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:

Assessment of magnitude of trauma

Organization of intervention efforts

Mental health debriefing*

Clinical intervention strategies

Clinical intervention

Networking with all other support services

Communicating with management(if circumstances dictate)

Use of multiple intervention techniques

Follow-up programs

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.

* 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.

Two journals that deal primarily with are therapy are: Art Therapy: Journal of the American Art Therapy Association and The Arts in Psychotherapy.
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John G. Jones, Ph.D., ABBP, ATR-BC Indian Health Service Fort Peck Service Unit Wolf Point, MT Email: jjones@bilb2.billings.ihs.gov