This online course builds on the work of leading experts, including Jeffery Mitchell, Ph.D., developing a unique approach to crisis debriefing with groups of trauma survivors. William Worden, Ph.D.'s "five life management skills" are applied to expand and clarify crisis debriefing techniques. Mental health professionals gain a practical and effective method for working with individuals or groups of trauma survivors.

Topics include: the purpose of crisis debriefing, the difference between counseling and crisis debriefing and the six phases of crisis, as experienced by the trauma survivor. Special issues are explored, including suicide events, murder, dealing with personality disorders in group, and simple versus complex PTSD. Controversies in the field of crisis debriefing are noted. Finally, the necessary components of crisis debriefing are presented, along with guidelines. Throughout this course the author shares his experience as a crisis debriefer and presents realistic case studies. The author of this online course is James A. Fogarty, Ed.D.

Learning Objectives
Upon completion of this course participants will be able to:

• Identify skills and techniques necessary to conduct crisis debriefing sessions with groups of trauma survivors.



• Develop an understanding of the major controversies regarding crisis debriefing.



• Identify trauma survivors who will need more treatment than a single session of crisis debriefing.



• Discuss the realistic purposes of crisis debriefing; healthy grief emotions versus crisis reactions; life management skills and the phases of crisis reaction.



• Identify components of crisis debriefing; personality disorders likely to disrupt the debriefing group process; issues relating to suicide and murder; media issues; and PTSD.

Overview of Crisis Debriefing
There are many notable books and a significant literature which explores the components of crisis debriefing. Dr. Jeffrey Mitchell, a leading founder of crisis debriefing, has developed Critical Incident Stress Management (CISM) and Critical Incident Stress Debriefing (CISD). CISM involves the more global management of crisis. CISD provides structure to the personal interaction during the crisis debriefing session. His work has stimulated many variations of crisis debriefing techniques.

This online course will assist the crisis debriefer to effectively interact with groups of trauma survivors, making crisis debriefing an important technique available to the mental health professional. One method to increase the effectiveness of techniques used by mental health professionals is to combine and blend technique models together. This online course blends the concepts and techniques of crisis debriefing with the concepts and techniques of the Five Life Management Skills. (See topic heading “Life Management Skills for Crisis and Grief Reactions” below.)

Crisis debriefing has certain limitations and disadvantages. First, crisis debriefing by its very nature is restricted in the amount of time feasibly utilized to assist trauma survivors. It is a process that occurs for several hours, usually following the crisis. Second, the crisis debriefer often does not have access to the personal history of each trauma survivor attending the crisis debriefing session. With these two major disadvantages, the goal of healing such issues as post-traumatic stress disorder and other crisis reactions is difficult. Research outcomes are mixed, regarding the effectiveness of crisis debriefing. If the goal of crisis debriefing is to heal trauma survivors’ symptoms, the research is not clear. This online course will follow this outcome debate in detail.

By placing the template of the Five Life Management Skills onto the various goal components of the crisis debriefing technique, such techniques can be further refined to yield superior results. Indeed, enhanced goals become a possibility. The major goals of this method (placing the template of the Five Life Management Skills onto crisis debriefing components) become twofold. First, to identify efficiently and accurately trauma survivors who will need more treatment than a onetime session of crisis debriefing allows. And second, to inject the Five Life Management Skills quickly into the awareness of trauma survivors to increase their likelihood of gaining a healthy adaptation to the current crisis. As explained in detail later, the Five Life Management Skills applied to crisis and grief reactions include:

• accept the reality of the crisis
  
• work through the pain associated with the crisis
  
• adjust to environments where the crisis occurred
  
• invest in other relationships
  
• remember as accurately as possible

Successful crisis debriefers must be familiar with various issues relating to mental health, counseling, therapy or social work. Within the time constraint of crisis debriefing, the crisis debriefer must quickly assess trauma survivors’ symptoms. This online course will address the following issues, with which the successful crisis debriefer must be knowledgeable.

• the realistic purpose of crisis debriefing
  
• healthy grief emotions
  
• crisis reactions
  
• life management skills
  
• crisis phases
  
• personality disorders likely to disrupt the group process in crisis debriefing
  
• special issues of suicide and murder
  
• media issues
  
• crisis debriefing components
  
• PTSD and Complex PTSD
  
• red flags of concern during crisis debriefing
  
• research controversies in crisis debriefing

Many writers and researchers have differing perspectives and view points on the topic of crisis debriefing. This online course offers one of these many perspectives. It is the hope of this author that course participants will be stimulated to learn and explore more about this fascinating topic for themselves. The need certainly exists for additional mental health professionals to further develop crisis debriefing skills. Demand for crisis debriefing skills will only increase in the foreseeable future.

Crisis Debriefing and Hope
Crisis Debriefing has many purposes, but there is one essential reason for crisis debriefing. That essential reason is to instill hope. Consider the following thoughts about hope:

“Whatever enlarges hope will exalt courage.”
Samuel Johnson - The Forbes Book of Business Quotations

“Hope is a good thing, maybe the best thing, and no good thing ever dies.”
Stephen King

Whenever a debriefer offers crisis debriefing to trauma survivors, the debriefer has an opportunity to instill hope. Trauma survivors gain hope as they learn skills to better manage life: skills offered within the crisis debriefing session. The debriefer enlarges hope and exalts courage. Once trauma survivors have the skills to manage life, hope enlarges and empowers. The debriefer helps participants realize that hope never dies. Humans have an innate will to heal in the aftermath of trauma. This realization represents a very hopeful position. The debriefer helps participants face their adversities head-on. Crisis debriefing offers a structure and plan for facing adversities.

After a trauma, some people become “stuck” on the trauma, while others manage the trauma well. The debriefer offers a quick injection of life management skills into trauma survivors, to assist their personal growth by adjusting to the trauma. When trauma survivors learn the skills to manage life, handle trauma and adjust to trauma, they receive hope. The debriefer’s greatest priority is to instill hope with trauma survivors, as they begin to adjust to a crisis.


Definitions of Crisis
“Crisis Intervention Book 2: The Practitioner’s Sourcebook for Brief Therapy”, by Howard J. Parad is an excellent resource and will be referred to throughout this online course. Dr. Parad gives the following definition. “A crisis is an upset in a steady state, a critical turning point leading to a better or worse situation, a disruption or breakdown in a person’s, family’s (and organization’s) normal or usual pattern of functioning. The upset, or disequilibrium, is acute in a sense that it is of recent origin.”

Everly and Mitchell (2000) define a crisis as “a response to some aversive situation, manifest or anticipated, wherein:

• Psychological homeostasis (equilibrium) is disrupted
  
  
• One’s usual coping mechanisms have failed to reestablish homeostasis
  
  
• There is evidence of functional distress or impairment (Caplin, 1961, 1964; Everly & Mitchell, 1999).

Mitchell and Resnik (1986) give the following: “any serious interruption in the steady state of equilibrium of a person, family, or group is considered a crisis. A crisis is a state of emotional turmoil. It is considered to be an emotionally significant event which acts as a turning point for better or worse in a person’s life.”

Flannery and Everly (2000) add to the previous definition: “A crisis occurs when a stressful life event overwhelms an individual’s ability to cope effectively in the face of a perceived challenge or threat.”

This author defines crisis as an unexpected traumatic event that disturbs trauma survivors’ psychological equilibrium. The traumatic event strips trauma survivors of their safety and security. When this event occurs, trauma survivors see no recognizable plan within their mind to adapt to or fix the event. Without a recognizable plan, trauma survivors experience a wide range of emotional reactions and trauma reactions.

Purposes of Crisis Debriefing
The following represent both the purposes and the advantages of crisis debriefing.

• Solidify a group after a crisis has occurred.
  
• Educate trauma survivors about crisis reactions.
  
• Assess how each trauma survivor is managing the crisis.
  
• Assess how the group is managing the crisis.
  
• Offer life management skills to trauma survivors early in the adjustment process.
  
• Discover the “red flags” of trauma survivors who will need more treatment.
  
• Clarify trauma survivors’ cognitive distortions
  
• Act as a referral source for continued treatment, as required.

Solidify the Group After a Crisis
Whenever a crisis occurs, it offers an opportunity for those who experienced the crisis to become more solid in their relationships. At the other end of the continuum, a crisis also presents the risk of destroying relationships. The debriefer can increase the likelihood of strengthening relationships for those experiencing a crisis together. Crisis debriefing components described later in this course feature lead-in questions which enhance trauma survivors efforts to solidify and develop mutual relationships.

Educate Trauma Survivors about Crisis Reactions
Many trauma survivors have never experienced a crisis prior to the event leading up to the crisis debriefing session. Participants who have experienced earlier crises may have never understood their own crisis reactions to the earlier event. The debriefer has a rare opportunity of giving trauma survivors a strong understanding of their emotional reactions to crisis. With crisis, trauma survivors can learn that their emotions are serving a vital purpose to help them heal.

Assess How Each Trauma Survivor is Managing the Crisis
This online course offers five categories of Life Management Skills adapted from William Worden’s Tasks of Grief. The debriefer will learn to place the Life Management Skills, like a template, onto crisis debriefing components. The debriefer can use the Five Life Management Skills as an assessment tool, to assess how effectively trauma survivors are managing a crisis. Debriefers can use the Five Life Management Skills to assess if trauma survivors are effectively managing the crisis, both in their personal lives and in their professional lives.

Assess How the Group is managing the Crisis
The debriefer can also utilize the Five Life Management Skills to determine how effectively the group is managing the crisis together. There may be situations in which a trauma survivor is managing well in his or her personal life, but not with colleagues.

For example, a bank employee traumatized at work with other employees may be effectively using the Five Life Management Skills in his or her personal life. But, bank employees may have a history of not functioning well together, which becomes intensified with the new crisis. An employee may have considerable support at home to manage the crisis, but little support at work. The debriefer with a good working knowledge of the Five Life Management Skills, can effectively determine why a group is functioning in an unhealthy or dysfunctional manner.

Offer Life Management Skills to Trauma Survivors Early in the Adjustment Process
Through the Educational Component of crisis debriefing, the debriefer can teach trauma survivors to utilize the Five Life Management Skills. The debriefer can also teach trauma survivors how to incorporate those Five Life Management Skills, when managing the current crisis.

Discover the “Red Flags” of Trauma Survivors Who Will Need More Treatment
One of the most vital components of crisis debriefing, is to discover the “red flags” indicating those trauma survivors who need additional treatment. The successful debriefer utilizes specific questions which are later described as components of the Five Life Management Skills to discover the “red flags

Clarify Trauma Survivors’ Cognitive Distortions
Crisis debriefing helps trauma survivors’ clarify their cognitive distortions related to the crisis. Some trauma survivors will harbor rigid patterns of thought, long before the trauma occurred. These rigid patterns of thought, called cognitive distortions, stop trauma survivors from effectively managing crisis. For example, a trauma survivor may harbor the cognitive distortion, “I can never adjust to this trauma”. This thought reflects the cognitive distortion of “all or none” thinking. The debriefer can have a cautious ear for such cognitive distortions, and can attempt to clarify them. If trauma survivors rigidly cling to cognitive distortions, the debriefer can view this rigidity as a red flag.

Act as a Referral Source for Continued Treatment
The debriefer has a unique opportunity to offer referrals to trauma survivors in need of more professional assistance. After determining which trauma survivors are in need of more help, the debriefer can act as a liaison by linking trauma survivors to appropriate treatment resources. The debriefer may routinely offer a list of local referral sources within a handout packet, as part of the Educational Component of crisis debriefing.


Universal Crisis
The author wants to mention two different categories of crisis: universal crisis and skill-specific crisis. A universal crisis is a crisis so catastrophic that anyone would experience crisis reactions. A universal crisis immediately strips everyone experiencing the crisis of safety, security, and survival. Anyone in a universal crisis would search their mind for solutions and not find any solutions. They will not find a Plan A, Plan B, or Plan C to help them with the current crisis at hand. This results in trauma survivors experiencing a loss of security, safety and survival, which I commonly call the three S’s.

For example, a woman was leaning against the front of her desk, directing her staff one morning, preparing for the workday. She happened to walk behind her desk. At that point, the Oklahoma City bombing occurred. She was in the building. In a split second, she was standing on a ledge, watching her colleagues disappear into the rubble of that blast. Suddenly, she stood on a ledge, experiencing the wind blowing. Her safety and security was suddenly stripped away. Imagine ourselves in that same crisis. We look into our minds for solutions but find none.

The inability of trauma survivors to find solutions becomes an integral part of the crisis experience. For example, if you are getting ready for work and you find your car has a flat tire, then Plan A (using your car to get to work) failed. When you look into your mind, you will find a Plan B (calling a friend), Plan C (calling an auto club), and other options. Finding these optional plans is comforting, eliminates insecurity, and eliminates both lack of safety, and concern for survival. With the Oklahoma City bombing example, there is no Plan A or any other alternative. This lack of finding any solution creates crisis within trauma survivors.

A Universal Crisis would universally affect everyone, regardless of his or her skill level and cognitive functioning. A Universal Crisis affects everyone because it is impossible to prepare for. A more recent example is the World Trade Center tragedy. When the World Trade Center exploded there was no solution for safety, security, and survival – everyone in that crisis would likely have crisis reactions, regardless of their skill level or cognitive functioning.

Skill-Specific Crisis
Another category of crisis reaction is referred to as skill-specific crisis. Survivor reactions to this category are influenced by the Five Life Management Skills within the trauma survivor. Two people may experience a similar, but less catastrophic event or crisis. One person may have the skills to manage the crisis. In other words, he or she has a Plan B, Plan C, or more. Because he or she has these skills, they experience no crisis reaction, personally. He or she is successful managing the situation. However, the other person, without the skills needed to manage a crisis, experiences the crisis to the extreme. He or she does not see a Plan A, Plan B, or any other solution. Without the necessary skills, crisis reactions occur.

For example, two people experience a divorce. One person has the skills to manage an adjustment to the divorce. He or she seeks out supportive friends and finds emotional outlets. He or she may consult with legal and mental health professionals for better decision-making. The other person may not have these skills. Instead of managing the divorce, the other person develops deep feelings of insecurity, a loss of safety and fear about survival. The latter person experiences crisis.


Two Different Concepts
Let’s take a look at counseling versus crisis debriefing. Counseling and crisis debriefing involve two different concepts. Counseling is usually a relatively long-term process that acts as an agent of change for issues affecting a client’s life. It requires a long-term commitment with the goal of creating change to a better life.

In the counseling process, the counselor helps clients from the beginning to the end of treatment, attempting to resolve issues. The counselor helps clients eliminate cognitive distortions and replace unhealthy behavior patterns with healthy alternatives. Counseling usually requires a relatively long-term commitment between counselor and client.

Crisis debriefing is a process, a very brief process, involving a short-term commitment between the debriefer and trauma survivors. The goals of crisis debriefing are different from long-term counseling. Although crisis debriefing has many goals, the main objectives of crisis debriefers are twofold. First, the debriefer needs to assess trauma survivors to identify those in need of additional clinical intervention. Second, the debriefer has a unique opportunity to introduce the Five Life Management Skills early in trauma survivors’ adaptation to a crisis.

Crisis debriefing is not a stand-alone technique and not a replacement for traditional psychotherapies. Crisis debriefing requires considerable training in traditional psychotherapies and diagnostics, because some trauma survivors will exhibit symptoms of various mental disorders. This author doubts that crisis debriefing cures anything. Instead it is a healthy starting point for trauma survivors’ adjustment to various crises. Crisis debriefing is the beginning of treatment for trauma survivors.

Many clinicians experience difficulty when first utilizing crisis debriefing as a technique. Clinicians have a habit of striving to resolve clients’ issues, which is a good habit, working with clients from beginning to end of the treatment process. When training experienced clinicians in the techniques of crisis debriefing, this author has noticed that they want to resolve clients’ issues in crisis debriefing sessions. Crisis debriefing does not allow for this complete process. It is a brief technique for assessment, unity of trauma survivors and the early introduction of the Five Life Management Skills.

Crisis debriefing is a technique that resolves little, but discovers much. It is a technique that trained mental health professionals can utilize to discover the immediate and future mental health needs of trauma survivors.


Fogarty’s First Crisis Debriefing
The following describes how this author stumbled into the first crisis debriefing session. There are two reasons for sharing this experience. First, I will use this story as an example when we explore the phases of a crisis, describing primary and secondary reactions. Second, I believe most mental health professionals begin performing crisis debriefing long before they are introduced to the concept formally. If you are a mental health professional, you probably have already experienced many of the crisis debriefing skill components. Training and study on the topic of crisis debriefing is important, because it helps you refine the crisis debriefing skill components you already have.

I performed my first crisis debriefing session, long before I learned about crisis debriefing. I have a good friend, who is a calm and competent funeral director. Many years ago, he called me one Saturday morning and said he had an emergency at his funeral home. He wanted me to come right away; I did not hesitate.

His funeral home has a small foyer up front, a hallway in the middle of the building, with a funeral room on the right side of the hallway and another such room on the left. I stood in the foyer waiting for the funeral director. As I was waiting, I could see a family was quietly attempting to have a funeral in the room on the right. There was another family in the room on the left. I could not see them, but I could hear them. They were screaming, swearing, and arguing with one another. The noise was tremendous.

The visitation was that evening so the funeral director expected two family members to come to the funeral home to check on everything, before the visitation. Instead, the entire family unexpectedly arrived at the funeral home, started arguing and lost control of their anger and rage.

I saw the funeral director coming down the hallway with a panicked look on his face. I asked what was happening. He told me the family in the room on the right was quietly attempting to have a funeral for their loved one. The family that was arguing, in the room on the left, was not suppose to be at the funeral home until later for an evening visitation. Then he told me about the family who was arguing.

This family’s 70-year old mother committed suicide. She took a shotgun and shot herself in the heart. Several of her adult-children usually came to her home for lunch, because they worked close to her home. Expecting lunch, they found her dead with a shotgun wound and a suicide note.

The funeral director looked at me and said, “I would like you to go in there and fix it!” And I said, “Sure!” as if I had a plan. I was not sure what to do about this situation, but the funeral director had a suggestion. He hoped that I could get them to leave. If they left, he suggested, we would be able to provide a structure for this family so they would have a better visitation that evening and a better funeral the next day. Not a bad idea, I thought. He also advised me that the eight adult-children were accompanied by their eight spouses and the fifteen grandchildren. Also, the deceased woman’s alcoholic husband was in attendance. Fortunately the alcoholic husband was sober for the occasion.

I had not yet seen the family when the funeral director advised the family that a psychologist was arriving. I walked into the room in which this angry family was arguing. I had never seen such behavior at a funeral home before. The first fact I noticed was that they were eight of the largest adult-children I had ever seen. They were intensely arguing and starting to get physical. I also noticed that almost everyone in that room was wearing a Harley T-shirt, which I considered a significant piece of information.

Stunned, I was standing by the door (which I considered a good location) when I noticed that the oldest brother, a massive man, was arguing with his sister. He spotted me, ran to me and looked at me to ask, “Are you the shrink?” I said that I was, at which point he said, “I just want you to know one thing. I hate shrinks!” I said, “Thanks for sharing that.” Then he went back to his sister to resume arguing.

I backed out of the door and encountered the funeral director who was behind the door, with a little smile on his face. I said to him, “I can’t even begin to tell you how much I appreciate this referral.” He said, “Would you get back in there?!?”

Fogarty’s Intervention
It took me a considerable amount of time to gather their attention. When I finally got their attention, I told them who I was and that I was a psychologist. I thought of an idea which they probably would not like. My hope was, that after presenting this Idea they would all get up and leaver the funeral home. I told them that we were going to do family counseling right here and now. They suddenly became quiet. Then I told them that they each had an individual decision to make. Each had to decide if he or she wanted to do the family counseling session or not. I told them whoever stayed would be in the family counseling session and whoever leaves would not. I thought this might motivate them to leave. They all looked at me and said, “Okay, let’s do a family counseling session”.

I felt somewhat perplexed, not knowing what to do next. I knew I had to find another location for the family counseling session, but where? I remembered that the funeral home had a nice meeting room in the basement. I told the family, “We could stay here and gather in a circle, or we can go downstairs to the meeting room.” They said, “We’ll stay right here!” So, I told them to each grab a chair and to gather in a circle. They did each grab a chair, but they made a U-shaped formation, including their mother’s casket within the circle. As we sat down, they looked at me as if to say, “Well, what’s next?”

I decided immediately that I needed to do most of the talking remembering that the other family was next door. Fortunately the other family would be leaving soon, to go to the cemetery. I thought if I could keep them quiet for thirty minutes, we could get into the difficult issues later. The only counseling component I could think of in which I did most of the talking was education. So, I coached them on the Five Life Management Skills, the healing emotions of grief and common trauma reactions. At the time, I did not know that education was a crisis-debriefing component. They quietly listened.

The education component took roughly thirty minutes. Meantime, the funeral director signaled that the other family had left for the cemetery. Now was a good time to delve into the family issues. But, I was not sure how to proceed. I did realize that it would be less threatening for this family to share memories about their mother. I did not realize at the time that sharing memories is a significant crisis-debriefing component.

Family members recalled several stories about their mother. Fortunately, no one became angry as they shared their stories. I noticed that they began discussing the dynamics of how their family functioned. Later, I realized that access to dynamics is an excellent feature of the crisis debriefing component of memory.

It became obvious from the dialogue resulting from their memories of their mother, that their mother was the scapegoat of the family. She was a quiet woman who took personal responsibility for other family members’ faults. It also appeared that no one ever objected to her family role, allowing her to continue as the family scapegoat. Family members did not realize any of this, while sharing memories of their mother.

I considered bringing this issue to their attention, but I also realized that they were a hostile family and would probably become angry. I tried doing so and said, “From many of the stories you are telling me, it sounds like your mother was the scapegoat of your family.” I expected them to become angry, but they quietly looked at me and said, “That’s right.” I did not know if they where placating me or agreeing, so I said it again. They replied, “We get it. She was the scapegoat of the family.”

I suggested that when families have scapegoats, they usually have unspoken rules they share about having a scapegoat. I asked them to consider what these possible rules may have been. The older brother said he knew what the rule was. He said, “We believe that we need to have a scapegoat in our family to survive as a family.”

I asked them what their earlier argument was about. Their mother (the scapegoat) was dead, but their rule about needing a scapegoat was alive and well. They admitted they were trying to set up another scapegoat. When I asked who the new scapegoat was, they all looked at their father. Five of his adult-children were trying to set him up as the scapegoat, while three adult-children were trying to stop it from happening. I asked if they really needed to have a new scapegoat and they all replied, “No”.

I had no confidence that this insight and calmness was going to last. Since they appeared to have become quiet and united, I hoped their unity might last long enough to get them through the visitation and the funeral. However, I believed that they would soon assign a new scapegoat, probably within the next few weeks.

Since they were calm, my immediate plan was to direct them into having a good funeral for their mother. I did not realize at the time that getting back to functionality by managing the crisis is a formal crisis debriefing component. I advised them that they needed to have a funeral that was caring and respectful for their mother, which they did. In fact, it was the most amazing funeral I had ever seen. They designed it themselves, and it was truly unique. There were fifteen Harleys in the funeral procession. This first concerned the pastor when he heard all of the Harleys coming toward his church. But he soon realized who the Harley riders were, so he became comfortable with the idea.

The family members appeared to be happy during the funeral, but I continued to believe that they would appoint a new scapegoat within a few weeks. Six months later, I was walking through a department store when four large people in Harley T-shirts came up to hug me. It was that family, so I asked them who had become their new scapegoat. They replied, “No one.” It took them a while to convince me, but they had, indeed not set up a new scapegoat.

Through this experience, I realized that crisis debriefing can offer a special opportunity due to the unique timing of intervention during a critical period in clients lives. It offers a unique opportunity in which families and members of organizations get an opportunity to discuss issues which they were reluctant to discuss previously.

There have been recent criticisms of crisis debriefing, some justified and some not. Various factors can make crisis debriefing effective, but especially the skill of the crisis debriefer. Another factor, which can enhance the effectiveness of crisis debriefing involves linking it with other treatment modalities, such as the Five Life Management Skills.


Phase I: Precipitating Event
Next, the phases of a crisis will be explored. What are the necessary factors that turn an ordinary situation into a crisis? A crisis must meet certain criteria before it can meet the definition of a crisis. The phases of a crisis are well described in “Crisis Intervention Book 2” by Howard J. Parad. Next, Dr. Parad’s outline will be presented, together with this author’s commentary.

A precipitating event is any event that leads to a feeling of crisis. I use the acronym TUSU. How was this acronym derived? Is the event traumatizing, unusual, stressful and unanticipated (TUSU)? In the example of the family at the funeral home, three of the adult-children went to their mother’s home to have lunch. Instead, they discovered her dead body with a gunshot wound to the chest and a suicide note.

This event would be a universal crisis, so their crisis reaction would be experienced by almost anyone upon finding a parent in the aftermath of a suicide. Finding her dead is the primary event. There is also a secondary event (unique to the individual or family) that can create crisis that is traumatizing, unusual, stressful and unanticipated. A secondary event is unique to the family or organization that is experiencing the trauma. In this case, not only is it traumatizing to find their parent has committed suicide (which is the primary event), but now for this particular family the scapegoat of the family is dead (which is the secondary event). The loss of the family scapegoat, the secondary event, creates a feeling of crisis because it is also traumatizing, unusual, stressful and unanticipated (TUSU).

In a botched bank robbery, three perpetrators panicked and killed a bank teller as they escaped from the bank. The bank employees experienced the primary trauma of witnessing their friend and colleague die during the robbery, which is the primary event. During the crisis debriefing session, it became obvious to the debriefer that the bank teller who died was the group’s cohesive element. The group was having difficulty maintaining cohesiveness after their source of cohesion died, which was the secondary event.

Phase II: Perception
People feel crisis after a traumatic event, because it disturbs their safety, security, and survival. No one can start to adjust to trauma until they regain these three S’s back into their life.

As with the example of the traumatized family at the funeral home, when a parent dies survivors realize the limit of their parent’s lifespan. They also realize the limit of their own lifespan. Our culture has a fear of death. We are busy experiencing life, liberty and the pursuit of happiness. In this pursuit, death is an enemy to avoid. When survivors experience a parent’s death, they also get a preview of their own death. They experience the primary perception of their own mortality. In our culture, considering our own mortality creates a feeling of insecurity, a lack of safety and tampers with the issue of survival.

There is also a secondary perception. The secondary perception is unique to the family or organization that is experiencing the trauma. With this family at the funeral home, the secondary perception has created feelings of insecurity and a lack of safety. They perceive that their family scapegoat is dead. Since the family scapegoat is dead, they fear becoming the new scapegoat: their secondary perception.

Phase III: Disorganized Response
People who have experienced a crisis are likely to experience disorganized responses, which can lead to chaos after a trauma. Trauma survivors experience a disorganized response in two ways: flight of thought and exaggeration of dysfunction.

Flight of Thought
Often trauma survivors experience flight of thought, which interferes with decision-making. Their flight of thought is often the result of searching in their mind for a solution to help a trauma situation, but finding no solution. They frantically continue to search within their mind, which compulsively results in uncontrollable flight of thought. Their frantic flight of thought usually does not stop when they are in a place of safety. Their flight of thought is temporary, but leaves them feeling disorganized. Their decision making during this time is often chaotic.

For example, shortly after experiencing trauma a woman described her story. As she started to explain what happened to her, her mind would wander off as she wondered if she let out the dog that morning; the flight of thought. Another example is the traumatized man who obsessively thought about escape plans from his home, in case of another trauma. When asked questions, he would start to answer but feel distracted by thoughts of keeping his home safe; his flight of thought.

Exaggeration of Dysfunction
Families and organizations which have a histories of dysfunction often exaggerate their dysfunction when experiencing trauma, as with the family in the funeral home described previously. Another example would be a family or organization, with a history of anger, which may rage when experiencing a trauma. Their rage results in chaos, which stops their effective management of the crisis.

Phase IV: Chain of Events/ Chain of Crises
Even when traumatized survivors manage a crisis in a healthy manner, crisis naturally creates more crises. For example, crisis debriefers, who assist trauma survivors, may become traumatized themselves, as the result of working with survivors through vicarious traumatization. Although crisis debriefing is a healthy management of a crisis, crisis naturally creates a chain of more crises.

The more dysfunctional the family or organization, the more additional crisis they will create. With the family at the funeral home, their mother committed suicide and they discovered the body. That’s a crisis. They created more crises with their dysfunction. Instead of grieving the death of their mother while at the funeral home, they created more crises by scapegoating each other.

Whenever in crisis, a particular woman would enter dysfunctional relationships with men who were alcoholics. Her father was an alcoholic. Despite the problems with alcoholic men and the difficulties they created for her, there was something predictable about alcoholic men in her life. Her decision to attach to alcoholic men led to more crises.

Phase V: Previous Crisis Becomes Linked to Current Crisis
The ways in which trauma survivors have responded to previous crises is an important question for the debriefer to ask during crisis debriefing sessions. Trauma survivors’ answers, describing their management of previous crises, will suggest how well they are likely to manage the current crisis and will give the debriefer an assessment of each trauma survivors’ coping mechanisms. As participants describe previous crisis in their lives and how they managed it, the debriefer can use the Five Life Management Skills to assess whether or not the trauma survivor managed the previous crisis in a healthy manner.

Phase VI: Mobilization of New Resources, Adaptation
Mobilization of new resources and adaptation are the essential goals of crisis debriefing. Debriefers help move trauma survivors in a healthy direction as they adapt to incorporating the crisis into their lives. But, crisis debriefing is only the beginning of the trauma survivors’ adjustment. Crisis debriefng is not a “stand alone” treatment, designed to cure the trauma reactions that survivors endure. It is best to view crisis debriefing as the spark of healing that starts trauma survivors onto a healthy path.


“Approach each new problem not with the view of finding what you hope will be there, but to get the truth, the realities that must be grabbled with. You may not like what you find. In that case you are entitled to try to change it. But do not deceive yourself as to what you do find to be the facts of the situation.”
Bernard M. Baruch

The following is adapted from Grief Counseling and Grief Therapy: A Handbook for the Mental Health Professional (3rd Edition) by J. William Worden, Ph.D.

Task One: accept the reality of the loss
Task One is rewritten for crisis debriefing: accept the reality of the crisis. Trauma survivors move toward accepting the crisis event and its associated fallout as reality.

Task Two: work though the pain of grief
Task Two is rewritten for crisis debriefing: work through the pain associated with the crisis. Although many trauma survivors feel grief following a crisis, they also experience one or more of the crisis reactions described later in this course. Examples of crisis reactions include: Bewilderment, Impending Doom, Feeling Stuck, etc. The debriefer can use these two versions of Task Two interchangeably. When a trauma survivor is managing the death of a loved one or friend who has died in the crisis, the debriefer can focus on grief emotions using the original version of Task Two. When the same trauma survivor is describing trauma reactions, the debriefer can use the rewritten version of Task Two.

Task Three: adjust to environments in which the deceased is missing.
Task Three is rewritten for crisis debriefing: adjust to environments where the crisis occurred. Some trauma survivors can take their time with their adjustment to the crisis environment. For example, in the Columbine shooting the students could take their time before adjusting to the library where the intense crisis occurred. Timing is an issue with this adjustment. Some of those trauma survivors may be ready to adjust to the library in several weeks. For others the adjustment may take years.

Many trauma survivors need to adjust immediately to the environment in which the crisis occurred. These trauma survivors do not have the luxury of time. Their trauma may have happened at work where they must return. For example, educators traumatized at school must go back to school no matter how severe the crisis. They do not have the luxury of waiting. Symbols of security may help survivors feel more comfort in such situations. For example, the school may hire many more security guards and increase their visibility.

Task Four: withdraw emotional energy and reinvest in another relationship.
Task Four is rewritten for crisis debriefing: invest in other relationships.To invest in other relationships occurs when a trauma survivor is open and honest about their grief emotions and crisis reactions, as shared during a crisis debriefing session or support group. This also occurs when two friends who are trauma survivors come together and invest in each other. They are open and honest with each other about their adjustments to the crisis. One of the goals of the debriefer is to initiate such investment with others, within the crisis debriefing session.

Task Five: remember as accurately as possible.
Dr. Worden does not offer a Task Five, but does mention memory within the writings of his book Grief Counseling and Grief Therapy: A Handbook for the Mental Health Professional (3rd Edition). The author of this online course prefers to differentiate the issue of memory as a distinct task. Memory (in the form of reminiscing) is also a very vital crisis debriefing component and it is usually included in most models.

Every trauma survivor may have a different version of the crisis they experienced. The goal of this task is to eliminate minimization and exaggeration of the crisis, so trauma survivors can obtain a realistic understanding of the crisis. The trauma survivor needs to have an honest working memory of the crisis. Variations of the crisis can occur, as the scope of crisis can often be large, with many perspectives. One of the goals of the crisis debriefer, is to help the trauma survivors put the entire puzzle pieces together to achieve an accurate global picture of the crisis. Just as a grief survivor has a relationship with the memory of the dead loved one, the trauma survivor has a relationship with the memory of life before the crisis.

In grief, when the grief survivor has an accurate memory of the dead loved one, less cognitive distortion occurs. This allows the grief survivor to accept the truth and invest, more easily, in others. The same is true for trauma survivors. If they have an accurate memory of a crisis, they can more easily accommodate the memory of other trauma survivors. Their accommodation allows for greater bonding with better adjustment.


Next, the nature of crisis reactions will be explored. The reactions that trauma survivors have to a crisis vary and are unique, but there are several common themes. Knowing these themes can help the debriefer anticipate trauma survivors’ confusion about their reactions. Understanding the purposes of crisis reactions will help the debriefer respond best to trauma survivors, by teaching trauma survivors the purpose and/or the normalcy of their reactions. When trauma survivors realize their crisis reactions are normal, they often feel more comfortable, more confident and they are better able to make a successful adjustment.

Bewilderment
Bewilderment is often the result of trauma survivors experiencing new and unusual emotions that are associated with the crisis. They don’t understand these emotions, consequently they become bewildered. Some survivors immediately feel the emotional reactions of a crisis. When this happens they often report they feel bizarre and bewildered. Since these trauma emotions are new to them, trauma survivors are not sure how they should interpret their new emotional reactions.

Survivors often believe that something is wrong with their mind. When they conclude this, they start to attach cognitive distortions to normal emotions. For example, they may believe that they are crazy, or will never feel stable ever again.

Suggestions for Bewilderment:

• The best theme for crisis debriefers to advocate is that trauma survivors’ feelings of bewilderment are not unusual or bizarre. The crisis is the usual and bizarre issue. Trauma survivors need to experience and feel their traumatic emotions. However, an understanding that their emotions are normal may help them apply less cognitive distortions to normal emotional reactions. The theme, “Your reaction is normal, but the crisis event is not” is a good theme to offer within crisis debriefing sessions.
  
  
• Trauma survivors also need considerable reassurance that their emotions are temporary, and not the result of a mental disorder.

Impending Doom
Another reaction that survivors have often associated with crisis is impending doom. Most people in our culture have never experienced impending doom, until they need to manage a crisis. Impending doom is the thought that you are about to die. The thought commonly associated with people who experience impending doom is that life, or life as we know it, is over.

The following is an example of impending doom. A man was walking away from the trauma of the World Trade Center as it was collapsing. He video recorded exactly what he saw as he calmly walked away. As the cloud penetrated the area, he thought he was at the brink of death. His thought about being at the brink of death continued to recur over the following weeks.

Impending doom is a crisis reaction that does not turn off like a faucet. When a trauma survivor finally reaches safety, impending doom often continues. It is common for trauma survivors to continue with this reaction.

Suggestions for feelings of impending doom:

• Trauma survivors, experiencing thoughts and feelings of impending doom are assisted by acquiring numerous symbols of safety. Since the World Trade Center, the airports have offered such symbols of safety. They have increased searches, increased X-ray of baggage, posted National Guard with weapons, and increased U.S. Marshalls. These many symbols of safety have increased travelers’ willingness to travel and have offered them feelings of security. This is consistent with Task III – adjusting to your environment.
  
  
• It is helpful to have an honest dialogue about the vulnerability of life. It is true that some world events are threatening to life. For many people, a direct and open discussion about the vulnerability of life is helpful. When a crisis is threatening, trauma survivors can bond as they discuss this reality. The Five Life Management Skills can enhance their discussion into a productive endeavor. Trauma survivors can face the truth and reality of the vulnerabilities of life (Task I). They can experience the emotions they feel about the vulnerabilities of life (Task II). They can adjust to their environment, by increasing the symbols of safety (Task III). They can invest with one another by openly and honestly talking (Task IV). They can remember as accurately as possibly life before the trauma and life since the trauma (Task V). Trauma survivors cannot make the vulnerability of life disappear. They can manage this reality in a productive and bonding manner, together, by using the Five Life Management Skills.

Feeling Stuck
Feeling stuck is a common reaction to crisis. Many trauma survivors feel overwhelmed by a crisis. They are not sure what action to take. When this happens, many trauma survivors fixate onto the events of a crisis and report feeling stuck.

Trauma survivors feeling stuck results from not knowing what to do or what to feel. There can be many individual differences with feeling stuck. If the crisis is a universal crisis (overwhelming for anyone no matter what their skill level), anyone may experience a crisis and feel stuck. If a crisis is skill-specific, feeling stuck would depend on the skill level of the trauma survivor. Depending on skill level, one trauma survivor may feel stuck, not knowing what to do to adjust to the crisis. While another trauma survivor, with better skills, may avoid feeling stuck as he or she responds by adjusting to the crisis. It is likely the trauma survivor, who adjusts well is using the Five Life Management Skills.

One common expression with feeling stuck is, “Can’t we just pretend this crisis did not happen?” This expression, coming from a trauma survivor, is often the first signal that the trauma survivor has few skills to adjust after a crisis. It is a statement that advocates denial of reality. In the past, school officials thought they helped trauma survivors, children at school, by getting back to the normal routine and forgetting about a recent crisis. Of course, this use of denial stops trauma survivors from managing a crisis properly.

Another expression of feeling stuck is, “I’ll deal with it later.” This is a signal of a trauma survivor who is fostering a delayed reaction. A delayed reaction may be psychologically healthy or unhealthy. If trauma survivors do not feel safety, security, and have concerns about survival, they cannot adjust to a crisis. For example, when the World Trade Center blew up on 9/11, many people were running from the scene. They may have seen friends die in the aftermath, but their priority was survival. They could not stay there and grieve, because they had no safety, security, and their need for survival was in jeopardy.

Many trauma survivors believe they never have to deal with the painful emotions, which come with the crises they experienced. They trick themselves into believing that they can tuck their painful emotions away, into their subconscious minds. If everyone could suppress their emotional pain with no bad result, there would be no need for mental health services.

The brain is an amazing healing mechanism. The brain wants to heal. When a trauma survivor suppresses emotional pain, the emotional pain is not the only emotion suppressed. Attaching to the suppressed emotional pain is happiness and contentment. This is the brain’s method for insuring that people deal with the events that affect their lives. The brain will not allow complete happiness and contentment until a person examines and heals trauma. In other words, trauma survivors need to exercise the Five Life Management Skills to incorporate life’s events, including crisis.

Suggestions for feeling stuck:

• The incorporation of the Five Life Management Skills helps give trauma survivors a concrete plan to manage crisis, which offers movement in a healing direction. For example, a debriefer can suggest to trauma survivors that they make adjustments to their environment to make them feel safe. This suggestion reflects Task III of the Five Life Management Skills requiring that trauma survivors take action.
  
  
• Debriefers can explain to trauma survivors that they will experience trauma emotions that will make them feel stuck. They are not actually stuck, since the experience of the trauma emotions is part of the healing process. As the healing process occurs, they will be able to progress from their trauma emotions.

Apathy
Apathy is the feeling of giving-up. “Why should I try?” Our culture supports the magical thought that if we are good people and behave well, nothing bad should happen to us. This is an irrational belief. The events of the World Trade Center have given us a perception of reality that has brought this issue back into focus, “There is danger in the world and it is unpredictable”.

When a crisis occurs it works as a projective device. As people recognize the danger in their lives, they experience different reactions. Some people reorganize their lives and thoughts, but continue to progress in their lives. Other people become fixated on the apathy question, “Why should I try?”, believing the world is too overwhelming and too dangerous to manage.

Associated with apathy is anxiety. Anxiety is different from fear, since fear is an intense reaction to an event or object. Individuals can simply avoid the event or object to reduce their fear. For example, if someone fears snakes, he or she will usually live and work in environments that are snake-free. This, of course reduces their fear reactions, even though they do not overcome the actual fear of snakes. Anxiety is an intense emotion in which people are not sure what is creating their anxiety. Experiencing their anxiety, but not knowing what corrective actions to take, they often become apathetic. What they do not realize is that anxiety, related to a crisis, is often due to the death of a life-sustaining belief. The life-sustaining belief; the world is a safe place.

When a crisis occurs, people realize the world is not as safe as their belief system previously suggested. In other words, a crisis is a reminder of the truth and reality that there is real danger in the world. This author has noticed that when clients understand this idea, it lessens their anxiety. Knowing what creates their anxiety transforms the anxiety into a more manageable fear.

Suggestions for Apathy:
Trauma survivors need to know why they feel apathy. Often, trauma survivors feel apathy because they are grieving the loss of the life-sustaining belief that the world is safe. To feel empowered, trauma survivors need to know they are feeling a normal grief reaction. They also need to understand the goal, as they progress with their grief. The goal is to gain a realistic perspective that their world is safe, but does have dangers within it. With accepting this revised belief, they can make appropriate adjustments.

Helplessness
When trauma survivors feel helplessness, they do not know what to do and they feel ineffective with every action taken. Trauma survivors who experience reactions of helplessness when in a crisis are having a normal reaction. For trauma survivors faced with a traumatic event they have never experienced before, it makes sense that they are not sure how to react. An important concern is; what do trauma survivors actually do in response to their feelings of helplessness?

Do they allow their feelings of helplessness to elevate further feelings of helplessness? Or, do their feelings of helplessness spur them into taking productive action? Again, trauma survivors’ brains want to heal after experiencing a crisis. When traumatized, the mind will push the person to seek a solution. When the trauma survivors find no solution in their thoughts, their minds will push them to realize they are helpless in the crisis and need outside assistance. A key question is, “Does the trauma survivor pursue assistance that is psychologically healthy or that is unhealthy?”

The follow is an example of unhealthy resolution of helpless feelings following a trauma. Sue had just broken off from a dysfunctional relationship with a boyfriend. She made this healthy decision just before a crisis occurred at work. The boyfriend had a history of playing numerous manipulative games during their relationship, but Sue always felt comfortable with such manipulation. She never got what she wanted out of such unhealthy relationships, but healthy relationships required her to take risks, which she was unwilling to do. Sue witnessed the murder of a bank teller at her work, during a robbery which went bad. Sue felt helpless but at the same time she felt compelled to do something to overcome her helpless feelings. Unfortunately, she reattached with the dysfunctional boyfriend. Although the relationship was dysfunctional, unlike her post crisis feelings of helplessness, such dysfunction was predictable and in a sense reassuring.

Perry experienced the same crisis, but his feeling of helplessness pushed him to express his emotional upset and to talk to his wife about the trauma and his reactions. His managing of the crisis is healthy, because he is experiencing the expected emotions (Task II) and he is investing in his wife (Task IV).

Suggestions for Helplessness:

• It is helpful for trauma survivors experiencing helplessness to break everyday tasks into smaller, more manageable tasks. This makes the management of helplessness less overwhelming
  
  
• As with the example of Perry above, it is empowering to employ one or more of the Five Life Management Skills when trauma survivors feel helplessness. All of the Five Life Management Skills are important, but one offers immediate empowerment. Task III (adjusting to your environment) promotes empowerment by way of active engagement with survivors’ environment, thus creating a safer environment. As survivors create a safer environment by engagement, they move away from feelings of inadequacy and helplessness.

Disorganized Thinking
Disorganized thinking is referred to as, “ADHD at full speed.” Some trauma survivors experience thought distractions after a trauma. They often say, “I am losing my mind. I can’t focus on anything”. Such reactions to disorganized thinking can destroy their confidence about managing the crisis.

Disorganized thinking is the result of trauma survivors looking for Plan A, Plan B Plan C, but never finding a plan. Some trauma survivors try too hard, unsuccessfully to find such plans. Many trauma survivors lock into a full speed flight-of-thought, which is temporary, but disturbing. One trauma survivor attempted to express herself throughout a crisis debriefing session, but every time she started to explain the details of what happened to her, her trivial thoughts would distract her. Such distracting thoughts included; “Did I let the dog out this morning?” or “Did I take out the garbage that morning?”

Suggestions for disorganized thinking:

• Trauma survivors need considerable reassurance that their flight-of-thought is temporary. It is helpful for them to understand that flight of thought results from the brain’s need to survive. The brain pushes the trauma survivor for solutions to the trauma. When there are no solutions, the brain pushes harder for solutions, but occasionally become disorganized in the process. This reaction does not turn off like a faucet, since it often continues even after the trauma survivor is safe and secure.

Preoccupation with Insignificant Events
When asked what trauma survivors were thinking when they first realized they were in a crisis, their response is often surprising. They will frequently reply with what appears to be an insignificant response. For example, one witness to a murder of a friend replied, “Did I mail that package? Oh, yes I did”. She believed that such a thought was insensitive, after witnessing the death of her friend.

In the case of a trauma survivor whose immediate response fulfills the criteria, “Did I do this? Yes I did”; this author explains that their brain is already starting to heal. When a trauma survivor thinks about insignificant events, these events may actually be quite significant. When traumatized, a trauma survivor experiences an event that has no solutions, which can shake the foundation of the trauma survivor’s self-confidence. When he or she focuses on experiences in life where he or she has empowerment, self-confidence begins to build. Experiences that fit the criteria, “Did I do this? Yes I did” remind trauma survivors of their empowerment in other parts of life. These reminders build confidence and suggest that their brain is already starting to heal.

Suggestions for preoccupation with insignificant events:

• Debriefers can routinely include questions in crisis debriefing sessions about trauma survivors’ thoughts when first realizing they were in a trauma. When the trauma survivors’ responses fit the criteria “Did I do this, yes I did”, the debriefer can explain that the mind is starting to heal.

Listed below are other examples of responses that fit the criteria “Did I do this, yes I did”:



Stuck on the Traumatic Memory
Because crises are trauma-laden, such events frequently overwhelm trauma survivors’ senses. Crisis, with its overwhelming nature, attaches onto the trauma survivor’s memory. It is difficult for the trauma survivor to defocus from the traumatic memory. Often, the trauma survivor cannot get the traumatic memory out of the forefront of his or her mind; consequently these memories become a major problem. Such issues are most common for trauma survivors during the early phases of adjusting to a trauma.

Suggestions for being stuck on traumatic memory:

• The fifth task of the Five Life Management Skills is to remember as accurately as possible. Debriefers can use this task to help trauma survivors focus on a more comprehensive memory, which helps the trauma survivor defocus from severe details of the crisis. For example, if a trauma survivor witnessed the death of a friend or loved one, the debriefer can ask, “Tell me about all your memories, so I have an idea what your loved one was like”. Or, if there was a crisis at work the debriefer can ask, “Tell me what it was like to work here, before this crisis occurred. Where did you spend most of your time? Did you feel safe here?” These questions draw the focus to a comprehensive memory, instead of a singular focus on the traumatic memory.
  
  
• Focusing on a more comprehensive memory also helps trauma survivors better adjust to the environment in which the trauma occurred. For example, as bank employees recall what their place of employment was like before the crisis, they defocus from the trauma incident. By remembering what made them feel safe previously, as well as where they could improve safety, they can better defocus from the intense traumatic memories.
  
  
• EMDR: Eye Movement Desensitization by Francine Shapiro. Dr. Shapiro (1996) sights twelve studies that offer support to the effectiveness of EMDR. EMDR attempts to reduce the intensity of the images associated with traumatic reminders. Sharpley et al found that EMDR was significantly effective in reducing the vividness of a mental image. In practice, many clinicians view EMDR as an effective and empowering means to help trauma survivors cope with difficult memories. For example, a trauma survivor trained in EMDR experienced a flashback (an intense and vivid recall of the trauma) during a business meeting, several months after a traumatic event. Using EMDR, the trauma survivor reduced the intensity of the flashback to a manageable memory, thus allowing the trauma survivor to effectively function during the business meeting. This also empowered the trauma survivor to later deal appropriately with the strong emotional components attached to the trauma.

Threats to Identity
Many people, who experience a life-changing crisis, also experience threats to identity. Crisis changes trauma survivors’ view of themselves and their view the world, in general. Major changes can occur in the structure and organization of their view of life. After a crisis, their identity (how they view themselves in the world) will often change.

For example, some people have “Die-Hard” Syndrome. Before ever being involved in a crisis, they believe they will act like Bruce Willis when a crisis occurs. In a real crisis, they have an ordinary, human reaction, which drastically changes their view of themselves. This can lead them to guilt and self-doubt. During a crisis debriefing session, it is important to discuss this identity issue. Trauma survivors need to know that their ordinary human reactions, during a crisis, are normal. Only in the movies do people act like Bruce Willis, and have such incredible skills during a crisis.

A crisis gives trauma survivors a view of themselves which they’ve never experienced before. This does not have to be a bad experience, because their reactions are truthful reactions, not fantasy reactions. Each of us needs to have life experiences exposing our real selves, and including our vulnerable selves. Some of these life experiences are joyous, while others are not. They are necessary, because we all need to know who we really are.
Another reason that a trauma survivor’s life-view canl change, is because their core belief about the world can change. For example, as noted previously, they may maintain the core belief the world is safe. The truth is that Americans have been functioning with the assumption that the world and our country is much safer than it actually is. In other words, the core belief (the world is safe) is not correct. It is true that America is safer than most countries, but very little in life is completely safe.

As horrible as crises are, and as much as we would like to eliminate them, crises offer the truth about the world. Crises can change how survivors view the world and if that view is more accurate, then such a view furthers their successful adjustment to life. If they have a realistic perspective of the lack of safety in the world, they can better take action to increase that safety.

Suggestions for threats to identity:

• The debriefer can discuss the common fantasies of responses to crisis, versus the trauma survivors’ real reactions. The debriefer can normalize the idea that people never live up to their fantasies when experiencing an actual crisis. Offering a nonjudgmental attitude is helpful

DEPENDENCE / INTERDEPENDENCE / SELF-RELIANCE
Three sets of skills needed to effectively manage life and particularly needed to manage a crisis include: Dependence, Interdependence and Self-Reliance.

• Dependence is the willingness to let others do something for you. Dependence is a helpful skill if it insures safety and security. Knowing when to be dependent and of course, when to stop being dependent are important skills for trauma survivors.
  
  
• Interdependence is a person’s willingness to take care of himself or herself and also to be helpful to others.
  
  
• Self-Reliance involves the skills necessary to effectively manage life alone, because in some situations there will be no one to assist.

Some trauma survivors become dependent after experiencing a crisis. Dependence is a common reaction and, at times, may be a healthy reaction. For example, if a person’s work environment is dangerous and he or she feels distracted because of surviving a crisis, dependence can be a helpful tool. That person could give the reigns of his or her work to someone else, to insure safety. This is an example of a healthy dependency, because it insures safety, security and survival.

The difficulty people have with dependency is over-dependency or not knowing when to take the reigns of life back. Jane had a job that required her full attention, because she did dangerous work handling chemicals. She experienced a crisis at work when one of her colleagues mixed two opposing chemicals, creating an explosion. This accident had shaken Jane; she experienced poor concentration. She gave the reigns of her work to a co-worker until her mind settled, which insured safety, security and survival. But after Jane’s mind settled and she could perform the work safely, she enjoyed passing the responsibility of the work onto others and continued her over-dependency. Since she was not taking the reigns, she was using over-dependency. If Jane would have taken the reigns of her work after her mind settled, she would have been using dependency in a very appropriate manner.

Interdependence is necessary for trauma survivors to perform well in the group process. If trauma survivors are willing to take care of themselves and willing to be helpful to others, they are usually productive in crisis debriefing sessions. Some individuals with personality disorders do not use interdependency. They do not know how to take care of themselves and they are not helpful to others. Without the skill of interdependency they either avoid coming to crisis debriefing sessions or they disrupt crisis-debriefing sessions. For example, people with avoidant personality disorder do not usually attend or, if they do attend they do not talk. People with attention-seeking histrionic personality disorder consume a group making the group dysfunctional. When a group of people is taking care of themselves and helping others, they are performing interdependence and creating a very productive group.

People also need to be self-reliant. There are times in life when a person must manage issues alone and self-reliance is helpful during those times. For example, trauma survivors invited to attend a crisis debriefing session need to make the self-reliant decision to attend. Trauma survivors need support and suggestions for handling the aftermath of a crisis, but they must be self-reliant enough to start using these new skills.

People need a blend of all three of these skills to best manage life. Trauma survivors who perform well in crisis debriefing sessions and manage life’s crises know when to be dependent, interdependent, and self-reliant. Trauma survivors, who have difficulty managing life’s crises, often do not know when to use these skills appropriately.


Introduction
People in crisis, often experience new and unusual crisis reactions. Because of the intensity of crisis reactions, many trauma survivors do not realize they are also experiencing grief emotions. Some trauma survivors may immediately feel grief emotions and others may not. This is often because some losses are obvious and others are not. For example, a trauma survivor who witnessed a loved one die during a crisis, may feel immediate grief emotions (assuming they are not experiencing brief numb-and-stunned reactions). Other survivors, who did not experience the death of a loved one, are likely to have grief reactions eventually. A loved one did not die, but a life-sustaining belief or beliefs may have died. For example, a trauma survivor who believes in God and believes that God will keep him safe, now feels intense danger following the crisis and questions the existence of God. This survivor will grieve the loss of his or her life-sustaining belief. So, grief reactions can happen if a loved one, friend, or life-sustaining belief dies.

Another complication results from the fact that we live in a “happiness” culture. The American culture is neurotic about keeping adults and children happy 24 hours a day, seven days a week. This is a complication, because many people in our culture do not realize the painful emotions associated with grief and that such emotions have a very meaningful purpose. If they do not know the purposes of painful grief emotions, trauma survivors may have an inclination to attach cognitive distortions to healthy emotions.

It is good to include the emotions of grief in the educational component of crisis debriefing sessions. It is recommended that grief emotions (and their purposes) be included in the handout packets, which survivors receive at crisis debriefing sessions.

Consider the importance of uncomfortable emotions with the following example. Imagine you are at work. You say a joke or a comment with your colleagues and there is a silence, filled with embarrassment. Embarrassment is an uncomfortable emotion, but it does fit the situation that you just created. If you attach good cognition to your uncomfortable emotion of embarrassment, you may conclude, “I’m not going to do this again at work”. This uncomfortable emotion of embarrassment, coupled with good cognition, creates helpful internal guidance; “I’m not going to do this again at work”. If children and adults have no knowledge of the purpose of their uncomfortable emotions, such as grief emotions, it increases the chance that they will attach cognitive distortions to healthy, but painful, grief emotions. Crisis debriefing is an opportunity for trauma survivors to learn about the purposes of their grief emotions.

This author, James A. Fogarty, Ed.D., in the book and online continuing education course “The Magical Thoughts of Grieving Children” (2000) describes the healthy grief emotions and their purposes.

Numb and Stunned
Numb and stunned are grief reactions in which the trauma survivor feels none of the grief emotions for a small period of time. This usually is very temporary. The numb and stunned reaction may last several minutes to several months. If this continues for an indefinite time, it may convert to an absent or delayed grief (Rando, 1993). Dr. Rando mentions that absent mourning occurs when mourners do not recognize the loss. Delayed mourning occurs when mourners do not react to the separation. When trauma survivors experience numb and stunned reactions, typically, they do not feel any intense grief reactions. They do appear to think clearly, however, because their thinking is not consumed by grief reactions.

The following items, from this author’s book and online continuing education course, “The Magical Thoughts of Grieving Children”, associate grief reactions with the purposes they serve.

• “Numb and stunned reactions protect the bereaved … from being overwhelmed by all of their intense grief emotions … by offering a gradual incorporation of the loss.”
  
  
• “Numb and stunned reactions also signal … that something unusual and significant has happened, and that they will need to make adjustments.”
  
  
• “Numb and stunned reactions are also a way for (survivors to) “brace” themselves emotionally following a trauma.”
  
  
• “Numb and stunned reactions allow (survivors) to gather information objectively and to observe others.”

Before trauma survivors can adjust to death of a loved one or to a crisis, they need to have developed a sense of safety, security and survival. Numb and stunned reactions help survivors find those “3 S’s”. If trauma survivors are emotionally numb and stunned, their thoughts tend to be more objective. Their clear thinking allows them to examine their environment. They are looking for people or places where they can feel safe and secure. Once they identify those safe people and places, they can gravitate toward safety. Once they feel safe and secure, the painful emotions of grief can better surface.

Complications can occur if they cannot find safe people and safe places. For example, an abused child may express deep emotions to an abusive father, about mother’s death. If the abusive father beats the child, there is no safety. Without safety, children delay their grief.

There are two ways to delay grief. Some people delay grief from one environment to another environment. A grieving person may not feel safety and security in one environment so he may delay experiencing the emotions of grief until he is in a safe environment. For example, a trauma survivor may not feel safe and secure at work, so delays grief reactions until he arrives home. Other people delay grief over a period of time. A traumatized child may get beat-up by an abusive parent when the child expresses grief emotions. When, after many years of delaying grief, the child becomes an adult and finally feels safe, his or her grief emotions may start to surface.

Attempts to Re-Create Coupled with Balancing Denial
After the death of a loved one, trauma survivors have a strong desire to get the loved one back. Fogarty (2000) suggests “(survivors) attempt to re-create the situations and experiences they had available when their dead loved one was alive”.

Although many trauma survivors are persistent, their attempts to get their dead loved one back will, naturally, fail. They usually try to get their dead loved one back by doing “people-replacement”. “People-replacement” occurs when a survivor tries to force others to have the qualities of the dead loved one. A common example is a man who remarries shortly after his wife dies. Instead of accepting his new wife and her unique personality, the man pressures the new wife to act like his deceased wife. If his new wife refuses, he may begin to learn that he cannot get his deceased wife back. He may face the truth that his first wife is dead. However, if the new wife tries to be like his previous wife, he experiences “people replacement”, while not accepting the reality of his first wife’s death.

A six-year-old boy’s mother dies and since her death, several months previously, he spends considerable time at his aunt’s home. One day he asks his aunt, “Can I start calling you mom? Will you do some of the special things mom did for me?” His aunt responds, “Oh no, your mother was so special that I could never replace her. We can do some of the same things you did with her, but we will also do different things because I am a different person”. This boy may have the greatest aunt in the world, but he will feel great disappointment with his aunt. His disappointment results from his realization that he cannot get his mother back. In other words, “attempts to re-create” teaches him that his mother is truly dead. It also teaches him that he will need to adjust, because life is now different. As he faces these truths, he is breaking through denial.

Many trauma survivors will want to go back to work, shortly after a crisis, and pretend the crisis did not happen. They believe this pretense will allow them to continue with their work and their life. But, this attempt to re-create their past, unchanged, does not work. They need to face the truth of the crisis and adjust to it.

An attempt to Re-Create has several purposes, it:

• helps trauma survivors realize that a loved one is dead or that a crisis actually occurred.
  
• keeps trauma survivors’ denial to a healthy minimum.
  
• reminds trauma survivors of their dead loved one’s importance.

Disarray
Disarray resembles the symptoms of Attention Deficit Hyperactivity Disorder (ADHD). As trauma survivors grieve, they appear distracted. When people exhibit symptoms of ADHD, they also appear distracted, and their attention wanders towards various thoughts. In contrast, people experiencing disarray appear distracted, but their mind tends to focus on the loss or crisis which they have experienced. Disarray is a mechanism, within the grief process, that pushes trauma survivors to focus on a loss or a crisis. In other words, disarray pushes survivors to deal with the reality that they need to manage.

Disarray has two purposes:

• Disarray is a barometer. When disarray is obvious, trauma survivors are signaling that they are actively focusing on the loss or trauma. When disarray subsides, the survivor is more attentive to current life.
  
  
• Disarray pushes people to think about their losses and trauma, reducing avoidance and denial.

Disarray can complicate the process of diagnosing trauma survivors’ mental condition. The usual misdiagnosis of disarray is ADD or ADHD. This author has seen many people, especially children, prescribed ADHD medications who in fact have other attention problems, such as disarray.

Anger
Anger is another common emotion occurring as trauma survivors adjust to a loss or the aftermath of a crisis. With grief, anger is often a secondary emotion. As a secondary emotion, it is a signal that there is a more primary emotion fueling the anger. The primary emotion needs to be uncovered and ventilated.

Consider the following secondary emotions that may fuel anger (Fogarty 2000):

• Abandonment – Someone leaves who you do not want to leave.
  
• Betrayal – Someone you trust turns against you and actively tries to hurt you.
  
• Disappointment – You count on someone but they intentionally let you down.
  
• Helplessness – You try to change something in your life, unsuccessfully.
  
• Embarrassment – Something weird or unusual happens, resulting in unwanted attention from others.
  
• Hopelessness – You wish something would happen, but you know it won’t happen.
  
• Sadness – Something happens that makes you feel sad.
  
• Anger is a signal that a primary emotion needs releasing.
  
• Anger is a barometer. When a person resolves an emotional issue, anger should subside. When anger subsides it is working as a barometer, suggesting the person is resolving the primary emotion.

Anger has many potential complications. Often, the greatest complication occurs as trauma survivors attach cognitive distortions to their anger. Cognitive distortions often fuel more anger, leading trauma survivors to engage in destructive behaviors. For example, a man’s wife died a very painful death with cancer. Witnessing her terrible death traumatized him. He was angry with the physician for not reducing her pain so, he wanted to hurt the physician He attached the cognitive distortion of “all-or-none” thinking to his anger. His “all-or-none” thinking fueled his anger and made him want to hurt all physicians.

When considering grief-related anger, the debriefer can examine trauma survivors’ rational thoughts versus cognitive distortions attached to their anger. Irrational anger is another “red flag”, possibly indicating that the anger is a secondary emotion. If anger is a secondary emotion it is a signal that another primary emotion needs ventilating. For example, a person may feel betrayed, but instead of expressing the feeling of betrayal, this person only shows anger. Anger (the secondary emotion) is a signal that betrayal (the primary emotion) needs releasing.

Anguish
When trauma survivors express anguish, their anguish looks exactly like depression. When feeling anguish or depression, they express their upset with the same tearful expressions. Depression and anguish are different, although their expression appears to be the same. Depression is a sadness filled with cognitive distortions, destructive to a person’s self-esteem. Anguish has no cognitive distortions and helps to heal the mourner.

Anguish has several purposes:

• Anguish and memory of traumatic events surface together. When trauma survivors feel anguish, they may be recalling a memory of their loved one or they may be recalling what life was like before a crisis impacted their lives.
  
  
• Anguish and love surface together. Anguish teaches a trauma survivor how much they loved the dead loved one. In the aftermath of a crisis, anguish may also teach them how much they appreciated their past feelings of safety.

Anguish becomes complicated when survivors become stuck with anguish. Anguish is connected to love, consequently some trauma survivors attempt to demonstrate love for a friend or loved one who died by staying in intense anguish. This belief keeps them stuck in intense anguish. Some may never progress in their process of grief.


Features of Personality Disorders
“A sailor without a destination cannot hope for a favorable wind.”
Leon Tec, M.D.

For a group process to be effective, trauma survivors in the group must experience interdependency. Interdependency is the trauma survivors’ willingness to take care of themselves, while offering concern for others.

For example, in a good marriage one spouse considers the viewpoint of the other spouse before major decisions become final. The other spouse does the same. They get together and discuss every detail and mutually agree on what actions to take. This is interdependency, because they are taking care of themselves and each other.

People with personality disorders have difficulty incorporating interdependency into their lives; over-focus on themselves and minimize the essential ingredient of focusing on others. As harsh as this sounds, people who have personality disorders tend to be self-centered.

DSM IV (1994) defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress and impairment.” In other words, a personality disorder is a person’s commitment to staying dysfunctional.

To the untrained eye, many people with personality disorders appear inadequate. In certain ways, this is true. People with personality disorders do not know how to manage life effectively, and are unskilled in the Five Life Management Skills. They particularly do not know how to apply the Five Life Management Skills to the difficult times of life, such as crisis. If they cannot invest in others in a healthy manner (Task IV), they cannot participate effectively with interdependency.

People with personality disorders are expert at being defensive. For example, a person with dependent personality disorder appears inadequate, because he or she needs to be dependent in every situation. But, this person still has considerable power. When at home, this dependent person will be dependent on his or her spouse. When at work, this person will be dependent on colleagues. If someone is uncooperative, and will not allow dependency, the dependent person will eliminate this uncooperative person from his or her life. Now that is powerful. It is maladaptive, but powerful.

People with personality disorders are often quite intelligent. Their difficulty managing life does not result from a lack of intelligence. They often exercise considerable intelligence when manipulating people by being dependent, borderline, antisocial, avoidant and more. They lack the skills to manage trauma, because they have not developed the Five Life Management Skills. However, they usually have the cognitive ability to learn the Five Life Management Skills.

People with personality disorders are rigid. They often do not progress much, after extensive treatment. Obviously they are not going to change or become cured during a short crisis debriefing session. If a person with a personality disorder is in your crisis debriefing sessions, the goal is to manage this person, so he or she does not lessen the quality of that session. To manage them, it is helpful to know what motivates them. So we’ll discuss that shortly.

People with certain types of personality disorders will not disrupt your groups. For example, people with avoidant personality disorder may not come. If they do come, they may avoid talking during the session. Rarely, would they disrupt the group. They rarely contribute and support others, but they are usually not disruptive. People with Narcissistic Personality Disorder believe that you have nothing to offer them so typically they don’t come.

THREE DISRUPTIVE PERSONALITY DISORDERS
There are three types of personality disorders that will disrupt your crisis debriefing sessions, including:

• Borderline Personality Disorder
  
• Histrionic Personality Disorder
  
• Passive-Aggressive Personality Disorder

Borderline Personality Disorder
The following diagnostic criteria for Borderline Personality Disorder is taken from the DSM IV. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more)of the following:

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
   
   
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
   
   
3. identity disturbance: markedly and persistently unstable self-image or sense of self.
   
   
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
   
   
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
   
   
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
   
   
7. chronic feelings of emptiness
   
   
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
   
   
9. transient, stress-related paranoid ideation or severe dissociative symptoms

Individuals with Borderline Personality Disorder have an exorbitant fear of abandonment. They focus their entire life on fearing abandonment. Because of this fear, they often become manipulative with many hidden agendas.

Their fear of abandonment often originates for valid reasons. Many people with Borderline Personality Disorder have experienced abuse as children, creating a feeling of abandonment within their childhood. Trull (2001) Hammond (2000) and Ross et al. (1998) found a relationship between Borderline Personality Disorder and childhood abuse. Dubo found that parental sexual abuse and emotional neglect were related to the self-mutilation often exhibited by adults with Borderline Personality Disorder. But, there are many people abused in childhood, who did not develop Borderline Personality Disorder.

In crisis debriefing sessions, trauma survivors with Borderline Personality Disorder will want to break boundaries and often become intrusive with other group participants. They will either love or hate the debriefer and the other participants; they do not manage their emotions well. Many of their reactions result from an inability to sooth themselves when crisis and losses occur. For example, this author counseled a family in which a loved one was dying. The surviving spouse had borderline personality disorder. For several days prior to his death, the spouse was in considerable pain. In his pain and frustration he said, “I wish I would just die and get out of here!” An emotionally healthy person would have the soothing thought, “He said that because he was in pain. If he had a choice he would not have cancer and he would stay with us.” With this soothing thought, the emotionally healthy person would not get angry and could be understanding. A person with Borderline Personality Disorder, without this soothing thought, may think, “He wants to leave me!” Of course, this complicates the ability for the person with Borderline Personality Disorder to adjust in a healing fashion. It also complicates their ability to offer support to others.

This leads to the next feature involving the borderline personality disorder; they have intense and unstable relationships. Instead of creating mutual relationships through interdependency, their goal is to break everyone’s boundaries. For example, in long-term counseling, they may want to move in with the counselor; demand more late-night phone calls; drive past the counselor’s home; want to know about the counselor’s personal life, and much more. Boundary breaking is their best skill.

People with Borderline Personality Disorder often give signals about feeling suicidal. They may be suicidal, but they also may use suicidal talk to grab control of others. Their suicidal talk appears manipulative whether their suicidal intent is realistic or not. Determining whether they are manipulative or serious is difficult. The debriefer must always take their suicidal talk seriously and make appropriate recommendations.

Histrionic Personality Disorder
If you attend a middle school play, there is usually an eighth-grade student who is overacting. If you put this same quality in an adult, the result is Histrionic Personality Disorder.

Diagnostic Criteria for Histrionic Personality Disorder (DSM IV 1999)
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following symptoms:

1. uncomfortable in situations in which he or she is not the center of attention
   
2. interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
   
3. displays rapidly shifting and shallow expression of emotions
   
4. consistently uses physical appearance to draw attention to self
   
5. has a style of speech that is excessively impressionistic and lacking in detail
   
6. shows self-dramatization, theatricality, and exaggerated expression of emotion
   
7. is suggestible, easily influenced by others or circumstance
   
8. considers relationships to be more intimate than they actually are.

People with Histrionic Personality Disorder are over-dramatic. Their greatest need is attention. They do not know how to attain healthy attention, because they do not know how to manage life. When they seek attention, they are often disruptive to the group process.

Dramatic as they are, their emotions are usually shallow. For example, when an emotionally healthy person feels anguish as a response to a loss, the healthy person can offer a deep network of thought that explains why he or she feels the anguish. When a person with Histrionic Personality Disorder expresses anguish, he or she usually cannot offer a deep network of thought to explain the anguish. The person with Histrionic Personality Disorder is mimicking the anguished person. The person with Histrionic Personality Disorder may have noticed that another group participant received considerable attention when expressing anguish. This motivates the person with Histrionic Personality Disorder to express anguish to gain the group’s attention. The anguish did not arise from a network of thought about the crisis.

People with Histrionic Personality Disorder will perform provocative behavior to gain attention. For example, as one group participant became emotional with anguish, the histrionic participant opened a newspaper, rattled it and started to read. Of course, her reading behavior did not fit and she stole the group’s attention from the anguished participant.

If someone died during the trauma, people with histrionic personality disorder act as though they were greater friends with the dead person than they actually were. They will exaggerate their relationship with the dead person, hoping to draw greater attention and sympathy from others.

Passive-Aggressive Personality Disorder
Another personality disorder likely to disrupt group process is the Passive-Aggressive Personality Disorder. The older DSM III is referred to, because DSM IV places Passive- Aggressive Disorder in an appendix.

Adolescents will often have a temporary streak of passive-aggression. Parents will ask their adolescent to do a task, and the adolescent refuses to do it, mostly to irritate parents. On the other hand, parents may ask adolescents to not do a behavior, which is the first behavior performed. Again, they irritate and anger others by doing the opposite.

Adults with passive-aggression often refine these behaviors to a subtle art. They are not as blatant as adolescents, but they are just as disruptive. As the debriefer performs a debriefing with a group, a participant with Passive-Aggressive Personality Disorder will offer subtle but effective disruptions. They will sway the group off task with humor, arguments, irritating remarks, callousness, and indifference. Their goal is to disrupt the purpose and goals of the crisis debriefing session.

Many people with Passive-Aggressive Personality Disorder will not attend a crisis debriefing session. When forced to attend, they often disrupt the group process. This feeds the need they want fulfilled, which is power. They have not learned to develop healthy personal power. Instead, they feel powerful by trying to strip others of power. Once they identity a person as an authority figure, they feel motivated to gain power by stripping power from the authority. In contrast, a healthy person who is powerful tries to empower others.

Dealing with Personality Disorders in Crisis Bebriefing Sessions

• Usually, the debriefer has no prior diagnostic information about the trauma survivors, because the debriefer is independent of the group. Group members often know each other fairly well. When one of them has a personality disorder, other group members may have methods for containing the personality-disordered person. They may have built-in corrections within the dynamics their relationships. If their corrections are not abusive, the debriefer can allow the corrections to occur.
  
  
• The debriefer can also use the “pencil technique”. When a personality-disordered person is disrupting the group, the debriefer introduces a pencil into the session. The debriefer can instruct the group that, due to interruptions, the group needs a new rule. The debriefer instructs the group that only the person holding the pencil is allowed to speak for several minutes. The debriefer insures that each person has equal opportunity to speak, by enforcing this new rule
  
  
• Another productive technique is the “counselor at the door”. A counselor, in addition to the crisis debriefer is located “at the door” for the entire crisis debriefing session. This counselor can tend to the personality-disordered person disrupting the group and see them for one-on-one counseling.

“Never deprive someone of hope – it may be all that they have.”
Unknown

Dr. Ken Doka is a wonderful grief therapist who has presented numerous seminars and has authored several books on the subject. He offers excellent models and information about the issue of sudden loss, such as suicide and murder. His “things-to-consider” for a sudden loss have been applied to crisis debriefing situations in this online continuing education course. Listed below is Dr. Doka’s “Things to Consider” with insights and examples from this author.

Natural v. Human-Made
When first hearing about the details of a crisis, consider whether the crisis was a natural event or human made. Examples of a natural event include an earthquake, tornado, hurricane, heart attack, and a car accident. When the crisis is the result of a natural event, Dr. Doka indicates that some trauma survivors become angry with the person who died or with God. This author has noticed that, if a community lacks preparation for a natural disaster, trauma survivors’ anger often ignites toward the leaders of the community.

When the crisis is human-made, such as Timothy McVeigh in Oklahoma City or the Maryland sniper shooter, or with the World Trade Center in which innocent people are killed, trauma survivors usually direct their anger at the instigator of the event. This is a helpful contribution from Dr. Doka, because the crisis debriefer can anticipate the direction of a survivors’ anger.

The Degree of Intentionality
The degree of intentionality has a significant affect on the intensity of survivors’ reactions to the crisis. Dr. Doka discusses three degrees of intentionality.

1. High Intentionality – Osama Bin Laden and Timothy McVeigh are examples of high intentionality. They intended to kill people and cause harm.
   
   
2. Recklessness – Recklessness means the person creating the crisis did not intend to hurt anyone, but the results may be just as devastating. For example, the college student who drives while drunk and kills three children. The college student did not intend to kill anyone, but his or her reckless actions resulted in tragedy. The survivors of recklessness have an intense reaction, but often not as intense as crisis with high intentionality.
   
   
3. Accident – An accident means there is no intention of hurting anyone and no recklessness. The crisis was the result of a pure accident. For example, boulders fell on a Pacific Highway in California. No one intentionally created this event and it was not the result of someone’s recklessness.

A special problem exists with “responsibility” in the American culture. Much of our culture does not believe in a pure accident. In crisis debriefing sessions, it is not uncommon for trauma survivors to want to hold someone responsible, even if the event was a pure accident or natural event. In other words, our culture does not believe in a “pure accident”. Some trauma survivors want to hold someone responsible, even though one is responsible. Of course, this spreading of responsibility hurts the healing process, as it promotes cognitive distortion and anger.

Another problem exists with “responsibility” in American culture; deciding who is responsible for an accident. For example, if you dug a deep hole in your front yard and someone fell in during daylight, you would probably be held liable. You did not cover up the hole and you did not post warning signs around the hole.

In other cultures, such as Ireland, different beliefs exist about the issue of responsibility. If someone walked through a yard in Ireland and fell in a hole in broad daylight, the owner of the home would say to the person in the hole, “You need to get a pair of glasses and what are you doing in my yard?” In other words, the owner of the house is not held responsible. The person walking in broad daylight needs to watch where he or she is walking. However, our culture tends to spread responsibility beyond those actually responsible, or even if no one is responsible.

Dr. Doka’s classifications of high intentionality, recklessness, and pure accident are helpful to the crisis debriefer. One purpose of crisis debriefing is to clarify cognitive distortions. When a debriefer hears trauma survivors changing an accident into recklessness or recklessness into high intentionality, the debriefer can advocate for the truth. If a trauma survivor is resistant to accepting the truth, this is a red flag, indicating the trauma survivor will need more treatment. Anytime trauma survivors are accepting cognitive distortions, this is a red flag for the debriefer. The more resistant a trauma survivor is to accepting the truth, the bigger the red flag.

Level of Suffering
When trauma survivors learn about the level of suffering their deceased loved one endured, such knowledge influences the survivors level of suffering. The greater the level of suffering experienced by their loved one, the greater the suffering experienced by the trauma survivors. For example, when Flight 800 disappeared in the Atlantic Ocean, a group of high schools students was aboard. The media interviewed a father of one student who said that he needed to know where his daughter was sitting on the plane. He hoped she was sitting over the wing of the plane. If this were the case, he would feel some relief knowing she died instantly. If he learned that she was not near the wing, he would have to imagine her falling from the sky while she was awake. If he learned t hat her suffering increased, then his suffering would increase.

It would be tempting to withhold this information from trauma survivors, believing we would reduce their pain. But, withholding information is a form of lying. If debriefers help trauma survivors avoid reality, debriefers are promoting fertile ground for cognitive distortions. If the debriefer offers painful information, the trauma survivors will receive the information from a debriefer offering it in a caring manner. Also, when the debriefer gives painful information to trauma survivors, the debriefer is also giving the message, “I believe we can manage this trauma together.”

Scope of a Crisis
The scope of a crisis involves the number of people involved in the crisis. The greater the scope, the greater the intensity. For example, in a family of six, trauma occurs to one family member but not the others. The non-traumatized five family members can offer the usual support to the one traumatized family member. The five non-traumatized family members may not experience crisis reactions, so they can offer their usual support. If the scope increases and trauma occurs to all six family members, their crisis reactions may inhibit their ability to offer quality support to one another. Examples of the greatest scope of recent times in this country include the Oklahoma City bombing and the World Trade Center. The Oklahoma City bombing affected the entire city and the state. The World Trade Center affected the entire country and possibly the world.

For the crisis debriefer aiding a family or organization, the scope of the crisis will quickly tell the debriefer about the availability of non-traumatized support people who may be available.

Degree of Expectedness
One of the salient features of crisis is its unexpectedness. With the unexpectedness of crisis, survivors cannot implement the Five Life Management Skills before the crisis occurs. For example, if a loved one is dying of cancer, hospice has likely performed well by implementing the Five Life Management Skills before the loved one dies. After the loved one dies the survivors’ grief is intense, but they have been prepared to manage the grief. With a crisis, there is no opportunity for the trauma survivors to implement the Life Management Skills before the crisis.

For example, with the World Trade Center, the Oklahoma City Bombing and Columbine, there was no opportunity for trauma survivors to use the Five Life Management Skills before these crises. This is one of the unique factors of crisis, and why the Five Life Management Skills need to be injected quickly into survivors’ thinking to aid with their adjustment.

The debriefer can use the items mentioned above when first learning about a crisis. These items offer a direction about the intensity of trauma survivors’ reactions. They also offer the possible direction of trauma survivors’ anger and support.

There are many types of crises that trigger trauma survivors’ crisis reactions. Although most trauma survivors experience the crisis reactions and grief emotions previously discussed, they may have unique reactions based on unique crises. The following section of this online course explores the unique crises of suicide and murder. It is helpful for the debriefer to have a solid understanding of these unique crises. The debriefer can forewarn trauma survivors of the unique reactions associated with such crises. If trauma survivors have advanced knowledge of potential unique reactions, they can more quickly and easily adjust when these reactions occur.


The Social Stigma of Suicide
Suicide survivors are those whose loved one or close friend has committed suicide. Suicide survivors often experience a complicated grief process. Contributing to the complications is the fact that their dead loved one chose to die. This is a perplexing and distorting issue, as suicide survivors attempt to adapt to their loved one’s suicide.

Judith M. Stillion (1996) offers a wonderful research summation of the reactions of survivors who have had a loved-one commit suicide, which will be a guide for the following. This author will add comment and make note of further research.

Calhoun (1982) has found the social stigma is ever present for suicide survivors. Our culture still views suicide survivors more negatively and offers less social support when compared with other types of survivors. This lack of support occurs because the potentially supportive people often harbor a unique thought process, which diminishes their effective support.

For example, the son of a man’s best friend commits suicide. The man goes to his friend’s home to offer support. As he offers support to his friend, in the back of his mind he thinks, “There must have been something wrong with my friend’s parenting skills contributing to his son’s suicide”. This man wants to support his friend, but at the same time, he wants to separate from suicide. If he believes the suicide originated with his friend’s parenting skills, then he convinces himself that it will not happen at his home. Unfortunately, in this case, the suicide survivor realizes the supportive friend is offering very little support.

Contributing to the problem of support, Neary (2000) found that suicide survivors displayed poorer social skills. This may be the result of the social stigma of suicide, which may inhibit the sociability of the suicide survivor.

Suicide survivors have a strong need to understand why the suicide happened (Calhoun 1988, Van Der Wal 1989). Some survivors become fixated on the question, “Why did this happen?” It has been helpful to advise suicide survivors to talk with clergy about this question. The Five Life Management Skills are also helpful when trying to get a suicide survivor to defocus off the “Why” question. For example, the debriefer may ask a suicide survivor about more positive memories (Task Five – memory). Or, the debriefer may ask how the suicide survivor will rearrange their home, so they feel more comfortable (Task Three – adjust to the environment).

Some suicide survivors will want to believe that their loved one died of an accident or murder, when suicide is obvious. Although Task One suggests that suicide survivors face the truth and reality of their situation, timing is important. A suicide survivor may temporarily need to believe their loved one did not commit suicide. They may not be psychologically ready to handle the thought that their loved one committed self-murder. The debriefer does not have the luxury of timing, since there are severe time limits within the crisis debriefing setting. Instead of enforcing the truth, the debriefer could view a suicide survivor’s unwillingness to accept reality as a large red flag. The suicide survivor will need more treatment. Denying the reality of the suicide is inconsistent with Task One, facing reality.

In long-term counseling, accepting the truth and reality of a suicide is important. For example, complications arise when one family member believes their loved one was murdered, but the rest of the family has accepted the obvious suicide. It may be impossible for this family to utilize the Five Life Management Skills together. If they have different beliefs, how do they invest in one another (Task Four)? If they have different memories of what happened, how do they remember this person (Task Five)? A suicide survivor, denying the suicide may also deny obvious symptoms of depression their loved one experienced while they were alive. In a short-term crisis debriefing session, the luxury of advocating the truth is not always available in these types of cases. But, when anyone walks away from truth and reality, they are not managing life – which is a huge red flag.

The Eternity Question
Another interesting topic presented by Van Der Wal (1989) is the suicide survivor’s concern that their loved one may not go to heaven. Imagine a client asking you this question, “Will my loved one go to heaven if he or she commits suicide?” What would be your response? Here are issues to consider:

• The debriefer may respond by asking the survivor, “What is your training and what is your belief about what happens to people who commit suicide?” There is a difference between training and belief. Survivors may have religious training, but their personal beliefs might be different. For example, someone’s religious beliefs may suggest that it is not possible for loved ones, who commit suicide, to go to heaven. The suicide survivor may have the same or different personal belief. The reverse may also be true. A suicide survivor may have had religious training stating it is possible that their loved one goes to heaven. They may personally believe it is not possible. It is this author’s experience that personal belief has the greatest impact on the suicide survivor. This question will help the debriefer discover the survivor’s personal belief, which usually has the greatest impact.
  
  
• The debriefer could respond with “God is loving and God forgives the sins of loved ones.” This is a good response, but an incomplete response. In our urgency to help survivors feel better, debriefers may like to give immediate hope that a suicide survivor’s loved one is in the comfort of heaven with God. Giving hope is one goal of a debriefer.
  
  
• What is missing is the caution. Various suicide survivors may view suicide in different ways. For one survivor, the response “God is loving and God forgives the sins of loved ones” may give her hope. For another survivor, if she hears there is hope after committing suicide, she may want to join the loved one by also committing suicide.

The following are examples of responses that offer hope and caution:

• I have to believe that God works overtime when this happens. I believe there is hope that your loved one is in heaven. But, you know you would not want to take the same action, because it hurts the survivors left behind.
  
  
• I believe that God will forgive this. God can better assess the turmoil a loved one’s experiences at that time. But we need to continue with life.

Other Reactions to Suicide
Kelly McIntosh (1992) found that suicide survivors blame other people or groups for the suicide of a loved one. If suicide survivors become defensive, they become linear in their thought processes. A suicide survivor may say, “He would not have killed himself, if his wife had not divorced him.” This is a step away from truth and reality. If divorce created suicide, with the current high divorce rate there would be many more suicides. This rigid thinking, offered by a suicide survivor, is an example of a red flag. The suicide survivor’s thoughts do not reflect truth and reality.

These researchers also suggest that suicide survivors, who believe they could have prevented the death of their loved one, experience intense grief. Bailey (1999) found that such suicide survivors experienced more feelings of rejection, and responsibility, as well as, “unique” reactions, more shame, greater perceived stigmatization, and more total grief reactions.

Brent et al. (1992) Saarinen (1999) and Neary (2000) discovered that suicide survivors had more depression and PTSD. Saarinen (1999) also found that such women were more inclined to be depressed than men. Since most suicide occurs at home, suicide survivors may likely experience the shock of discovering an ugly situation with the dead body of a loved one. Often they enter their home, as any other typical day, to find the horrible experience of a loved one who has hung or shot themselves. This discovery is extremely traumatic, triggering for many suicidal survivors post-traumatic stress disorder.

Reed and Greenwald (1991) found that suicide survivors experienced less shock and numbness than other types of survivors. These researchers mention that 79% of suicide survivors had warnings that their loved one was considering suicide. When warnings occur before a loved one’s suicide, suicide survivors experience less numb and stunned reactions. Without warnings, it is probable that suicide survivors’ numb and stunned reactions will last longer.

After a loved one commits suicide, it is not uncommon for the surviving family and friends to gather. When discussing the signals of suicide, it is surprising how many signals the loved one offered before committing suicide. Often the problem is that no one person had a global picture of how suicidal the loved one actually was.

There are times when families gather, after the suicide of a loved one, and they find absolutely no warnings. Often this person, who offered no warnings, appeared happy and content in life. Many people who offer no warnings before committing suicide have a masked depression. They function well with a happy smile, but hide a deep and dark depression.

Kovarsky (1989) found that when a loved one dies in an accident, the grief reaction for surviving loved ones has a high initial reaction and diminishes over time. When surviving a loved one who suicides, survivors’ grief reactions remain level or increase for a much longer time than if it were an accident. Miles and Demi (1991) found that parents experience greater loneliness when their child died of an accident. Parents experienced greater guilt when their child committed suicide.

Demi (1984) also found that surviving spouses, of those who committed suicide, had greater guilt and resentment during the second year of grief. Spouses often have great sympathy within the first year, after their loved one committed suicide. During the second year the survivor’s thoughts change. They start to view their loved one’s suicide as a self-murder. They also realize that their loved one’s suicide has made their life more complicated. Life becomes more stressful, especially if children are part of this process, increasing suicide survivors’ feelings of anger and resentment.

Callahan in 2000 found that suicide survivors that witnessed the “scene of the death” experienced the highest predictor of stress. He also found that support from family and friends was the “strongest protective factor”. One of the most significant findings for promoting the healing of suicide is the role of spiritual well being. Fournier (1998) found that spiritual well-being had a significant effect on “improving adaptability by reducing stress when analyzed independent of other coping resources”. Fournier also found that “self-mastery” had a similar effect as a coping resource in reducing stress. This author would advocate the Five Life Management Skills, as a means to self-mastery when trauma survivors are managing their trauma.

When the debriefer is performing a crisis debriefing session with people who have had a loved one or friend commit suicide, the debriefer can use this information as a reference by reviewing these many research articles. Good research gives us insights into the potential issues suicide survivors often experience.


Media’s Role
According to the Department of Justice website www.fbi.gov, and this varies a bit depending on the year, it is not uncommon to have approximately 16,500 murders each year in the United States. Five survivors per murder yields approximately 82,5000 individuals who suffer the death of a loved one by murder per year in the United States.

Murder offers unique intrusions into the lives of murder survivors, including law enforcement, criminal justice, and media. The law enforcement and criminal justice systems are necessary intrusions, but the media is not and media intrusions can be harmful.

The following represents the author’s commentary. Although there is good media, the prevalence and motivation of some media involved in the trauma of people’s lives may create more trauma. For example, if I were working again as a school psychologist, I would expect the media to report a school shooting which may occur within our country, such as the Columbine shooting. But, do citizens need to see, over and over again, the young man fall from a window out of the Columbine school, holding his wounded head? Did we need to see that fifty times each day during the crisis?

Another good question is, how do children and adolescents view these terrible media experiences? Working with adolescents, during the time of Oklahoma City bombing, was insightful. Many adolescents, who saw that building crumble, had reactions of fear. Others thought it would be neat to copy it. This latter group of adolescents viewed this media as a “game plan”.

Consider the escalation of trauma from the following two examples of media coverage. After I finished presenting a professional seminar I was heading for the Los Angeles Airport during rush hour. Suddenly traffic stopped. I was close to a set of stackable highways, for which L.A. is famous. I could see that something was happening on the top stackable highway. There were many television helicopters providing a live feed into local television stations. I turned on local talk-radio to find out what was happening. From the radio I heard enraged parents, with children screaming in the background.

I later learned there was a deranged man on the top highway with a rifle. He stepped out of his truck and threatened everyone with his rifle. He burned his truck, then lit his pants on fire. They were hot, so he took them off. The helicopter cameras were feeding a live picture of these events into homes throughout L.A. Finally he put his rifle in his mouth. Every camera in the helicopters turned off their live feed, except for one. The television station that had broken into afternoon cartoons continued the live coverage. This media travesty traumatized children throughout L.A. who were watching afternoon cartoons, as they witnessed the graphic suicide of this man. This unnecessary expansion of such trauma occurred for no reason other than media irresponsibility.

In a second example, a mother was watching afternoon cartoons with her son when the news broke in and reported there had been a fatal accident. The name of the teenager was withheld pending notification of the family. But this woman recognized the car, license plate and the sneaker hanging out of the body bag. This “impersonal” media notified her of the death.

I believe in first-amendment rights, but not for situations in which children and adults are induced to experience post-traumatic reactions. Most professions have ethics committees, but where is the ethics committee for the profession of media? Without a well-developed set of ethics with an ethics committee, media is not a legitimate profession. If any therapist were to hurt a client with words, an ethics committee would be available to monitor, educate, reprimand or eliminate the professional’s license. The media have no such monitoring system to protect the public.

The media also seems to have a special status with lawmakers. If a storeowner sold liquor to minor children, the storeowner could lose his or her license to sell liquor. If a movie theater owner sells an “R” rated movie to a minor child, nothing happens. The movie theater owner continues to stay open.

Murder and Its Effects
Murder survivors are those who survive, following the murder of a friend or loved one. Complicated grief is one of the unique features experienced by many murder survivors. Healthy grief is difficult enough when a loved one has died from a heart attack or a pure accident. When a murderer intentionally and viciously kills a loved one, murder survivors do not have the luxury of healthy grief. Just as with other crises, their usual coping skills are often not effective, as they attempt to incorporate this horrifying loss into their lives. The factors which add to the complication of murder survivors’ grief, are multiple.

Nova reports that murder survivors often want revenge. Revenge drives murder survivors to restore the belief that the world is orderly and just. A need to feel hopeful again also drives murder survivors. To feel the world is orderly and just, they turn to the criminal justice system.

The goals of the criminal justice system and its quality of services have a profound effect on murder survivors. The criminal justice system may often have goals which are opposite those of murder survivors. The criminal justice system is responsible for justice and punishment, but it is also responsible for rehabilitation and correction. These latter considerations may conflict with the goals of murder survivors.

The quality of services provided by the criminal justice system has a huge impact on the lives of murder survivors. Hatton (2001) reports that clinicians who specialize in assisting murder survivors report that the “treatment failure was related more often to environmental factors (such as poor criminal justice system) than personal variables or issues in the relationship with the deceased.” Murder survivors feel out-of-control because their loved one was murdered. It is a good assumption that a poor criminal justice system will contribute to the murder survivors’ out-of-control feelings.

Another experience that heightens murder survivors’ anger and belief that the world is not orderly, is the rights of the murderer. Murder survivors have lived through an experience in which a murderer has stripped away the rights of their loved one. Their fairness and balance of fairness is challenged as they sit in a courtroom and hear about the rights of the murderer. This one factor can significantly complicate murder survivors’ grief process.

Another complicating factor for murder survivors is that the death of their loved one is a public event, usually including the media. The media often intrudes upon survivors at their home, in the courtroom and in other public arenas.

When the police apprehend the perpetrator, murder survivors often have a euphoric response. However, a severe delayed-grief response replaces the short-lived euphoria. The first component of their delayed-grief follows the frustrations of delays in the trial proceedings. Trial delays can last for a considerable time, delaying survivors experience of normal grief responses.

Once the trial begins, murder survivors frequently have angry reactions to the blatant concerns about the perpetrator’s rights, often mentioned in court by the defense attorney. They often hear their loved ones maligned. Of course, their deceased loved ones are not in court to defend any maliciousness said about them.

Trial delays and lengthy trial proceedings, cause murder survivors to prolong and delay their grief responses. When the trial is over, there is usually an appeal process that can also take many years.

Debriefers can assist survivors by warning how the delays of the criminal justice system may affect them. Consider the following reactions when murder survivors cannot access their normal grief reactions:

• Murder survivors have a high divorce rate.
  
  
• Increased sleep disorders, including nightmares and insomnia.
  
  
• Uncontrollable sobbing and hysterical laughter.
  Physical reactions, including headaches, chest aches, and fatigue.
  
  
• Sprang, McNeil, and Wright (1989) mention that murder survivors often “feel victimized by police investigations, overwhelmed by a sense of rage at the perpetrator, and often release their rage and anger through revenge fantasies”.
  
  
• Batten (1998) found that murder survivors experience loss in three classifications: Testifying, Reverberations and Reconstitution. Testifying occurs when murder survivors discuss the details of the loss and their relationship with the victim. Reverberations involve the “aftermath” of the loss, including their grief and legal complications. Reconstitution includes the memorial for the victim and spiritual issues of the murder survivor.
  
  
• Armour & Peterson (2001) found that survivors’ had five themes of meaning, regarding the murder of a loved one:
  
  • “This is a nightmare you don’t wake up from.”
    
  • “I feel betrayed by those I thought cared.”
    
  • “What rights don’t I have anymore.”
    
  • “Belonging relieves my alienation and loneliness.”
    
  • “The intense pursuit of what matters is the meaning of life.”

There is another unique area of concern for murder survivors; many survivors have rescue fantasies. Rescue fantasies can be frustrating, because murder survivors often fantasize about how they might have come to the rescue, saving their loved ones. In practice, I have found that murder survivors’ rescue fantasies produce tremendous guilt and, for some, this guilt has a compulsive quality. For example, many parents obsess about the “would of’s” and “could of’s” when considering their children’s murder.

Rescue fantasies are more difficult for murder survivors who do not know what happened to their missing loved ones. When the survivor knows what happened to a murdered loved one, the survivor has one horrifying experience to remember. When the survivor does not know the actual scenario (for example, missing POW or missing child), the survivor is likely to imagine thousands of possible scenarios. Thoughts about these many scenarios repeatedly victimize the murder survivor. Of course, a murder survivor’s imagination can be worse than reality.

Another complication, mentioned by Gyulay (1989), occurs because the community’s initial reaction of rage and shock quickly subsides. Survivors continue with their reactions, leaving them out of sync with the community. Murder survivors may feel a lack of support, and at times, hostility from community members who fail to understand the murder survivors’ continued reactions of grief and rage.

It is helpful for debriefers to forewarn murder survivors about their likely, unique reactions to murder. If not forewarned, murder survivors often attach cognitive distortions to these unique reactions. For example, this author counseled a man whose daughter was a murder victim. He delayed his grief response through the lengthy trial delays and the seemingly endless appeal process. As he was sitting in court once again, because of another appeal by the murderer of his daughter, he was again hearing the details of his daughter’s murder. This father started laughing uncontrollably. Imagine the potential for cognitive distortions he could attach to his laughter. He needed truthful thoughts, which included good knowledge about his laughter reaction. I advised that the tension he experienced needed releasing, either by rage or laughter. Since he could not rage within the courtroom, he laughed. His was not a fun belly laugh, but laughter from tension.

It has also been found that murder survivors who experienced “death row mediation/dialogue sessions” generally report a very positive experience. Such sessions involve contact between survivors and the death row inmate. They report movement in their grief process, feelings of relief and gratefulness for the sessions. The debriefer can recommend these sessions to murder survivors, as a goal within a crisis debriefing session.

Debriefers offer a helpful service by forewarning murder survivors about their possible, unfamiliar reactions. When murder survivors know the purpose of their unique reactions, they can attach healthy thinking to these reactions, increasing the probability of realizing that their unusual reactions are normal.


The Two Types of PTSD
Debriefers need a good working knowledge of Post Traumatic Stress Disorder (PTSD), because many trauma survivors experience PTSD. It is impossible to make this diagnosis shortly following a crisis, because one of the criteria for this disorder is a 30-day persistence of symptoms. Most crisis debriefing sessions occur within one to fourteen days of the event, but the debriefer may see early signs of PTSD. A debriefer’s knowledge and forewarning to trauma survivors about the symptoms of PTSD and Complex PTSD is helpful.

There are two groups of trauma survivors of concerned, when performing crisis-debriefing sessions. The first group consists of trauma survivors who have experienced previous trauma. The current crisis may ignite their suppressed symptoms of PTSD from an old crisis. For example, throughout her childhood Allison’s father physically abused her. She recalled the physical abuse, but suppressed the traumatic emotions about the abuse. She never experienced or managed her traumatic (PTSD) emotions. When a co-worker physically assaulted her, her suppressed traumatic emotions ignited. Not only did she experience the current traumatic emotions from the assault at work, but she also experienced intense emotions from years of abuse, which overwhelmed her.

The second group consists of trauma survivors with Complex PTSD. There is considerable research, offered in this online course, documenting the existence of Complex PTSD. Complex PTSD involves a set of symptoms that are more severe that PTSD, as defined by the DSM-IV. Complex PTSD is often the result of more severe trauma and/or trauma over a longer period of time.

Research offers mixed results about crisis debriefing’s likelihood of reducing trauma survivors’ PTSD symptoms. A better goal for the debriefer is to determine which trauma survivors have initial PTSD symptoms, suppressed PTSD symptoms that are surfacing, or Complex PTSD.

Criteria for PTSD
The DSM-IV (1994). defines PTSD as “the development of characteristic symptoms following exposure of an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or close associate…” In other words, a number of horrible things happen to themselves or others that they witness. Consider the Simple PTSD criteria from the DSM-IV:

A. The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
   
   
2. The person’s response involved intense fear, helplessness, or horror.

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event.
   
2. Recurrent distressing dreams of the event.
   
3. Acting or feeling as if the traumatic event were recurring.
   
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
   
5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, as indicated by three (or more)          of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
   
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.
   
3. Inability to recall an important aspect of the trauma.
   
4. Markedly diminished interest or participation in significant activities.
   
5. Feeling of detachment or estrangement from others.
   
6. Restricted range of affect (e.g., unable to have loving feelings).
   
7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life).

D. Persistent symptoms of increased arousal as indicated by two (or more) of the following:

1. Difficulty falling asleep.
   
2. Irritability or outbursts of anger.
   
3. Difficulty concentrating.
   
4. Hypervigilance.
   
5. Exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Crisis Debriefing and PTSD
All participants in a crisis debriefing session have experienced Criteria A, exposure to a traumatic event. For some trauma survivors, the current trauma may be the first traumatic event they’ve ever experienced. For others, the current trauma may be one in a long history of trauma. As a debriefer, one rarely knows the history of each trauma survivor within the crisis debriefing session. A full understanding of PTSD helps the debriefer to see potential “red flags” expressed by participants.
Helpful questions which brings such “red flags” to the surface are, “What previous crises have you experienced, big or small? And, how did you manage those previous crises?” As trauma survivors respond, the debriefer may notice signs of PTSD.

Effective use of the Five Life Management Skills may assist survivors to effectively manage PTSD symptoms, over time. Trauma survivors response to the debriefer’s question, “How did you manage those previous crises?”, can indicate whether or not the Five Life Management Skills were effectively utilized.

When considering Criteria B (the traumatic event is persistently re-experienced in one or more ways), the debriefer may hear trauma survivors mentioning dreams, flashbacks (a sense of reliving the trauma), disturbing recollections, and reaction cues. Such responses can make them more sensitive to cues within their environment, which may set off old traumatic emotions. For example, Marie entered the crisis debriefing session several days after a crisis. As she entered, she experienced flashbacks from an old trauma. When she was a child, her father severely beat her for many years. The crisis debriefer resembled her father, igniting her old traumatic emotions. Marie is re-experiencing an old trauma, because the recent trauma allowed Marie’s previous traumatic emotions to surface. Of course, Marie’s reaction would be a huge “red flag”, indicating she needs extensive treatment beyond the crisis debriefing.

Regarding Criteria C of PTSD (persistent avoidance of stimuli associated with the trauma), many trauma survivors believe they can avoid trauma reminders. They often have the magical belief that if they avoid reminders of the trauma they will feel better. Of course, this magical belief promotes denial and interferes with recovery. Marie, from the previous example, thought she was in charge by managing her previous traumatic emotions through suppression. In reality, her previous trauma was in charge of her. She should have felt safe with the debriefer, because the debriefer was actually a safe person. But, she could not see the safety of the debriefer because of her previous traumatic emotions. This resulted in her trauma actually controlling her.

Regarding Criteria D, one of the most noticeable symptoms is hypervigilence. Hypervigilence is a heightened state of arousal, in which the trauma survivor is constantly on alert for more potential trauma. Behaviorally, trauma survivors with hypervigilence appear to have ADHD symptoms. They display strong distraction. Persons experiencing ADHD are distracted by numerous thoughts and environmental stimuli. Trauma survivors experiencing hypervigilence focus on all potential dangers and constantly search their environment. The debriefer can ask trauma survivors, “Have you noticed a need to constantly search your environment for potential dangers?” Another signal is the exaggerated startle response. The debriefer can also inquire about trauma survivors’ startle reactions since the trauma.

Complex PTSD
The post traumatic reactions of some trauma survivors exposed to severe abuse and violence are more severe than the PTSD criteria advanced by the DSM IV. Although Complex PTSD is not officially a DSM IV disorder, the research and experience of clinicians becomes quite convincing that such distinction can be informative. Awareness of Complex PTSD symptoms can alert the debriefer to the most significant “red flags” of all.

Judith Herman presents the following symptoms for Complex PTSD in her book titled, “Trauma and Recovery”:

1. A history of subjection to totalitarian control over a long period of time. Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems of sexual and domestic life, including survivors of domestic battering, childhood abuse, physical or sexual, and organized sexual exploitation.
   
   
2. Alterations in affect regulation, including:
   
   • Persistent dysphoria
     
   • Chronic suicidal ideation
     
   • Self-injury
     
   • Explosive or extremely inhibited anger
     
   • Compulsive or extremely inhibited sexuality
3. Alterations in consciousness, including:
   
   • Amnesia or hyperamnesia for traumatic events
     
   • Transient dissociative episodes
     
   • Depersonalization/derealization
     
   • Reliving experiences, whether in the form of intrusive post-traumatic stress disorder symptoms or in the form of rumination
4. Alterations in self-perception, including:
   
   • Sense of helplessness or paralysis of initiative
     
   • Shame, guilt, and self-blame
     
   • Sense of defilement
     
   • Sense of complete difference from others (a sense of being lonely, a belief that no other person can understand)
5. Alterations in perception of perpetrator, including:
   
   • Preoccupation with relationship with perpetrator
     
   • Unrealistic attribution of total power to perpetrator
     
   • Idealization or paradoxical gratitude
     
   • Sense of special or supernatural relationship
     
   • Acceptance of belief system or rationalizations of perpetrator
6. Alterations in relations with others:
   
   • Isolation and withdrawal
     
   • Disruption of intimate relationships
     
   • Repeated search for rescuer
     
   • Persistent distrust
     
   • Repeated failures of self-protection
7. Alterations in systems of meaning
   
   • Loss of sustaining faith
     
   • Sense of hopelessness and despair

Experientially, these symptoms appear to be a blend of PTSD, Borderline Personality Disorder and Dissociative Disorder. Horrifically abused clients, especially those abused over long periods of time, generate the symptoms of Complex PTSD. Most of such symptoms that debriefers encounter are recent and of short duration. But, the debriefer is the independent person who is helping a group of trauma survivors. Often the debriefer does not know the history of each trauma survivor within the debriefing sessions. On occasion the current crisis ignites a past pattern of trauma that a trauma survivor has never resolved. These trauma survivors are likely to mention symptoms reflecting Complex PTSD. If the debriefer is aware of these symptoms, the debriefer can make appropriate referrals and insure the safety of such trauma survivors.

Differences between PTSD and Complex PTSD
This author has found that an essential difference between PTSD and Complex PTSD is that the symptoms of PTSD are more episodic. Trauma survivors with PTSD have periods of time during which they feel stable, mixed with episodes of PTSD symptoms during which they feel unstable. Trauma survivors with Complex PTSD often experience constant and more persistent symptoms.

Specifically, trauma survivors with PTSD feel episodes of mood fluctuation and/or suicidal preoccupation. Trauma survivors with Complex PTSD feel constant and persistent mood fluctuations and/or suicidal preoccupation. In practice, this author has found that trauma survivors with complex PTSD have much more severe dissociative episodes with complete feelings of ineffectiveness, regarding the management of life.

Another unique aspect of Complex PTSD is the perception of the perpetrator. As Dr. Herman (1992) includes in her criteria for Complex PTSD, some trauma survivors accept the beliefs or the rationalizations of the perpetrator. Usually this acceptance of the perpetrator’s belief system takes considerable time. But there are occasions when this acceptance of a perpetrator’s belief system occurs quite quickly.

This author was fortunate to receive hostage negotiation training from the Department of Corrections in the State of Wisconsin. The trainers presented a video of an actual hostage action that occurred at a local television station. Usually when hostage-takers take control of a television station, they make announcements to the world. An employee of the television station was wise enough to turn off the antenna, but also wise enough to keep the cameras rolling. The result was a recording of this hostage action, which lasted for several hours.

Accepting the beliefs of a perpetrator has long been established, dating way back to the Stockholm Syndrome. What surprised me was how quickly hostages accepted their perpetrator’s beliefs. In the several hours of this hostage action, the hostage-takers forced the anchor-news people (the hostages) to have a relationship with them. As the anchor-news people developed a relationship with the hostage-takers, the relationship was intense, as you can imagine. The anchor-news people could not fake having a relationship (hearing the hostage-takers’ concerns and started to become sympathetic), because they needed to survive. So the anchor-news people developed a genuine relationship with their hostage-takers. The degree of this genuine relationship became evident when the SWAT team rushed the hostage-takers. When the SWAT team entered, one of the anchor-news people threw his body in front of a hostage-taker, offering protection.

This example is significant because the anchor-news person was willing to risk harm for a perpetrator he had known for only several hours. In other words, acceptance of a perpetrator’s belief system can occur in a very short period of time. This acceptance, of the perpetrator’s belief system does not require months or years of trauma.

Why can two individuals experience a similar trauma, from which one develops Complex PTSD, yet the other develops no PTSD symptoms? Research is starting to give us some clues. If the debriefer is aware of the factors that create resilience in trauma survivors, debriefers can better assess trauma survivors’ needs. Saunders (2000) asked the question if formal kinship, informal kinship, and spirituality reduce the effects of trauma in Africa-American children. He found through this study that the nature of childcare through kinship, informal kinship and spirituality did buffer children from Complex PTSD.

Variables that increase risk for self-destruction, have been noted by Hughes (2000) in research on the effects of childhood sexual abuse and adult suicide behaviors. Hughes extrapolated from the childhood sexual abuse seven predictors of suicidal behavior in adulthood, including:

• A high degree of exposure to childhood sexual abuse
  
• The lack of childhood social support
  
• Overall severity of childhood maltreatment
  
• Adult re-victimization
  
• Symptoms of a dysfunctional self
  
• Dysphoric symptoms
  
• Traumatic symptoms

Of these seven symptoms, the three that most highly correlated with Complex PTSD were dysfunctional self, dysphoria and trauma symptoms. These three symptoms also predicted suicidal behavior to the exclusion of the other symptoms.

Vielhauer (1996) found that Complex PTSD was more correlated to childhood abuse, with no differences across abuse type. Vielhauer found that affect/impulse modulation, negative self-perception, and interpersonal difficulties were the “hallmark” features of Complex PTSD. Other factors that fostered the development of Complex PTSD were abuse severity, perceived life threat and invasiveness of sexual abuse.

For the debriefer, these three symptoms (dysfunctional self, dysphoria and trauma symptoms) expressed by a trauma survivor would suggest a large “red flag”. Again, one goal of crisis debriefing is to determine which trauma survivors need further treatment. These symptoms would suggest a definite need for further treatment.

Flashbacks and Treatment
One very un-empowering aspect of PTSD and Complex PTSD, is the flashback. Flashbacks are an intense and vivid recall of the trauma experience. During the moments of a flashback, trauma survivors feel they are re-experiencing the trauma, including intense emotional reactions.


The Critics
“In case of dissension, never dare to judge till you’ve heard both sides.”
Euripides

One of the major pioneers of crisis debriefing is Jeffrey T. Mitchell, Ph.D., who developed the well-known Mitchell models of crisis debriefing; Critical Incident Stress Debriefing (CISD) and Critical Incident Stress Management (CISM). Many organizations have accepted the usefulness of his model, including:

• Federal Aviation Administration
  
• United States Air Force
  
• United States Coast Guard
  
• U.S. Secret Service
  
• Federal Bureau of Investigation
  
• Airline Pilot’s Association

Dr. Mitchell has critics who suggest that his model of crisis debriefing is ineffective or harmful to clients. The following research on the topic was selected for objectivity.

Alte Dyregrov, Ph.D. offered the article “Psychological Debriefing – An Effective Method?” He noted that several researchers had written letters to the editor of the British Medical Journal in 1995, asking for more randomized, controlled studies of crisis debriefing. Furthermore, they stated that several studies reported a negative effect of the method. In addition, they wrote that the actual method could aggravate the traumatic process, and that it has an ideological and symbolic value which is greater than its genuine helping value. Several studies reviewed later in this article were also taken as ‘proof’ that crisis debriefing has no effect. These researchers were respected experts in the traumatic field, and their reservations against debriefing naturally have left many professionals in doubt about the necessity and effectiveness of debriefings. In this article (written by Dr. Dyregrov) it is proposed that their critique was based on studies that did not warrant the negative presentation they gave of debriefing.

He continued by saying and listing those studies reporting no effect and positive effects of crisis debriefing. Dr. Dyregrov offered a critique of these articles with a conclusion, as follows:
“Several studies have been published over the last years concluding that debriefing does not have a positive effect on mental health measures following critical events. These studies are founded on weak methodological designs, and it would be wrong to draw firm conclusions regarding the usefulness of this technique.”

Dr. Dyregrov continues to summarize the weaknesses. The highlighted weakness in most of the studies is about individual patients and not the group process. Dr. Mitchell is firm that crisis debriefing is a group process.

Dr Dyregrov continues “In my opinion the debate on debriefing is not only a scientific but also a political debate. It entails power and positions in the therapeutic world. As a technique presented by Jeffrey T. Mitchell in 1983, crisis debriefing represented a threat to the psychiatric professional elite. Throughout his teachings Mitchell has argued that traditional psychotherapy or a traditional psychiatric way of thinking was not appropriate for the population of emergency personnel for whom the method was developed. And, that health personnel with a psychiatric background often would need to relearn some of their thinking and their work methods in order to become good practitioners of the method. In addition, many of the people being trained in the technique both in Australia and North America were support personnel and mental health workers working outside psychiatric institutions. Crisis debriefing thus has been partly self-help and consumer driven, where the recipients of the services had more control than in traditional academic and medical approaches based on a more psychiatric disease model. Mitchell had also strongly emphasized that debriefing is not a form or substitute for psychotherapy (see Mitchell & Everly, 1991, p.211). Using crisis debriefing as part of crisis intervention has thus been part of a non-psychiatric approach, and therefore it was only natural that there would be a reaction from the ‘psychiatric establishment’. The critique in Australia was raised by some of the best-known psychiatrists within the trauma field, but it was based on studies that investigate the effect on individual follow-up. This, in my point of view, indicates that the debate not only entailed the question of whether debriefing worked or not, but also a more political stance.”

Everly and Mitchell, in their article “The Debriefing ‘Controversy’ and Crisis Intervention” did a wonderful job of reviewing all relevant research. Within this article, they reminded researchers of the basic terms, which other researchers have distorted. Dr. Everly and Dr. Mitchell indicate that Critical Incident Stress Debriefing (CISD) “is actually a proper noun (Mitchell 1983). CISD refers to one form, or model, of group crisis intervention, sometimes generically referred to as psychological debriefing. As group psychotherapy is to individual psychotherapy, the group CISD is to individual crisis intervention.” Continuing, Dr. Everly and Dr. Mitchell state “CISD represents a highly structured form of group crisis intervention and represents a discussion of the traumatic model, or critical incident.” Dr. Everly and Dr. Mitchell criticize much of the negative research about their model because a good portion of the research is about individual crisis intervention, which does not reflect critical incident stress debriefing.

Dr. Everly and Dr. Mitchell criticized much of the research that is contrary to crisis debriefing, for the following reasons (the bulk of the research):

• A lack of standardization of the debriefing model. None of the studies mentioned assessed the CISD model created by Dr. Mitchell.
  
  
• A lack of standardization of subjects. Dr. Everly and Dr. Mitchell claim that in some studies researchers placed the more psychologicaly and physically traumatized subjects in the treatment groups, yet they placed less traumatized subjects in control groups.
  
  
• The idea that crisis debriefing is a stand-alone treatment. Dr. Everly and Dr. Mitchell view crisis-debriefing as part of a process of treatment, not a replacement for psychotherapy. It is not a treatment for depression.

Dr. Everly and Dr. Mitchell also describe research in support of Dr. Mitchell’s specific model of CISD. Everly and Boyle (1999) meta-analyzed five studies “processing control conditions.” This analysis did find the specific technique of CISD to be effective.


Research is an important part of the therapeutic process. Research should guide those of us who apply techniques, such as crisis debriefing. Research should tell us if practitioners should or should not apply a technique to certain populations. Research can also tell us what enhances or detracts from the effectiveness of a technique. Whether you are pro or con about crisis debriefing, politics should not guide researchers. Anyone who is not objective in his writing is not an objective researcher. Whether pro or con on the issue of crisis debriefing, researchers should not have specific agendas. My graduate professors taught me the null hypothesis is a good attitude for researchers. Objectivity is the golden rule of research.

The full body of research on this controversy would be a book of its own, and too extensive for the purposes of this seminar. It is important that practitioners are aware of the controversy and the research. With all the beautiful databases at university libraries, it is easy to find the research about the controversial issues of crisis debriefing.

Practitioners lack interest in academic politics, territories, or who is going to get the next government grant. As a practitioner, research should guide us to be as effective as possible in all treatment modalities, including crisis debriefing. As a practitioner, I also recognize that cognitive distortion of all-or-none thinking. With a few exceptions, to believe that any treatment is absolutely good or absolutely worthless reflects the cognitive distortion of all-or-none thinking.

So let us turn our attention to the research that helps to refine the technique of crisis debriefing.

Dr. Every and Dr. Mitchell (2000) conclude, from their research review of CISD, the following pieces of information:

1. Artiss (1963) found the therapeutic elements of proximity, and expectancy had reduced psychiatric morbidity for American combat soldiers.
   
   
2. Solomon & Benbenish (1986) found that early intervention, proximal intervention, and the role of expectation were each associated with a positive outcome.
   
   
3. Parad & Parad (1968) reviewed 1,656 social work cases and found crisis-oriented intervention to be effective in reducing florid psychiatric complaints and in improving patients’ ability to cope with stress.
   
   
4. Borow & Porritt (1979) found through randomized experimental design, that multicomponent crisis intervention was superior to single crisis tactics.
   
   
5. Many of the studies that are critical of crisis debriefing reflect individual treatment, suggesting that individual crisis debriefing is not effective. (Which is true, it is a group design instead.)
   
   
6. Crisis debriefing should not be a stand-alone treatment or replacement to psychotherapy.
   
   
7. Lee, Slade, & Lygo (1996) studied women who were debriefed after a miscarriage. Debriefing was not effective with individual clients who had symptoms of post-partum depression.
   
   
8. Robinson & Mitchell, (1993, 1995) with emergency medical services personnel; Nurmi (1999) with rescue personnel in the wake of the sinking Estonia; Wee et al., (1999) with emergency medical technicians subsequent to Los Angeles riots; Bohl (1991 with police; Chemtob et al. (1997) with healthcare providers subsequent to Hurricane Iniki; and Jenkins (1996) with emergency medical personnel in the wake of a mass shooting. All of these investigations offer varying degrees of evidence for the effectiveness of the CISD intervention.
   
   
9. Watchorn (2000) indicates group debriefing sessions serve to prevent the development of PTSD. (The author is not completely convinced of that. But it is a piece of evidence that is suggestive.)
   
   
10. Deahl et al. (2000) in the only randomized investigation of the CISD model of debriefing, found CISD effective in reducing alcohol use and symptoms of anxiety, depression, and PTSD.
    
    
11. …the British Psychological Society (1990) and Mitchell and Everly (1997; Everly and Mitchell, 1999) argue that crisis debriefing should be multi-faceted.
    
    
12. Clearly, crisis intervention technologies such as CISD and CISM are best directed toward acute situational adversity, well circumscribed stressors, and acute adult-onset traumatic reactions (Dyregrov, 1997, 1998, 1999; Richards 1999; Everly & Mitchell, 1999)

Now let’s take a look at the debriefer. One great influence, for the effectiveness of any technique including crisis debriefing sessions, is the experience and training of the mental health provider. This seminar offers many relevant topics which debriefers need a thorough knowledge. It is advisable that debriefers know the crisis reactions, PTSD symptoms, Complex PTSD, grief emotions, diagnostics, Five Life Management Skills, and phases of a crisis. Debriefers also need to know the reactions of specific trauma, such as suicide and murder. Debriefers need to know the guidelines of crisis debriefing and the crisis debriefing components. Debriefers also need a full array of training in counseling and clinical experience.

I advocate that crisis debriefers have, at least, a Master’s Degree in a mental health profession. One critical factor of crisis debriefing is its brevity. A person, not thoroughly trained in mental health, could easily miss important individual symptoms or important group dynamics. With the criticisms of crisis debriefing, it is important the debriefer is a qualified mental health practitioner.


“Change has a considerable psychological impact on the human mind. To the fearful it is threatening because it means that things may get worse. To the hopeful it is encouraging because things may get better. To the confident it is inspiring because the challenge exists to make things better.”
King Whitney Jr.

General Considerations
Mitchell has offered various guidelines which are described in this section, incorporated with some material by John Weaver. This author has added several original guidelines and other insights, as well. Crisis debriefing, like other forms of counseling, offers many variations. The following guidelines are suggestions and not written in stone.

When designing a crisis debriefing session, it is helpful to consider the locale of the session, for example, a “safe place in the same building”. Imagine that an explosion occurred in the kitchen at a local hotel and you are debriefng the hotel staff. It is helpful to have the session at a safe place in the same hotel. A conference room, far from the trauma site, may be a good location.

One of the major advantages of being on-site, but in a safe area where the trauma did not occur, is that the trauma survivors could have the option of visiting the trauma site before or after the session. Of course, a debriefer would be available to assist trauma survivors in this process. This is important because trauma survivors usually have to go back to work shortly after the trauma. This visit, to the trauma site, may help desensitize trauma survivors, especially when assisted by a trained professional.

There are times when the building, where the trauma occurred, is no longer available (such as the Oklahoma City bombing). There is no choice, so another neutral site may be the only option. The debriefer can offer the trauma survivors a visit to the trauma site after a debriefing session.

Mitchell also mentions that it is helpful to have the crisis debriefing session within 14 days of the crisis. When considering the time element, doing so too soon is often a problem. Like other types of counseling, timing is important. During the first 24 hours, many trauma survivors are experiencing numb and stunned reactions or temporary hysterical reactions. These two reactions can be counterproductive to the crisis debriefing session. It is helpful that debriefers perform the debriefing sessions quickly, to offer the template of the Five Life Management Skills. When adjusting to trauma, trauma survivors may or may not be utilizing the Five Life Management Skills. The quicker the debriefer offers the crisis debriefing session, the sooner the debriefer can place the template of the Five Life Management Skills within a group of trauma survivors.

If ideal conditions do not prevail, so the debriefing session can not be accomplished within the first few days, then it can be done within 10 to 14 days after the crisis. There can be advantages to such a delay. As you review the crisis debriefing components mentioned in this seminar, one component (Management) asks trauma survivors what they have done to manage the current crisis. If they have more time to manage the crisis (10 to 14 days), the debriefer can reach a better assessment of trauma survivors’ natural utilization of the Five Life Management Skills.

During severe trauma with great devastation and death, the debriefer can offer multiple debriefing sessions in a short period of time. For example, with the devastation of the World Trade Center, those working in the rubble may become overwhelmed in a short period of time. Others become almost obsessed with working through the rubble, while ignoring the emotional effects of the devastation. Thus, it may be helpful to have several debriefings over a number of days.

Individual vs. Group Crisis Debriefing
There is controversy regarding the benefits of individual versus group crisis debriefing. Mitchell responded to these criticisms, as noted previously. One common response by Dr. Mitchell is that crisis debriefing is a group process. One of the major advantages of crisis debriefing is the dynamics created by the group process. Previously noted research, which found crisis debriefing ineffective, was later criticized because the research utilized individual rather than group process. Dr. Mitchell has made it clear that group needs to happen in crisis debriefing.

Mental health professional have offered individual services to trauma survivors that may have varied effectiveness. Technically, crisis debriefing has not occurred unless it fits within the boundaries of the group process.

Dr. Weaver’s suggestion to place a counselor at the door can be very useful. This author has used the technique many times. Debriefers have reported that, when requested, they can have a counselor at the door approximately 50% of the time. For example, if I were to perform a crisis debriefing at a school, I would ask that a school psychologist or school social worker be outside the door. The guideline has several advantages. First, it is helpful to have someone at the door to stop people from interrupting the debriefing session. Second, if a trauma survivor bolts from the group, the debriefer has to decide if he or she should stay with the group or attend to the individual who left. If the person at the door is a counselor, the debriefer can stay with the group while the other counselor attends to the individual.

There is a third, more distinct, reason to have a counselor at the door. This third reason considers personality disorders. For example, one of the trauma survivors may also have histrionic personality disorder, and may severely interrupt the group process. The debriefer, who knows the motivation of histrionic personality disorder is attention, can utilize the at-the-door counselor productively. The debriefer could gently mention to the person with the histrionic personality disorder, “There are times when a trauma survivor needs to talk much more than a group can allow. That is why we have a counselor waiting by the door who offers one-on-one attention.” It allows the personality disordered person to receive individual attention. This also allows the group to become more functional, without the personality disordered person in the group.

Traditionally, the debriefer does not allow extra people, who were not part of the crisis, in a crisis debriefing session, as advocated by Dr. Mitchell. Trauma survivors may find extra people as intrusive. This author has spoken with three debriefers who warned about a very unique problem with extra people. On more than on occasion, in which trauma survivors asked debriefers to allow their special support person in a debriefing session; the debriefer later discovered that the special support person was actually a news reporter looking for a story.

The debriefer can break a larger group into a smaller group, since most group therapy specialists would advocate groups between 8 to 12 members. Of course, this is an ideal number, and there are occasions for which only a smaller number of survivors are involved, so the group would be smaller. With groups of 15 or more, the debriefer may want to create smaller groups.

If there were a large number of trauma survivors, with multiple debriefers; part of the crisis debriefing session could include the entire group. For example, the debriefer could do the orientation as a large group. Next, break into smaller groups for the more sensitive crisis debriefing components, and later gather as a large group again for the closure component. (Components are explained, as follows later.) The following are four considerations for breaking a large group into smaller groups.

1. This can be done randomly with sign-up sheets or a one–two count. One’s going to the first group and two’s going to the second group.
   
   
2. The debriefer can break groups into smaller groups by intensity level. If a debriefer were to debrief the Columbine students, one group would be the students who could not get out of the library; the highest level of intensity. Another group would be students who were not in the library, but could not get out of the school (second highest intensity). Another group would be students who got out of the school and were safe with the police (lowest intensity).
   
   
3. Breaking into smaller groups can occur if there is a natural status. If trauma occurred to ten administrators and ten employees, a natural division would be a group for administrators and a group for employees. This may be more effective because administrators and employees may have different concerns to address.

Another natural division for groups of children is by mental age. Abstract reasoning starts at age 8 years for most kids. Since abstract reasoning is beginning its early development through age 8 to 10 years, this is a natural division. Children with early abstraction need a different quality of dialogue than older children. For example, more “fill-in-the-blank” needs to be done with them. Their ability to see cause-and-effect is not strong, so a debriefer needs to fill-in considerable information for their full understanding. Another natural break is for children of ages 11 to 13 years who have a better understanding of cause-and-effect, but not as strong as older teenagers. Then the final break, from 14 to 18 years, for children having the strongest abstract reasoning.

Debriefing Notes
Another important issue involves continuity of the debriefing sessions. Anything that disrupts continuity of sessions can interfere with good outcomes. Typical disruptions include cellular phones, beepers, people leaving the session early, and the debriefer writing notes during the session. The debriefer can reduce disruptions by requiring trauma survivors leave their beepers and cellular phones outside debriefing sessions. This is not always possible, since prison guards and police have concerns for security. If possible, the debriefing session can be off-site for such groups, allowing beepers and telephones to remain outside the debriefing session. If the session must be on-site and during work hours, then the debriefer may have to set aside this rule, due to security requirements.

If the debriefer writes notes during the crisis debriefing session, the debriefer will disrupt the continuity of the session. Trauma survivors attending the session will often stop and wait for the debriefer to finish writing. Some trauma survivors may become suspicious about the notes and about whom the debriefer will share the notes (such as bosses and administrators).
It is important for the debriefer to summarize crisis debriefing sessions in written form, including: who attended, their concerns, how well they implemented the Five Life Management Skills, and referrals made. These notes are the property of the debriefer and not to be shared with others.

The advantage of summary notes is to refresh the debriefer’s memory, if issues arise later. For example, the debriefer may eventually see one of the trauma survivors for individual counseling. Reviewing the summary notes will refresh the debriefer’s memory and allow for better preparation for continued counseling sessions.

Scheduling and Attendance
It is helpful for trauma survivors to be contacted by a fellow session member, regarding: the time of the session, that it will last 2 to 3 hours, and the location. This author could find no research to support the idea that a familiar person making this initial contact increases attendance, but many debriefers suggest that a familiar contact does increase attendance. For example, if there is a trauma at a hotel during the day, a night manager (that most employees like) would be a good candidate for making those initial contacts. The non-traumatized night manager is not receiving any undue pressure, whereas, a trauma survivor may not want the additional responsibility.

There are several opinions regarding forced versus voluntary attendance to crisis debriefing sessions. Forced attendance has the major disadvantage of decreased motivation. Often people forced into any counseling have poor motivation. Most experienced counselors would agree. Occasionally, survivors who are forced to attend do have a productive experience. More often, they quietly attend or become disruptive, especially with passive-aggressive reactions. Weighing both outcomes, I recommend giving traumatized survivors the choice of attending crisis debriefing sessions.

Some trauma survivors may tell the debriefer, before a session, that they need to leave early. The debriefer can offer the option of staying for the entire session or seeing the person for one-on-one for counseling. The debriefer should work to avoid people leaving early because of the “magnetic effect” which occurs when one trauma survivor leaves the debriefing session early and other trauma survivors feel the same magnetic pull to leave. The debriefer asks trauma survivors to stay for the entire session, and if one trauma survivor cannot, the crisis debriefer can offer a one-on-one session to preserve the integrity of the group.


Orientation
The goal of orientation is to set up the rules for the crisis debriefing session and to insure that trauma survivors understand the reasons and advantages of their involvement in crisis debriefing.

Information about confidentiality is often the best start to orienting trauma survivors. The crisis debriefer can make a statement about the debriefer’s commitment to confidentiality and that the contents of the crisis debriefing session will not be shared with anyone outside the group. If a non-traumatized employer hired the debriefer, (an employer not included in the crisis debriefing session), the statement can be made that the debriefer will share no information with the employer. This is vital because the debriefer (who is usually independent of the group) may not be fully aware of the history of the group; some trauma survivors may be comfortable with their employer while others are not. The debriefer must receive agreement from the employer, prior to conducting the crisis debriefing session, regarding confidentiality.

The debriefer also should require that no trauma survivor within the crisis debriefing session may break confidentiality, as well. The debriefer can suggest that before participants share information discussed in the session, the participant must get permission from other participants.

“Speak for yourself” is a request especially designed for trauma survivors exhibiting personality disorder behaviors within sessions. The three types of personality disorders noted previously (Borderline, Histrionic and Passive-Aggressive Personality Disorder) will tend to disrupt the group process, so management of their excess talk is required. The “speak for yourself” rule can be effective in limiting such excessive talk, by requiring participants to only speak for themselves. The debriefer can also suggest that only one person speak at a time.

The debriefer can state clearly that no rank should be exercised during the crisis debriefing sessions If a participant is an employer or has rank as a policeman or corrections officer, the debriefer can briefly meet with this person beforehand. The debriefer can suggest that this person of rank not take a controlling or leadership position during the session. Observation of this request helps each participant better understand how the crisis impacted them. With police and corrections officers, the debriefer may have the session off-site so the officers can wear their street clothes. This removes the symbol of rank. During the orientation, the debriefer can mention that rank does not exist during the crisis debriefing session.

The debriefer can announce that support people not involved in the crisis may not attend the crisis debriefing session. As mentioned earlier, this eliminates the potential news reporter attempting to gain admittance. Also, some trauma survivors may not be comfortable with a support person who might be a stranger to them.

An important goal of crisis debriefing is to normalize trauma survivors’ reactions. Normalization helps participants understand that their otherwise unusual emotional reactions are normal, under the circumstances. During the orientation process, the debriefer can advance the normalization process by advocating for trauma survivors to ask any questions throughout session. Through questions, trauma survivors often reveal their reactions to a crisis.

Another guideline is not forcing participants to talk. For some trauma survivors, it may have taken considerable courage to attend a crisis debriefing session. They may not want to talk, but instead want to learn and listen. The debriefer can allow them this comfort. Since the crisis debriefer does not understand participants’ prior life experience of trauma, forcing active participation may be counterproductive for some. For example, if the debriefer pointed out one participant and asked, “Tell us exactly what you experienced during the current crisis?” – that participant may feel further intrusion.

When the debriefer offers lead-in questions to the entire group, it is best to allow each participant to decide when to respond. Once a trauma survivor responds, this offers the debriefer permission to ask further questions. This gives each trauma survivor the choice to express themselves or to not speak.

To further orient participants, the debriefer may address the advantage of crisis debriefing and the need for crisis debriefing. The following example of a globe is helpful in this regard:

“A crisis is like a globe. Each person here today experienced a small part of this larger globe. One person saw this piece, one person saw another piece, and another person saw yet another piece. It is hard to get a full picture of a crisis and how it affected everyone. Without this full picture, you might think, ‘Well, why in the world did he do this during the crisis?” or “Why in the world did she do this during the crisis but not do that?” With a more complete picture of the entire globe of the crisis, you may realize “Oh, now I understand why he or she did that!” This understanding is the goal of crisis debriefing; to have a full global picture of what happened to you and your fellow participants. With such an understanding, you can stay united.”

This explanation offers a concrete example of the advantage of crisis debriefing. The advantage includes a deeper understanding of each trauma survivors’ experience and the promotion of unity.

To further address the need of crisis debriefing, the story of the dogs of Oklahoma City is helpful. The search and rescue dogs, during the aftermath of the Oklahoma City bombing, became dysfunctional. The following story can be helpful during orientation:

“I want to tell you a story about the search and rescue dogs during the aftermath of the Oklahoma City bombing. These dogs had found so much death in the rubble that they quit working. They sat down and quit working! This demonstrates a goal of crisis debriefing; to stay functional. A crisis is a life-changing event that requires considerable adjustment – but trauma survivors need to remain functional during this process.

Well, the dogs in this example were no longer functional because of finding so much death. The trainers were not sure how to debrief the dogs to make them functional so, the dog handlers decided to plant live people in the rubble. They picked up their dogs and almost had to lead them to the live people placed in the rubble. Finally, the overwhelmed dogs started working again. Crisis debriefing serves much the same purpose for trauma survivors. Crisis debriefing helps us feel more normal again. We need to realize the impact of the trauma, while we learn to stay functional. If trauma impacts a dog that way, just imagine what it does to a human being who has a great deal more comprehensive reasoning.”

Another helpful story involves the woman on the ledge during the Oklahoma City bombing, as follows:

“A woman, who worked as program director was addressing her staff just before the bomb exploded at Oklahoma City. She was leaning against the front of her desk and happened to walk behind her desk as the bomb ignited. She witnessed her desk and her colleagues perish into the rubble of the explosion. She was standing on a ledge with no place to go; her safety was totally gone because there was no way that she could help herself. She had to rely on others. The same is true for people who have experienced a crisis together. We must rely on one another as we manage these crises.”

This story will be revisited later, during exploration of the Closure Component, because it contains another significant aspect that is helpful for concluding the debriefing session.

Crisis debriefing components provide structure and direction to crisis debriefing sessions. Although components are presented in order below, the debriefer can use components in any order, as necessary. The components have lead-in questions to initiate the topics of the components. It is helpful for the debriefer to offer the lead-in questions to the entire group, allowing each person to choose to respond. Once orientation is complete, the debriefer can initiate the following crisis debriefing components.

Global Picture Component
The general goal of the Global Picture component is to draw out a global description of the trauma survivors’ perception of the crisis. The debriefer wants a good understanding of the experience that was traumatic, unusual, stressful and unanticipated. Remember the acronym discussed previously - TUSU? Is the event traumatizing, unusual, stressful and unanticipated? Specific goals of the Global Picture Component include:

• To pull together a comprehensive and accurate picture of the crisis experience.
  
  
• To reduce exaggeration and minimization.
  
  
• To advocate for the Five Life Management Skills, especially
  
  • Task One: Facing the truth and reality of the crisis.
    
  • Task Four: Investing in others

By asking trauma survivors to describe the crisis, as best as they can, the debriefer is drawing out the entire puzzle pieces of the crisis. This allows the crisis debriefer and the trauma survivors to formulate a more accurate and complete picture of the crisis. When this occurs, trauma survivors are approaching the truth and reality (Task One) of the crisis experience. Task One, from the Five Life Management Skills is a cornerstone of adjusting to a crisis. This is important because if trauma survivors are not actively managing the truth and reality of their crisis, then cognitive distortions can have a greater impact. If the group is facing the truth and reality of a crisis together, they can also more favorably invest in one another (Task Four).

For example, one family member witnessed a suicide of a loved one and another family member (who wanted to change reality) insisted that it was an accident. It will be difficult for these folks to invest in one another (Task IV) if they’re not both accepting the truth and reality of what happened. They are on two different playing fields.

For the debriefer, red flags ignite when two trauma survivors are reporting a vastly different experience; when one of the trauma survivors is reluctant to face the truth and reality of a situation. The goal of the debriefer is to not attempt to convince the dissenting trauma survivor. There may be deep psychological reasons a trauma survivor cannot accept the truth and reality of a crisis. For example, a parent of a child who committed suicide may be psychologically unprepared to accept the truth of his or her child’s suicide. It would be unwise for the debriefer to push the reality that it was a suicide. It is best for the debriefer to note this as a red flag suggesting a need for follow-up treatment.

The following lead-in questions are helpful to gain a global understanding of the crisis:

• Tell me exactly what happened to you right when this crisis occurred.
  
• What exactly did you see that was happening around you?
  
• What exactly did you hear around you?
  
• Did you notice any unusual aromas or smells?
  
• What happened to others around you?
  
• What do you recall thinking when you first realized you were in this crisis?

Consider the purpose of each of the preceding lead-in questions. Tell me exactly what happened to you right when this crisis occurred. This question helps determine each trauma survivor’s piece of the puzzle. As each trauma survivor adds his or her information, a more global picture is constructed. If a trauma survivor exaggerates the trauma, their piece of the puzzle does not fit. As dialogue occurs, the trauma survivor who exaggerates will need to reduce their exaggeration to make the puzzle pieces fit. In effect, this question is advocating for the Life Management Skill of facing the truth and reality of the crisis (Task One). Attention and exaggeration is not the only reason for survivors to distort the picture of their experience. The trauma from a crisis is overwhelming, thus exaggerating the experience for some trauma survivors.

The following questions serve a similar purpose. What exactly did you see that was happening around you? What exactly did you hear around you? Did you notice any unusual aromas or smells? These three questions promote truth and reality by focusing on the senses that trauma survivors utilize when they experience a crisis – hearing, sight, and smell. By helping trauma survivors to remember all three sensory experiences, their memories can become more accurate.

What happened to others around you? Crisis is a traumatic and absorbing experience. A trauma survivor has his or her experience to recall. They also may have memories of what happened to others involved in the trauma. Recalling what happened to themselves and others starts to bring the puzzle pieces together. This often reduces exaggeration or eliminates minimization. As they recall the crisis, the exaggerations fade away as the truth fits into a more accurate global picture.

What do you recall thinking when you first realized you were in this crisis? This question uncovers those “insignificant” thoughts, which are not always so insignificant. As previously mentioned, many trauma survivors have seemingly insignificant thoughts when they first realize they are in a crisis. For example, a trauma survivor seeing a good friend die in a crisis, may think, “Did I let the dog out this morning? Yes I did.” It would be easy for trauma survivors to become self-critical, having such thoughts after experiencing the death of a friend.

The debriefer can explain to trauma survivors that “insignificant thoughts” are actually confidence builders. When these thoughts fit within the criteria “Did I take care of this? Yes I did.” - the brain is starting to heal. The brain realizes that the trauma survivor has no empowerment during the crisis. So, the brain reminds the trauma survivor of other parts of life where he or she does have empowerment.

Management Component
The goal of the management component is to ascertain how well trauma survivors have managed the crisis so far. The debriefer wants a good understanding of how well each trauma survivor is starting to manage the crisis; individually and as a group.

By asking the trauma survivors what they have done to manage the crisis individually and together, the debriefer can determine if the trauma survivors are progressing with the Five Life Management Skills or not. For example, when a trauma survivor says, "I have noticed that I have been getting very upset and talking to my spouse and good friends about the crisis." - the debriefer can assess that this trauma survivor is utilizing Task Two (feeling the emotions associated with the crisis) and Task Four (investing in others). Specific goals of the Management Component include:

• To determine if trauma survivors are managing a crisis with the Five Life Management Skills.
  
  
• To assess skills trauma survivors have used in previous trauma.
  
  
• To determine if trauma survivors are adjusting at home and at work.

Dr. Mitchell (2000) suggests that crisis debriefing occur within 14 days after the crisis experience, or as soon as possible. However, it is often advantageous for crisis debriefing to occur several days after the trauma. For example, if the debriefing occurs 10 days after the crisis experience, the trauma survivors have had more time to exercise the Five Life Management Skills. When the debriefer asks lead-in question reflecting the management component, the debriefer may achieve a better assessment of each trauma survivor's use of the Five Life Management Skills.

For the debriefer, red flags ignite when trauma survivors' responses do not reflect the Five Life Management Skills. For example, if a trauma survivor drinks more alcohol since the crisis, this of course does not reflect the Five Life Management Skills. Or another trauma survivor may enter another dysfunctional relationship instead of managing the crisis. These are red flags, suggesting these trauma survivors are not adapting well to the crisis.

Lead-in questions helpful in determining whether or not a trauma survivor is managing a crisis include:

• What previous crises have you experienced (small or large)? How did you manage those crises?
  
• How have you managed this crisis, at home, with your family?
  
• How did you manage this crisis with your co-workers?
  Who have you talked with about this crisis? What did you say?
  
• Do you feel other people understand your crisis experience?

The following explains the purpose behind each lead-in question. What previous crises have you experienced (small or large)? How did you manage those crises? The way in which a trauma survivor managed a previous crisis will likely affect his or her management of the current crisis. When trauma survivors respond to this question, the crisis debriefer can use the Five Life Management Skills as a guidepost to determine if the trauma survivors' management of previous crises fits the Five Life Management Skills. This is a good predictor of how trauma survivors will manage the current crisis.

How have you managed the current crisis, at home, with your family? How have you manage the current crisis with your co-workers at work? These two questions help the debriefer determine the trauma survivors' attempt to manage the crisis at home and at work. Home and work are the two most common environments for social support. If the crisis occurred in one environment, trauma survivors may feel comfortable using the Five Life Management Skills in one, both or neither of the environments. Of course, the more freedom a trauma survivor feels to express himself in both environments, the greater his adaptability. In reverse, the more restricted a trauma survivor feels to express in both environments, the more difficult his or her adaptability.
It is helpful for trauma survivors to view both his home and work as supportive. It is helpful for debriefers assist trauma survivors to consider who they feel most comfortable with in each environment. This will help trauma survivors identify the specific people they may invest with (Task Four - Invest in others).

Who have you talked with about this crisis? What did you say? This question allows the debriefer to determine if trauma survivors are actively investing in others (Task Four), and who those others are. By asking trauma survivors, "What did you say?" - the debriefer can determine the level of investment trauma survivors are getting and offering to each other.

Do you feel other people understand your crisis experience? This question allows the debriefer to determine the reaction of others to the trauma survivor. Trauma survivors offer a mix of responses when discussing others' reactions. Some trauma survivors indicate excellent acceptance and others find no acceptance from others. The debriefer needs to encourage trauma survivors to continue to invest with others, always considering who they feel safe with, sharing his or her experience.

Emotional Assessment Component
The purpose of the emotional assessment component is not to force trauma survivors to emote, rather to assess the emotional reactions trauma survivors have experienced, regarding the current crisis. This process determines normalcy versus red flags issues. Some trauma survivors emote during the debriefing and others do not. Many trauma survivors have emotional reactions before the debriefing session and other will reserve their emotional reactions until later. Trauma survivors need to know that their emotional reactions are normal.

When debriefers hear descriptions of emotions or see emotional reactions from trauma survivors that reflect grief and/or trauma reactions, the debriefer can describe their reactions as normal. Since the current crisis may be their first crisis ever experienced, they have nothing to compare it with, in terms of their emotional reactions. As discussed earlier, emotional reactions to crises are often intense and seem unusual. Trauma survivors can easily conclude their reactions are bizarre, even though such reactions are typical traumatic reactions. As noted previously,trauma survivors need considerable reassurance their reactions are normal.

If reactions are not typical, the debriefer can suspect that a trauma survivor requires additional treatment, beyond the crisis debriefing session. For example, if a trauma survivor reports that he has had constant panic attacks over the last five days since the crisis, the debriefer immediately recognizes a large red flag. Of course, the debriefer will not normalize this reporting. Instead, the debriefer recognizes these extreme reactions and makes a referral for further treatment. Goals of the Emotional Assessment Component include:

• Assess emotional reactions of trauma survivors.
  
• Assist trauma survivors to accept their typical grief emotions and crisis reactions as normal.
  
• Determine if trauma survivors are experiencing atypical emotions such as panic attacks, severe depression, PTSD, or Complex PTSD.
  
• Assist survivors describe their trauma emotions and begin implementation of Task Two - experiencing and managing emotional reactions.

The following lead-in questions are helpful in assessing emotional reactions:

• Who have you shared your emotional reactions with about this crisis?
  
• What emotions have you experienced?
  
• Are there reaction cues that make you more emotional?
  
• Are there emotions you are experiencing that you are concerned about?
  
• Are there any emotions you have experienced that you are reluctant to share?

The following explains the purpose behind each lead-in question. Who have you shared your emotional reactions with about this crisis? This question allows the debriefer to assess the comfort level of trauma survivors when sharing their emotions. If trauma survivors can immediately recognize several people they are comfortable with sharing emotions, they are more likely to express their emotions (Task Two) and more likely to talk to others about their emotions (Task Four).

What emotions have you experienced? Some trauma survivors may emote during the crisis debriefing session and others may not. Emoting is not a goal or requirement of crisis debriefing. Some trauma survivors may rationally talk about their emotional reactions. This is fine. If they emote or discuss the emotions they have experienced, the debriefer can assess the trauma survivors' emotional reactions. This will allow the debriefer to determine the normalcy of trauma survivors' reactions.

Are there reaction cues that make you feel more emotional? Reaction cues are signals that trauma survivors may have extra-sensitive issues. For example, if the debriefer looks like the perpetrator of a trauma, trauma survivors may initially have difficulty feeling safe with the debriefer. This usually dissipates as trauma survivors get to know the debriefer.

Sometimes reaction cues reflect past issues of sensitivity. One trauma survivor may have been abused as a child and the current trauma has features of the previous abuse. These reminders (reaction cues) may create exaggerated symptoms reflecting PTSD or Complex PTSD. The trauma survivor's exaggerated symptoms can be a red flag to the debriefer.

Reaction cues are important to reveal because they may inhibit a trauma survivor's adaptation to a crisis by inhibiting the Five Life Management Skills. When trauma survivors have a previously unresolved trauma, they are often in a protective stance. They drain considerable energy by constantly being on guard. With so much concern about safety, trauma survivors with previously unresolved trauma are likely not usually utilizing the Five Life Management Skills.

Are there emotions you are experiencing that you are concerned about? Are there any emotions you have experienced that you are reluctant to share? These last two questions are the debriefer's final attempt to uncover any emotions that trauma survivors are reluctant to share. Trauma survivors who are quiet about their emotional concerns are often trying to convince themselves to talk. A little careful prodding (with these two questions) may nudge them to respond.

Silent trauma survivors do not have silent minds. When trauma survivors are reluctant to speak, there is often a part of their mind that is trying to convince them to talk. That part of their mind is the part that wants to heal. When it is gently probed, the healing part of the mind may finally convince a trauma survivor to talk.

Memory Component
A primary goal of the Memory Component is to help trauma survivors maintain a complete memory of what life was like before the crisis. Trauma survivors need a good recollection of life before the trauma. Their memory needs to have an honest portrayal of what they lost. Their complete memory holds reminders of the issues that need to be resolved. Also, if trauma survivors have accurate memories, they are less likely to apply cognitive distortions to their crises.

Debriefers can ask trauma survivors to recall their memories of a loved one or colleague that died in the crisis because some trauma survivors become stuck on their traumatic memories. For example, a trauma survivor witnessed the death of a colleague at work. It would be easy for the trauma survivor to become stuck on his or her memory of that traumatic experience. By directing the trauma survivor to recall a more comprehensive memory of the colleague, the debriefer can guide the trauma survivor away from that "stuckness" of the traumatic memory. It is good to recall trauma, but it is not healthy to become stuck on traumatic memories.

The Memory Component is consistent with Task Four - remembering as accurately as possible. Trauma survivors need to establish a relationship with the memory of what they've lost. To some trauma survivors the loss may be obvious. For example, a loved one or friend died and the survivors easily recognize their loss. In other cases, their loss may not be obvious. Perhaps no one died but a life sustaining belief may have died. For example, a trauma survivor lost the life sustaining belief that the world is safe. Another trauma survivor lost the life sustaining belief in God. Another trauma survivor may have lost the life sustaining belief of hope. When trauma survivors lose a life sustaining belief, they can experience full grief reactions.

Survivors need to recall the life sustaining beliefs they had before the crisis, to successfully regain them. Many survivors may be simply unaware that such a belief had been lost. For example, a trauma survivor may have lost the belief that the world is safe. This belief may be recalled, and modified to be more realistic, given new circumstances. Another trauma survivor may need to change their view of God as their absolute protector, but not eliminate their belief in God. Specific goals of the Memory Component include:

• To promote an accurate memory of the environment before the crisis occurred. This allows trauma survivors to manage accurate information and reduce cognitive distortions.
  
  
• To promote an accurate memory of the person who died. This also allows trauma survivors to grieve with accurate information and reduces cognitive distortions.

Regaining life-sustaining beliefs may or may not occur during a crisis debriefing session. Trauma survivors do, however, need to initiate memory of what they've lost, whether the loss is a loved one or a life-sustaining belief. When trauma survivors indicate that they have lost a life sustaining belief - this is a red flag for referral and continued treatment.

The following lead-in questions help trauma survivors recall memories:

• Please describe what it was like to work here before the crisis occurred. Where did you spend most of your time? What was the atmosphere like? Did you feel safe here?
  
  
• What was this person like who died? Did you know him or her well or just as an acquaintance? Discuss as many memories as you can recall.
  What did you believe about the world being safe, before the crisis occurred? Do you still have that belief in safety?
  
  
• What did you believe about God, before the crisis occurred? Did these beliefs change in any way?
  
  
• "Do you feel hopeful after experiencing this crisis?

The following explains the purpose behind each lead-in question. Please describe what it was like to work here before the crisis occurred. Where did you spend your time? What was the atmosphere like? Did you feel safe? This lead-in question helps the debriefer determine the trauma survivors' images of the environment prior to the crisis occurring. As trauma survivors recall the environment and their interactions together with each other, they are giving the debriefer a strong understanding of those dynamics. As trauma survivors recall life before the crisis, they also describe the dynamics of how they operated together prior to the crisis. The Memory Component gives the debriefer a quick assessment of dynamics. Remember this author's story about crisis debriefing with the angry family at the funeral home? As they recalled stories about their mother who killed herself, it was easy to see the dynamics of the family. It was easy to realize that the mother was the family scapegoat.

What was this person like who died? Did you know him well or just as an acquaintance? Discuss your memories as you can recall. Very often when a loved on or colleague dies, the red flag is up for more follow up care. Many will need more treatment, especially those who witnessed the death. It is important for trauma survivors to recall the person who died. In our earlier discussion about the grief emotion of anguish; anguish is an intense emotion that is connected to memory and love. Memory is a vital part of the grief process which reduces cognitive distortions.

What did you believe about the world being safe, before the crisis? Do you still have those beliefs? What did you believe about God, before the crisis occurred? Did these beliefs change in any way? Do you feel hopeful? These three questions are designed to assess the three most common life-sustaining beliefs affected by crisis: the world being safe, the belief in God, and the belief in hope. If a trauma survivor obsesses about the loss of any of these life-sustaining beliefs, this is a red flag for more treatment.

The Educational Component
The goal of the education component is to teach trauma survivors about the skills they'll need to manage the crisis. The debriefer wants trauma survivors to have a good basis of knowledge about crisis reactions, the Five Life Management Skills, and the purpose of grief emotions following crisis.

As the debriefer instructs about the Life Management Skills, it is helpful for the debriefer to use examples that were mentioned in the actual crisis debriefing session. For example, a trauma survivor mentioned that he had become emotional while talking to his spouse and good friend about the crisis and his reactions to the crisis. During the Educational Component, the debriefer could remind the group of the trauma survivor's statement, explaining that the reaction is healthy because it fits within the Five Ways to Manage Life. When the trauma survivor is emotionally upset the debriefer can point out that, this reaction is within Task II (feeling the emotions that fit the situation). When the trauma survivor describes discussing his feelings with his spouse and good friend, the debriefer can mention that this is within Task IV (investing in others). All of the crisis reactions described previously, including all of the grief emotions, can be related to participants' reactions in a similar fashion.

The essence of this instruction is to eliminate the trauma survivor's feelings of bizarreness associated with experiencing trauma. Trauma survivors need to know their trauma reactions are normal. Education is a great step in the process of normalizing the trauma and their traumatic reactions.

The debriefer can provide a handout with the general information, which includes the grief emotions, the crisis reactions, and the Five Ways to Manage Life. The Education Component can also be customized for special trauma, such as murder and suicide. The debriefer can use the information offered about the issues of murder and suicide. This customization can occur for suicide survivors and also for those experiencing a murder.

The debriefer can also add local referral sources to the handout packet, mentioning relevant resources that fit the group's needs. In summary, issues related to the Education Component include:

• Review the Five Life Management Skills
  
• Discuss the purposes of the emotions of grief
  
• Address the common crisis reactions and why they occur
  
• Customize for the specialized issues of murder and suicide, when relevant
  
• Provide local referral resources

Closure Component
The debriefer can offer several special messages to trauma survivors during the Closure Component. In the section of this seminar describing the Orientation Component, a story was mentioned about the woman left standing on a ledge after the bomb exploded in Oklahoma City. She witnessed her colleagues fall into the rubble and perish, while she survived. The debriefer can remind the trauma survivors about this story and then tell the rest of the story.This woman eventually went back to work but, with a very different mindset. She probably had an extra concern about safety in the building, and she may have temporarily needed certain support people in her life. But she went back to work; she maintained functionality.

Maintaining functionality is an important goal of crisis debriefing. Trauma survivors need to accept the truth of the crisis they have experienced, but continue to be functional. Crisis is a life-changing event, but it does not have to cripple. This is an important message within the Closure Component for trauma survivors.

The Closure Component also provides a ritual that signifies unity and hope. This ritual can come in many forms. Here are several suggestions for closing rituals:

• A moment of silence
  
• A moment of silence with hands held
  
• A prayer
  
• A silent prayer with hands held
  
• An agreement to have a memorial service

Often it is best to ask trauma survivors which options they are comfortable with. This gives them input and empowerment during the closure of the crisis debriefing session. The advantage of a memorial service, to be held in the near future, gives trauma survivors the advantage of time to better plan the service - adding more meaning to the ritual

CASE STUDIES
Listed below are case studies, including specific questions designed for the reader to consider while developing effective responses, based on material presented in this course. For each case study, consider how to lead the group taking into consideration the Five Life Management Skills and the Crisis Debriefing Components.

Case One
A deranged man walks into an elementary school with a shotgun. He enters a third grade classroom, mumbling incoherently about wanting a job. As the third grade teacher approaches, the man panics and starts shooting. The entire episode takes only five minutes. Before bolting from the school, he kills two children and wounds one. One student dies in the arms of the teacher. The police catch the man before the crisis debriefing session occurs.

The debriefer will debrief the educational staff, (teachers, principal and secretary) five days after the crisis. The following describes the crisis debriefing participants:

• Third Grade Teacher - This teacher is the most emotionally wounded of the entire group. She knew the children well, and witnessed the entire episode.
  
  
• Principal - The Principal is a caring person who witnessed the aftermath of the shooting. The Principal called 911. The Principal is receiving criticism from the media for not keeping the school safe.
  
  
• Secretary - The Secretary originally received phone calls from frightened parents, when they first heard about the school shooting. Now the parents are calling with anger. The Secretary is receiving considerable anger from parents who are demanding the school have meetings about keeping their children safe.
  
  
• Histrionic - One teacher did not see the crisis and did not know well the children that died, nor the traumatized teacher. This teacher has Histrionic Personality Disorder.

What reactions would you expect from the person who has histrionic personality disorder? How would you manage this person's attention-seeking, which may disrupt the group process? Hint - Review the portion of the course that discusses managing personality disorders.

What emotions and crisis reactions would you expect from the most traumatized teacher in this group and the other trauma survivors? Hint - Use the emotional component to normalize emotional reactions that fit the crisis and loss. Also, the debriefer can red flag trauma survivors who have extreme reactions that are not normal.

How you would present the idea of discussing the memory (Task Four) of the children who died and the safety that previously existed, which are now gone? What truth and reality would you promote? What truth and reality would you not promote? Hint - Would you talk about the gory details of the incident? Would it be helpful or more traumatic?

What questions would you ask about their adjustment to the school environment? Hint - This question reflects Task Three (adjusting to environments). Stop participants from dialoguing about safety policy. Direct them to consider what they need, in order to feel personal safety.

How would you phrase questions to ask these trauma survivors how they have been managing their crisis, since it occurred? Have them consider how they have managed their crisis in their personal lives and with colleagues. Hint - This is where the debriefer actively uses the Five Life Management Skills. As trauma survivors respond, the debriefer can determine if their responses fit within the Five Life Management Skills.

Consider the topics of the Educational Component that you want to present to these trauma survivors. This scenario involved a murder, so consider customizing a handout packet and Educational Component to include the reactions of murder survivors.

Consider how, in your own words, you would close the session with the two themes: (1) the crisis is bizarre but your reactions are normal and (2) participants need to stay functional, despite this life-changing event.

Case Two
A bank robbery occurs that goes bad. Three men walk into a bank to rob it. Immediately, one of the men knocks the guard to the ground, holding a gun to the guard's head and continually threatening to kill him. As the other two men rob the bank, they panic when realizing a bank teller has alerted the police by pressing a hidden button. In their panic they start shooting and kill the teller who alerted the police. The three men escape and the police never catch them.

The debriefer will debrief the bank staff two days after the crisis. The bank will open two days later. Below are descriptions of each participant in the crisis debriefing session:

• Head Teller - The head teller was a good friend of the person who died. She witnessed the entire event from beginning to end. The head teller is feeling strong emotions of grief
  
  
• Bank Teller 1 - This bank teller was right next to the teller who died, and is having flight of thought, with poor concentration. When asked questions, he starts to answer, but then goes off on irrelevant topics.
  
  
• Bank Teller 2 - This bank teller also witnessed the entire crisis, and has feelings of impending doom. She is fearful about coming back to work.
  
  
• Guard - The guard feels tremendous guilt and completely responsible. He believes that he did not perform his job properly.
  
  
• Loan Officer - The loan officer witnessed the aftermath of the shooting, and called 911. She feels emotional distance from the rest of the group, although the loan officer is usually very close to everyone in the bank.

How would you ask the trauma survivors, in your own words, exactly what happened during the trauma? How would you ask the survivors, in your own words, to offer as much detail as possible, without being intrusive? Hint - It is a good idea to ask the lead-in question to the entire group, allowing individuals to respond as they choose.

What would you advice the distressed bank teller, who cannot concentrate? What red flags would you anticipate as you work with this group? How would you advise the loan officer, who is feeling emotional distance? What are some emotional reactions you would expect the guard to experience? How would you introduce the suggestion that these trauma survivors discuss their emotional reactions to the crisis?

Since only two days have passed since the crisis occurred, there has been little time for these trauma survivors to manage the crisis. What would you ask them to assess, regarding their skills in managing the crisis?

What are the advantages of having these trauma survivors remember what it was like to work at the bank, prior to their crisis? How would you ask them, what they need in order to adjust to their work environment today? Offer suggestions of how they can continue to invest in others, as they go back to work and support one another.

Consider how, in your own words, you would close the session with these two themes: First, the crisis is bizarre but your reactions are normal and Second, participants need to stay functional, despite this life-changing event.

Case Three
A woman comes home after a day of work. She goes down into the basement to do the usual load of laundry, but she senses that someone is behind her left shoulder. She looks to find that her teenage son has hanged himself. There is a suicide note and she reads it. She cuts him down and carries him upstairs. As she carries him upstairs, she convinces herself someone murdered him. She calls the police. There is no forensic evidence or suspect to suggest a murder. The crisis debriefing is occurring two weeks after the death.

The debriefer will debrief the family of this teenager, including the mother. Below are the descriptions of each person within the crisis debriefing session:

• Mother - She believes that someone murdered her son. She argues with other family members or withdraws if they disagree. She will not accept the idea that her son committed suicide.
  
  
• Father - He believes his son committed suicide. He recalls his son feeling depressed. As with most parents who are suicide survivors, he feels guilt.
  
  
• Brother 1 - He is not sure if it was a suicide, but wants to support both his mother and father in their beliefs.
  
  
• Brother 2- He has been acting like his bother who died, instead of being himself.
  
  
• Sister - She believes her brother committed suicide, because she heard him talk about it. She is reluctant to say it was a suicide, because her mother distances from her when she does.

With the division between mother and the rest of the family, how would you first address the issue of suicide versus murder with this family? Hint - If a family has a great division about the cause of death, the debriefer can tell them to work the Five Life Management Skills together. How would you do this?

Since the family does not share the same memory of how he died (mother recalls the death as a murder and the rest recall the death as a suicide), are there reasons the Memory Component may be especially important in this case? Hint - What can they agree on?

Even though they disagree about the cause of death, they can still grieve together. Consider how you would attempt to get them to invest in one another (Task Four) and to adjust to the environment (their home) together (Task Three).

As you have them put together the global picture of what happened, mother's piece of the picture reflects distortion, because she is not accepting the reality of a suicide. What do you think will happen when the mother's piece of the picture does not fit with the rest of her family? How can you utilize this situation to benefit mother and the family? Hint - The Global Picture Component makes it obvious if one of the trauma survivors has distorted reality.

What is your goal for this mother? Do you want her to accept the death as a suicide during the crisis debriefing session? Or do you want to just red flag her unwillingness to accept reality (Task One)? What special instructions might you have for her family members, if she refuses to see her son's death as a suicide?
Consider how, in your own words, you would close the session with these two themes: First, the crisis is bizarre but your reactions are normal and second, they need to stay functional despite this life-changing event.


"Be careful that victories do not carry the seed of future defeats."
Ralph W. Sockman

Research Findings
Debriefers often need debriefing for themselves. Considerable research supports the existence of vicarious traumatization. Supportive research suggests that crisis debriefing for the debriefer is helpful. Crisis, even when managed in a healthy manner, creates more crises. Particularly following catastrophic crises, crisis debriefers need debriefing. The following literature deals with Vicarious Traumatization:

• Everly et al (1999) found that crisis debriefing alleviates the effects of vicarious psychological distress in emergency care providers.
  
  
• Wertz (2001) found that it is common for trauma therapists to experience "PTSD symptom -like behaviors", although theses behaviors do not constitute a diagnosis of PTSD. It was found that cumulative or recent exposure is not related to reports of PTSD behavior but such behavior is related to the level of absorption and emotional empathy.
  
  
• Erikkson et al (2001) investigated relief and development personnel. It was found that the more life threatening events they experience through their clients, the more likely they were to get PTSD-like symptoms.
  "Weaks (2000) studied vicarious trauma and coping in psychotherapists as they related to a reduction of PTSD and disruptions of cognitive schemata. It was found that 71% of therapists experienced PTSD symptomalogy that was clinically significant after working with clients that had been traumatized.
  
  
• Bennett et al (1999) found that vicarious traumatization is characterized by the PTSD-like symptoms, feelings of self-doubt, a tendency to pull away from primary relationships, and a cathartic release after talking to colleagues that understand trauma - as a normal reaction to doing trauma therapy. Their research found five themes:
  
  
  1. Vicarious traumatization is a normal reaction to doing trauma therapy
     
     
  2. Vicarious traumatization will change you, as a person and as a therapist.
     
     
  3. Therapists will gain new awareness of the preciousness of relationships.
     
     
  4. Therapists change the pain of listening about trauma into a healing experience.
     
     
  5. Spirituality is the bridge to healing.
  
  
• Pannell (1997) found that all types of violent exposure - direct, indirect and vicarious - showed a strong relationship with PTSD symptom severity and diagnosis.
  
  
• Cunningham (1997) found that clinicians working with sexual abuse were more negatively affected than those clinicians who worked with cancer. Clinicians working with sexual abuse reported more disruptions in several cognitive schemas, including safety schemas, trust, and self-esteem. Sometimes researchers use "schemas" like the author uses the term "life-sustaining beliefs".

Taking Care of the Debriefer
Just as crisis reactions are normal and expected within trauma survivors, vicarious traumatic reactions for debriefers are also normal and expected. Most debriefers are cognitively bright, which usually offers the strong ability to visualize. Debriefers can imagine the trauma others experience. So, it makes sense that they can be at least minimally traumatized by the many stories of crisis survivors. Depending on the coping resources and previous histories, the impact of vicarious trauma may become severe for some debriefers.

Debriefers need much more than crisis debriefing for themselves. Listed below are suggestions for maintaining oneself, while assisting trauma survivors:

• Attend a support group, at least once a month. If no support group exists, initiate a support group, including community members who provide grief counseling services and crisis services to survivors.
  
  
• Attend retreats designed to replenish your spirit. This may include religious retreats, couples retreats, fun family retreats, and silent retreats.
  
  
• Replenish your debriefing skills by attending seminars and reviewing the research literature. Today, reviewing research is easy. Go to any university library to find databases that offer all the available research on any topic, within seconds. The confidence of knowledge is a cornerstone to maintaining good mental health. Know your field of work, and know it well.
  
  
• Always work as a team. Teams naturally debrief as they work together and naturally gather after their work. Natural debriefing is an important tool. World War II veterans had to make long trips home after their war experience. They had time to naturally debrief, as they gathered and talked together. Viet Nam vets did not have this luxury. Their trips home were much quicker, so their PTSD reactions were more pronounced. I firmly suggest working as a team and naturally debriefing together.
  
  
• Balance the workload, so you do more than only debrief trauma survivors. Many enjoy counseling because they can see people heal, as they work over long periods of time. The debriefer does not experience the healing process take place, but only experiences the initial response. This places a greater burden on the debriefer.
  
  
• We can ventilate tension with rage or humor, so why not do humor? Humor, that does not hurt anyone, is a great tension release and is part of the healing process. Keep your humor alive. If you lose your humor in the line of work, it is time to do something else.

Vicarious traumatization creates a twofold need. First, debriefers need screening and considerable education on mental health issues. This author has noticed that a segment of debriefers require much more education concerning mental health issues. Such lack of education, coupled with untreated traumatic histories can create difficulties for the debriefer and the trauma survivors with whom they work. Second, more research is needed to determine under what circumstances debriefers are most likely to require debriefing after working with trauma survivors.

One great influence for the effectiveness of any technique, including crisis debriefing, is the experience and training of the provider. This online course has presented numerous relevant topics, of which debriefers need a thorough knowledge. It is advisable that debriefers know the crisis reactions, PTSD symptoms, Complex PTSD, grief emotions, diagnostics, Five Life Management Skills, and phases of a crisis. Debriefers also need to know the reactions of specific trauma, such as suicide and murder. Debriefers need to know the guidelines of crisis debriefing and the crisis debriefing components. Debriefers also need a full array of training in counseling, psychology or social work and clinical experience.

I advocate that crisis debriefers have, at least, a Master's Degree in a mental health profession. One critical factor of crisis debriefing is its brevity. A person, who is not thoroughly trained in the mental health field, could easily miss important individual symptoms or important group dynamics. With the criticisms of crisis debriefing, it is important for the debriefer to be a qualified mental health practitioner.


Types of Local Referral Sources

• Grief support groups
  
• Trauma support groups
  
• Local Red Cross services
  
• Clinicians specializing in PTSD and Complex PTSD
  
• Clinicians specializing in Eye Movement Desensitization Response
  
• Clinicians specializing in the treatment of personality disorders
  
• Victim assistance programs
  
• Grief specialists
  
• Financial sources
  
• Suicide prevention specialists
  
• Advocates for murder survivors
  
• Family therapists
  
• Child therapists

Crisis Reactions

• Bewilderment - Not understanding the new emotions of crisis.
  
• Impending Doom - The immediate fear of dying or fear of harm.
  
• Stuck - Feeling stuck on the trauma and the overwhelming emotions.
  
• Apathy - The feeling of giving-up.
  
• Helplessness - Not knowing what to do.
  
• Disorganized Thought - The mind becomes very distracted.
  
• Preoccupation with Insignificant Thoughts - Did I do this? Yes I did.
  
• Stuck on Traumatic Memory - The crisis emblazes on the mind.

Grief Emotions

Numb and Stunned

• "Numb and stunned reactions protect bereaved … from being overwhelmed by all of their intense grief emotions … by offering a gradual incorporation of the loss."
  
  
• "Numb and stunned reactions also signal … that something unusual and significant has happened, and that they will need to make adjustments."
  
  
• "Numb and stunned reactions are a way for (survivors to) 'brace' themselves emotionally, following a trauma."
  
  
• "Numb and stunned reactions allow (survivors) to gather information objectively and observe others."
  
  Attempts to Re-Create
  
• Helps trauma survivors realize that a loved one is dead or a crisis actually occurred.
  
  
• Keeps trauma survivors' denial at a healthy minimum.
  
  
• Reminds trauma survivors of their dead loved one's importance.
  
  Disarray
  
• Disarray is a barometer. When disarray is obvious, trauma survivors are signaling that they are actively focusing on their loss or trauma. When disarray subsides, the survivor is more attentive to current life.
  
  
• Disarray pushes people to think about their losses and trauma, reducing avoidance and denial.
  
  Anger
  
• Anger is a signal that a primary emotion needs releasing.
  
  
• Anger is a barometer. When a person resolves an emotional issue, anger should subside.
  
  Anguish
  
• Anguish and memory surface together. When trauma survivors feel anguish, they are recalling a memory of their loved one or they may be recalling what life was like before a crisis impacted their life.
  
  
• Anguish and love surface together. Anguish teaches a trauma survivor how much they loved the dead loved one. In the aftermath of a crisis, anguish may also teach them how much they appreciated past feelings of safety.

Information for Suicide Survivors

• Grief of a loved one who commits suicide is complicated for everyone. If your grief lingers, it is not because you are reacting incorrectly.
  
  
• Make sure you feel comfortable with your support people.
  
  
• Supportive family and friends are your best assets. Stay close to them.
  
  
• Try not to obsess on the question "Why?" Think about the Five Life management Skills instead.
  
  
• It is very possible your loved one can go to heaven. Talk to your clergy about this issue.
  
  
• Watch your guilt. If you experience guilt trips, get counseling.
  
  
• You will eventually get angry with your loved one for committing suicide. This is normal. Allow yourself to have this normal reaction, but express it in a healthy manner.
  
  
• Spirituality also helps to heal your grief.

Information for Murder Survivors

• Media will be intrusive. You do not have to talk with them.
  
  
• This type of grief is complicated. If your grief lingers, it is not necessarily because you are doing something wrong.
  
  
• Realize the criminal justice system and the police have a job to do, and that they can be quite intrusive.
  
  
• There will be times you may feel out of control. This is normal.
  
  
• In court, you will hear a lot about the rights of the murderer. Be prepared!
  
  
• In court, you will hear your loved one maligned. Be prepared!
  
  
• There will be trial delays and appeals. These will delay your grief. If you cannot access your grief, you will have reactions that are normal, but feel strange. These reactions may include:
  
  
• Nightmares
  
  
• Uncontrollable crying
  
  
• Hysterical laugher
  
  
• Physical reactions, such as chest pains and stomach upset
  
  
• Distract yourself from rescue fantasies, by contacting friends and professional support people.

Five Life Management Skills Rewritten for Crisis Debriefing

1. Accept the reality of the crisis.
   
2. Work through the pain associated with the crisis.
   
3. Adjust to environments where the crisis occurred.
   
4. Invest in other relationships.
   
5. Remember as accurately as possible.

Copyright James A. Fogarty, Ed.D.
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