Trauma Response Profile: George S. Everly, Jr., Ph.D. and Jeffrey T. Mitchell, Ph.D.

George S. Everly, Jr., Ph.D. and Jeffrey T. Mitchell, Ph.D. developed the International Critical Incident Stress Foundation over a decade ago. Today, it is the largest organization of its kind providing education, training, and consultation on the topics of crisis intervention, psychological trauma and disaster mental health for the emergency services professions throughout the world. The Foundation coordinates an international network of disaster response teams. Dr. Everly is a leading authority on human stress and psychological trauma. He serves on the adjunct faculties of Johns Hopkins University and Loyola College in Maryland. Dr. Everly was a Harvard Scholar, Harvard University, a Visiting Lecturer in Medicine, Harvard Medical School and Chief Psychologist and Director of Behavioral Medicine for the Johns Hopkins' Homeward Hospital Center. He is the author, co-author, and editor of 12 textbooks and over 125 professional papers with his works translated into Russian, Arabic, German, Swedish, Polish, Portuguese, Korean, and Spanish. Dr. Jeff Mitchell is the President of the International Critical Incident Foundation. He is the developer of Critical Incident Stress Management (CISM) and its related programs which is utilized by over 700 communities throughout the world and in over 23 nations. Dr. Mitchell is a Clinical Associate Professor of the Emergency Health Services Department at the University of Maryland. He has over 130 publications on critical incident stress, crisis intervention and the treatment of stress in emergency personnel. Drs. Everly and Mitchell both serve on the Board of Scientific & Professional Advisors of The American Academy of Experts in Traumatic Stress.

JSV: The two of you have very different backgrounds. Can you tell me about your careers and how you came to collaborate?

GSE: Academically, I was initially trained in business administration and was intrigued with the study of human behavior within business organizations. Subsequent to the completion of my studies in business I decided that it might be even more interesting to try to understand not only how to describe and predict behavior, but change it. I became interested in clinical psychology. Somewhere along the way, I also became very interested in psychophysiology. My family had a history of high blood pressure and I was interested in seeing whether some of these new techniques that had been emerging, at least in the United States, such as meditation would be of any value. We started experimenting with meditation and biofeedback. I was very lucky to work in a laboratory that was one of the largest in the country where we studied biofeedback applications, blood pressure and general stress. From that point, I specialized in the area of stress. When I graduated I was really looking for more of an academic orientation and saw myself as more of a laboratory scientist and academic. And then a guy by the name of Jeff Mitchell introduced himself and, Jeff, I'll let you pick it up from there and we'll go back and forth.

JTM: I started off as an elementary school teacher teaching science to the sixth grade. I got interested in fire service so I became a volunteer firefighter and eventually rose to the rank of Lieutenant and worked for the fire service for 9 ½ years. I wanted to become a child psychologist and was actually studying to do that. I got more and more interested in the stress that was going on with the emergency services personnel that I was working with. Gradually, I started to move toward the Ph.D. and then I found myself in the position of doing my dissertation on Paramedic Stress. I needed to do some testing for the dissertation and found that George Everly had actually developed some tests that were quick scales that could get a good assessment of an individual's stress level. I talked to him about that and read his publications. I was quite impressed with the work that he had done and he helped me to organize the statistical design for the testing on my doctoral dissertation. I began to refer people to him including individuals who I had been meeting who had quite a bit of posttraumatic stress. He actually pulled off some significant cures of people who, when I first met them, I thought would never be able to stay in the emergency services profession. George was able to work with them - to get them back on track again. And then we just started to do things together, like education programs and large conferences. Since my focus was crisis intervention and his was the treatment of traumatic stress, it seemed to be a good match. I was taking care of the prevention end of the experience and George was taking care of people when they already had been exposed to significant trauma and had developed posttraumatic stress, so it was a good match there. And we both thought a lot alike in terms of crisis intervention and traumatic stress and its impact on people. Since 1982, we have been working together to build this field to assist people who deal with crises.

GSE: Jeff was kind enough to invite me to speak at a number of conferences he had held at University of Maryland - Baltimore County (UMBC) and this was a world that I was pretty unfamiliar with at that time. As I was saying, I was pretty much in the niche of a laboratory scientist and academic, but as Jeff had mentioned, I had developed a clinical specialty in treating stress disorders and I had a behavioral medicine clinic. What intrigued me about the world that Jeff had introduced me to was that I saw people such as fire fighters who were at unusually high risk for developing this newly recognized diagnosis of posttraumatic stress disorder. But I think that it was in 1988 when Jeff invited me to go to Australia with him to attend a conference on emergency services stress that I remember having a certain conversation with him. I said to him "These people are at such high risk, occupationally, and there doesn't seem to be anything in place to really assist them." There wasn't a line of study or support for them other than the work that Jeff was beginning to generate out of UMBC. So I looked at him half-jokingly and half-seriously and said "You know, what we really need to do is create a foundation that would focus it's efforts in support of emergency services personnel from the psychological mental health point of view." He must have taken me seriously! At that point, we started really thinking about how we could do such a thing - if it was even possible. In 1989, the International Critical Incident Stress Foundation was formed.

JTM: George had referred to UMBC several times. I am a member of the faculty there in the Department of Emergency Health Services. At the time I met George, I was an instructor working my way toward the Ph.D. I am now a Clinical Associate Professor in the Emergency Health Services Department. I had come out of the field of firefighting paramedic work and transferred my knowledge and education into working with emergency personnel. By 1988, I had finished my dissertation and Clinical Associate Professor of Emergency Health Services was my full-time job when George proposed that we perhaps could work together to put together an institute or foundation to assist emergency personnel. I thought it was time for me to do that. I went part-time at the University of Maryland and put the rest of my energy into creating this non-profit organization. The organization was basically designed to provide education and assistance to emergency personnel, and when George and I started, it was basically two people in the foundation. There is now over 5,000 people who belong. So in the last 10 years it has had remarkable growth. We started off with two education programs and we now have at least a dozen courses that we offer in the field of traumatic stress - everything from dealing with traumatized children to dealing with disasters and more. We provide innumerable consultations with people who call in with problems dealing with traumatic stress and are asking for assistance. Basically right now we are handling nearly 20,000 incoming phone calls a year from all over the world and about 35,000 - 40,000 written requests for information each year. We provide quite a bit of information. We also have a 24-hour hotline in the Foundation that is answered by police and fire communications personnel who then either tell folks where the local teams are for them or they can provide them with one of our team members for consultation if necessary. The services are very broad. We also do a lot of disaster coordination for emergency mental health services and take care of the high risk key personnel.

JSV: Jeff, do you want to give that phone number?

JTM: The emergency 24-hour a day phone number is (410) 313-2473. The routine number for non-emergencies is (410) 750-9600.

GSE: I think that one thing that Jeff mentioned that is worth reiterating is that we didn't start out to just do this on a grandiose scale necessarily. This was very much a part-time endeavor. I was very fortunate enough to be trained and have as a mentor, Theodore Millon, who's area of expertise was personality disorders. I was very much interested in doing that research. When I left the University of Miami, I went to Harvard where I worked directly with David McClellan, and again his area of interest was behavioral medicine and stress. But, in a surprising kind of way, the growth of the Foundation began requiring more and more and more of my time. I came back to Baltimore to work in one of the Johns Hopkins Hospitals as the Chief of Behavioral Medicine and Chief of Psychology and it got to a point where the Foundation just required more and more time. I still teach at a local college called Loyola College in Maryland and I also teach part-time at Johns Hopkins. But I think part of what makes it work - a lot of our success - is that Jeff and I come at the problems from two very different point of views. The good news is we think a lot alike but we come from two very different experiential backgrounds. I guess I have more of an academic and scientific background and Jeff has far more of an applied background and those two backgrounds seem to work very nicely together.

JSV: What are your respective roles with the International Critical Incident Stress Foundation?

JTM: I serve as the president, so that means I put signatures on a lot of things that need to be signed. The Foundation is run by a volunteer board of directors and I essentially serve as the highest ranking operations officer in the Foundation (and certainly have the co-founder position there). We have a Director of Operations who works immediately in my jurisdiction in terms of the line and then we have an Office Manager and somebody who handles memberships. We have a receptionist and we have somebody who handles the scheduling of conferences. We have another person who takes care of the World Congress process. My job is just to keep all the things running from the official point of view for the Foundation. I'll let George talk about his role.

GSE: I started out as Chairman of the Board of Directors and found that that particular position required so much time and took me away from the training and day-to-day operations. I guess technically I'm Chairman of the Board Emeritus at this point. I am in charge of strategy, planning, policy making and Jeff is pretty much the person that makes it happen. So I come up with the ideas and Jeff makes them happen, all with the oversight of the Board of Directors. We are a non-profit organization and in 1997, we received United Nations (UN) recognition.

JTM: In 1997, the International Critical Incident Stress Foundation was recognized as a non-governmental organization in special consultive status to the United Nations. We assist the UN and countries worldwide where they have been running into significant stress problems.

GSE: Another part of my job, from a policy point of view, is acting as a liaison, not only with the United Nations, but also with other groups such as The American Academy of Experts in Traumatic Stress.

JTM: George and I are also two of the main faculty for teaching education classes for the Foundation. We are not the only two - there are at least ten faculty members who were brought on by the Foundation to provide different courses throughout the world, wherever they're requested. We also coordinate a cadre of over 300 basic course instructors who have been trained to educate in courses throughout the United States and Canada and some of the European countries.

JSV: As developers of Critical Incident Stress Management (CISM), what goes into a successful response to a traumatic event?

JTM: We have found that firefighters listen to firefighters more than they will to mental health professionals or to clergy. You'll find that police officers listen to police officers, nurses listen to nurses, EMT's listen to EMT's, dispatchers listen to dispatchers, you could go on with a list like that. We have put a lot of emphasis into training peer support personnel who become members of Critical Incident Stress Management teams. They are one very important piece of the success of Critical Incident Stress Management. The second piece is to have mental health professionals oriented to the needs of these specialized groups such as emergency personnel or pilots or groups that they don't usually have coming into their offices very frequently. We've look at it as a multi-pronged approach and I think that this is an important aspect. We have peers, we have mental health providers and we have clergy who train together. They learn this material together and then perform different aspects and roles on the team. So it is this teamwork approach that makes the response successful.

GSE: I think from the broad or "big picture" point of view. The foundation was originally formulated to provide training, consultation and direct support to emergency service personnel from a psychological perspective. We brought something unique to the mix, however. Historically, what we were doing is crisis intervention. We were doing training, consultation and intervention under the overall heading of crisis intervention. So it's not like we invented a new field. We applied crisis intervention principles to a group of professionals who had been, to some degree, neglected as recipients of these types of services. Along the way, we knew we had to make some adjustments to the way crisis intervention would be practiced when compared to a civilian population. Techniques such as critical incident stress debriefing and the whole genre which we now call Critical Incident Stress Management (CISM) emerged. In effect, what the foundation really is, is a crisis intervention foundation. However, we apply crisis intervention in a way that, historically, it has never been applied before. This is in a very comprehensive way. We have a comprehensive, total, multi-component approach to crisis intervention and it has proven successful to the point that the models are now being used with populations other than emergency service personnel. It's being used by the airline industry, by industries, school systems, psychiatric hospitals, and general medical hospitals. The programs are very successful and they seem to be generally applicable. Some of the best work is that of Dr. Raymond Flannery out of Harvard Medical School, who has taken the Critical Incident Stress Management model and adapted it into something he calls the Assaulted Staff Action Program. Dr. Flannery has generated a series of studies demonstrating the efficacy of the Critical Incident Stress Management approach as it applies to hospitals and community mental health centers.

JSV: I am a firm believer in the benefits of utilizing a multifaceted approach that capitalizes on local resources and outside resources as needed.

GSE: And that's important - because the system works best when you use local resources as well as external resources. Whether that means peer counselors and mental health professionals or whether it means bringing in other experts from other areas. For us, Critical Incident Stress Management is utilizing the most appropriate resources in the most appropriate way. We use the following analogy. No one would go out and play a round of golf armed with just one golf club. Well, we submit that no one would - or really should - do crisis intervention armed with only one crisis intervention technique or modality. Critical Incident Stress Management is an amalgamation of many crisis intervention techniques that have been integrated in such a way that you use the best technique for the particular need at the particular time. And again, the golf analogy seems to work for some people - you certainly wouldn't play an entire round of golf with a putter, nor with a driver, but under the right circumstances, the putter is the best club for one situation, the driver is the best for another. And contrary to what some people misunderstand - the field is not only about Critical Incident Stress Debriefing (CISD). This is one powerful technique that has been developed by Jeff Mitchell. It is a group crisis intervention technique, but it is only one of seven or eight basic techniques that we utilize. So when people are trained in Critical Incident Stress Management, they go through a number of our courses so that they can work with individuals, large groups, small groups, families and mass disasters. And we, I think, now have the distinction of coordinating the largest crisis response network in the world with standardized training.

JTM: I want to reiterate something that George said because I think that the point is extremely important. As the developer of the CISD model, I think that it is important to mention that it is and always has been a group intervention tactic. And I talk about it as a tactic because in emergency services, we talk about strategy and tactics. Strategy is the big picture - what your goals are and what you're trying to achieve. Tactics are individual components that assist in carrying out the overall goals. You don't put out a fire with ventilation alone just as you don't arrest a subject with surveillance alone. CISD is one tactic. It is the group tactic and it's designed for a specific function. We also emphasize doing many other things including one-on-one interventions, family support, etc.

JSV: With so many exciting changes taking place in the area of traumatic stress (e.g., neurobiological findings, etc.), what things to you think are in need of greater investigation at this time?

GSE: I think we're just beginning to understand some of the neurobiology of trauma. There has certainly been some very good work done up to this point. I think there needs to be much more work done. I think that if we look at Kaplan's model of prevention if you remember back from 1964, he talked about primary, secondary, and tertiary prevention. Primary prevention involves removing the stressors or risk factors, secondary prevention is crisis intervention and acute symptom mitigation and tertiary prevention involves treatment and rehabilitation. There will always be a need for what we do at the Foundation, which, again, is crisis intervention. There will always be a need for treatment. But I think the future lies in the area of how to make people crisis and trauma resistant and that is where we are beginning to turn some of our efforts. I equate it to giving people in high-risk occupational groups - "psychological body armor." We provide soldiers and police officers with, literally, body armor to go out and do combat. Well, I think we need to get to the point where (and we are getting to this point), we are capable of arming people in high-risk occupational groups and whom are at high risk for things like acute and posttraumatic stress disorder. We need to arm them with a sense of "psychological body armor" so that they actually become more resilient to trauma and stress factors. And to me that's the future and that's the very exciting area that we need to go in. Science for science sake is fine, but I happen to believe that science needs to ultimately improve the human condition. We need to move into the area of primary prevention when it comes to acute and posttraumatic stress disorder.

JSV: I certainly agree that we need to inoculate support personnel and survivors essentially through education and early intervention among other things.

GSE: That's just part of it. There is some very, very exciting work being done by Peter Jonsson and people in Sweden. We are collaborating with them on ways of actually making the human being less vulnerable to traumatic situations. For law enforcement, fire suppression, paramedics and military personnel, it could represent a rather remarkable breakthrough.

JTM: Critical Incident Stress Management is prevention-oriented. Some people have mistaken CISM or one of its single techniques, debriefing, as therapy and CISM is not therapy. They are prevention-oriented programs. They're more about trying to prevent the problem from taking hold than trying to cure the problem once it's there. I think that another exciting challenge besides what George had just mentioned is trying to help people recover who have been traumatized badly by some of the experiences that they have had. And what I find very exciting now is the linking of prevention efforts of CISM with some of the newer and very dramatic therapies, such as Eye Movement Desensitization and Reprocessing (EMDR). For instance, one of the things that we have experimented with involves conducting EMDR very shortly after meeting an individual either on a one-on-one individual consult or picking an individual out of a debriefing. That individual may have had a pretty significant reaction to an event. A trained therapist will work with the individual very, very soon after they've been assessed in a debriefing. We have been finding that when you get to them that quickly, there is a recovery rate that is really remarkable. I think nobody should be fooled that it's a finger-waving technique. There's a lot of work that goes into it. There is a very heavy cognitive focus when you're properly doing EMDR. Therapists really need to know what they're doing and be properly trained to be able to provide that particular therapy. But when we joined it together with the resources of the CISM team, it has had a very powerful impact.

JSV: The front cover of your book Human Elements Training for Emergency Services, Public Safety and Disaster Personnel, shows a police car in a ball of flames. It's a very provocative image, one of the things that in fact drew me, besides your names to that particular publication. What led up to the development of this informative instructional guide?

GSE: Jeff, you want to tell the story about the picture?

JTM: Yes, I'll start off with the picture. The picture was a Maryland State police officer who was the tail car on the torch run for the Olympics. I believe it was in 1992. He was the tail car and he was a distance behind the runners who were holding the torch and running the torch across the United States. A truck came down a hill and became out of control. This trooper saw this image in his rear view mirror and knew that the runners were going to be in deep trouble so he sped ahead, and caught up to where the runners were. He had his lights and sirens going and this had not happened in the race up to that point or in this torch run at that point. When he did this, people did turn around and then they saw what was coming and they got out of the way. He then jammed on the brakes and as he rolled out of the vehicle, it was hit by the truck. So here's a trooper who risked his life to save the runners, knowing that had he not done that, the truck would have plowed into the tail of the Olympic torch run. So that was the story behind that and luckily the trooper was not injured, although it did destroy the vehicle. That dramatic picture was picked because we need to get across to people, again, the importance of education. If we can let them know what traumatic stress is, what causes it, what its effects are, and how they can react to it, then we can do a lot more for prevention. The Human Elements Training text really was the instructor guide for teaching a variety of traumatic stress and crisis intervention courses to emergency personnel. It tries to give them that one "leg up" on the situation so that they're less prone to being traumatized. They need to know (if something happens) what the symptoms of traumatic stress are. It' been my experience in this field that when people recognize the symptoms of stress they tend to call for help earlier, they tend to get help earlier, they recover faster, they stay on the job longer, they stay healthier, and they go back to work and I think that if there is anything that I want to contribute to people, it is helping them stay healthy and happy on the job, and healthy and happy in their lives. What we're trying to do is make a difference. It may not make a difference in 100% of the cases, but if we can make a difference in a large number of the cases, we'll be satisfied with the work.

JSV: In your work with police officers, firefighters, paramedics and others who are the "first on the scene," what are your observations of the responses of these individuals to such traumatic events such as motor vehicle accidents, bombings, and other catastrophic experiences?

JTM: I think that smaller events, in their minds, such as auto accidents, are just "one of those things," but when the incident has children involved, when there's a direct threat to them, when there's stress to their family members, or when there's something particularly gruesome, then I think that we see vicarious traumatization with these people. We see people who can develop a wide arrangement of stress symptoms from anxiety to depression, depending on how long they've been dealing with it. We've seen very good people taken out of service. We've seen people unable to go back to work again. And sometimes, they have handled thousands of cases and one case is that last straw that breaks the camel's back and we've watched people go out. One of the reasons I got into this work in the first place has to do with a gentleman in my unit, when I was a firefighter, who joined the fire department when I had joined. We took the training together, we took the early classes together and three or four weeks after we had come out of the training to get in the fire service, he encountered an episode in which there was the death of a child in a fire. This particular individual was very, very deeply impacted by that and he left service two or three days later and never came back to the fire service again. He seemed to be a very strong individual all the way along, and one of the things that I did learn was that his wife had just given birth to their first child. He had related to that very strongly and he really started to see his own son in the image of the burned child and he was unable to get passed that. So he left the fire service and I thought, wow, we really can lose good people. The other thing that happened to me along those same lines was when I was Regional Coordinator of Emergency Medical Services. I had a five-county area of Maryland that I was responsible for. I found that when we were training 1,500 EMT's per year and we were giving them a 3-year certification, our total numbers never went up. We were always just filling the positions. And when I did some studies on why these people were leaving service, essentially I found that the vast majority left service because the stresses were building and there was nobody that they knew who could talk with them about this. So those are some of the key trigger points in my life that said "we've got to have a better way" and there's got to be something that we can do to keep healthy people healthy and functional people functional and keep them back on the job and keep them healthy in their lives. That is the core of where my work started.

GSE: Posttraumatic stress disorder, in my opinion, when it's in it's most severe form, is one of the most difficult of the psychiatric disorders to treat. I think it was in 1989 or 1990 when Arthur McNeil Horton and I published one of the first, if not the first paper, on the evidence supporting the notion that in some cases PTSD resulted in a cognitive deficit that could potentially be biological in nature and therefore permanent. We need to focus on treatment - we need to come up with innovative rehabilitation and treatment modalities. But I also think that what you see emerging is, quite literally, a standard of care in high risk industries where there are people at high risk for psychological trauma. These people need to have access to Critical Incident Stress Management and crisis intervention programs. The Occupational Safety and Health Administration (OSHA) has pretty much endorsed this notion by saying that anyone in the health care industry, social services industry, aviation industry and late night retail should have access to crisis response services and capabilities. The problems we see including violence in schools and in the workplace indicate a need for such assistance from a prevention point of view. How do we mitigate symptoms? How do we ultimately help people become stress resistant? This is the direction that I see the Foundation moving. We have been doing this already and continue to expand into these new areas.

JSV: As you are aware, The American Academy of Experts in Traumatic Stress is a multidisciplinary organization with more than 140 areas of specialization represented. The Academy recognizes that traumatic events are an unfortunate part of the human experience that professionals and workers from many fields work with on a regular basis. What do you see as the major advantage of an organization such as the Academy that is dedicated to increasing awareness and, ultimately, improving the quality of intervention with survivors of such events across such an eclectic group?

GSE: I'll respond initially, then Jeff, you can follow up. I think it boils down to something simple, but very powerful. The first is, The American Academy of Experts in Traumatic Stress fosters awareness. As Sir Francis Bacon said, "information is power." If we are aware that there is a problem, then there will be people motivated to address the problem. The second thing I think that The American Academy does is to foster discovery, innovation, creativity, and advancement. And I think that an organization like The American Academy helps us strive for raising, to some degree shall I say, the level of quality assurance in the field while promoting creativity and innovation - all with the ultimate goal of being able to better serve people in need.

JTM: I think one of The Academy's major contributions has to do with the fact that this field is so much bigger than any of the individuals in it. To achieve great things, we need to join resources together and have a multidisciplinary approach (as The Academy does). Instead of competing, we need to cooperate. Working together, I think we have greater potential to make a larger impact. No one will listen to a small organization with a few members, but when you have a large organization that cuts across the boundaries of many, many professions, then politicians will listen, governments will listen, the citizens will listen, perhaps a serious difference can be made rather than trying to do this all by one's self. I just don't think it's a good idea to work alone in this field - we need to be allied with one another and assist one another in making progress to do something to mitigate the impact of traumatic stress in people's lives.

JSV: Do you believe that law enforcement agencies and emergency personnel training programs provide adequate training to their staff?

JTM: It depends on where you are. There are a few places that are in fact providing quite an adequate preparation for their personnel, but there are many other places that have not caught on to the fact that there is a significant need to do something to assist their personnel to prepare them for their field work. There are many places that emphasize a high level of technical training, so they're doing really well on the technical aspects of the job, but where we've seen a lot of it fall down is the human element. People have not been skilled and trained in doing crisis intervention. They have not been skilled in stress awareness. They have not been skilled in stress prevention. So a large number of groups that I have seen over the years have not risen to the challenge. We congratulate those who have seen a challenge and have done something about it. We encourage those who have not trained or who are not providing education, to start moving in that direction because it is crucial to the survival of the personnel of the next century.

JSV: George, do you want to add anything to that?

GSE: I think Jeff has covered most of the bases, but I think it may be worth pointing out how some agencies such as the FBI, the ATF, the Secret Service and the Marshall Service, were leaders in recognizing the potentially debilitating nature of law enforcement work that their agents perform. We certainly take our hats off to those people who were leaders in the field in the early days.

JSV: Although it's taken some time, we're discovering more and more about the effects of secondary traumatic stress on caregivers. What advice do you have for those who treat trauma survivors? Are there any suggestions that you could offer to help buffer caregivers from becoming traumatized and/or overwhelmed through their efforts to assist others?

JTM: I think each person finds some of their own ways to help manage the stress on the job. One of the things that our organization does and that your organization does, is try to collect the experiences of other people and try to understand what they have been able to do and then try to educate others. We try to mitigate traumatic stress by helping people (i.e., caregivers) to understand that they did not cause the incident to occur - whatever that awful incident may be. They didn't play an active role in causing the damage. Their role is to do something to repair the damage or to alter the course of the damage. One of the things to remember that is crucial (if I were to take the collective knowledge that I've picked up from so many others) is not to accept responsibility for another person's tragedy. You need to look at it and say "this is a horrible thing, it's terrible that it happened to them, but it is not my incident" but don't accept personal ownership for the situation. I think that is one of the first things to consider. Another step that can help emergency personnel, again, if I were to take the collective knowledge that people have shared with me over the years, is to look at the situation and try to make it an intellectual response rather than an emotional response. In other words, if a person keeps focusing on a particular thing - "isn't this horrible... isn't this awful... I feel so bad for those people," they have a better chance of getting caught up in this. They instead need to look at the situation and say "yes, it's a very bad event, but I have to keep my head on my shoulders and I have to make a decision of what it is that I can do to make a difference for these people." They may say "what can I do to help and what steps do I need to take?" or "what are the tasks that I can perform that can help people in this situation to deal with the situation - to process it and begin to recover from it?" I think that if people can recognize these aforementioned things, then they'll be one step closer to maintaining their own health as they do this work. I think another thing I'd say is that people need to recognize that they are vulnerable and if they do get impacted by an event, they will need the maturity to recognize that they've been impacted and the maturity to seek out support from appropriate resources whether those resources may be with family, clergy or resources of a Critical Incident Stress Management team. George?

GSE: My gosh... you've covered it pretty well. If I'd add anything, it would be just to reiterate, perhaps in different terms. Both the people that are affected and the people who treat victims of trauma and crisis need to understand that the crisis or traumatic event is not this person's fault. But, nevertheless, they do have some ability, not to control the crisis, necessarily, but to control their response to the crisis. I happen to think the cognitively-oriented therapy approach is particularly applicable in this field. And to some degree, that is also consistent with the notion of psychological body armor and immunization by setting appropriate expectations. Consider the three concepts of crisis intervention - immediacy, proximity, and expectancy. Expectancy may be the most powerful variable within that triad and, again, what we need to do is prepare people cognitively for crisis and traumas as best as we can and as best as we can anticipate. For the ones that we can't prepare for and anticipate, then I think we need to arm people with a sense of self-efficacy that they can play a positive role in their recovery and not just simply be a passive victim.

JSV: You have both been instrumental in defining and operationalizing the term "psychotraumatology" as it relates to psychological trauma. How did this term evolve and why do you believe it's a more precise description of the events associated with traumatization and it's aftermath?

GSE: I started using the term "psychotraumatology" because the term that had previously been used was something called "traumatology." If you look up traumatology in most standard medical textbooks, you'll find that traumatology is about the study of wounds - physical wounds - and there seemed to be something missing! Someone had even told me that there was a traumatology center at one particular hospital, but again, they dealt solely with physical wounds. So in an effort to make the term more technically correct, we had to bring the concept of "mind" into it. In fact, if you quite literally look up "traumatology" in the dictionary, it will say "the science of wounds resulting from external force or violence." I think it's easy to confuse physical traumatology with psychological traumatology. So I simply suggested, in an article several years ago, using the term "psychotraumatology" which, literally, refers to the study of psychological trauma, whether it is the factors that produce it, the sequelae itself, or the factors that contribute to treatment and rehabilitation. It's designed to be a more technically-specific term.

JTM: I was quite happy when George started using the term because I came out of the field of emergency medicine and there was mass confusion going on regarding this term. They were just throwing the word "trauma" about all over the place and many, many folks were getting it confused with physical injuries. It helped to more clearly define the field by having this term "psychotraumatology."

GSE: So, ultimately, when I (with Dr. Jeff Lating) edited a book on trauma, of course we called it Psychotraumatology, as a way of trying to capture the broad scope of the entire field.

JSV: And, on that note, in the groundbreaking book, Psychotraumatology, George, you define the "Two-Factor Model of Post-Traumatic Stress." Can you describe this practical and state-of-the-art perspective?

GSE: Well, it was an interesting challenge because as part of my career, I was trained as a psychologist and in another part of my career, I was trained in the biomedical sciences. The study of stress is the study of the inextricable intertwining of mind and body. And that's what stress is. And psychological trauma is the most extreme variant of that intertwining. I like the work of Leonardo DaVinci who said, "first, study the science, then practice the art." In the early 80's, it appeared to me that we were running off treating PTSD without really knowing what it was. So my colleagues and I decided that we would try to take a phenomenological approach and say "well, where is the lesion?," "what is it?" and "What is it that we're really trying to do here?" "What part of the brain or body are we trying to mend?" And what we discovered was really a two-factor phenomenology that we had a brain in overarousal. I wrote a paper called "PTSD as a Disorder of Arousal." I was fortunate enough to work with Dr. Herbert Benson at Harvard Medical School. He and I formulated that concept many years ago - that stress-related diseases were disorders of overarousal. PTSD fit this to a tee. But then the questions came up - "Well, what drives what?," "does the biology drive the mind or does the mind drive the biology?" And my opinion is that it is the psychology that drives the biology, if you will. The mind drives the biology. So we then had to understand that psychologically, there was a "functional lesion" also. We believed that we discovered that the lesion is some insult or injury to some basic core and very personal belief system. And it is that injury to this overarching belief system which William James and the like called the Weltanschauung. It's a German word which means "world-view." A very important world-view somehow has been threatened, challenged, or even destroyed by the trauma. This insult or injury then releases this remarkable physiologic cascade that has the ability to not only overstimulate neurons, but to create a toxic condition. And we wrote some early papers on what we called "excitatory toxicity," where the same chemistry that serves the brain in normal conditions, in trauma can now, quite literally, destroy the brain.

JSV: And, specifically, there is data looking at the hippocampus. And the hippocampus - in terms of it's function in arousal and memory - it fits so well with some of the primary symptoms that we see when we assess and treat traumatic stress and PTSD.

GSE: Well, that's what we look for. But basically we, as phenomenologists, say "well, where is the lesion?"and "Where is PTSD hiding?" And we can explain all of the symptoms of PTSD by looking at the functions and dysfunctions of the hippocampus and the amygdala.

JSV: What do you perceive as the most important factors for clinicians and professionals including non-mental health personnel, to consider when intervening on behalf of a survivor of a traumatic event (e.g., a plane crash)?

JTM: I think there are several important factors to consider when assisting people in crisis. First, you do whatever you can to stabilize and cut down on the amount of stimuli in the environment. If you can cut down on auditory, visual and olfactory stimuli, then right off the bat, you've already taken some key steps to get the person in the right position for support messages. For the survivor, I think containment is important. We must find out what they perceive are their initial needs. A lot of times they just need information, so you want to try to fulfill those things. If it's an Operations person, they're going to continue to do operations and they're not going to be paying much attention to their own needs, so they have to have "mission completion." Before people can hear psychological support messages, they have to be finished doing their job. Or if they're in the situation, they have to have a sense of security - a sense that the dangers have been mitigated and taken away from them or else they will not be able to hear those messages. So, when we start thinking about rescuers and victims, you have to start looking almost at two different tracks - one has different needs than the other. It boils down to the same thing - stabilizing the current situation and making sure the mission is complete for them. I think another thing that's quite important is that people should not go beyond their training levels, no matter what they are doing. Never go beyond what you really know how to do. Also, never open up anything in crisis intervention that cannot be "put back in the box," so to speak, within the allotted time. So if you only have 10 minutes to work with somebody, you don't want to get into conversations that are going to take you 45 minutes. People have to be aware that sometimes there is "a time and place for all things," as the Bible says, and sometimes it's just not a good opportunity to open people up. I think that you have to really look at three issues that I'm always concerned with and I suggest that others look at as well - the "target" - who you are trying to help?, "timing" - is it the right timing to do what you need to do? and what "type"of help are you going to offer? And if we're always looking at "target," "timing," and "type," then we're going to make a little bit more sense out of what we're doing. We will be in a better position to know who needs the help, when is the best time to reach them and what type of help they need. Not every type of help is appropriate under certain circumstances. For instance, in disaster, you don't use debriefing until weeks after the disaster is over. But you would do a lot of one-on-one support in what we call "on-scene support services." So you have to choose the right intervention at the right time and apply it to the right group.

GSE: I'll take the risk of just oversimplifying what Jeff has said. To quote Hippocrates, "First do no harm." When you are working with rescuers, what you need to remember is get out of their way. Don't be part of the problem. Don't be an intrusion. Be a support. One of the most common complaints we hear is that sometimes well-meaning mental health and crisis interventionists will actually get in the way, especially while doing on-scene support. So, "do no harm" to the rescuers by staying out of their way, giving them some distance, but be there to support them when they need it. And then "do no harm" to the civilian population by not using powerful probing and interpretational techniques that may take hours, days, or weeks to resolve. Don't open a door that you can't close. Again, "do no harm."

JSV: In the many years that both of you have been involved in crisis intervention, do any specific events stand out in your memories that you believe have influenced you both personally and professionally?

JTM: Well, certainly from a traumatic point of view, I have been on events that have left pretty indelible marks with lots of very strong memories. I think in life we have a choice of becoming bitter or better and when I went through some of those events, I decided rather than let them make me bitter, that I was going to take those opportunities to try to do something to make me better and make other people better over the circumstances. So, I think that some of the loss of the life and events that I have encountered - they really stick. Some of those experiences include baby deaths, young people killed unnecessarily and terrible auto accidents and things like that. I've seen a variety of those things in my life.

GSE: I think there are three events that have impacted me - Kuwait, Croatia, and the Oklahoma City bombing. These things impacted me on an existential level. When I was responsible for training the Kuwaiti therapists who were treating epidemic PTSD, I obviously spent a lot of time in Kuwait. The experience of war first hand and being responsible for treating the aftermath of war had a major impact on me existentially. It changed my life in such a way that I certainly appreciate life more now. I guess that I appreciate each day a little bit more than I might have otherwise.

JSV: As members of the Board of Scientific & Professional Advisors of The American Academy of Experts in Traumatic Stress, are there any suggestions or concluding comments that you could offer to our members with regard to assisting survivors of traumatic stress?

GSE: Get training. I don't think you could be overtrained in this particular area. When human lives are at stake, it is important to continue your training no matter how well trained you think you are. I think you have to understand that there are different constituent groups. There's the general civilian population, there's the military, there's the emergency service personnel and there are certain religious communities. It's very important to understand the sociology and the culture of the people that you are trying to intervene with. Most people can go through an M.D. or Ph.D. program without getting a whole lot of training in crisis intervention. I think specific training in crisis intervention is essential before you go and do this work. Some understanding about the population that you're trying to help is also essential.

JTM: It has been my experience in traumatic work that the more practical we make the intervention tactics, the better it is. We just had an episode of that with our Foundation when people were asking for things to do to help survivors of the flooding in Mexico. We had sent them our sheets on what to do in a crisis event and we sent it to them in English. They asked permission to translate it into Spanish, which we gave them, and they ended up giving out nearly 50,000 of these sheets. So I think that providing information and making this information accessible to the citizen population is a great contribution.

JSV: I'm glad you brought that up Jeff. A while ago, the Academy implemented an Automated Fax Back System to facilitate the dissemination of information worldwide. In addition, the Academy maintains documents called Trauma Response® Infosheets. Their purpose is to provide survivors of traumatic events with valuable information to assist them in their recovery and provide professionals, across disciplines, with practical information to assist them in their work with survivors.

GSE: I'd add one last thing, too. I think, Joe, that it is important for organizations such as The American Academy of Experts in Traumatic Stress and the International Critical Incident Stress Foundation to find as many ways as possible to collaborate and work together. I think we can, together, be a very positive force in helping victims of crisis and disaster. Unfortunately, I see organizations that are out there competing and it's almost like they are competing for victims and the like. I think one thing that I've always been very impressed with about your organization is your willingness to collaborate toward a higher goal, if you will. And that's why I'm very proud to be associated with The Academy.

JSV: We're glad to have you both. I think that, in general, there's just too much work to be done. When we talk about the nature of trauma, we have to remember that no one discipline, specialty, or profession owns it. I would agree that together, we'll be more effective in our mission to assist survivors.

JTM: I just want to say that I'm really delighted to be part of the Board of Scientific & Professional Advisors of The American Academy of Experts in Traumatic Stress. I really appreciate the invitation and I think it's going to be exciting working together. I look forward to it.

JSV: Well, we're glad to have you, Jeff.

GSE: Joe, this has been an honor.