The Interventions

There are lots of arguments about the best ways to help such client groups. These range from the long-established, but now heavily criticized, technique of debriefing, (Dyregrov, 1997; Mitchell 2004,1983), to the very modern approaches using such cognitive-behavioral techniques as eye movement desensitization, (Shapiro, 2001), emotional freedom therapy (Hartman 2000), and so on. At the core of all these approaches, at least in the immediate aftermath of a traumatic incident, is the need to address the disabling cognitions, the distorted beliefs, and the maladaptive thinking that the traumatic experience has engendered. Put simply, whatever views therapists might hold about best practice for the long-term approaches to helping traumatized clients, in the short-term, normalization appears to often be the key early need for clients and this usually means focusing the therapeutic interventions at core cognitive levels. Cognitive processing of a traumatic incident means keep on linking the clients thinking processes back to what they perceived as happening as the incident progressed. It is a circular and an iterative process.

In my own psychotherapy consultancy practice I get involved as a "trauma expert," (if there really is such a calling), in the aftermath of quite a lot of serious and dramatic events. In my experience, even the aid professionals have difficulty in handling the emotional needs of the traumatized victims. Indeed, they are often not much better at handling their own psychological discomforts either! Following is an example.

Background

In October 1999, just on the outskirts of London, thirty-one people died and hundreds were injured when a Thames Trains service went through a red signal and collided with a Great Western InterCity Express. One can only roughly estimate how many people were directly, (passengers) or indirectly, (relatives, colleagues, friends, etc.) suffered emotional damage. The figures run to at least the low thousands. In addition, major psychological effects were discovered in many of the emergency service workers. I was tasked to facilitate two groups of passenger survivors, none of who had any significant physical injury. However, they all apparently felt sufficiently emotionally pained to prompt them to voluntarily take up the psychological therapy. In Group 1 there were six women and three men, of various ages and in Group 2 there were five men and seven women. In neither case did I ever learn anything striking or of any significance about their backgrounds, origins, or personal circumstances. We met in a small conference room in a hotel that had been requisitioned for the purpose. Their presenting emotional conditions ranged from anger, through deep sadness to ongoing tenor.

Group 1

To begin with, I asked each participant to describe their entire day, from when they got up on the morning of the crash to when they got to whatever or wherever represented a safe place for each of them. I wanted each of them to tell me their story. This was not done on a one-by-one basis that started at breakfast time and went through to bedtime but one that was undertaken on a horizontal time-slice basis that took all of the participants in turn through the first segments of their day, then all of them through the second segment and so on. Although we wanted to hear from everybody, the trick was to keep the group focused on the individual task in hand while at the same time not wanting to suppress anybody's need to urgently express themselves if necessary, whether or not it was their "official" time to tell part of their own story. What became obvious at an early stage was a need in some of the participants to deal with their own feelings by sabotaging the emotional "downloading" of other group members. For example:

Participant A: "As I cowered by the track side, I kept on worrying about getting home in time to pick up my dry cleaning as I was going to a PTA meeting the next day and I didn't want to look scruffy and let my children down"

Participant B: "My immediate worries were for everybody else. I had already probably saved one guy's life by dragging him clear and I knew that the most important thing was to care for the injured"

Looking at Participant A, I could see that she was starting to feel ashamed of herself. Possibly she was feeling personally diminished by only having such apparently trivial worries when "Mr. Hero" was rushing round selflessly risking life and limb in the service of his fellow victims. The danger was that A, and possible other group members too, would be silenced by their awe of B's apparent heroism. The essential element in working in this way with traumatized clients is to keep bringing them back to the "what were you thinking—what did that happening mean to you"? This is because such an approach is consistent with the classic principle of any cognitive therapeutic intervention in that the thinking precedes the action or the feeling.

Thinking, including maladaptive thinking, is the cause of perceptions, emotions, and emotional discomfort; it is not the result of inappropriate emotions or perceptions. In the case of the exchange, by asking both A and B what their individual thoughts were, at the time that they each were referring to, we could get their responses into proportion. In addition, and probably most important of all, they could both learn to understand themselves and to normalize their own cognitions. As it happened, it turned out that A had been thinking about how the crash might affect her immediate family and B had been thinking that he was in immediate danger and so he found that displacing this fear into activity helped him to cope. It is clear from this example that the trauma therapist's early stages interventions need to be targeted at continually "closing the loop." This concept is perhaps better illustrated by one of my experiences when I was working with Group 2.

Group 2

This group of victims all described a common scene from their experiences:

There was a huge bang; a huge jolt and the train went all over the place. I was thrown around all ways and there were incredible noises— screaming, crunching, banging, explosions and the sound of huge pieces of metal crashing together. It was like hell had opened up. Then it stopped and I found myself outside the train sitting on the track. There was a hush, no noise, and no sound at all. Then from one direction I heard a mobile phone starting to ring, and then from somewhere else another phone joined in, then another and then another and another and another. Gradually the air became full of the sound of phones ringing. It was the sound of life!

This is a hugely dramatic story and, as some of the survivors talked about this experience it became clear that its power was putting all of us, everybody in the room, back at the crash site. It filled our being and we all were there, at the actual event, at the actual time. Now let's get back to therapeutic reality and see if we can close the loop. Put simply, the story wasn't true! The crash happened on a busy mainline train junction, under a crowded airport flight path and in a busy, heavily trafficked London suburb. There was no period of silence— and that particular survivor's story existed only as a perception, albeit an incredibly powerful one. What was the real situation? It had to be one of noise, shock, and fear. Where did the belief come from that all was quiet? After all, this was real life at a major, and still ongoing, disaster. With hindsight, my best professional guess now is that this misperception probably had its origins in some erroneous thinking patterns, (cognitions), that if noise equals danger then silence equals safety. Therefore, in order to save themselves, my storytellers had to create their own reality because the real life situation that surrounded them was far too threatening. So how did I intervene? In this case I didn't—I was overwhelmed too! Sometime you just can't avoid go ing with the flow. Sometime the best intervention that a therapist can make is simply not to make one!

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