PTSD 101

When reporters seek a trauma survivor's comments soon after the event, they have a high likelihood of encountering one or more of the emotional states mentioned above. The reason that Acute Stress Disorder is not diagnosed until two days of symptoms have elapsed and PTSD requires four weeks of symptoms is because these symptoms are common and not indicative of a psychiatric condition in the immediate aftermath of a major life disruption. As time passes, there is a greater possibility of emotional composure. But there is also a possibility of distorted recollection, selective memory and competition from many other interviewers, each with a different agenda, each raising new questions in the mind of the person interviewed. Therefore, even from a psychiatric point of view, there is no formula for setting the ideal time for a post-traumatic interview.

Assume you have access to a clerk who was robbed at gunpoint an hour ago. She appears uninjured. You might begin, "Have you had a chance to discuss this with anyone else?" This tells you where this interview is in the predictable sequence of police investigations, insurance and management inquiries and conversations with family, friends and others, including other reporters.

It also allows you to follow up with questions about those discussions, if they occurred. An interviewee reveals a lot about conversational preferences, when given the chance. For example, he or she might indicate a desire to talk at length, to be brief and to the point, to learn about the incident from you or to get away from the scene - all in response to an open-ended question such as, "How was that previous discussion for you?"

Then you can set the stage for your interview, having assessed your subject's attitude and emotional state before he or she regards you as being responsible for his or her feelings. Have your subjects focus on how someone else made them feel.

Consider a very different interview. It is the one-year anniversary of a major catastrophe such as the Oklahoma City bombing and you are assigned to interview a survivor who now lives in your small town outside of Oklahoma. You telephone to arrange a meeting. This story, a year rather than an hour later, will deal with emotions throughout that year and on this anniversary date. The incident is less important than the impact of the incident on one individual through time. The interview may - probably will - cause vivid recollections. Do you mention this over the phone? Or do you assume that a willingness to be interviewed signifies a willingness to revisit painful memories?

The fact that this is a feature rather than a news story gives you more flexibility in arranging the time and place, meeting once or on several occasions. But you the journalist may be the cause of emotional injury, since this person was exposed to major traumatic stress and has reached some new adjustment state that you will disrupt. In a way, this is a more delicate, difficult situation.

Setting the stage is important regardless of the timing of an interview. A trauma survivor should be approached with respect, neither gingerly nor casually. This is a person who has witnessed and lived through a newsworthy event outside normal experience, someone who has something to share with the community and who undertakes some re-exposure to traumatic memories by talking with you. If you convey respect for this situation, then you are off to a good start.

Consider the possibility that a survivor might be more comfortable at home or might want to be out of the family circle. Some might feel more secure with a friend or relative present.

The clerk robbed at gunpoint would probably be encountered first at the convenience store. But if she had the authority to leave, to be joined by a friend, you might get more details, more spontaneity, than if you stayed at the scene of the crime. Of course, a deadline might preclude taking an extra hour to learn about the emotional impact of the robbery on your witness/victim. Obviously, if you can remove someone to a comfortable, secluded place, the chance of interruption is reduced and concentration is enhanced.

As a psychiatrist interviewing survivors, I often find two people at my office when I expected one. The second is the mother, spouse, sister or friend. I want that person present, if my patient wants the person there. Sometimes the patient just wants the person to wait outside, to be there for the drive home. But the patient would be embarrassed to say so in front of the companion. I have found it best to ask the patient to step into the office for a moment, so that they can express their preference, then I can tell the companion to join us or wait for an hour.

Interviewing people as a Red Cross volunteer at disaster sites is more like the field conditions journalists encounter. When serving in that capacity, I set the stage as best I can, trying to assess quickly whether a person wants privacy or the proximity of others and whether the comfort level is greater with the door open or closed. One woman preferred to sit on the floor, surrounded by her soggy belongings, as she sought help at a shelter after the 1994 Northern California floods. This woman was agoraphobic before the floods, more so afterward, and I earned her trust by bringing social workers and small-business loan specialists to her, rather than having her join the crowd in the busy service center.

To set the stage for an interview, remember that the person may be in a daze, may be numb, may be easily startled, may be hypervigilant, may be confused. But they can usually tell you the setting that will suit them best. This may require a companion, an open door and several breaks for self-composure.

As an interviewer, you can either elicit or avoid emotion. Do you want to see and hear a person's emotional state? Or do you want the individual to describe his or her feelings without displaying them? A person can tell you, "I was very upset, crying all the time, unable to work . . .." Or they can sob as they speak.

Most reporters would prefer to have their interviewees describe rather than display strong emotions (TV talk-show hosts excepted). So would I, in initial interviews with trauma survivors. My ultimate objective is to help them master their uncontrolled feelings. Therefore, I usually say that we can, if possible, defer dealing with the full impact of the event until we know each other better, until some progress has been made.

I explain how, several weeks hence, we will get to the central part of the traumatic experience. But that is done when I am treating PTSD, by definition a persistent problem, at least a month long, with intrusive emotional recollections. At other times, for example when debriefing Red Cross volunteers, I want to see strong feelings, if they are present, to get them talked out before the volunteer goes home (and to show respect for the person and for his or her emotions). That is the point of the debriefing.

But journalists are not PTSD therapists or after-incident crisis debriefers You are interviewing a witness who will become the subject of a story. From an ethical point of view, you should afford your interviewee as much control as possible and as much foreknowledge as possible. You can do this by explaining your journalistic objective. For example, you might begin, "I'm really interested in the facts of the robbery. I know this may be upsetting right after it happened, but I won't be reporting on how he made you feel." However, if your intention is otherwise, you could say, " . . . and I am interested in how he made you feel, then and now. Readers need to know what kind of impact these events have, and I thank you for being willing to describe them."

It is not uncommon for tears to flow during the telling of an emotional event. Therapists offer tissues. I usually say, "I'm accustomed to hearing people while they are crying, so don't worry about me." I neither urge nor discourage someone from continuing to talk, but I do try to normalize the situation. Reporters should bring tissues if a tearful interview is anticipated.

When survivors cry during interviews, they are not necessarily reluctant to continue. They may have difficulty communicating, but they often want to tell their stories. Interrupting them may be experienced as patronizing and as denying an opportunity to testify. Remember, if you terminate an interview unilaterally, because you find it upsetting, or you incorrectly assume that your subject wants to stop, you may be re-victimizing the victim.

Some people who have suffered greatly, for example, torture victims in Chile, have benefited psychologically from the opportunity to provide testimonials, and the benefits have been substantiated by research.

Members of the Michigan Victim Alliance, who serve as interviewees for the journalism students at Michigan State University, report some PTSD symptoms (anxiety and intrusive recollections for one or two days), but an overall increase in self-esteem, because their stories have been heard. Often, the facts are told with considerable depth of feeling.

So the issue is not really should you, the journalist, attempt to control your subjects' emotions, but rather, how can you best facilitate a factual report, a full report, and give your interviewee a sense of respect throughout.

Should journalists offer the equivalent of a Miranda warning? "You have a right to remain silent. Anything you say can and will (especially if it is provocative or embarrassing to somebody important) be used on the front page."

That would not work. But the medical model of informed consent could be adapted for interviews with trauma victims. You might explain: "This procedure - interview and article - has benefits for the community and may benefit you. Remembering, however, may be painful for you. And your name will be used. You might have some unwanted recollections after we talk and after the story appears. In the long run, telling your story to me should be a positive thing. Any questions before we begin?"

The first set of responses after shocking events involve the pathways of the autonomic nervous system, connecting the brain, the pituitary gland, the adrenal gland and various organs of the body. Blood is shunted from the gut to the large muscles. The pupils dilate. The pulse accelerates and the stroke volume of the heart increases.

These physiological changes, shared by all mammals, prepare us for fight or flight. We are in a state of readiness for dealing with the threats our ancestors faced on the great plains of Africa: wild beasts, sudden storms, deadly enemies. We are not adapted for fine motor movements, nor for deep conscious thought. The surge of adrenaline and pounding heart we experience when our car skids on an icy highway does not help us maneuver that modern challenge.

Our danger biochemistry is atavistic. We have to fight these bodily changes as we respond to modern mechanical dangers, such as a high-speed skid in an automobile. There are perceptual changes as well. Our focus on a source of danger, be it a wild beast or a pistol pointed at us, is intensified. Objects in our peripheral field of vision begin to blur, a function not only of the organs of perception but the result of how impulses are received, recorded and analyzed in the brain.

Detectives, doctors and journalists all know the implications of this phenomenon: Details are notoriously distorted, except for a few central features, when eyewitnesses report from incidents of threat and sudden danger.

Sometimes, a powerful threat is prolonged, as in a hostage incident, a kidnapping, some assaults and rapes. Many natural disasters - a flash flood or hurricane - may place one in mortal danger for hours rather than seconds or minutes. Short, deadly traumas include gunshots, explosions, earthquakes and fires.

When extreme stress is prolonged (days or weeks), adaptive mechanisms collapse. This is rare. But in animal experiments, mammals suffer hemorrhagic necrosis of the adrenal gland - literally a bloody death of that organ, and, soon after, death of the organism itself.

Far more frequently, humans in states of prolonged, catastrophic stress enter a second stage of adaptation. Hans Selye, the physiologist whose stress studies guide the modern era, called this a stage of resistance, following a stage of shock. Now the organism is on high gain, accustomed to the increased flow of adrenaline, consciously appraising what has previously been grasped automatically.

At this point, a crime victim knows that he or she is a victim, although the person may be thinking, "This can't be happening to me." At this point, details do become evident, particularly to the trained observer. And, in group hostage situations, there is often a ritual calm, when confusion and feelings of threat diminish. This is the time when negotiations may be successful.

Disaster workers recognize a heroic phase, a second stage after the initial bedlam, when all is shock and confusion. In the second stage, people help one another, lives are saved, lost children are found. Hope and exhilaration coexist with fear and grief.

Eventually, there is a return to some equilibrium in the body, the mind and the community. This may be a time of depression and demoralization: The high-energy condition is gone. There is debris. There is loss. There is pain. Reality sinks in.

This is also the time when the press leaves. A survivor who might have been annoyed by too much attention could feel abandoned and forgotten.

Several authors describe stages after shocking events occur or disturbing news is heard. Kubler-Ross defined the denial, fear, anger and eventual acceptance after learning one has a fatal illness. PFLAG, Parents and Friends of Lesbians and Gays, describe similar stages, not all of them reached, by parents who are unprepared for the revelation that their children are gay. Stages are merely guidelines, not applicable to everyone who encounters unforeseen stress.

A journalist may want to consider the particular sequence of stages or phases that an interviewee has experienced, where that person is now and how each stage affects the perception of events.

A discussion of stages may help the interview process, without actually "leading the witness." Consider saying, "Sometimes people go through a stage when they act without thinking, when they don't even know what is happening," and you may elicit an interesting narrative. Some people need to be reminded that they acted instinctively. Then they can recall what occurred just before that phase and right afterward.

My patient who was thrown to the floor by the "cooler bandit" recalled months later that she hid her wedding ring under a shelf, as she lay in the fetal position, expecting to be shot. She forgot this particular event during the time that she was experiencing fear and shame and all of the PTSD symptoms listed in the diagnostic manual.

For me, it was of special note - her instinctive protection of a valuable symbol, her refusal to yield that icon to her assailant. This woman was full of self-blame for not sounding the secret alarm, for behaving like a coward. Therapy required a diligent search for evidence to the contrary, proof that would convince her. (I was already certain that she had done what any reasonable person would have done to survive an armed robbery.) She recalled hiding her ring as we talked about the instinctive, automatic things that some people do. And she finally agreed that her instincts were correct.