Tissues and Tears

John D. Weaver, LCSW

Helping professionals and volunteers who provide immediate psychological first aid (PFA) and ongoing emotional support to traumatized persons in the wake of natural disasters, transportation accidents, abuse/crime victimization, acts of terrorism, etc., face an invisible danger – secondary traumatic stress (STS) reactions - which are a normal response for many professional caregivers. Symptoms may include anxiety, grief, anger flashbacks, disturbances in eating, and difficulty sleeping. Repeated exposure to STS, or even a single, intense exposure, can be quite toxic. Our level of exposure to STS needs to be monitored and addressed. Fortunately, it generally responds well to PFA and support, especially from peer colleagues. We each need to recognize our exposure to this kind of toxic stress and to do so we must heed the one key indicator - tissues and tears.

My 40+ year career as a clinical social worker has been spent working in various community mental health settings, primarily providing traditional assessment and treatment services to consumers of all ages with all range of diagnoses. I’m a bit of a crisis junkie, so my passion during that time has been offering crisis intervention services, which I often did overnights and weekends to earn extra money. I entered the community mental health field when pagers were relatively new. I found I liked wearing a pager, volunteering for overnight and weekend emergency team shifts, and responding to all sorts of mental health crises. Many of my peers loved diagnosing and treating persons with serious mental health issues during regular business hours but hated handling crises, being on-call and responding to homes, emergency rooms, etc. Some peers even lost their appetites and couldn't sleep if they ever had to cover crisis shifts. 

I liked the spontaneity and the need to sometimes fly by the seat of my pants. It was a break from routine and I tend to be calm in crisis. The fact that things seemed out of control around me did not frighten me. Rather, it brought out the adrenaline rush that focused me in a zone of problem solving skills one seldom taps in routine practice. Until the crash of a light plane, all of my crisis work was the typical stuff one sees in mental health facilities, including suicidal thoughts, threats, and/or attempts, acting out behaviors and aggression toward others, self mutilation, family conflict, child abuse, and domestic violence.

Then, one beautiful summer afternoon, I responded to a crisis call to support a family and a fire department after a small plane crashed in a residential neighborhood, killing two young adults. This experience was different – dealing with sudden grief and loss and providing psychological first aid rather than the usual counseling to ease tension, interrupt family conflict, stop someone from harming self or others, and/or arrange voluntary or involuntary treatment. As stressful as routine crisis work was for many of my coworkers, whom I had invited to join me in this intervention, this experience was very different. Seeing healthy young people die on a beautiful summer afternoon and suddenly facing their own mortality may have been the difference, but several of my colleagues told me afterwards not to ever call them again for incidents like that one.

Okay, that surprised me at the time. I was just learning that crisis intervention following disasters - with the graphic nature of the scene, the intense sights, sounds, and smells, and the sudden loss of life - creates a dramatically new and challenging layer of stress on the helpers. Events like this can break through our health defenses and leave us feeling exposed and vulnerable. I was simply more comfortable with this sudden and intense grief work than many of my peers.

A few years later the American Red Cross was recruiting mental health professionals to volunteer in support of military families who might lose loved ones in the first Gulf War and I signed up. That volunteer role has since shifted into supporting disaster victims and, in many cases, families who lose loved ones in mass-casualty incidents like airline accidents and acts of terrorism.

Generally, my pattern has been to “keep a stiff upper lip” during my disaster assignments and then have a good cleansing cry at the end. That alone is saying something because males of my age in my culture were raised with a message that we were not supposed to cry and therapists are trained to maintain strong boundaries. But, knowing that women tend to cry more freely than men and also tend to live longer than men, I’m comfortable with my habit of having a good cleansing cry when needed.

Following the 9/11/01 crash of United Flight 93 here in Pennsylvania, I served as the Disaster Mental Health (DMH) Coordinator for the Family Assistance Center. Over the course of 12 days, we supported site visits and memorial services for about 500 family members of the crash victims. Afterwards, my cleansing cry lasted all the way home (a five hour drive) and it also didn’t end there. For the next several days, I found myself having random acts of crying when I heard certain songs, saw news coverage, recalled a memory, etc. They were short – just a few silent tears – but this response (classic secondary trauma), was different. In catastrophic situations like this one, even people with strong emotional toughness experience increased feelings of raw nerves, tiredness, and vulnerability.

I had a two-week break (back doing my regular paying job) and then served two weeks as a DMH volunteer in NY City, supporting the Red Cross World Trade Center operation. During the break, I basically tried to limit my exposure to news and features about the personal stories of victims and survivors. While serving in NY I was primarily in an administrative role. That allowed me to further limit my direct exposure to victims’ and survivors’ stories and the risk of additional STS. I might not have done that and might have overexposed myself, had I not taken note of the tears and the tissues lesson from previous experiences.

Once it was all over, I allowed myself time alone - time to reflect on the experience and process the strong emotional reactions. One of the ways I did that was to read a book of vignettes about helping people remember and honor lost loved ones (Sarah York's Remembering Well...).  I'd received it from the publisher, who gifted copies to helpers who served in NY. I would read it in small doses - read a chapter, put it down, cry, and then did something else. The next day I would do it again, kind of like cleaning out a wound so that it might heal properly. I also wrote about my experience. Writing serves as a form of self debriefing for me and it often yields practical and publishable material I can share with other helpers.

Serving in a support role for people who have lost loved ones is more like attending viewings and funerals than it is to traditional counseling sessions. Consequently, the helpers may sometimes silently tear up as they perform their support roles. That is fine as long as the helper response is not so strong as require others to stop and support you. Know your baseline responses and heed the messages tears and tissues may be sending you. There is a time to help but there is also a time to take a step back and let others take this one. And, there is a time to call on your colleagues for peer support. Save yourself for the long haul; there are always more disasters and opportunities to serve.

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This article was written to help promote the Caregivers film and portions of it have been published in theguardian.com as:

 Gulf war to 9/11: how social work takes me to disaster zones