your experience and your stress, who reflect your feelings, has proven to be valuable. this survivor group is run by a suicide hot line, the samaritans. [ann smolin] i find that groups are very useful for having people talk about what's bothering them, for feeling that they're not alone, not different, that they're not isolated in their kinds of feelings. one of the things they learn most is no matter how bad something feels, it's going to feel better, that other people have been there and other people have been able to go on, that they don't get stuck, that things do change. when people don't get back on track, when they show signs that stress is undermining their ability to function, and if this period lasts less than six months, psychologists say they have an adjustment disorder, but how do we know when someone's reaction

is normal and when it's an adjustment disorder? is the suicide survivor's grief normal or abnormal? does the widow of the policeman grve too long? what about that man getting divorced or that woman losing her job after 12 years? you feel yourself, when things aren't getting better for you, when you become dysfunctional, when your life becomes unmanageable, when things aren't going the way you want, when you've given yourself some time and you still feel, "i can't get back to work, "i can't get out of bed, nothing has any interest to me, my relationships are bland, and i don't want them," and one day you say, "this has gone on too long." or it might be that somebody else says it to you-- that, "ok, it's been "x" amount of time, "and you're still not up to speed at work,

or you're still not any fun to be with at home." then we would say this is abnormal. there is another clinical condition that is associated with stress. it's called post-traumatic stress disorder. [radio] 913, 914, we have a touch down-- extensive damage, people screaming for help. be advised, it just passed route 8. it's headed northeast towards 275. willseed and creek-- a house exploded. 46o, creek and blainsfield is a shambles. some events are so enormous, so life-threatening, that we would expect anyone to react to them with sizable stress. i called the insurance company. he said, "so sorry. everything's excluded. you have no coverage whatsoever," so here's over $1oo,ooo, and we're just about wiped out. i don't know what i'll do. sometimes reactions to natural or man-made disasters

go beyond temporary heightened stress. some people react with persistent anxiety, long-term nightmares, recurrent memories of the disaster, or, conversely, a numbing loss of any feelings at all. this is the syndrome of postraumatic stress disorder. dr. mardi horowitz is a psychiatrist at the university of california medical school at san francisco and an authority on post-traumatic stress disorder. post-traumatic stress disorder has three important elements-- one is that there has been a trauma, experience that's usually extraordinary for the person and shocking very frequently, often terrifying or having a death anxiety or a big terror event involved. and the second component is often some kind of intrusive experience, whether it's of a pang of very intense emotion,

a recurrent visual image repeating the perceptions. and the third component is often a kind of numbing or denial or omitting of memories that one would expect after such a serious life event. man-made disasters tend to create more victims of post-traumatic stress disorder than do natural ones. so it was that many veterans of the vietnam war showed signs of ptsd after returning. almost 16 months of my life was spent in a jungle. i'd seen a base camp only two months, and that was a wk here and a week there. the rest was living with bugs. now bugs bother me. loud noises--like my daughter screams, and that's it. i'm back, right back there again, because when you're into a flashback, you really don't have any feelings

except the thoughts in your mind. it's like a videocassette in your head, and yohave no "off" button until your mind says "off." your heart starts pumping. your blood starts running. it's just like if you're walking across the street and you don't see a car coming, and he slams on the brakes and you get that "shoo" feeling. then--zip--from there you're off and running. it always comes back, like sound, smell, taste even. uh, it always brings back a little flash. it only lasts about a second to five seconds. sometimes it lasts longer when a helicopter goes by. i figure myself sitting at the gunner turret on a helicopter and letting loose, and what my feelings were then was a complete fear. uh, mostly the fear comes over you.

for the smell of urine, you know. when somebody dies, they let go. that's a very--that's one thing that will set anybody off, and, uh, you just start, you know, huffing and puffing, and your mind and your blood and your heart starts pumping. your feet start shaking. you just have no control over your body. you have no control. i went through about 16 jobs. uh, i just felt lost. there was alienation, and i tended to isolate. i didn't deal well with relationships. i didn't deal well with people. uh, i didn't get along with my family. i was depressed. i had incredible anxiety attacks... and to this fire i fueled alcohol. when i left vietnam, people didn't want to hear about my experiences over there.

people just wanted to close the door on vietnam. well, i had a lot of heavy experiences inside my mind, and to bury it, i drank and i did drugs-- and to relieve the pain and the anguish and the anxiety i had building up inside me that no one wanted to know. at the uniformed services university of the health sciences in bethesda, maryland, dr. andy baum is studyg post-traumatic stress disorder in veterans. [dr. baum] we bring vietnam veterans and various control group subjects into our laboratory, and we ask them to watch a film which most people would consider stressful, but which combat veterans may find more stressful because it's a film of combat surgery. we measure their blood pressure and their heart rate

before, while, and after they view the film to see how reactive they are to that kind of stressful, relevant stimulus. plse work rapidly. we ask them questions about how they feel, whether they are experiencing symptoms of somatic problems-- headaches, backaches, pains-- whether they're depressed or anxious, and whether there are certain kinds of situations that seem to make them feel that way. i think the thing we're most interested in and the thing i most want to understand how these acute events become such long-term albatrosses for people and why it is, while most people can deal with these things, why it is some people have so many difficults. i believe the long-term stress responses cause changes in our body which are bad for us. i want to find o how to prevent those changes.

relaxation and oth standard ways of managing stress, i can't imagine working for 2o years. if we can find some way of changing how people think about these events or helping them to understand that if they hold on to thesevents, it won't be adaptive for them, maybe we can prevent the thing from happening. only some veterans develop post-traumatic stress disorder, though many continue to undergo heightened stress, and the baum study has revealed that the most important factor in determining whether they feel long-term stress isn't how much combat they experienced, but whether they have intrusive or uncontrollable thoughts. one of the things we think is going on there is this notion that people are reliving the experiences. what that does is re-create the experience for them. every time they experience that, they may be experiencing another of these biological reactions.

whenever i think about that, i'll experience stress, and i may experience all these biological changes again, and if i do that for the next 1o years, i'll find myself aroused a lot, and that's not necessarily good. veterans are not the only people to suffer post-traumatic stress disorder. dean kilpatrick is director of the crime victims research center in charleston, south carolina. among other matters, he's concerned with the experiences of rape victims, ma of whom suffer from post-traumatictrs disorder. um, there have beenseveral s of re in the generalpopulatn that indicatthat probably at least 13% of all adt women, perhaps as much as 25% of all adult wom, sotime during their lifetimes have experienced a re. basically, a person might have ofcurrent memori, about the bad events.

for example, you might have a re victim who finds herself constantly having memories that she can't get out of her mind, like someone who has a tune that they keep thinking over and over, and they don't want to think about it, but it keeps coming back-- very disturbing memories about the assault and its effect. my stomach was literally doing cartwheels. i mean, i could feel my stomach palpitating. um, hyperventilating-- i could not get my breath. my throat blistered like i had strep throat. the night after i was assaulted, going back into work thinking, you know, "life is going to go on, and this is not going to effect me." and i could remember a young lady who had been severely sexually abused by her mother's boyfriend, sitting in isolation with her, listening to her tell me her story,

and the whole time realizing i was totally decompensating. i stayed in the apartment i think about seven or eight months after i was raped, and then i couldn't take it anymore. i was scared to bthere by myself, and the fear-- it was very strange because the incident happened in the morning, but the fear came out at night. if i was doing whatever i had to do during the day, everything was fine. when i got home from work and i did activities you need to do, everything was cool, but once it was time to go to bed, it was like panic again. i guess everybody has this feeling that it's a terrible thing for it to happen, but you never think it will happen to you. i would go out in the streets any time of day or night.

i didn't have a car, and i lived in a small, inner-city neighborhood. this was my first apartment, and i was real active, riding my bicycle and going out and doing whatever i wanted to, and after i was raped, i didn't feel free to do that anymore. i felt very vulnerable. it's a self-shattering experience. so that, um, you're grappling to find-- pick up the pieces, you know, so you can put it all back together. you feel like a puzzle that's been strewn, and you have to look for pieces of yourself. you do tend to go underground to a degree, so i avoided relationships with men. um, i was very cautious in any relationship... with men, and i think that i became real nervous in certain social situations. i also tried to be, you know,

the good little girl-- you know, keep smiling, put up the front, pretend this didn't happen to you, and it will go away. i ignored it to the best of my ability, but that doesn't mean it wasn't taking its toll. what are the strategies for coping with major stress? one of the major successes in the c.o.p.s. program has been we've come out and told law-enforcement agencies that the macho image really has to go. for years, the officer's been trained to show no emotion. we're telling law-enforcement agencies now, those officers involved in traumatic incidents, involved in the incident where their friend was killed, have got to unwind. they've got to let their emotns show. they've got to be allowed to cry. one of the things that has been shown to be effective with a variety of types of disasters and crimes

and other stressful events is social support. by social support, we mean several things, one of which is your ability to get the types of emotional support that you need from family, friends, neighbors, that kind of thing. however, we also mean socl support in a real instrumental kind of sens- that if you have been in a disaster, let's say, and your house has been damaged, what you may nd more than mental health counseling is somebody to fix your roof, and u maneed someplace to stay, and you may need somebody to look after your kids. so those kinds of things-- i mean, meetg your basic needs for food, shelter, whatnot are very important, just as much as meeting your emotional needs. social support allows people undergoing stress to talk about their problems, and as we've pointed out, there's clear evidence

the right kind of talking helps. what happens is there's almost a compulse need to talk over and over and over again about the situation. i probably drove my family crazy talking about being notified, the trip to the hospital, all those events that surrounded that critical incident. and the trouble that most survivors have is they find nobody to talk to. everybody is telling them, "don't think about it. go on with your life and pretend didn't happen." it seems like a healing occurs every time you express this. but sometimes talking isn't helpful. it's when the story becomes simply repetitive, word-for-word over and over and over again, and hooks into the same emotion d nothing seems to be changing that you're stuck in a different kind of mechanism, which is this obsession. that's when you begin to wonder, why is this person stuck?

when people are stuck, psychotherapy is one often useful way of resolving feelings about stressful situations. first, you try to find out why this is not an easy matter for them. what has this stress related to in their past life, either in their childhood or more adult experiences? why is this particular thing giving them such a hard time at this point? and when you find out, you try to resolve the underlying kinds of issues. i don't talk about it at work, but if it comes up, i say what the cause of death was. as ann smolin said earlier in the program, self-help groups, where people share feelings with others in a similar situation, are also helpful. and, uh, it was very difficult, and i came here, and it was a great help to me.

i was able to cry and say what i wanted and listen to others and, uh, feel for the others. it was a complete shock, and i thought at that point and the weeks following that i would never be the same again, and fortunately i found support groups-- this one and one in brooklyn-- which has helped me tremendously. the connection is the support group. the people in the group are the ones i want to talk to because they know about it. nothing helps one as much to understand as to be understood. when you hear somebody else say the words you have felt, it tremendously gives you a sense that you are not alone. there is hope. someone else has gone through it.

some innovative therapies appear to help when obsessive thinking about stressful events gets in the way. one of these cognitive-behavioral techniques is called stress inoculation therapy. at the crime victims research center, dr. kilpatrick and dr. connie best use stress-inoculation therapy to help rape victims. in this scene, they demonstrate it with graduate students. what we found in working with crime victims and other trauma victims is they experience anxiety in each of three channels. it can be the physical, the cognitive, or their thought channel, and the behavioral channel. one thing that's true about that, too, is that one effect of crime is to really make people feel pretty helpless and powerless, and so that by giving them an array of coping tools to use,

what that does is, it gives them some control back over their own emotions and their own lives. i wanted practical steps. i wanted to know, where do i begin with addressing these reactions, the effects of this sault? um, i didn't have a whole lot of choice anymore because it was-- it affects every aspect of your life. to address the fear and anxiety they may be feeling physically, we do a couple of very basic techniques that we think that people find useful. the first one is actually teaching some deep-breathing exercises. i know some of you have taught deep breathing, so i'd like to do some. if you have a different way, we can talk about that. breathe in... and exhale. more. the rest. all of it.

the breathing exercises and relaxation exercises do work, and they are very practical and very empowering because it's saying, "i can get a grip. i can figure this out and handle this." another kind of exercise that we teach people to help address the physiological feelings is something called jacobsonian deep muscle relaxation. are you familiar with that? ok. basically, like, everybody, make a tight fist. keep the tension in it. hold it. you might even feel a slight tremor. hold it, feel tension, and quickly relax, and as you do, i want you to be very aware and have your patients be aware of the difference between tension and relaxation. the next thing we'll turn to that's probably the meat and potatoes of the stress-inoculation is guided self-dialogue. it very painful to have every wild thought you never wanted to hear circulating around in your head,

especially when you're trying to go to sleep. the mind chatter can drive you crazy, and you have to exchange mind chatter for self-talk. first of all, we'll tell people that usually when they think of a future event, they feel overwhelmed. imagine being a crime victim going to court. what we try to say is, one thing that is effective with an incoming stressor is to break it down into pieces and parts. if you can work on parts, they don't feel as overwhelmed. can they develop-- and you may have to help them-- some guided self-dialogue to get them through that? an example would be, "well, you know, it's going to be pretty scary, "but i have three or four days. "i can practice what i'm going to say. "if i start feeling nervous, "i've learned a lot during therapy.

"i know some relaxation techniques, "um, and i can start working now with three days notice to prepare for it." the important thing about this is that we're trying to get them to analyze what they say to themselves before, teach them more positive self-statements about preparing for the stressor, experiencing the stressor, and getting overwhelmed. the spectrum of stress is broad, and so are the ways we handle it. though everyone needs some outlet for pain and grief, luckily, not everyone requires psychotherapy. in fact, most of us go through life with many stressful periods which we manage to handle, partly because stress can also be positive, helpg us avoid danger or goading us into fruitful activity, and in part because we hav our own techniqu for handling mild daily stressful situations-- we complain, we make jokes, we put things in perspective,

or we take time off from exposure to stressors. there are also assets that people have. assets is the best way to say "friends." people with many frids tend to be more resistant, as do people whose experiences have taught them how to cope. even when we are confronted with major painful situations, we often find we can get control over stress. we have resources to cope. in a disaster situation, the vast majority of people are actually wonderful about their ability to cope with the event, in the immediate situation, especially. people are really super. they're courageous. they help each other. they are resourceful. they come up with adaptive solutions. they rarely panic as long as they're not trapped and as long as they don't have a failure of someone seen as a leader. people who adapt the best in the long run

are people who have learned that they're competent, who have an abiding sense of values, and who have commitments to other people that sustain them in moments of sorrow and grief and rage. i guess, kind of a take-home point with me is that one of the things that is important to recover from any type of traumatic event is some sense it had meaning and there's something i can do. i can't change the past, but i can change the future. ve observed that there comes a point for many people when you can make choice. you can say, "there's somethg else i can do." it can be as simple as going for a walk, calling a friend, doing something, and there's a choice point that says, "ok. either i'll relive this experience again, or i'll take active steps to not relive the experience."

when you recognize that you're choosing, then you have the opportunity to do something different about it. a year and a half down the road is when i went to my second c.o.p.s. seminar. i could recognize the new ones by the look in their eyes. the survivors who are new have dead eyes, like shark eyes. there's no depth and no life, and i knew i still looked like that. i knew i had choices to make. i could choose to let the anger destroy me, or i could conquer it and strike some blows as far as changing attitudes. so it was a conscious choice for me, and i can look back and see the girls and i have made it. we weren't happy about it, but it feels good to turn a negative experience into a positive action, and we'll keep making it.

[horns honking] [jackhammer] [siren] captioning performed by the national captioning stit inc. captions copyright 1991 alvin h. perlmter

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