped, being out of control, etc.

As an example, one middle-aged male shared how he was still feeling a sense of dis-ease since Tuesday that eluded his cognitive grasp. He saw the parallel with his previous combat experience, connecting the devastating rubble and gray ash around the fallen World Trade Center to the bombed out fields in Vietnam. But the disorientation was perplexing. I asked J. if it was possible that the subconscious memory being stirred was related to the tragic death of his first wife; she had been trapped in a fire in their home. J. was not home at the time. He now acknowledged not having made this association, then proceeded to connect the fiery ball and flames from the Twin Towers to his past traumatic loss and feelings of helplessness.

C. Encourage Cognitive Clarification of Emotions and Grief Process

1. As mentioned, reinforce the universality of post-traumatic effects, the increased sense of vulnerability, identity confusion, invasion of boundaries, etc.

2. Also, explain the grief process -- the progressive psychological and behavioral effects, or stages, that individuals tend to experience during times of profound loss and change. While there is a rough sequential order, a person may pass over a stage or make two steps forward and, then, inexplicably fall back to a previous emotional state or stage.

3. Here is a succinct listing of the grief stages. (Email me, stressdoc@aol.com, for further elaboration of the grief stages.)

1. Shock and Denial or "It Can't Happen Here!"
2. Fear, Panic and Shame or "Oh God, What Do I Do Now?"
3. Rage and/or Helplessness or "How Dare They!" or "Oh, No, How Could They!"
4. Guilt and Ambivalence or "Damned If You Do or If You Don't!"
5. Focused Anger and Letting Go or "Damn It, I Don't Like this, but How Do I Make the Best of It?" and "Freedom's Just Another Word"
6. Exploration and New Identity or "Now You're Ready to 'Just Do It!'"
7. Acceptance or "The Glass Is Half Empty and Half Full" and "Turning a Lemon into Lemonade"

Remember, there is no absolute or appropriate time frame for evolving through the grief stages. However, being stuck for a prolonged period of time may be a sign of clinical depression, not simply a lingering post-traumatic effect.

D. Key Crisis Concepts

Definition: Crisis is a heightened state of emotional vulnerability that produces an acute need to regain a sense of psychic control and mind-body equilibrium, that is, to reduce the profound tension and return the person to some pre-crisis level of adaptation. However, in a crisis state, by definition, one's usual coping mechanisms are not proving sufficient. Here lies the double-edged -- "danger" and "opportunity" -- nature of crisis. A heightened vulnerability and sense of threat may challenge the person to move beyond habitual ways of responding. With sufficient support and encouragement a person may allow himself to become more dependent on others, to reach out for resources and or experiment with new or improved methods of problem solving. Conversely, lacking support or ashamed of displaying neediness, an individual in crisis may regressively withdraw or turn to escapist behavior and other dysfunctional adaptations.

1. Explain that crises are time-limited, that is, usually within one to six weeks, a person will regain a state of mind-body equilibrium. However, the ongoing war status, the possibility of more terrorist strikes or counterattacks to American reprisals means many individuals will ebb and flow through heightened tension if not crisis states.

2. Fortunately, there is a learning curve. Effective coping with an initial crisis sequence often helps prepare an individual for positively responding to and for managing subsequent crises or trauma effects.

E. Post Traumatic Coping

1. Strive for Realistic Control. Discourage the person from trying to achieve an absolute sense of control of his or her external environment, as this will invariably leave one feeling more at risk. The Serenity Prayer is relevant here:

Grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference.

2. Seek Sources of Support. Encourage individuals to find sources of support when feeling the need for nurturance or reassurance. Are there supportive/nurturing resources available at home, at work, through church, with friends -- in person, over the phone, on the Internet; is there an online or offline support group available?

3. Take Some Concrete Action Steps. Encourage the person to focus on two or three actions steps that would help the individual feel a small but significant degree of enhanced safety and security. For example, one woman stated that getting a gas mask for her and her cat and stocking up on bottled water would help her feel better. (I declined asking what the cat would think of her plan.)

4. Explore the Need for Counseling. Let people know about the counseling option. If in the next few weeks the person feels stuck in one of the grief stages or the post-traumatic symptoms are not subsiding, professional guidance is indicated. One woman approached me after a recent organizational grief session. Some personal "past issues" had surfaced briefly. She shared having recently met a terrific guy and didn't want her baggage to mess things up. After exploring her workplace mental health insurance coverage she will be calling for an appointment; a classic example of a proactive crisis problem solving response.

5. Communicate Optimism. Reaffirm that post-traumatic stress is natural, that crisis can heighten a person's problem solving capacity, enhance a person's communal circle of support and that the grief process may be a catalyst for potent healing and growth producing energy.

As I once penned:

Whether the loss is a key person, a desired position or a powerful illusion each deserves the respect of mourning. The pit in the stomach, the clenched fists and quivering jaw, the anguished sobs prove catalytic in time. In mystical fashion, like Spring upon Winter, the seeds of dissolution bear fruitful renewal.

Some questions and answers to help us all in these traumatic times. Practice Safe Stress.

09/23/01

Mark Gorkin is a Licensed Clinical Social Worker, speaker, trainer and "Online Psychohumorist," known throughout the web, AOL, and the nation as "The Stress Doc." Specialty areas: organizational change and conflict, team building, creativity and humor. (1616 18th Street, NW #312, Washington, DC 20009-2530, (202) 232-8662).