Will stress-related disorders be the 9/11 aftershocks?
By Dennis Pillsbury
For many of us who lived through the '60s, the concept of surrealism becoming reality is not necessarily a foreign one. For some, these reality shifts were chemically induced. For many others, reality shifts came about from dramatic societal changes within our country. Almost overnight, the dream world of the '50s, where prosperity reigned and was seemingly endless, collided with the nightmare of body bags returning from a small Asian country about which very few of us knew anything. The shock was nearly overwhelming. We became a nation divided. We faced catastrophic disappointment: America wasn't as perfect as we'd been taught by both parents and teachers.
The floodgates of stress opened. We saw Americans dying, Americans involved in all types of actions that many found dubious. The aftershocks were enormous: Families were divided, one president chose not to run for reelection, a civil rights leader and a presidential candidate were assassinated, another president resigned and the first-ever, non-elected president took over.
And many who had followed the advice to "drop out" never quite managed to drop back in. Posttraumatic stress disorder (PTSD) became a common phrase.
Today, America once again feels aftershocks and we are hearing about PTSD affecting the general public. The terrorist attacks on the World Trade Center and the Pentagon not only killed thousands of people and damaged or destroyed buildings that were viewed as icons, but they also undermined a belief that, despite what was happening in the rest of the world, we were safe and secure.
Unlike the slow and gradual changes of the '60s, about which we were forewarned by civil rights actions that exposed the weak underbelly of the '50s society, this change was thrust upon us in one horrific day. Admittedly, we had warnings. American lives overseas had been lost to terrorist attacks. An earlier attempt to blow up the WTC had been made. But we continued to believe that our homeland was safe.
Before September 11, did we ever imagine that we would go to an airport in the United States and see armed security? And does it really make us feel any safer when we reflect on the fact that, as Newt Gingrich observed at a recent Professional Liability Underwriting Society meeting, these civil servants are from the same group that overreacted at Kent State?
Did we ever imagine that we would be talking about PTSD as a possible workers compensation problem? Did we ever think that counselors who got their feet wet helping soldiers deal with their experiences in Viet Nam or Iraq or Bosnia would be brought in to help American workers?
"It was the best of times, it was the worst of times."
--Charles Dickens
When Dickens opened his novel A Tale of Two Cities with the above, he was writing about another catastrophic event in history--the French Revolution. And like most tragedies in human history, it brought out both the best and worst in people--as has the WTC tragedy.
The worst was graphically displayed for all to see, over and over again, on every television station in the nation on September 11. The best followed soon after as New York City firefighters and police officers ignored their own safety and went into the rubble looking for survivors--in some cases, paying for their heroism with their lives. We heard about the heroes on one flight who apparently fought back against their hijackers so their plane crashed into a field in Pennsylvania rather than reaching its intended target.
And then there are the everyday heroes who carry on, despite the occasional, nearly overwhelming desire to just lie down and cry and not get up again. Those who, despite the constant bombardment from the media, continue to do their jobs and refuse to let the terrorists win through disruption.
We also saw the insurance industry and its policyholders at their best. As David Gibbs, president and CEO of Travelers Claims Services, noted at the National Workers Compensation and Disability Conference in November: "Out of the smoke and rubble have come more than valuable lessons. We saw (a) new model in action.
"Teamwork, empowerment, and sensitivity to employees' emotional as well as physical needs have been the new priorities all across the board." Speaking at the LRP-sponsored event in Chicago, Gibbs continued that a great deal was accomplished in a very short period of time "by focusing on the individual--by jumping over traditional boundaries and by applying technology to enable people on the scene to make decisions and take action promptly."
He pointed out that well over 18,000 claims were involved. "Some claims for stress and anxiety disorders that would have been disputed prior to September 11 were processed immediately--without hair splitting. Procedures were streamlined, making the system easier to use. Companies were concerned about people first, and payout later."
Gibbs said, "The attack on September 11 marked a genuine watershed in the relationship between insurance customers, insurance companies, brokers, agents, government officials and health care providers.
"Customers who before would have been busy micro-managing their insurance providers--issuing instructions, checking adjuster notes and pulling nurses off of claim files--instead began asking those with the right knowledge and expertise for solutions, and treating their insurance and service providers more as business partners than as vendors."
At "Ground Zero"
The emphasis on teamwork among all disciplines was displayed at "Ground Zero" as insurance industry catastrophe specialists tried to get to the site. "The City of New York was unbelievably helpful," says Ray Stone, vice president-catastrophe operations, Travelers Insurance. Travelers had a cat van in Hartford that made the trip to Manhattan and was there on the evening of the 11th and to lower Manhattan by the morning of the 12th. Catastrophe specialists drove to the site from as far away as Florida and Chicago.
"This was really quite different from any other catastrophe," Stone continues, pointing out that "I've participated in every catastrophe since Hurricane Andrew. The logistical challenges were extraordinary because of the disruption in air travel and the fact that this was a crime scene. The City of New York helped us solve logistical problems and find appropriate locations for the vans. We were completely operational by the 12th."
In addition to bringing claims personnel and crisis counselors to the scene, the vans also brought fully automated systems to handle claims processing and check issuance on the spot.
When the vans reached the location, "it really was surreal," says Stone. "Four blocks away was a smoking pile of rubble. We only saw rescue workers and emergency vehicles and people walking north with their belongings."
Claims people faced tenants and homeowners who needed additional living expense payments to cover hotel costs. "There was a need for emergency advance payments to cover these costs," Stone says. "But almost more important was that our claims people were listening. For the first month or so, everyone who came in had a story that they needed to tell someone. Some of those stories were really devastating and emotional and had a strong impact on our claims people."
He continues that the crisis care counselors "did training for all of our claims people so they could learn to recognize stress and help people deal with it. The job turned out to be much more than processing claims and writing checks."
Overwhelming response
"Every claims person at 'Ground Zero' was a volunteer," Stone says. "We asked people if they felt it would be too much and nobody wanted out. And we continued to monitor the situation as what seemed to be a never-ending stream of claimants kept coming in with their stories. We regularly asked our people if they needed to get away from it for a while and nobody did. People wanted to help. No one really crumbled. At times, we even had to make people take a break. And these are people who work 28 days on and seven off. They were putting in 14 to 16 hours a day."
However, as Stone points out, this is not over by any means. "These claims have a long tail. They are ongoing. Many of these people will never be able to return to their residence or place of employment."
Because of the long-term nature of these claims, the catastrophe people have moved into apartments in the area.
"This event really has brought out the best in people," Stone concludes. "Consider the fact that, according to the last figures I heard, the insurance department had received only nine complaints. Fraud has been virtually nonexistent, and that's not because we're ignoring the possibility. Our people are trained to detect possible fraudulent behavior and have the databases in the cat van to help them with that. There just hasn't been any fraud. There also have been far fewer stress claims than we anticipated. That all speaks volumes about the insurance industry and the claimants."
Is stress a hidden danger?
The fact that there have been very few stress claims does not necessarily mean that there are not people feeling stress. More likely, it means that these people are keeping a "stiff upper lip" a la the British during the Blitz. However, stress, whether reported as a claim or not, still can manifest itself in physical ways and it is important to recognize the signs of possible PTSD so that serious physical or emotional problems don't emerge.
To do that, it would probably help to look at stress and what it does. As we're all well aware, stress happens on a regular basis. And, as long as it is short-lived, it is not a problem. Here's what happens:
"When experiencing stress, human beings experience what is known as the 'fight or flight' response," Richard Pimentel, senior partner with Milt Wright & Associates, Inc., Chatsworth, California, told attendees at the workers comp conference. "In the first alarm stage, the adrenal glands release hormones that prepare and stimulate the body for action. The heartbeat accelerates, glucose is supplied to provide energy, and blood flow is redirected to the working muscles."
He likened the initial feeling to "the exhilarating feeling we get when we ride a roller coaster." However, what happens if the roller coaster ride lasts indefinitely and you've lost control of the situation? As Pimentel explains, "when the stress does not resolve and the employee feels that there is no solution in sight, serious problems can occur. Heightened and prolonged levels of the hormones and other biochemical changes associated with stress can lead to: exhaustion, insomnia, depression, anxiety, headaches, high blood pressure, weakened immune systems, back pain, and increased risk of heart attack.
"As you can see, stress is more than an attitude. The results of prolonged stress are just as physically real as a broken leg."
Pimentel goes on to explain that good stress might be termed a "challenge." The difference between a healthy "challenge" and "unhealthy stress," he suggests, "is the reality or the perception of the person being able to control or positively affect the outcome." He then notes that "what makes terrorism so terrifying is not just the threat of loss of life, injury, or illness, but also the common belief that there is nothing we can do to alleviate or reduce these risks." Then, piled on top of that feeling of loss of control is the constant reminder by the media that the threat is still there and may now include smallpox or "dirty" nuclear bombs or any of a host of weapons about which the news media seem to enjoy speculating. And just what the heck are we supposed to do every time we're placed on heightened alert?
Early intervention
Early intervention is one of the keys to dealing successfully with acute stress disorder from which many were suffering after September 11. "If it lingers on for more than 30 days, it can emerge as PTSD and that's far more difficult to treat," says Bob VandePol, director of account relations, Crisis Care Network. The Crisis Care Network has a long relationship with Travelers and has been used to handle a variety of workplace tragedies. "Immediate trauma response allows people to get better better and quicker," VandePol says. "On September 11, we met with 72 employee groups; we met with 106 on the 12th, and it continued at that pace for about a month.
"Our first call came from an HR director for a company located near the Trade Center. Her people needed help dealing with the tragedy, as did she. She and her husband traveled to work together on the train until they reached downtown Manhattan. From there he walked to his office in the World Trade Center and she walked two blocks in the other direction to her office. They could see each other's offices from their workplace. She had just been on the phone with him. The conversation went--'Hi, honey. How ya doing? Oh my God!'--and then a plane hit the Trade Center right near his floor." And that was the first of many calls for help.
VandePol, who has a master's in social work and advanced training in trauma response, says his firm uses a technique called critical incident stress management (CISM). It was first developed for use with firefighters, law enforcement and emergency room personnel--individuals in high stress jobs--and proved efficacious. It now has become the standard of care for business and industry.
CISM is "very effective at mitigating the trauma," VandePol continues. "There is a very predictable set of symptoms associated with acute stress disorder and our job as debriefers is to provide this structured intervention. There are seven steps involved in CISM (see box on page 105); but before you even begin the process, you first need to make certain that you are dealing with a group of similarly affected individuals. That's very important. You don't want some of the people in the group to be further traumatized by the experiences of others."
The long term
The real question facing America now is whether September 11 will have a significant long-term effect that will result in increased numbers of PTSD cases and stress-related health problems. "Clearly, every American has experienced a sense of loss and increased vulnerability," notes Mark Raderstorf, president of Behavioral Management, Inc., Minneapolis. This has been exacerbated by news that continues to "renew the public's anxiety and fear."
As noted above, PTSD with its far greater health risks, results from stress that continues for a period of 30 days or more. And there are those who are concerned that large numbers of PTSD cases may be the "aftershock" of the 9/11 tragedy.
"PTSD is an anxiety disorder that often ruins relationships, affects occupational functioning and, in more extreme cases, leads to thoughts of death or completing a suicide," according to Raderstorf, who is a licensed psychologist. Although PTSD is a relatively rare occurrence because it does require that an individual "witness or be a victim of an event that seriously threatens their physical well-being or livelihood and which also is outside the normal experience," Raderstorf continues, the events of September 11 "left an unusual number of Americans susceptible to PTSD."
The National Center of PTSD has identified nine risk factors that increase the chances for development of PTSD symptoms:
* Female
* Age 40 to 60
* Poor coping skills
* Poverty or low income status
* Presence of children in the home
* For women, presence of a spouse, especially if he is significantly distressed
* Living in a disrupted or traumatized community
* Secondary stress
* Loss of resources.
"In addition to these risk factors," Raderstorf says, "other factors affect how individuals respond to trauma. Some individuals have a higher capacity to tolerate trauma while others seem to have a lower psychological immunity to these events."
The key is to recognize the symptoms of stress both in yourself and in others and to react quickly to alleviate those symptoms. As with acute stress, "there are treatments available that greatly reduce the symptoms common with PTSD," Raderstorf points out, including medication management for sleep disorders and/or depression. "Most individuals will return to full function in a period of weeks with the appropriate medications to alleviate their symptoms. However, if an individual does not experience significant improvement of symptoms after two or three months, a referral to a psychiatrist is appropriate."
He adds: "Some individuals with PTSD may require hospitalization. Hospitalization usually occurs when an individual experiences significant changes in basic areas of functioning such as sleep, eating, energy, poor concentration, or suicide thoughts. Individuals with these types of impairments are at risk for work-related injuries, strained relations with family and/or coworkers and a significant decline in productivity. Hospital stays," Raderstorf says, "are typically three to five days and symptom-focused in the absence of other mental health factors that affect progress."
The events of September 11 have made all of us combatants and ask all of us to be heroes. That is stressful indeed. But we do have an important role to play. As Pimentel noted in his address: "We are the home front. Our economy and those ideals we hold as important are now what we must defend. We defend them with our performance and dedication to rebuilding the American economy and way of life. ...
"Terrorists cannot defeat or destroy our country militarily," he concluded, "so they hope to trick us into destroying ourselves using our own fear as a weapon. Fear will not protect us; it will only paralyze us into accepting defeat. Ignoring risk will not protect us; it will only make us vulnerable to further attack. We must replace fear with caution. Caution is fear tempered with knowledge. Courage is not the absence of fear, but action in the face of fear. The action that we ... must take is informed action--action that leads us to a necessary and obtainable goal. That goal is a marketplace not driven by the whims and threats of our enemies, but by the courage, hard work and dreams of our people." *
Bob VandePol, director of account relations, Crisis Care Network, lists the following phases in the debriefing process.
1. Introduction phase: Create safety by providing the group with the guidelines for the session. Participants are already feeling a loss of control, so let them know what will and will not be happening.
2. Fact phase: Go around the circle and have them all give their names and tell you what they saw and heard. This helps them step outside of the incident and re-engage the logical portions of their brain function. "We find that each person has just a snippet of the whole. It's usually the gaps in the story that wake you up at three in the morning."
3. Thought phase: "We ask for volunteers to share what was their first thought. That usually produces the most important thought or most troubling thought about the incident for them and gives them a chance to move to the next phase. Thoughts are safer to share than feelings."
4. Reaction phase: "This is where we ask them what the worst part of the tragedy was and what would be the one part they would erase if they could. Often the most emotionally intense portion of the debriefing, the reaction phase offers people opportunity to share images and feelings they likely can share nowhere else."
5. Symptom phase: Follows logically as "we move from what affected them to what's been their reaction to it." Symptoms include inability to sleep or to eat, fear to get on an elevator, an inability to concentrate, and so on. "We try to normalize the symptoms for them and let them hear that the others in the group are experiencing the same things. They need to understand these are normal reactions to an abnormal event; otherwise, the symptoms themselves can cause anxiety and exacerbate the problem." For example, the inability to concentrate can stem from the normal reaction to stress, which is to be on heightened awareness. "You're ready to fight or run. Your peripheral vision is better. You're hyper-vigilant, which means you probably jump at the slightest sound. And, of course, the frontal lobe of your brain isn't being used and that's the part you need for concentrated logical thought processes. All those 'symptoms' are useful if you're in the middle of a war in Afghanistan, but they can really inhibit you in an office job."
6. Teaching phase: "Once we've normalized the symptoms, we then provide them with concrete tips they can use to get back to some type of normalcy. These include all those things your grandmother told you: eat healthy, get plenty of exercise and rest. We tell them to do whatever they can to get a good night's sleep. Exercise is important because it stimulates the release of endorphins and helps to sweat out the poisons. Selectively seek out support from other people--use caller ID to avoid those people who only add to the anxiety. Go back to work, but don't expect that you'll be at full capacity or that the people who work for you will either. After incidents of workplace violence, productivity can be down as much as 80% for the next two weeks. And this was a gargantuan case of workplace violence.
"Take on tasks at which you can succeed and, if you're a manager, assign people tasks at which they can succeed. Consistent with systems theory, all these things create ripples like the pebble tossed into the pond, i.e., when you go back to work, that helps your spouse and your kids because they don't have to worry about when you're going to go back to work. Their anxiety lessens and that helps the people around them. It was immensely helpful when President Bush and Mayor Guiliani urged people to get back to work. The structure, focus, normalcy, and exposure to similarly affected peers was likely instrumental in reducing the number of stress claims."
7. Re-entry phase: "Focusing on individuals, we work with each person on concrete steps they can take to overcome individual obstacles in their own return-to-work and return-to-life plans. For example, if a person has to travel on an airplane for work, we'll help her or him get over the anxiety. If you get bucked off a horse, at least get back on a pony, so to speak."