The purpose of this paper is to share ideas and techniques employed in an effort to provide mental health intervention following a mass casualty disaster. The information presented in this paper comes primarily from work done with the survivors of the bombing of the federal office building in Oklahoma City, OK, on April 19, 1995. One hundred sixty-nine people died and over 500 were injured at 9:02 of that day. Each of these individuals had families, loved ones, friends, fishing buddies, and multiple acquaintances, and the ripples of trauma generated by this powerful blast were felt nation wide and around the world.

The efforts made to organize meaningful mental health intervention following a traumatic event of such a magnitude never before experienced in our nation will be presented. Organizational and clinical issues, general and specific techniques employed, impact on the survivors of a trauma of this magnitude and the compassion fatigue suffered by the caregivers will be addressed. General topics to be discussed include debriefings for survivors and their families, intervention with bureaucratic managers and coordination of services and networking with other agencies. Specific interventions, including individual therapy, group therapy, art therapy and traditional healing will be presented.
 

The first task facing me was organizing some type of intervention with the minimal support staff available. Our agency, the Indian Health Service, was called on for assistance in aiding the survivors and their families of the federal agencies involved. Those federal agencies appealing for assistance were the Social Security Administration (SSA) (16 of 64 workers killed), Housing and Urban Development (HUD) (35 of 120 workers killed) and General Service Administration (GSA) (multiple members with severe injuries). The Employee Assistance Personnel (EAP) individuals for these agencies, came to the scene, but quickly observed that the necessary skills and number of persons needed having those skills far exceeded what they were able to offer. We (IHS) were the only Federal Agency with clinical personnel readily available.

Meetings were held with the EAP persons to ascertain their assessment of the needs, what types of interventions were indicated, the numbers involved and the extent to which our agency was going to be able to do to meet these needs. The next step was to contact a representative (usually the administrator or acting administrator) of the three agencies to get their perspective. The primary need expressed by the agency representatives was for some guidance regarding what was going on with the survivors, their families and the families of the casualties, emotionally, and what to expect as time passed. Surprisingly, none of the personnel in these agencies had been given any type of debriefing, particularly regarding grief, loss, the impact of trauma, and what emotional reactions they might experience.

The IHS Area Director granted me permission to assemble a team of clinicians to be available for intervention purposes. Debriefing sessions were scheduled with each of the agencies, and in a two-day period, I conducted debriefings for over 120 personnel. All of the clinicians that were ultimately to work with the survivors were in attendance at each of the debriefings. Due to uniqueness and magnitude of this trauma, the debriefings were as much learning experiences for the clinicians as they were for the survivors. As we listened to the concerns, fears, questions and desires of the survivors and their family members, it became painfully aware that we were dealing with a magnitude of trauma and loss most of us had never faced in our careers. Sign-up sheets were made available at the end of the debriefing sessions for group, individual, and family and child therapy. Once the information was collected, assignments were made and the intervention proceeded. A total of six therapists were made available. Our child psychiatrist worked with individual children, three therapists worked with SSA, and I worked with HUD, SSA and GSA. I was actually given an office in the HUD’s new office space, and spent three days a week there. In addition, I conducted survivors’ groups in a church due to lack of facilities at HUD, and on site for on SSA and GSA, on a regular basis. The work with SSA and HUD continued for 6 months. Groups included survivors, families and children’s groups. While most of the survivors preferred group therapy, a few of them, including most of the administrators, preferred individual therapy.

The debriefings served the following purposes:
 

1. Allowed survivors and families to get acquainted with us
2. Allowed survivors to be familiarized with some of the dimensions of grief and traumatic loss they would likely experience
3. Provided opportunity for some ventilation of frustration, fear and anger
4. Gave us an idea of the type of intervention the survivors preferred and was indicated
5. Provided information to allow for planning and staffing
6. Gave us a clearer picture of the nature and magnitude of the trauma experienced by these individuals.

Several issues arose that were completely unexpected, unusual and unique to this situation. Some of these included: Issues of when the survivors should go back to work, what could actually be expected of them, from a productivity perspective, where the new office space would be, dealing with out of town supervisors, some of whom were more sympathetic than others, and coping with a total loss of work capacity and previous work environment, including the building.  Parking places, color of carpet and furniture in new spaces, and just who was going to do the work, were all unforeseen problem areas. In some instances, virtually everyone in some sections or departments was gone, so outside personnel had to be brought in before any type of work could begin. Each agency handled the situation differently. HUD chose a downtown site, with a dark parking lot, only a few blocks from the remains of the federal building. SSA moved to a mall away from the bombing site and GSA stayed where it was, a short distance from the wreckage. GSA personnel, due to the nature of their work never took any time off. HUD was out of the office for well over 2 months, and SSA went back to work in about one month.  Other things that varied were the expectations of management, either imported (in the case of HUD) or regional or national, in the case of GSA and SSA. Do to the unique nature of this disaster, no one knew nor could they predict, the functional capacity, emotional or cognitive, of these professional employees.

One of the issues that had to be dealt with immediately was the response to cues or "triggers", which were rampant. For instance, when mail started to come, correspondence addressed to the deceased workers was a constant reminder that they were no longer there. Immediately following the bombing, those survivors in the building, 95% of whom were injured, found themselves in total darkness and immersed in the thick smoke of the explosive, burning cars and multiple other fire sources.  Darkness and loud noises were major cues and often caused serious reactions. The parking lot that the HUD employees had to use was a dark, poorly lit place, and some of the employees could not bring themselves to get out of their cars once they parked. A few of them had to be escorted to there offices. It is hard for us to imagine what it would be like to lose our work site, completely, including desk, computers, personal belongings, files, everything that identified our jobs.

It is apparent from the incidents cited above that the survivors’ capacity to work was going to be greatly diminished for some time, thus the ensuing meetings with various management personnel. It was obviously much easier to get "closure" in Dallas, Atlanta, Denver or Washington, D.C., than it was in Oklahoma City. In fact, closure rapidly became a four-letter word among the survivors, and still is to this day. I met repeatedly with managerial personnel to advise them on the capacities (or lack of capacities) of the workers.  The survivors, after about three months, were capable of about 50% working capacity, but most of them had a difficult time spending an entire day at the office. Once again, each agency handled it differently. While HUD was off the longest, when the workers came back, they were expected to pretty well take up where they left off prior to the bombing, which they were not able to do, and this caused considerable frustration. The SSA had a more lenient outlook, and while they went to work more quickly after the bombing, they were not expected to function at full capacity and there was more leniency with regard to going home when the stress became intolerable. Incapacitation was experienced both in the emotional and cognitive realms.

The office building HUD moved into had to be completely renovated, complete with loud banging, dust and noises, all of which were serious cues and caused considerable fear and stress. A committee selected black and dark gray for a color scheme, in an already dark building. At this point the survivors rebelled and I was asked to intervene. Fortunately, there is good research available on what color schemes enhance both performance and a pleasant, calming atmosphere, so we were able to get the colors significantly modified. While these may seem trivial to the outside reader, they were major issues for the survivors. An important factor these examples demonstrate is the extreme hypersensitivity that developed in seconds and will last for a lifetime.

One of the keys to successful intervention is quality assessment. In the treatment of trauma victims, especially in the early stages, the situation is often fluid and time is of the essence. The critical issue in assessment, from my point of view, is a thorough understanding of the nature of the impact of the trauma on the individuals, groups and organizations.  The magnitude of the trauma must also be clearly understood, or at least as clear as we can determine. Some helpful guidelines by which to evaluate the dimensions of the traumatic experience, as well as formulate a needs assessment strategy are postulated by Williams & Sommer (1994). The information presented by Williams and Sommer is invaluable and is recommended as a "must read" for those doing this type of intervention.

The concept of magnitude and the understanding of it in the perspective of the nature of the disaster are central to making a quality assessment. In the case of the OKC bombing the magnitude was of immense, almost incomprehensible proportions. All of the dimensions of traumatic experience were present. The scope of the disaster directly, seriously and tragically impacted on every dimension of the survivors’ lives, to include physical, psychological, spiritual and social. This factor posed a major problem when trying to find a place to begin the intervention process.  Another dimension was the sheer number of people lost. It was not just one colleague; it was ¼ of the entire office staff, with the other ¾ being injured. For example, for the HUD survivors, there were 35 funerals to attend in a two week span. Many of the people went until in one of the survivor’s words, "I just couldn’t cry any more. I had no more emotions left in me". Guilt also accompanied the inability to go to any more funerals, so more demons with which to wrestle.  The clinical issue to be gleaned from the consideration of the magnitude of the trauma is that the more pervasive and intrusive the trauma is, the greater the emotional and physical impact on the person, therefore, the greater the need for broad-spectrum intervention. The emotional and cognitive issues will be considered at this point. With regard to emotional issues, most of the classic PTSD symptoms were readily apparent. The most apparent symptoms with this particular populations were: hypervigilence, hypersensitivity, lability, recurrent and intrusive recollections of the event, distressing dreams, intense psychological stress at exposure to internal and/or external cues, and physiological reaction on exposure to cues. There was an extensive amount of evasive behavior exhibited in an effort to avoid cues.

Darkness, loud noises, smoke, strangers and Ryder trucks were prevalent fear producing stimuli. Feelings were dulled, the future seemed almost non-existent, and loss of interest in usual activities was common. Many symptoms of depressions were also present, including sleep disturbance, appetite disturbance, and irritability. Grief responses were intense and prolonged. Tears were common place with virtually all survivors. Sometimes there was a cue that initiated the weeping, and sometimes it was spontaneous. There was a general feeling of just being lost and to a certain extent, confused. There was in intense amount of anger, fear and bitterness. The senselessness of the act was painfully confusing and unfathomable. The needless loss of life, the loss of friends, loved ones, family members, work place and the total disruption of their lives, was simply too much to comprehend or even try to make sense of.

The pervasive sense of meaninglessness of life and inertia was most disturbing to these people, the majority of whom were well-educated, highly motivated individuals with responsible positions. To not be able to even come close to performing at the level to which they were previously accustomed and, further, to not be able to muster up the energy or motivation to do so, soon became very disturbing to the survivors. Several of the survivors suffered significant levels of survivor guilt. Several of the employees were attending training at local colleges and universities, and they were deeply affected by not only the loss of colleagues and work site, but by guilt.

Suffice it to say, many of those who, had they been there, would have been killed or injured. In addition to the emotional trauma, 95% of the survivors who were in the building at the time of the blast were injured, many critically and had to deal with, in some cases, life threatening injuries, follow-up surgeries and in some cases, permanent disability. Many suffered multiple cuts, requiring sutures and often leaving scars. A vital to be aware of is the existence of a pre-existing mental health and/or substance abuse problem. In each of the cases that was dealt with during the course of intervention, the psychological problem and/or substance abuse problem was significantly exacerbated.

All but one of the individuals that I personally knew about who did not return to work or eventually took medical retirement, had pre-existing mental health or substance conditions. Stress related physical problems emerged over time, as did depression, anxiety and PTSD. Several of the survivors who were in the building suffered blast-effect-hearing loss, some to the point of having to have hearing aids. Not to belabor the obvious, but is clear (95% of building occupants killed or wounded) that both mental and physical healing were needed, and that presents an added dimension for the trauma mental health worker. After a few months, the emotional dimension of the grief and trauma subsided a bit.

Those who needed medication, primarily for depression, were on their medication and generally in some type of psychotherapeutic aftercare. When these individuals went back to work, they were in no way prepared for the cognitive deficits, particularly with memory, they would encounter. This was a major set back for them and there was no quick solution. Forgetfulness, pre-occupation, mild disorientation, inattention, distractibility, loss of focus, slowness in processing data, confusion and actual physical (motor) slowness were not uncommon.

These problem areas had a serious impact on initial job performance and productivity. For example, virtually all of the SSA and HUD personnel were proficient with the use of computers. I saw individuals sitting at their desks in tears because they had forgotten their password, could not remember access codes or what to do once they got into the computer. The emotional impact of the cognitive deficits became a focal point of treatment for many of the survivors. Educational information regarding trauma effects on memory, the nature of amnesia and other related educational materials helped to provide some understanding of what was going on, and to ease some of the survivors’ distress and feelings of ineptness.

The postbombing trauma came in stages. Following is a rough sequence of developmental events/stages needing to be dealt with, along a temporal dimension: 1. Massive loss (death, injury, work site) 2. Funerals and intense grief 3. Survival guilt 4. Attempt to return to work, and 5. Significant reduction in job performance. This staging process was a result of the assessment efforts and provided guidelines on how and where to begin with intervention.

As is often the case with the victims of severe trauma, words often fail them. There is so much emotionality that attempts to talk, explain, or otherwise deal with the event(s) verbally often end in lability and tears. Taking this into consideration, and after having a chance to interact with many of the survivors at our debriefing sessions, I chose to use expressive therapy techniques, particularly, art therapy, as the primary intervention modality.

Art Therapy is a widely recognized form of expressive therapy. Following are some of the reasons this particular therapeutic approach was incorporated:

1. Magnitude and multidimensionality of loss suffered by the victims required a multidimensional intervention approach.
2. The fact that most of the victims had talked and cried until they were spent, with little relief.
3. The flexibility and versatility of art therapy (use with individual, groups, adults, children, group projects, etc).
4. Art therapy is an expressive technique and is a multidimensional therapeutic approach.
5. Art therapy requires the patient to utilize his/her whole brain in the therapeutic process, by engaging the cognitive, affective, creative and perceptual capacities of the patient.
6. The therapeutic effects of art therapy are experienced immediately, due to the participation in and immediate processing of the directed task(s).
7. The nature art therapy is such that specific affective areas can be addressed meaningfully and effectively by creating specific experientials.
8. The "doing and sharing" process of art therapy promotes feelings of sharing, caring, togetherness, security and safety, all of which had been so, shattered by the bombing.
9. Art therapy can be done at home, i.e., journals, and gives the individual a therapeutic expressive modality any time they time they need it.

Art therapy is a way of expressing one’s self in a nonverbal format, initially, followed by processing the art product verbally. One of the key elements of doing experientials is that the finished product gives the person a sense of distance from the emotions expressed therein. This is an important element in working with trauma victims, for often without that distance, the trauma is too painful to address. The patient can now deal with the issue(s) at hand more easily because it is now out in the open. Two processes are at work in all art therapy tasks, the process of doing the work and the emotions experienced, as well as processing and verbalizing about the finished product.

This intervention strategy was proposed to the administrators of the various agencies, was well received, and funds for necessary art materials were made available. Multiple media were provided in an effort to give the individuals a wide range of choices, as well as provide for more flexibility in selecting experientials. Each person seen was given a set of colored pencils and a sketchpad for the purpose of beginning an individual, personal therapeutic journal. The individuals brought these journals to each session, and it was their option whether or not to share them with the group members. The survivors were seen in groups and individually. The groups were done on a weekly basis, sometimes twice weekly. Individuals were seen weekly or preventive maintenance (pm) basis as time allowed.

Several interesting issues arose, from a mental health standpoint, that had to be sensitively and judiciously addressed. The mental health bias came to fore and many of the individuals were fearful that they would be punished for attending group. They were fearful that they would be developing a "psychiatric record" and future supervisors might not be as understanding as those that were there and survived the experience. Further, there was a lot of distrust and suspiciousness and at this time in their lives, these individuals did not trust the system or anything else very much. Perhaps most importantly, after what these people had been through, to have them be considered as having "mental problems", along with everything else, added insult to injury.  At the time of the bombing, some agencies were down sizing and the employees were wary of anything that the agency might use to put he or she on the unemployment roles. Needless to say, this added another dimension of stress to an already high stressed population. Suffice to say there were certainly enough pressing therapeutic issues to choose from!

Specific art therapy intervention techniques included:
 

• Bridging Exercises

The bridging exercises included bridging from pre-trauma to present time, or a particular posttrauma time along a variety of variables. Bridging variables related to emotions, work site, relationships, etc. A typical instruction would be: "Construct a bridge depicting your sense of personal security from 9:00AM, April 19, 1995, to the present time. Elements to be included are: beginning point, nature of bridge, purpose of bridge, what is under the bridge, and end point of the bridge." If they did not do so in the course of the exercise, during the verbal processing, each person was asked to place himself or herself on that bridge. As the patients progressed, they appeared further across the bridge. The subject matter for the bridging exercises, as well as most of the art therapy exercises, came from the most pressing concerns voiced by the group members. The need for therapist flexibility was imperative.

• Feeling Maps

Instructions for the feeling map are as follow: "Use a different color to represent the following feelings: joy, fear, sadness, love of self, love of others, and anger. Let the strength and nature of the feeling inside you determine the size, shape and color of the expressed feeling. Please do not use stick figures or happy face characters to represent your feelings. Don’t worry about the size, shape etc., just let the feeling flow from within you." Both the feeling map and the bridging exercises were excellent serial measures of progress. The victim had a self produced visual pictorial of the difference (generally progressively positive) in feeling states, etc., from previous work.

• Anger Resolution

Each person was given a piece of butcher paper approximately 2’ wide and 4’ long. The instructions were as follow: "I want you to stand up and blacken that entire piece of paper. I want to you feel the anger flowing out of you onto that paper. Use as much force and energy as you can. See how black you can make the paper, if it tears, . Do not  worry, just keep working." The survivors were given a rest period following this, wherein they could process the experiential. The is a physically and emotionally exhausting task. After processing the first phase, each person was given a large erasure, and was asked to: "Take the erasure and create something positive in the sea of blackness that you have just created." This was a meaningful, healing experience for this group of people, with many metaphors and images of the bombing emerging. Some of the metaphors included: rising from the rubble, emerging from the darkness, healing in the midst of pain, a ray of light, of hope, and in an all-consuming sea of darkness.
 
• Self Image

 

 

The survivors were asked to produce self-portraits, in order to assess their self-image along a continuum of time and a variety of dimensions and/or roles. Examples of topics/roles included emotional, employee, spouse, friend, parent, etc. Instead of the usual two image experientials, the participants were asked to produce three: an image of themselves at 9:00, April 19, an image of themselves at 9:30. April 19 and a current self-image. This experiential also proved to be a good serial measure of progress.
 

• Loss and Grief Resolution

The magnitude of loss was so extensive in this disaster that it was difficult to know where to start. The issue was addressed by employing three different experientials. Initially, the survivors were asked to construct a memorial. In all of these experientials, little structure was provided, and a wide range of media materials was made available. The second experiential consisted of the survivors being asked to celebrate the lives of those who had been killed by portraying memories of them when they were living. The final dimension was to produce a portrait celebrating their own lives and that they had survived. These were extremely difficult tasks for these brave people to undertake. The last one, in particular, caused survival guilt to surface in some of the participants.

• Journeys

Multiple variations of the "Journey" experiential were used. These Journeys required the individuals to produce a graphic that depicted them traveling from a negative place to a positive place. Instructions included the requirement to portray barriers along the way, side-roads, and support and strength found along the way. In view of the magnitude of the traumatic event experienced. multiple journey topics were readily available. Some examples were: fear to safety, incompetence to competence, darkness to light and helplessness to strength/control.
 
• Situational Topics

 

 

     Within about a month, the patients grew in their confidence in the art therapy process and would suggest specific areas with which they were having a difficult time. There was no way, at least I knew of none, to predict all of the areas of one’s personal existence that would be disrupted, and to what degree, by this horrendous incident. As a result, the patients directly suggested many of the experiential topics and appropriate experientials were then selected to best address the issues.
 

• Review of Previous Art Work

       On a fairly routine basis, about once a month, serial experientials were reviewed with the patients. This turned out to be a revealing, as well as reassuring experience for them. The most graphic changes were in themes, colors and interactional levels. Themes gradually changes from hopeless and overwhelmed to positive and hopeful images Colors emerged from blacks, grays and deep reds to much lighter and pastel dominated hues. Images of loneliness, isolation and disconnectedness slowly evolved into images containing others, interactive themes and the ability to demonstrate reliance on others.

     In addition to the expressive therapy employed in this effort, more traditional "talk" therapy was
     also utilized. A considerable amount of the individual therapy was not expressive therapy. The
     primary goal here was to offer a supportive, non-judgmental atmosphere for the people to
     ventilate, grieve and attempt to deal with the multitude of issues haunting them. As time passed,
     problem solving, in terms of how to come to some sort of understanding, some type of partial
     peace and efforts to get their lives headed in some direction, became the major objective of therapy.
     This experience, at least for myself, reinforced the need for multidimensional therapeutic
     intervention.

     Other interventions and/or efforts and relationships that greatly assisted the survivors are worth
     mentioning. It should be understood that all the resources available should be employed. Mental
     health intervention alone is far from adequate. Friends, co-workers, families, churches, community
     support, employer sensitivity and support, extended families, relief agencies, neighbors, and just
     caring and sensitive people in general were invaluable. There were many Native Americans
     working in the building, many of them being employed by HUD. After exploring with them the
     possibility of doing some culturally appropriate healing ceremonies, it was determined that the
     opportunity to do a sweat lodge ceremony would be valuable. A sweat lodge experience was
     arranged with a local tribe and it was a powerful healing experience for these individuals, many of
     whom brought family members.

     In reviewing the intervention efforts and what factors enhanced or impeded the healing process, an
     important factor that significantly affected the recovery process emerged - acceptance. For several of
     the people with whom I worked, the survivor being alive ended the tragedy for the family. When
     Mom or Dad made it home safe, at least for some family members, their fear and trepidation were
     gone, but in many respects, was just starting for the survivors. Some spouses just could not
     understand why their mate just did not get over it, be glad they were alive and go on with life as
     usual. This was devastating to the survivors involved. One of their primary pillars of support
     simply was not there for them, and not only that, was often derogatory and insensitive to the
     enormous pain, sense of loss, guilt and sorrow the survivor was suffering. One of our smallest
     groups was a group for the spouses of survivors. Most spouses were sensitive and understanding,
     or were at least compassionately supportive of their mates. The intolerant spouses had no desire to
     change, feeling that their mate should "cowboy up" and quit moping around. This lack of spousal
     support and understanding was a critical factor in delayed and impeded the healing process.

STAGE IV:

IMPACT ON CARETAKERS

     The therapists from IHS would periodically get together and discuss how things were going, not
     only for the patients, but for themselves as well. Most of the therapists knew, directly or indirectly,
     someone who was affected directly or indirectly by this tragedy. I attended a small downtown
     church, about 10 blocks from the building. The church building suffered some damage, but by far
     the greatest tragedy was that two members of the church were killed in the building. This was a
     story repeated throughout the city and surrounding communities. The caretakers were absolutely
     overwhelmed by the magnitude of emotional pain and devastation suffered by this group. Feelings
     of helplessness, inadequacy, desperation and frustration were rampant. Where to start? How to do
     it? What tragic issue do you undertake first? How fragile are the patients? What if I can’t help them?
     The questions and challenges seem endless. The survivors’ needs were overpowering, and the
     cries for help, for relief from their enormous pain, seemed at times to be relentless and unending.
     To not identity with the survivors was virtually impossible. We too were members of the
     community; those were our fellow federal employees, church members, civic club members,
     parents, and friends. We, the community, the state and the nation, were aghast and appalled that
     such a hideous act of wanton terrorism, resulting in death, injury and devastation of our fellow
     citizens, could ever happen in our nation. To have it been perpetrated by our fellow citizens added
     even more consternation, confusion and disbelief.

     It became quickly apparent to my fellow therapists and I that for us to survive and be of any value
     to these wonderful, but devastated people, we really needed to get it together in a hurry. For the
     patients, the decision was made to deal with one issue, one debilitating feeling at a time, and at the
     same time, assisting in some self-healing strategies as we progressed. The art therapy experientials
     proved most helpful in this area. The finished products, the serial measures that indicated, in the
     patient’s own art, that progress was being made, were like rays of sun light, beacons of hope for
     the victims and a sense of achievement for the therapists. Facilitating the survivors’ capacities to
     deal with some of the massive posttraumatic aftermath proved to be invaluable for them as time
     went on. I participated in all art therapy experientials. This helped me to stay grounded and deal
     with the effects of the trauma that directly impacted my life. Deepening bonds with friends, a more
     profound appreciation for nature, life and relationships, and learning and gaining strength from the
     bravery of these courageous individuals were all sources of emotional support.

     While attending conferences, gaining insight from good training and participating educational
     programs is invaluable, I am not sure that one is ever prepared for such a tragedy. Share your
     experiences with others, learn from others’ successes and failures, but above all, be prepared for
     being overwhelmed, frightened and confused. Trust in your abilities, learn from the victims and,
     some how, as quickly as possibly, try to get some type of perspective on the trauma that will let
     you, in turn, work with others who are struggling and hurting. This is no easy feat, and there are not
     pat solutions. The better we are grounded in who and what we are and are about, and know the
     strength and availability of our own support systems, the easier we will be able to gain some
     perspective. Above all, do not be ashamed or hesitant to get help for yourself, after all, that is what
     we are encouraging the other survivors and victims to do!

     Another group of individuals who have had a difficult time and, now, after over four years, are
     starting to exhibit some serious posttraumatic symptoms are the rescue workers. Many of these
     courageous firemen, EMTs, police officers medical personnel and other first responders, who dug
     through the debris for over two weeks, recovering the remains of the victims, are having serious
     difficulties. Those involved in the recovering of the babies from the day care center, those who,
     early on the scene could only watch as some of the victims cried for help and slowly died, unable
     to do anything due to the massive weight and extent of debris, are have haunting memories and
     flashbacks. A recent article in an Oklahoma City newspaper (Oklahoma Gazette, January 19, 1999)
     indicated some alarming statistics among the rescuers. Increased divorce rate, increased alcohol use,
     increased retirements and/or resignations, increased domestic violence and a significant increase in
     posttraumatic symptomology have been documented. These individuals are entering the three to
     five year window, post trauma, which seems to be a critical period for rescue workers in incidents
     of this magnitude. Among those involved in the rescue and prosecution process, there have been 6
     suicides. The article in the Gazette further indicated that by the end of 1997, there had been 30
     successful suicide interventions of local firefighters and their families. There were approximately
     12,000 bombing rescue workers and over 2/3 of them reported handling body parts. Of the 50
     rescue dog handlers who participated in the recovery process, 7 of the first 10 who responded to
     the site of the bombing have since left the search and rescue service. In addition to rescue workers,
     others who have been caught in the seemingly endless ripples of the blast after math are law
     enforcement officials, FBI investigators, prosecutors and even reporters. These individuals found
     themselves inundated in the tales of horror and misery that stemmed from the bombing survivors
     and victims.

     Considerable effort has been made to make mental health assistance available. The Project
     Heartland center has counseled over 9600 since 1995. Another program, entitled the Critical Incident
     Workshop was founded to offer free assistance for people experiencing bombing-related stress.
     This program is headed by the wife of a man killed in the bombing, and recently received a grant
     from the U. S. Justice Department. In addition, the Oklahoma City Police and Fire Departments, as
     well as other law enforcement agencies have all made efforts to have appropriate assistance
     available for their personnel. The need for continued healing efforts is real. The magnitude of the
     trauma is accurately reflected in the breadth and depth of its impact. Hopefully it is clear that the
     entire community was deeply affected by this massive trauma, and the healing must indeed be for
     community wide and be a community effort.

STAGE V:
RE-TRAUMATIZATION

     Due to the nature of this particular tragedy, it has been in the public eye virtually since its occurrence
     nearly fours years ago. The press was merciless. There was virtually nothing else on television,
     radio, or in the newspapers. The agencies had designated spokespersons and that took some of the
     pressure off the survivors. Individuals were free to speak with the press, but few did. Rumors
     abounded and were printed. The rescue efforts took weeks, and no one gave up hope for the last
     missing person, until the body was found. The agony seemed eternal. Then the trials of the
     perpetrators began, and the horrors were relived, time and time again. Many of the survivors were
     called as witnesses in the trials held in Denver. Once again, the press was relentless in its pursuit of
     stories from the survivors. Often, those things that trigger posttraumatic responses can be avoided
     relatively well. However when the nations newspapers, radio, televisions and all other forms of
     media, are obsessed with it, escape is virtually impossible. Cues and triggers were, and still are,
     abundant. Re-traumatization is a critical factor with which the provider must deal. It can often undo
     in a moment what may have taken hours of therapy to achieve. If at all possible, early in the
     intervention, the patients should be made aware of the concept of cues, triggers, etc, in an attempt to
     prepare them, as best we can, for their responses. Also, some type of strategy for avoiding those
     particularly painful cues as much as possible should be developed. For the sake of survivors,
     victims, families, etc., somehow, an appeal to the media for some type of sensitivity must not go
     unheard. Our free press can be excruciatingly abusive and insensitive in its pursuit of headlines,
     by-lines and first in the breaking news. Hopefully, lessons can be learned by the entire community
     on how to facilitate healing and provide support to those innocents who survive.

 STAGE VI:

CONCLUSION

     As mentioned earlier in this paper, closure is a four-letter word, at least among the survivors I
     worked with in this particular tragedy. I concur. Perhaps the better term, and hopefully a more
     reasonable, attainable goal is perspective. The fact that this horrible bombing occurred will never go
     away, it happened. Those friends, loved ones, children, mothers, fathers and fellow workers lost
     are never coming back. That is the reality. Life goes on, however, and each of these individuals
     clearly understands that, and strives for some sort of normalcy daily. It has been a struggle, and will
     continue to be so. From several personal interviews recently with survivors, they estimate that most
     of them who have returned to work are working at about 85 to 90% capacity of their pre-bombing
     level of efficiency. They have learned, at least partially, to live with this, and it is not so painful or
     totally dominating as it was initially. They have learned a much deeper sense of appreciation for life
     and tend to try very hard to stop and smell the roses. Quality of life and the pursuit thereof have
     become far more important than quantity and materialistic elements. A significant amount of
     progress has been made but there is still work to be done. In this particular case, the search for
     perspective will go on, likely forever. That is not to say that these people cannot have, or do not
     have productive, meaningful lives. For many, because they have stopped and taken a hard look at
     what really matters in life, they have more meaningful lives than ever, with clear and rewarding
     priorities established. The specter of that bombing will always be a part of their lives. Perspective is
     the goal.

     The keys to intervention in major tragic events such as was experience in OKC are:

             1.Assessment of magnitude of trauma
             2.Organization of intervention efforts
             3.Mental health debriefing*
             4.Clinical intervention strategies
             5.Clinical intervention
             6.Networking with all other support services
             7.Communicating with management(if circumstances dictate)
             8.Use of multiple intervention techniques
             9.Follow-up programs
            10.Taking care of the care takers

     My sincerest hope is that you never have to employ the lessons shared with you  here. If you do, take care of yourself, get help, share ideas and engage all the support systems available, for your patients and yourself. It is at once the most challenging of times and the most rewarding of times. The good news is that the vast majority of these wonderful individuals want very much to get well, experience some healing and to resume their lives. They do make the best of patients, and that is our salvation: their motivation, the enormous effort they are willing to put forth and the results of such effort: change and progress.

Deep traumatic emotional wounds leave scars, much in the same way that physical wounds do. Somehow as a society and as a profession, we are willing to readily accept the physical scars and     rather rapidly move beyond them. Perhaps we should approach emotional wounds the same way,      i.e., do our best to help them heal, heal in such a way that they do not greatly interfere with life,  and then go beyond. We in mental health seem to have some abiding penchant for never accepting  an emotional scar as a part of life, as something that must be dealt with as well as possible, but that will always be there. Emotional scars, like physical scars do not have to dominate our lives, and we do have to learn to live with them. Perhaps our focus should be more on assisting the trauma victim in gaining perspective on the scar, accepting it as well as possible and moving on to deal with now and the future.


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     * It is my opinion that the intervention process should be a continuation of the debriefing with as
     little disruption as possible. In this particular model, those who either did the debriefing or were
     present and introduced at the debriefing did the intervention.  References

     Williams, M. & Summer, J. (1994) Handbook of post- traumatic stress. Westport, CT: Greenwood Press.
     Oklahoma Gazette, January 13, 1999, Vol. XXI, Number 2.

   Additional Suggested Readings

    Auerbach, S. M. & Spirito, A (1986). Children exposed to natural disasters. In S. M. Auerbach and A.
    L. Stolberg (Eds.) Crisis intervention in children and families (p. 197) Washington D. C.: Hemisphere
    Publishing.

Brett, E.A, & Ostroff, R. (1985). Imagery in PSTD: an overview. American journal of psychiatry, 142,
417-424.

Gillis, H.M. (1993). Individual and small group therapy for children involved in trauma and disasters. In C.F. Saylor (ed.) Children and disasters (pp 165-185) New York: Plenum Press.

Golub, D (1985). Symbolic expression in post-traumatic stress disorder: Vietnam combat veterans in
 art therapy. The arts in psychotherapy, 12, 285-296.

Herl, T.K. (1992). Find the light at the end of the funnel: working with child survivors of the
Andover tornado. Art therapy: journal of the american art therapy association, 9(1), 42-47.

Landgarten, H. (1981). Clinical art therapy: a comprehensive guide. New York: Bruinner/Mazel.

Malchidi, C. ((1990). Breaking the silence: art therapy with children from violent homes. New York:
Brunner/Mazel.

Menninger, W. (1957). Military psychiatry: learning from experience. Topeka, KS: The Menninger
Foundation.

Stronach-Bushel, B. (1991). Trauma, children and art. American journal of art therapy, 29, 48-52.

Tibbetts, T. (1989) .Characteristics of artwork in children with post-traumatic stress disorder in
     northern ireland. Art therapists: journal of the american art therapy association. 6(3) 92-98.

Williams, T. (1987) . Post-traumatic stress: a handbook for clinicians. Cincinnati, OH: Disabled
American Veterans.

Note: Two journals that deal primarily with are therapy are: Art Therapy: Journal of the American Art
     Therapy Association and The Arts in Psychotherapy.

     _________________________________________________________________________________________________________________________________________________________________________________
 
 

                                           John G. Jones, Ph.D., ABBP, ATR-BC
                                           Indian Health Service
                                           Fort Peck Service Unit
                                           Wolf Point, MT

                                           Email: jjones@bilb2.billings.ihs.gov
 
 
 
 
 
 
 

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John G. Jones, Ph.D. ABBP ATR-BC
Indian Health Service, Fort Peck Service Unit
Wolf Point, MT