MENTAL HEALTH MOMENT

             MENTAL HEALTH MOMENT
              November 10, 2000


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                 SURVIVOR GUILT

Existential survivor guilt was first identified by Cobb
and Linderman (1947)in their study of survivors of the
Coconut Grove fire in New York in 1942. Such guilt is
characterized by the survivor's confusion over his or
her having lived and the meaning of this survival:
"Why did I live when other people died?" With war
veterans and holocaust victims, we sometimes see
variations on this theme: the survivor wished to change
places with the person who died, and the guilt is 
expressed as "I should have died, and they should
have lived." Often, their own lives have been chaotic
since the stressor. They feel that the person who died
would have had a better life and more to live for. War
veterans frequently say that the ones who were killed
in war were the lucky ones. Their pain and suffering
are over and their names are on a monument. After
hearing about the trauma in an interview, the question
can be asked "How come you lived through that?" Quite
often the response is "I don't know. I ask myself that
question all the time." or "Perhaps there is some purpose
for my life after facing the probabilities of my own
death."

Content guilt, as contrasted with existential survival
guilt, is a result of a person's having done something
to ensure his or her survival. This might have been to
avoid responding to others in need, to have made a
decision that resulted in other's deaths, or to have
sought refuge for oneself when others remained threatened
or suffering. This is a much easier form of survivor 
guilt to treat because the avoidant nature of this form
implies a conscious effort to survive or operate 
effectively in the traumatic environment.

Because survivor guilt has both emotional and intellectual
components, a major treatment goal is to separate out
the affective and cognitive elements. The survivor must
learn that it is okay to feel sad about someone's
having died in a traumatic situation, but it is not
rational or appropriate to feel total responsibility
for that person's death. A war veteran or disaster
survivor, failing to comprehend that, will blame him/
herself for the death of a friend, failing to realize
that the enemy or the disaster was the killer. The war
or the disaster should be blamed, not those who lived
through it. 

Abreaction

One course of treatment prescribed is individual therapy
initially, followed by group or marital therapy, depending
on the individual and the presenting problems. It is
essential to get the story before putting a person in
a group. While much of the real healing takes place in
group, its precursors are in individual treatment.
Putting a person into a survivor's group without knowing
the story is like an attorney examining a witness on
the stand without knowing in advance what the witness
would say. Not all survivors are appropriate for all
groups, and most groups are homogeneous and trauma-specific
(i.e. combat veterans, special operations operatives,
rape victims, medical personnel, disaster victims,
mass casualty survivors, etc.).

Getting The Story Of The Traumatic Event

Trauma victims tend to remember the actual event in a
slow-motion time warp, and often have tunnel vision. 
They forget many of the environmental factors in the
trauma situation. The longer the trauma has been in the
past, the less they remember of the environmental
situation.

For a therapeutic intervention to be successful, one
must get the story of the trauma in precise detail.
For example, it is helpful to know the details about
environmental conditions, particularly smells, articles
of clothing, and other situational cues. It is important 
for them to tell you about the trauma scene as clearly
and vividly as possible. It may be important for them
to bring in memorabilia, such as newspaper clippings,
photographs, letters written to relatives or friends,
or perhaps audiotapes. Sometimes it is important to
remind them that people do not die from crying, and
that once they start crying they will stop. The more
they tell the story, and the more successful you are
with them in resolving the guilt issues, the less intense
the emotions become.

Many stress victims are reluctant to discuss their
guilt feelings or the trauma that they experienced. It
is often necessary to spend several hours with them to
uncover the traumatic situations involved.

Treatment Considerations

One goal of counseling is to separate the rational or
cognitive component from the emotional "grief" component.
Trauma victims seem to have a great need to hang on to
the guilt. Therefore, to make them accessible to treatment
you must let them maintain that affective component
while you attack the issue of responsibility. It may
often be helpful to make a comment like, "Gosh, that
was a horrible thing. That must make you feel very sad."
This gives words to their feelings of grief. People with
survivor guilt really don't think that others can
understand them. As you continue in treatment with them
and continue to give them the affective part of the
survivor guilt, the anguish will diminish over time.
The intensity of their sadness begins to diminish as
they begin to understand more about the trauma
situation. The main goal in counseling with survivor
guilt is to allow them to feel the sadness but to attack
the issues of responsibility. There are a variety of 
ways of doing this and the therapist is limited only
by his or her imagination. Some suggestions are
explored below:

Shared Responsibility

The technique of getting survivors to share responsibility
for what happened starts with pointing out other factors
involved in the incident itself. One of the factors
may simply be one of time and space. They may have been
in the wrong place at the wrong time or they may simply
have been victims of a random act. Many people who have
been raised in organized religions tend to feel that
what happened to them was paying them back for some
past sin. With disaster victims, you focus on the fact
that the disaster was responsible for the deaths. The
disaster was responsible for the situation in which the
trauma occurred. You do not necessarily try to absolve
them of all responsibility, depending on their trauma
situation.

Cognitive Restructuring

Survivors of trauma tend to remember the traumatic
situation in an unchanged way. Their initial perception
of the event is the way they continue to view it, as
if the traumatic event were frozen in their memories.
The healing process involves thawing those memories
and looking at them realistically. Because the memories
have a very negative focus, the goal of cognitive
restructuring is simply to look at the original trauma
in a different light.

The first step a client seems to go through in cognitive
restructuring is one of confusion. That is a very
positive sign that he or she is beginning to doubt the
original perceptions of the situation and is realizing
that perhaps the trauma has other aspects that have been
ignored, forgotten, or devalued. It is good to make a
point of letting clients know why this confusion is a
good sign - a sign of change. When dealing with survivor
guilt, it is important to find out what kinds of words
people use to talk to themselves when they are thinking
about the trauma situation, and to help change these
words.

Clergy Referral

Trauma victims' religious beliefs are often either
strengthened or weakened. They frequently say, "Where
was God when I need him?" Trauma counselors should 
have some contact with clergy in their community. It
is most important to have a clergyman who can listen
to these rather dramatic and sometimes gruesome stories
in a non-judgmental and practical way, but with a
sensitivity to the theological implications for the
victim.

The Message Is: The Victims Did The Best They Could

The bottom line of many of these concepts is to leave
the survivor of trauma feeling that he or she did the 
best job in the situation that could have been done
considering the circumstances and the resources
available in the situation. As victims start to realize
this, they often feel a need to do some form of restitution
such as reaching out to other trauma survivors or 
making themselves available to the media for discussions
about their experiences. One way to help them get to
this point is to ask them how long they need to continue
to make themselves suffer. Certainly the trauma survivor
feels that no amount of retribution or restitution can
make up for the loss of a friend or loved one, and
perhaps the best they can do for that lost person is
pull themselves together and make their own lives
positive and productive.

Techniques/Special Points

A variety of techniques have been found useful with
many individuals suffering survival guilt.

Many people suffering from survivor guilt can be helped
substantially if the trauma happened when they were
young and their youth becomes a subject for discussion.
Many Vietnam veterans were quite young when the trauma
occurred and they acted in a way that is now causing
them the stress. With them, as with other young trauma
victims, pain revolves around self-punitive survivor
guilt that results from the way they behaved during the
trauma. This is an opportunity to discuss with them
the moral development of adolescence. Essentially,
adolescent idealism means that people in their late
teens and early twenties hold to very high moral
standards. They tend to see the world as black and
white, but when they find themselves in a trauma
situation such as war, they soon learn that there are
many gray areas. Nevertheless, they still judge
themselves years later rather harshly because their 
moral development was frozen in time. Now they need
to look at the moral aspects of their behavior in
light of their further experiences in life. Point out
that now they know life is not fair. Adolescent
idealism holds that life is fair, that good things
should happen to good people, and bad things should
happen to bad people. Clinging to this adolescent
belief system obviously leads to a very self-punitive
position.

Included in the discussion of age in relation to the
trauma, it must also be noted that there are often
massive amounts of peer pressure from others in their
group.

Empty Chair

Gestalt techniques tend to be particularly effective
in dealing with survivor guilt when one can pose such
questions to the client as, "If Joe were here and alive
now, sitting in that chair, would he blame you for
your actions, or if you had died instead of Joe, would
you blame him for your death?" One is limited only by
one's imagination in using such reversal techniques as
writing a letter to a person who did not survive a
trauma or to a dead relative with whom there is
unfinished business.

Time

As discussed earlier, a person in a trauma experiences a
warp in the perception of time. Events seem to unfold in
slow motion, and retrospectively the person tends to think
that they had more time to make decisions than they actually
had. It is important to clarify how much time was actually
available, how quickly the decision had to be made, and
that given the information they had, they (not someone else)
were in the best position to decide how they should act and
likely did the best they could. It is also important to
discuss the amount of experience they had had in similar
trauma situations. If they had been in combat for six months,
one would expect a different type of response than if they
were on their first day of combat. Very similar parallels
can be drawn with police officers and other emergency
workers.

Technical Aspects

In working with victims who have on-the-job traumas, such
as military, police, medical and other emergency workers, it 
may be very important to look at a trauma from a very 
technical sense. Did they in fact act correctly in that
situation? Did they react according to procedures and
standard policies? In working with police, military and
medical persons in certain trauma situations they often
find themselves having to make decisions that are normally
made by persons much higher up in the line of authority.

Pride

It is helpful to maintain a positive focus and glean as 
many positive aspects of the person's behavior (during the
trauma) as possible. The therapist continually looks for
things in clients that can reinforce pride in their unit,
their profession, or their behaviors.

Symbolic

There are many ways to ameliorate the guilt that someone 
else was killed in a trauma. Many trauma victims have used 
arts and poetry to express some of the feelings they've
had toward the missing person or their feelings about the
involvement in that situation. In working with suicidal
people with survival guilt, some of the better interventions
have included communicating that, "As long as you are alive,
the memory of the victim remains." With some trauma victims,
it may be necessary to visit the graves of buddies or loved
ones who died, or review newspaper or other media reports
of the trauma. Vietnam veterans may need to look at the
Book of Friends (a registry of all those who died in Vietnam),
the DAV Vietnam Memorial in Angel Fire, New Mexico, the Wall
in Washington, D.C., or participate in some other forms of
recognition that someone actually did die. In group therapy
some sort of memorial symbol can be held during the last
group session. It can be as simple as having a moment of
silence and as complex as having a ceremony of lighting
candles, talking about the death of a friend, and burning 
his or her name into a piece of plywood with a map or other
symbol sketched on it.

Healing And Purification Rituals

Wilson (1986) describes the role of the Native American 
Sweat Lodge as a form of group therapy for combat veterans.
This can be a potent and dramatic healing experience when
utilized in conjunction with more traditional forms of
therapy.
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SELECTED REFERENCES:

Bard, M. and Sangrey, D. (1986). The crime victim's book.
New York: Brunner/Mazel.

Cobb, S. and Linderman, E. (1947). Neuropsychiatric
observations. Annals of Surgery.

Horowitz, M.J. (1976). Stress response syndromes. New York:
Jason A. Ronson.

Wilson, J.P. (1986). Native American healing and purification
rituals: Implications for the treatment of post-traumatic
stress disorder of Vietnam veterans. Cleveland, Ohio:
Cleveland State University, unpublished manuscript.
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by trying the following descriptors: Vietnam veterans and PTSD,
posttraumatic stress, PTSD and healing, Native American and
PTSD, Treatment and PTSD, Age and trauma, trauma, victims and
trauma, religion and trauma, culture and trauma, cognitive
restructuring and trauma, grief and trauma, responsibility
and trauma, etc.
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     Contact your local Mental Health Center or
     check the yellow pages for counselors, psychologists,
     therapists, and other Mental health Professionals in
     your area for further information.
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Partial List Of Agencies Involved In Disaster Assistance

Federal:

Department of Health and Human Services
Public health and welfare functions

Federal Emergency Management Agency (FEMA)
Coordinates all Federal services in Presidentially
declared disasters; Arranges for temporary housing;
Liaison with local emergency management organizations.

Department of Labor
Unemployment insurance

Department of Agriculture
Farmers Home Administration (FHA)
Food stamps - food commodities - disaster loans

Small Business Administration (SBA)
Disaster loan program for homes and businesses

STATE

Department of Public Assistance
Assistance to welfare clients (Federal assistance program)

Department of Health
Immunization
Prevention health measures as necessary
Department of Mental Health (Referral of disaster victims
with mental health needs)

National Guard - except when called into Federal 
service

Civil Defense
Assistance to communities on damage to public facilities
(some states have separate disaster preparedness agency)

LOCAL CITY/COUNTY GOVERNMENT
The local/county level counterparts of State Government
provide the following services:

City/County Government
Declaration by public proclamation of emergency when
situation cannot be handled by existing relief agencies,
ptivate and governmental, operating in the normal manner.

Civil Defense
"To prepare comprehensive plans and programs for the civil
defense in bothe enemy-caused and natural emergencies."

Establishes Control Center

Coordinates all efforts

Police Department
Suppression of criminal activity
Dispersal of crowds
Traffic control
Organization and control within the damaged area
Alerting people to emergency and evacuation

Fire Department
Alerting through telegraph section
Minimize or prevent the effects of fire 
Assistance with water supply, street clearance, and
demolition

Associated General Contractors

Rescue and engineering services
a. Clearance of streets
b. Repairing bridges

Bulldozer operations

Department of Health and Hospitals

Medical services including emergency first aid, ambulance, etc.

Health Division

Sanitation
Immunization
Vital statistics
Public health nursing

Coroner's Office

Collection, identification, and burial of dead

Department of Streets

Clear and maintain the streets for traffic
Formulate and enforce emergency traffic regulations in
cooperation with police 
Garbage/rubbish collection and disposal

Department of Public Utilities

Rehabilitation and maintenance of water supply, lighting,
heating, and power 
Coordination of activities of privately owned utilities

Bi-state Transit

Vehicles, fuel, etc.
Provide drivers

Civil Air Control

Reconnaissance
Movement of key personnel and light equipment

Telephone

Communications

Radio Amateur Civil Emergency Services (RACES)

Short-wave radio

Radio/TV Networks

Communications

Human Relations Commission

Volunteer committee responsible for protection of citizens.
Subcommittee includes churches.

Department of Welfare

Responsible for all emergency welfare services, including
feeding, housing, and financial assistance. Augmented by
ARC and private social welfare afencies.

VOLUNTARY AGENCIES (partial list)

American Red Cross (ARC)

In addition to immediate assistance - food, clothing, rent,
transportation, temporary home repairs, medical and health
needs, selected furnishings, and personal occupational
supplies and equipment and other essentials:
Refers families to Government disaster programs; provides
additional assistance to families with major needs for
whom such Government programs are not available.

Catholic Charities

Wide variety of services which differ from one diocese to
another.

Christian Reform World Relief Committee

Building advisors - builders, interviewers.

Church of the Brethern

Cleanup, building

Mennonite Disaster Service

Cleanup, building
Some feeding and child care

Salvation Army

Feeding
Shelters
Counseling
Household furniture, etc.

Seventh Day Adventists

New and used bedding
Clothing and comfort kits, diapers
(warehouse: Lansing, MI)

Society of St. Vincent de Paul

Food
Clothing
Assistance to the aged, infirm, poor, and children

Volunteers of America

Feeding
Sheltering - differs with location

Church of the Latter Day Saints (Mormon)

Food
Clothing
Shelter
Cleanup, rebuilding, household furniture
Mental health counseling
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